"hospital_name","last_updated_on","version","location_name","hospital_address","type_2_npi","license_number|VA","To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","attester_name"
"Sentara Hospitals","2026-04-01","3.0.0","Sentara Norfolk General Hospital","600 Gresham Dr, Norfolk, VA 23507","1437119310|1346314192|1649345158","H1896","true","Melinda Hancock"
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","billing_class","setting","drug_unit_of_measurement","drug_type_of_measurement","modifiers","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|methodology","standard_charge|min","standard_charge|max","additional_generic_notes"
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service","","","","","","","facility","both","","","25","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","facility","both","","","50","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","facility","both","","","59","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy","","","","","","","facility","both","","","EC","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered intravenously","","","","","","","facility","both","","","JA","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Administered subcutaneously","","","","","","","facility","both","","","JB","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount","","","","","","","facility","both","","","JG","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital","","","","","","","facility","both","","","PN","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","facility","both","","","Q0","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","facility","both","","","RT","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes","","","","","","","facility","both","","","TB","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","facility","both","","","TC","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Aetna","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Aetna","VA Preferred Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","BCBS","Anthem Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","BCBS","Anthem HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","BCBS","Anthem Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","BCBS","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","BCBS","Anthem PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","BCBS","Healthy Blue Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Cigna","Open Access Plus B Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Cigna","PPO/POS","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","First Health","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","MedCost","Virginia Link Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","MedCost","Virginia Plus PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","MedCost","Virginia Standard PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","MedCost","Virginia Ultra PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Multiplan","PHCS PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Optum","Transplant","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Sentara Health Plan","Exchange","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Sentara Health Plan","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Sentara Health Plan","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Sentara Health Plan","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","Sentara Health Plan","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","Community Plan - NC Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","Community Plan - VA Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","DSNP Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","OneNet Workers Compensation Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","Options PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","UnitedHealthCare","QNBR Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Medicaid level of care 13, as defined by each state","","","","","","","facility","both","","","UD","","","WellCare","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","14591.94","14591.94","14591.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","28558.68","11023.77","33762.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","16975.52","16975.52","16975.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5472.35","724.44","7642.31","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","39763.58","39763.58","39763.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","19131.42","7491.56","68217.23","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2746.99","2746.99","2746.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","18466.47","7713.09","75952.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","6852","4176.03","21591.6","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","27187.94","27187.94","27187.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","23203.47","8117.97","23207.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4930.44","3513.72","8660.37","53","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9405.36","9405.36","10694.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","13122.96","7536.78","18875.13","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","12127.71","12127.71","12127.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","17544.85","17544.85","17544.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","9120.85","9120.85","11940.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","18386.37","17187","24353.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","16391","12224.97","24194.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3358.09","2611.73","6103.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6481.57","6481.57","6481.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6639.7","6639.7","6639.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","31.15","31.15","31.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18.67","18.67","18.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","12983.39","12983.39","12983.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj cefazolin sodium, hikma","0788","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","89182.68","89182.68","89182.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","80252.91","76871.22","80252.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","23658.74","23658.74","23751.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","80252.91","80252.91","80252.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","52009.04","52009.04","52009.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","23203.12","23203.12","23399.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","24592.85","24592.85","28371.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","23331.26","23331.26","23331.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7897.36","7897.36","7897.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","25637.24","25637.24","25637.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","11286.91","11286.91","11286.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, lidocaine in d5w, 1 mg","0795","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4.4","4.4","4.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","862.89","862.89","862.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epoetin alfa, non-esrd","1686","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","5920.01","5920.01","5920.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","19076","19076","19076","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","23577","23577","23577","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","15390.61","15390.61","18996.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","58265.39","58265.39","58265.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","18300.22","17831.34","18678.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16072.61","14950.51","17509.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","13620.26","13620.26","13620.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7859.31","7859.31","7859.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","14340.15","10430.32","18883.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str,Yttrium-90","2616","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","25896.55","25896.55","25896.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","33393.21","33393.21","33393.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","33542.7","32215.06","34130.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","8580.92","8580.92","8580.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6924.71","6924.71","6924.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","18017.58","18017.58","18017.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","11069.52","11069.52","11758.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8192.05","8192.05","8192.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-stranded,P-103","2641","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","9066.5","9066.5","9066.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","8794.43","8794.43","8794.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Brachytx, non-str, HDR Ir-192","2646","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","173.9","115.53","481.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","262.13","118.1","772.53","79","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","191.63","191.63","191.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","215.83","177.45","255.3","177","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","305","126.31","427.31","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","305","131.78","457.02","113","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","305","140.67","526.49","452","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","126.31","101.05","239.98","1211","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","247.68","177.72","259.82","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","126.03","78.14","321.65","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","124.21","117.99","137.72","1370","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","116.88","116.88","145.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","407.35","407.35","407.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","172.26","172.26","240.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","213.88","171.48","236.78","404","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","123","98.4","125.51","1014","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","128.14","23.9","210.99","83","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","101.04","29.25","211.36","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","31.2","31.2","31.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","120.59","101.29","177.22","761","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","587.25","190.03","1003.85","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","223.57","200.55","735.3","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","221.95","193.29","235.84","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","173.85","173.85","466.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","68.44","68.44","174.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","179.33","179.33","252.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1266.28","1266.28","1266.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","188.07","180.51","307.74","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","129.29","129.29","129.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","209.7","28.05","260","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","88.06","88.06","88.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","208","203.61","221.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","63.22","63.22","63.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","199.63","199.63","15064.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","386.73","386.73","386.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","188.07","180.51","272.24","123","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","255","175","311.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","67.23","67.23","85.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","198.11","195","315.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","33.39","33.39","88.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","260","238.48","796","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","197.45","187.32","304.32","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","87.36","87.36","87.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","300.77","74.25","849.6","75","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","192.44","72.44","292.35","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","113.16","113.16","113.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","224.87","167.54","375.25","704","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","255.75","219.2","465","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","397.6","197","497.31","96","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","266.14","131.76","512.31","382","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","33.23","18.02","157.42","92","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","109.58","109.34","109.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","340.87","61.02","799.14","96","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","325.79","325.79","325.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","44.83","44.83","212.14","102","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","297","297","297","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","224.87","167.54","357.37","1541","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","115.65","13.95","151.76","65","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","225","148","425","187","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","315.75","222.6","421","45","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","421","294.7","499","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","50.81","25.69","157.79","180","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","430.29","157.26","1075","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","398.57","160.44","1015","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","233.35","181.15","370.85","296","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","135.8","107.77","157.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","111.53","111.53","155.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1152.36","461","3144.08","263","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","681.22","301.17","1643.4","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","625.59","391.41","3333.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","272.24","200.95","579.22","2101","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","787.46","305.24","1721.28","117","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","695.64","142.63","1598.83","426","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","772.94","483.36","1720.89","1213","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","236.21","134.2","459.32","490","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","446.31","241.95","785.27","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1250.79","468.41","2679.55","291","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","552.76","353.12","2856.26","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","700","700","700","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","169.48","159.06","451.07","434","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","241.11","241.11","241.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","1048.91","1048.91","1048.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","468.41","468.41","468.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","99.73","99.73","99.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","250","250","250","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","272.24","200.95","515","4419","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","211.43","127.08","473.61","275","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","529.9","415","765","591","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","568.5","402","758","168","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","529.9","131.25","757","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","250.75","136.6","479.06","632","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1344","433.35","2673.88","68","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1605","520","2875","225","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","300.03","221.95","592.27","786","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","1169.55","1169.55","1169.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","492.69","220.36","688.95","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","362.42","238.51","620.9","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","3908.95","1561.4","9599.62","275","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","2979.83","1075.68","5539.51","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1132.45","614.85","4256.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","523.61","242.93","1107.31","1732","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","1508.93","654.48","3896.78","156","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1655.02","617.44","3254.92","470","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1777.57","941.51","3549.89","1305","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","516.09","309.57","1024.02","670","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1333.19","467.73","2962.47","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3384.38","1604.34","5720.15","357","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","2429","1102.48","5000.86","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","519.01","302.6","1010.82","739","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","390.43","390.43","583.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","1502.54","1502.54","11304.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","3083.91","3083.91","3083.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","471.97","239.55","957.55","3535","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","507.92","269.22","1004.7","439","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1792","758.81","2042","815","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1520.25","894.85","2027","227","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1672","372","1963","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","525.06","305","998.37","772","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","3688.31","1452.5","5196.8","84","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","4028.8","1628.8","5280","231","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","511.59","258.17","1173.46","665","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","2651.69","1204.49","18506.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1004.19","976.71","2296.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1232.99","465.26","3704.71","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4692.16","2051.79","18486.99","156","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","4422.86","2036.65","12551.42","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1141.12","851.44","7080.16","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","683.99","260.96","1792.89","1008","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2308.53","962.43","6375.29","121","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2201.9","990.94","5120.53","377","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2566.36","1604.51","7082.89","917","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","813.8","550.05","1964.01","771","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1618.41","1119.44","7678.57","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4739.19","2514.51","12018.29","252","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","4035.79","1586.35","15541.29","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","791.01","567.96","2424.75","594","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","4348.81","4348.81","4348.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","175","175","175","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","616.1","260.8","1308.41","2110","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","775.72","532","2286.88","469","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","4328","1822.71","4780","622","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","3483","2182.5","8739.43","141","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","3326.89","1704.8","4631","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","833.13","533.59","2355.05","699","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","4303.72","2458.42","6161.43","62","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","4486","2170.13","5380","194","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","626.15","256.16","1576.12","468","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","6708.56","4450.52","9647.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1515.87","1144.27","6615.88","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3366.49","974.2","7567.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","20903.07","20903.07","26828.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","8661.56","8661.56","8789.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","23118.05","23118.05","23118.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","10001.65","10001.65","10001.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1024.01","1024.01","1024.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2368.18","2368.18","2368.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","5627.99","5627.99","5627.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5628","5628","5628","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","367.44","367.44","367.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3840.5","3840.5","3840.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","7202.87","7202.87","7202.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1470.06","1470.06","1470.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1168.64","934.28","12457.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","879.47","879.47","879.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","521.27","309.57","543.12","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","524.24","406.54","583.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","543.12","61.39","996","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","170.26","148.9","352.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","499.22","116.83","1121.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","963.86","279.09","1542.98","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","302.84","302.84","302.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","192.37","44.83","302.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","530.28","412.77","561.73","101","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","127.08","127.08","561.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","425","175","3277.68","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","424.8","252.6","568.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","165.6","129.65","658.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1754.02","1046","2859.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","550.29","540.94","582.94","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1926.4","1926.4","1926.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","404.37","404.37","404.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","276.97","276.97","276.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4616.09","2882.59","18130.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1772.57","770.22","2752.94","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","543.12","493.06","1078.8","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","546.83","546.83","546.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1066.5","1066.5","1066.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3040.35","3040.35","3040.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","544.12","478.27","4030.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1358.93","1356.77","4384.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","534.64","534.64","534.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","650.21","396.16","953.99","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","568.5","568.5","568.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","529.9","529.9","529.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1023.59","1023.59","1023.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","620","620","1439.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","892.4","599.23","2296.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","867.27","867.27","867.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2002.46","1954.37","3000.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","658.32","658.32","1108.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4805.47","4805.47","4805.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","17313.76","17313.76","17313.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","572.8","572.8","572.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1473.5","1473.5","1473.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1452.01","851.56","1792.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","2375","2375","2375","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","972.35","972.35","972.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","11979.8","11979.8","11979.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","5983.99","5983.99","5983.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6960.3","4302.48","9093.47","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2813.78","314.25","3523.25","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2289.66","2289.66","3513.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","5744.59","4454.56","8616.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","6846","6846","6846","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1661.07","1322.01","2203.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2324.84","2300.34","5156.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","7114.13","5345.47","8885.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2813.78","2700.64","3335.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7238.04","7238.04","7238.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1580.28","1580.28","1998.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","7565.45","7565.45","7565.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3833.71","3833.71","4334.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7485.04","7485.04","7485.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","35016.86","35016.86","35016.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","9065.44","9065.44","9065.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","11976.18","11734.38","12434.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2813.78","2700.64","2813.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4995.47","4484.86","5891.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","10997.05","10997.05","11495.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","8801.89","7830","12068.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3968.94","3087.43","5881.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2824.2","39.64","3821.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","7609.59","7609.59","7609.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5648.24","5648.24","7691.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","4411.02","4411.02","4411.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","12544.55","12544.55","12544.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1456.43","735.25","15540.75","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","2604.56","2604.56","2604.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","935.57","521.27","2207.84","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","1989.38","749.69","3181.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1709.58","425.73","2651.49","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2005.11","1611.19","2301.66","66","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","660.24","510.91","670.04","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1406.12","1124.89","2256.86","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","3166.92","3166.92","3166.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","237.11","237.11","777.56","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","935.57","521.27","1937.62","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","371.98","353.04","674.28","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1157.51","424.8","3246.78","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","730.34","475.74","1539.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","592.53","320.27","694.1","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2683.58","1849.61","3405","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","68.61","34.3","4304","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1176.85","1011.54","1987","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1185.28","1185.28","1185.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","3087.04","2824.05","6977.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","10226.41","4832.14","14520.01","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1947.41","1078.38","2839.47","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","4628.83","2266.28","4757.74","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","4350.4","3303.68","5296.4","96","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4841.52","3519.89","5390.08","233","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1553.81","1201.01","1588.11","76","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6236.58","6236.58","6810.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7634.24","3408","11035.9","43","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","5646.73","4106.49","9581.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1120.58","1079.6","1436.37","108","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","1386.8","1386.8","1386.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1988.69","1069.37","2839.47","106","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1268.84","1197.6","1559.69","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3880.14","1668.04","6286.36","154","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","3586.81","703.39","6477.6","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","8772.03","3178.31","23470.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1359.51","1099.6","1684.39","60","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1289.52","245.55","2260.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1097.54","273.22","4703.4","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1987","1794.06","2505.5","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","5715.01","5715.01","5715.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7747.32","7747.32","7747.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","8256.88","8256.88","8256.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","19890.96","18515.4","35122.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2920.93","2507.35","3475.42","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","6303.19","4802.92","7984.04","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","7472.25","6220.36","8988.09","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","8485.31","6788.23","9362.67","63","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2780.8","2579.29","5782.41","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","12051.4","4698.03","18249.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2317.43","2206.98","5475.7","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2824.31","2507.35","4387.85","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2413.14","2185.31","2731.64","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","7985.9","4166.55","11060.68","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9946.92","6790.61","12110.18","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2678.09","2249.59","6103.52","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","4109.16","2761.42","11944.01","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3031.15","3031.15","3031.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","17202.39","17202.39","17202.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8963.64","8963.64","8963.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","17542.16","17542.16","17542.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","31818.07","24275.83","47832.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6121.91","6121.91","8795.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","10021.52","8433.36","19149.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","12401.79","10647.78","21083.74","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3434.84","3366.24","6005.04","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","11726.83","10221.79","19900.56","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5220","5220","5220","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","12714.5","12714.5","12714.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5828.84","3249.64","9143.6","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4788.02","2774.16","7898.52","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3669.73","2923.85","6845.54","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","10053.74","6404.1","16821.5","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9357.81","8186.8","17576.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5685.79","3777.65","6275.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","12454.82","12454.82","12454.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","11157.3","10465.53","18354.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5000.11","1919.23","5740.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","27950.56","18486.63","40861.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","18777.66","18777.66","18777.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15594.71","4595.48","16258.5","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","15603.72","15603.72","15603.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","20946.31","18922.9","21333.74","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","8138.3","6036.68","9121.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","18587.93","15929.07","20480.25","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8980.08","8980.08","8980.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","9672","7293.97","10529.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","21793.72","21793.72","21793.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7898.45","5452.96","8445.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15594.71","2734.08","16316.4","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","12925.48","5882.67","17298.46","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8034.93","5905.83","8301.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","11001.02","3561.63","20473.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","18191.93","18191.93","18191.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","4881.83","4571.07","5125.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","26197.75","24694.21","27701.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","16861.22","16183.19","16905","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12293.51","12293.51","12293.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","30203.4","30203.4","30203.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","11172.12","11172.12","11172.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8814.56","8814.56","8814.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10339.83","10339.83","10339.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","15257.94","15257.94","15257.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7153.34","7153.34","7153.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","14221.6","14221.6","14221.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","61044.57","61044.57","61044.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","56915.51","56915.51","56915.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","16913","16913","16913","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","54638.5","54638.5","54638.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","20966.21","20966.21","20966.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","15365.03","15365.03","15365.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17468.52","11225","19723.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","18002.12","13024.75","33024.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","7226.75","7226.75","7226.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","44102.25","44102.25","44102.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","877.79","877.79","877.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1249.76","1249.76","1249.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","332.08","332.08","342.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","505.85","505.85","505.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1295.21","1115.35","1501.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4765.31","4079.52","5235.46","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1431.47","1250.17","1568.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","4422.56","4390.33","4726.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4561.96","4561.96","4561.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","20509.89","20509.89","20509.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4890.16","4890.16","4890.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1295.21","1071.68","2515.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1527.49","1419.69","4825.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","4428","532","10705.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","452.14","452.14","452.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1448.54","1257.94","5906.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","4323.11","4323.11","4323.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5180","5180","5180","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1480.29","1400.41","3606.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","18146.33","9136.56","40487.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5507.78","3153.3","8410.11","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","8676.25","8676.25","8676.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","10315.39","9022.03","23069.4","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2861.78","2793.18","6589.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","9279.42","9279.42","9889.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6931.5","6931.5","6931.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7476.04","7476.04","7476.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3515.06","2882.14","7212.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3955.74","2904.55","8071.92","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2778.28","2542.51","5309.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8711.06","4205.67","11169.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7820.56","7820.56","7820.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2693.18","2693.18","3301.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4751.14","4751.14","7865.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","24759.08","24759.08","24759.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","26070.76","25467.5","39445.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10836.49","10836.49","10836.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7952.68","7579.8","11369.69","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","19056.94","18718.94","19523.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","20903.75","20056.44","37730.54","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","22605.64","19561.36","23712.76","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6619.02","6614.98","12567.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8187.12","8187.12","8187.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","12507.17","9794.78","19616.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6524.1","6444.1","6885.1","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","6330.6","6330.6","6330.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7885.42","3335.67","11846.04","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","10030.76","7623","16026.1","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6524.53","6004.93","7559.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","12779.27","10938.09","14813.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","7029.89","7029.89","7029.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","6625.09","4042.14","11623.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","25826","25826","30423.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","22910.09","22910.09","22910.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8490.64","8490.64","8490.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","9679.49","9679.49","9679.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","38582.22","30317.91","49847.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14617.34","8341.1","23554.96","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","37271.3","37271.3","42091.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","38122.15","34414.7","41587.81","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","42305.46","33637.91","42473.72","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","11368.94","5340.31","13039.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","15184.28","15184.28","15184.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","17975.43","17975.43","32343.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","24163","24163","24163","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","11959.99","11407.24","12599.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10455.98","7502.65","21541.86","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","18153.67","12929.24","20049.43","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","12136.41","12136.41","12136.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","18559.87","18559.87","26934.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","19949.89","19949.89","19949.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","11864.27","11375.42","15644.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","28438.47","28438.47","28438.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15729.39","15143.88","19067.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","40687.23","40687.23","40687.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","49392.78","49392.78","49392.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","57620.21","56016","60538.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","20488.95","20488.95","20488.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","55297.26","55297.26","58115.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","35421.72","35421.72","35421.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","17361.46","17287.22","17381.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","18157.6","15551.56","33035.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14297.35","9910.88","16754.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","17425.78","17425.78","17425.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","22566.78","22566.78","22566.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","29489.89","29489.89","32730.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","28834.3","28834.3","28834.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","805","805","983.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","188.07","188.07","188.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","199.25","199.25","199.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","249.96","242.93","386.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","280.86","280.86","280.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","875","875","875","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","223.97","223.97","223.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","308.21","308.21","308.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","148","148","148","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Airway Endoscopy","5152","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","29458.24","29458.24","29458.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","5641.3","4865.76","11319.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4795.11","4527.03","5641.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1982.85","1982.85","1982.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1303.17","1246.65","2891.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3340.45","3340.45","3340.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7682.29","6588.03","11241.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1514.9","1221.04","4908.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1645.9","1327.4","1646.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6208.13","3393.37","6301.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2659.87","2552.91","4164.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7246.99","7246.99","7246.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1355.45","1355.45","1452.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","4958.85","4958.85","7839","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3973.87","3973.87","3973.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1965.2","1965.2","1965.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","15936.51","13411.98","22005.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5577.77","5577.77","5577.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2776.1","2664.47","5402.12","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","8661.22","8661.22","10826.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","10735.76","9435.55","19565.64","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","11811.18","9649.01","12061.18","62","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3226.74","2891.07","6398.1","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6688.85","6688.85","6688.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5421.69","4208.38","6846.41","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3112.46","3112.46","6230.84","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2776.1","2664.47","5402.12","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","5551.29","3839.8","9515.43","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3224.96","2815.17","5285.65","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","6658.83","3478.3","10291.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3104.97","2759.98","3475.46","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","12739","8329.4","16211.5","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3137.9","2765.02","5605.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","14329.18","14329.18","15352","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","20396.58","20396.58","27350.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11797.59","11797.59","11888.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","19564.01","19564.01","19564.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","21641.6","18306.32","40578.94","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6398.1","6398.1","8893.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","21601.64","21601.64","21601.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","11887.56","11887.56","11887.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","12608.44","12608.44","12608.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8854.38","7438.63","14325.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","14808.52","10688.07","18626.37","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8118.72","7001.06","9993.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","20088.07","20088.07","20389.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","9710.71","9710.71","9710.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","22550.59","9310.01","29248.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12853.96","12853.96","12853.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","249.96","249.96","1823.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1166.3","777.7","1716.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1169.13","1169.13","1169.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","4684.19","425","5265.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","222.54","222.54","222.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","215.83","87.28","278","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","982.5","982.5","982.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1807.84","1807.84","1807.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3382.33","3382.33","3382.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","30","30","30","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2458.91","2458.91","2458.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2847.94","2847.94","2847.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1886.62","1886.62","2878.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","535.64","535.64","535.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8810.42","8810.42","8810.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1146.4","1146.4","1146.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2825.15","2825.15","2989.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","421","421","421","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","711.87","711.87","711.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2630","2630","2630","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4845.75","4554.1","4848.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2149.15","2149.15","2149.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","4223.27","4223.27","4223.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","765","765","765","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7279.62","7279.62","7279.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","16100.13","8548.87","17352.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3135.47","3135.47","7341.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","9282.56","7618.47","9523.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","10109.1","7006.37","10609.1","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2791.67","2791.67","2791.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","9201.34","8147.73","10184.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5982.71","5982.71","5982.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4859.88","4784.96","8359.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","14884.85","14884.85","14884.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2684.66","2500.53","2872.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3732.39","2198.68","7388.62","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","7110.91","5147.11","9400.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5481.03","2801.31","6554.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9396.99","8015.61","12599.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2549.08","2549.08","6250.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","9152.81","9152.81","9152.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","12397","11739","14876.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5991.5","5991.5","5991.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","30007.82","19453.59","46149.99","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","27150.72","27150.72","27150.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6544.15","6118.64","9231.84","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","15697.28","15364.71","30379.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","18077.78","15791.11","18577.78","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17885.47","14906.77","19351.99","64","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5411.26","4252.63","7875.49","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","11463.69","11463.69","11463.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","9033.23","5220","12394","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","12641","12641","17835.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7218.56","5260.48","9747.55","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","42438.12","42438.12","42438.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6818.33","6118.64","8771.12","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","12092.44","6085.88","17200.44","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5800.02","5327.63","8875.91","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","11364.32","8568.32","28880.26","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","52425.44","52425.44","52425.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5265.93","4649.76","9085.34","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","19241.92","19241.92","30835.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","19475.1","16099.16","32572.92","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7243.62","6349.53","9427.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","18187.64","18187.64","18187.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","32338.61","32338.61","32338.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","84753.19","84753.19","84753.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","94827.19","78684.16","104053.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","33928.85","33928.85","33928.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","30883.08","30883.08","30883.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","98180.42","98180.42","98180.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","30215.22","30215.22","30411.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","34003.05","34003.05","34003.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","28799.43","26827.25","41721.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","30161.59","30064.59","30358.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","31984.15","31984.15","31984.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","29493.83","29493.83","29493.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cochlear Implant Procedure","5166","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","3389.15","3389.15","3389.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","3600.65","3600.65","6131.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1072.27","1029.16","1408.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2052.98","1683.89","2256.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2022.53","1772.53","2147.3","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","606","531.04","652.73","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1941.62","1718.12","2218.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","560.71","154.88","965.48","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1072.27","1029.16","1072.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","590.1","296.1","1425.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1370.81","1155.35","3037.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","4084.29","1424.26","4802.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","570.85","309.03","607.45","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","335.2","312","3405","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1461.17","1461.17","1522.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","3723","3723","4172.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","7473","6419.71","29358.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2425.34","1072.27","5398.99","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","4561.59","4561.59","4561.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","4878.49","3902.79","4878.49","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","5081.79","4212.24","5081.79","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1498.14","1204.14","4303.49","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7437.4","3977.41","16189.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1106.18","1056.2","2845.03","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1641.24","1072.27","3976.26","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1188.67","1164.17","1482.67","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2678.03","1848.44","4118.19","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","3835.52","3551.25","3913.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1359.22","1037.1","2900.27","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","5771.14","5771.14","9969.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","287.82","287.82","287.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1703.17","1112.74","9556.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2042.37","2042.37","2042.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","8180.68","6970.55","13282.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","12357.23","11217.69","18876.53","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","10296.46","8422.73","10296.46","118","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3594.83","2994.73","6099.97","43","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","9242.45","6261.55","9242.45","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","9884.53","8401.85","9884.53","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3055.69","2697.99","5188.26","104","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3382.58","3382.58","3382.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","10049.8","7694.06","22406.62","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","12396.9","12396.9","12396.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2592.55","2504.19","5749.5","96","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3120.21","2994.73","5344.86","80","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2920.8","2403.28","3004.1","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","4821.81","3757.39","9456.34","76","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7201.44","4466.2","10450.48","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","6577.92","6258.11","17552.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2847.46","2343.96","4574.18","69","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1071.02","281.02","16863.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","3972.26","1085.61","16726","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3237.95","3107.74","5421.03","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7054.4","7054.4","7054.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5396.89","5396.89","5396.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","41576.94","41576.94","49787.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","15873.55","15873.55","15873.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17647.78","14347.51","17683.76","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5223.9","5156.46","9734.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5298.51","4980.01","9803.89","45","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","16476.29","13807.36","17905.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","13787.97","13787.97","13787.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","17172.55","17172.55","17172.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6880.06","4768.98","10488.99","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","35140.04","35140.04","35140.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5159.41","4127.52","12247.2","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","11100.52","8425.71","21973.68","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6489.81","5139.66","14602.07","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","12258.64","10919.8","18848.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5058.25","4333.25","8788.91","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","25826","25826","25826","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","45095.5","3045","46439.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5203.03","5203.03","10274.33","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","20013.08","20013.08","21096.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","24178.33","8291.41","34704.56","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","22797.08","22797.08","28444.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8638.89","8638.89","8638.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3450.27","3450.27","3800.77","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","9416.34","6114.12","9444.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","9600.96","7450.9","13595.58","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","10271.91","8256.49","18651.47","166","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5867.61","2765.53","10690.99","124","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6871.63","6871.63","8503.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","24925.11","16360.09","37267.09","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5525.51","2658.96","8996.6","148","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3457.57","3450.27","3888.45","69","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5646.97","2986.56","8563.18","123","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","9322.07","4784.86","18285.35","88","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","13200.13","8337.1","15445.48","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","20117.75","11238.69","38587.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","6107.4","2823.76","8839.99","77","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","21059","18415.88","43158.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","20486.92","16648.77","23420.25","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3730.49","3580.47","5424.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4737.98","4737.98","4737.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10999.47","10999.47","10999.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","19974.86","19974.86","27188.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17868.14","16578.73","19029.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6761.72","5344.86","9560.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5588.47","5201.37","8343.32","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","17905.29","17905.29","17905.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5890.75","5890.75","5890.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5495.1","5054.1","9414.14","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5441.75","4353.4","10505.36","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8990.67","6851.89","11042.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5463.96","5072.67","10946.6","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9715.25","9715.25","9715.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","15887.3","15887.3","15887.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5356.81","4268.04","7663.34","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5648.18","5546.55","5778.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","20076.35","20076.35","20076.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","37667.71","21354.62","51827.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","33300.97","33300.97","35431.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","32200.84","30414.22","35614.38","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","35176.93","30624.27","37098.58","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12473.57","5568.79","16022.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","11090.71","9845.98","14725.3","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","28167.09","5220","41102.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","10605","9721.19","12324.06","74","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10760.33","9473.96","13054.66","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","16172.34","13379.4","28671.09","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12409.94","6891","18622.06","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","17258.83","10969.28","26812.89","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","10611.64","8485.26","14251.17","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","4046","4046","4046","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","28726.49","24631.9","50365.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15890.39","15890.39","17141.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","20552.13","20552.13","20552.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","48006.91","48006.91","48006.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","52728.95","8788.97","110268.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","58742.11","53429.36","58742.11","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7973.48","7973.48","7973.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","17282.15","15640.71","29677.73","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","56392.02","56392.02","57096.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","11121.81","11121.81","11121.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7780","7780","7780","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","16879.11","16593.65","22313.02","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","20090.31","20090.31","29816.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","17138.58","13710.87","17138.58","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15305.7","13315.33","15326.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","27687.26","27687.26","27687.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","16802.54","16236.82","34266","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","40436.01","40436.01","40436.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","47450.25","47450.25","47450.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7132.37","7132.37","7132.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","58605.95","58605.95","58605.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7788.39","7788.39","7788.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","6564.41","6564.41","6564.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pacemaker and Similar Procedures","5221","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","10564.24","10564.24","10564.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","54546.16","54546.16","54546.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7724.77","7724.77","7773.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","25490.23","25490.23","77042.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11493.34","11493.34","11493.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5580.22","5580.22","5580.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","19762.25","19762.25","19762.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7633.35","7535.35","19489.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7604.91","7509.28","7604.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8204.68","8204.68","32455.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11031.17","86.91","11493.34","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9575.8","9575.8","14034.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","10845.8","10845.8","10845.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","25371.38","25371.38","25371.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5438.94","5438.94","5438.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","17787.07","17787.07","17787.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","33678.15","33678.15","53915.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","26456.97","26456.97","26456.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","33885.4","29489.32","59243.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11103.33","11103.33","11103.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","10438.23","9870.71","14125.48","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","32365.75","29949.84","59891.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","29291.73","29291.73","29291.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","9645.44","9163.49","11556.15","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9694.51","4392.26","15697.84","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","13311.39","10974.03","21705.92","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","13029.17","13029.17","13029.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","11038.15","9376.16","11874.73","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11447.44","11447.44","11447.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","34675.12","34675.12","34675.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","71714.56","71714.56","71714.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","62387.8","62137.8","62395.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","18305.88","17843.66","18594.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","276.5","276.5","276.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","17939.69","17939.69","18305.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16285.57","16285.57","16285.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","11454.83","11454.83","11454.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","23342.77","23342.77","23342.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","17449.97","17449.97","17845.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pacemaker and Similar Procedures","5224","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","54207.17","54207.17","54207.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","31231.01","31231.01","31231.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","21298.35","21298.35","21707.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","63853.23","63853.23","63853.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","21192.53","21192.53","21388.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","21129.5","21129.5","21129.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","21202.42","21202.42","22143.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","66956.88","66956.88","66956.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","130128.77","130128.77","130128.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22143.61","22143.61","22143.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","61026.79","61026.79","77800.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","31231.01","31231.01","32604.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","88185","88185","88185","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","87466.72","68820.51","104881.57","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","31087.72","29765.31","31131.82","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","77201.44","77201.44","100687.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","64970.23","58851.71","84242.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","13117.92","13117.92","13117.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","30459.8","28995.98","30656.1","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","30306.79","28829.41","30600.79","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","28056.12","24927.35","36120.71","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","31231.01","26047.5","31303.43","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","25185.4","25185.4","25185.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","46601.24","46601.24","46601.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","29623.48","25200.65","32825.08","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","107751.51","91522.23","129201.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","32461.49","32461.49","32461.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","3491.52","2476.2","6122.4","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","2445.41","2320.68","4043.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1423.13","997.65","10589.27","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2436.87","1818.19","7253.37","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2138.66","1644.5","5675.8","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2620.93","1721.72","7731.01","161","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","853.52","615.35","2073.3","99","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2603.98","1974.52","20328.82","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","649.91","487.46","2128.96","118","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1235.91","997.65","3901.41","80","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","753.9","599.19","2276.3","70","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1803.2","1130.98","15945.56","66","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1858.94","1495.38","5386.91","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2719.35","2719.35","2719.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","659.78","493.45","1353.26","69","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2523.47","799.72","3511.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","908","350.22","4192.84","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1281.17","1046.01","2052.88","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1868.58","1868.58","1868.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1320.79","1320.79","1320.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","14300.28","13918.82","18892.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2986.67","2857.21","3393.21","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","29342.24","9228.99","39451.05","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1859.4","1307.83","6201.96","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","9753.93","9526.13","10526.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2864.07","465.04","3335.14","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2037.58","1018.79","4287.49","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","5893.36","3830.18","74276.05","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2869.66","2337.24","5718.07","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Blood Product Exchange and Related Services","5242","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4380.84","3362.7","8674.42","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1400.59","1026.37","1459.27","124","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2753.09","1927.16","4600.58","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2944.35","2467.84","5531.4","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","3067.05","2556.96","3220.41","161","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","894.47","531.87","920.17","85","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4283.14","3408","5233.11","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","3471.67","3471.67","3471.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","462.62","462.62","1422.4","58","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","1526.02","1526.02","1526.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1335.45","1026.37","1459.27","222","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","640.99","551.34","1011.43","85","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1899.21","1110.51","4403.39","75","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2055.7","1521.13","3066.43","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","3642.55","2939.29","3799.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","759.39","573.5","1800.11","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","4068.8","2788.02","5226","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1453.44","559.47","3874.57","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1631.83","1631.83","1631.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","3850.12","3850.12","3850.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","6743.77","5023.42","19154.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10523.83","10523.83","10523.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1459.27","1400.59","3754.36","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","4693.37","1861.01","5298.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","5610.03","4393.39","5957.39","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6080.65","5379.3","6205.65","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1487.5","1383.05","1707.59","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4564","2146.92","6846","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","3572.97","3572.97","3572.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1387.31","1330.88","1862.25","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1459.27","1400.59","2401.78","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1448.45","1315.6","2362.23","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2177.15","1574.48","3927.87","43","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2971.16","857.66","5684.89","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","786.58","786.58","786.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1491.04","1358.56","1775.06","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5086","3969.94","5226","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3067.48","2953.66","3067.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","5266","5266","5266","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2356.6","2356.6","2356.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","10251.81","10251.81","10251.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3911.65","3911.65","6540.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","10265.54","10265.54","10265.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","12195.82","9976","12445.82","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3390.99","3138.26","3729.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","10479.2","10479.2","10479.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7697.75","7697.75","7697.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3225.79","3225.79","3225.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3135.2","3091.1","3637.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3584.61","2879.93","7212.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2754.5","2176.5","3754.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","4035.65","4035.65","4233.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3221.89","2787.73","3559.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","31849","31849","32779.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4248.79","4248.79","4248.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","15945.75","15945.75","15945.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1187.9","1187.9","1187.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","5582.22","5336.97","9683.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1391.78","1391.78","2311.75","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2450.9","927.51","2677.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2982.49","2729.28","2982.49","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","893.63","829.62","897.28","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2863.17","2863.17","2982.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3840.35","3840.35","4564","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","878.71","815.75","878.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1391.78","1391.78","1450.09","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","807.83","551.67","870.17","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1892.25","1504.34","9338.95","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2192.35","1743.04","4285.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2589.88","2589.88","2589.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","853.11","853.11","895.77","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5086","5086","5226","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1504.81","1504.81","2499.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","5086","5086","5086","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","6040.77","4632.96","6614.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","4841.27","4841.27","4841.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","3857.15","3523.94","5785.73","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1450.09","1391.78","2087.67","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","5193.47","5193.47","5193.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3702.84","2837.98","5554.26","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1155.7","1144.49","1733.56","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4564","4564","6846","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","4280.22","4280.22","4280.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1136.39","1136.39","2233.32","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1450.09","1391.78","2087.67","79","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","834.44","793.15","1369.55","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2181.99","1612.87","3925.04","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2577.98","2032.7","3750.3","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","4215.73","4215.73","4215.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1159.42","1103.3","1737.7","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5086","2679.33","6100.5","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1504.81","1444.3","3166.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","7773.68","5226","7839","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2494.63","2494.63","2494.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2048.77","2048.77","2048.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","6364.59","6364.59","6364.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2941.87","2941.87","2941.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","8052.89","8052.89","8052.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","6898.64","6889.86","8602.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","8165.52","5596.67","8971.23","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2688.01","2688.01","8971.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","6001.59","6001.59","6001.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2202.1","2202.1","2202.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2498.73","2136.89","3206.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2617.44","2617.44","2617.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","4780.24","2460.77","6993.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","6056.06","6056.06","6056.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2391.8","2391.8","2391.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2566.13","2566.13","2694.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","3532.46","3532.46","3532.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","10591.51","10591.51","10591.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","4329.28","4329.28","6255.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","8111.5","8111.5","8111.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5538.07","5538.07","5538.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","15276.64","15276.64","15276.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17838.18","14036.15","19473.51","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6403.42","5719.76","9811.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5496.66","5447.66","5736.76","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","18394.44","17799.62","18566.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4113.93","4113.93","4113.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7052.06","7052.06","21592.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5296.29","5296.29","5296.29","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5022.82","4545.27","5387.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6369.52","3953.56","7502.55","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5719.76","5719.76","6277.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","6189.14","6099.07","9092.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","21800.58","21800.58","21800.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5232.09","4678.95","5300.69","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","14778.16","13496.23","17245.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6184.29","6184.29","6184.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","15580.44","15580.44","15580.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","32649.36","32649.36","43285.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","10362.89","10362.89","10362.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","11082.8","11082.8","11082.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","11294.67","8915.74","11544.67","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5857.96","3335.63","6188.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3140.42","3052.39","3424.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5220","5220","6117.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","7357.74","7357.74","7357.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3010.28","2960.3","5408.33","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6188.68","5474.27","7314.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","5994.58","3852.27","16166.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3182.07","3074.27","3368.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","8745.94","5355.56","11431.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","5217.05","5217.05","5217.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3481.49","2885.73","3481.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","16726","16726","16726","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","16726","16726","16726","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1522.4","1522.4","1522.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","17251.59","17251.59","17251.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17361.76","17160.66","20412.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6188.68","6188.68","6188.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","10265.67","9115.64","11284.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","17179.11","17179.11","19597.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6111.8","6111.8","6111.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5636.96","5636.96","5636.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","14521.39","14521.39","17411.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","20929.7","20929.7","20929.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6965.14","6965.14","6965.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5690.29","5690.29","5690.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","14163.73","14163.73","14163.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6481.47","6481.47","6481.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","21441.19","11171.86","38632.69","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","25285.56","20658.43","34834.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6247.24","5254.14","9106.93","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","13013.13","8989.75","17132.3","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","15330.04","13000.74","17873.42","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17405.65","13441.16","19086.05","128","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5689.26","5237.55","8470.5","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","9580.72","9580.72","9580.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7502","4564","18208.54","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","24597.45","24597.45","24597.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5182.12","5182.12","10034.29","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6121.77","5112.32","8794.05","88","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5289.24","4850.15","9618.37","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","10871.12","6865.68","16576.03","96","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","10916.27","8785.05","14778.86","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","4522.94","4522.94","4522.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5585.6","4585.85","8766.18","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","21964.34","19402.52","29654.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","25526","21338.71","35460.73","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6691.3","5841.29","9062.81","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","11466.85","11466.85","11466.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","23917.68","23917.68","23917.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","45313.89","32291.82","57299.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","26848.9","23239.96","30573.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","31827.62","28533.08","34059.46","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9148.25","8202.2","11182.36","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","13780.04","10568.46","14821.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","31130.6","27456.1","33761.94","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","11645.04","8506.99","16060.24","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","12124.37","8027.43","13873.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8511.34","8159.09","11684.25","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","13004.23","9695.77","13344.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","15885.39","7743.52","24000.07","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","24425.28","22995.07","26914.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","29674.03","29674.03","29674.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","11087.99","9893.16","13345.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","41592.2","31178.62","45117.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","39805.5","23134.5","43149.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8495.29","2760.42","11372.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10419.29","10419.29","10419.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","901.69","901.69","901.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","866.12","866.12","1226.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","491.05","491.05","491.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","271.1","271.1","271.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","861.09","861.09","861.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5112","5112","5112","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","771.42","771.42","5572.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","471.3","383.27","1451.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","398","398","398","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","225.81","225.81","225.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","396.74","396.74","396.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","5869.4","5869.4","5869.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2183.49","2183.49","2183.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","5025.99","1983.49","5078.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","836.54","836.54","836.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1620.79","1620.79","1620.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","202.3","202.3","1533.35","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","483.04","483.04","5889.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","603.8","547.3","1636.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1880.12","1551.82","2364.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","592.35","503.02","1750.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","355.07","355.07","523.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","4347.52","4347.52","4347.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","14725.04","8472.57","17498.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","5459.61","5459.61","6701.31","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","6031.24","5933.21","6501.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6413.65","5361.13","6701.31","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3115.18","2191.48","3463.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1689.39","1554.87","2993.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4564","4107.61","4731.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1533.35","1533.35","1974.35","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2283.29","2163.8","3245.7","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1675.88","1636.68","1955.18","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3700.98","2142.82","6494.01","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","4453.03","4297.42","5210.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","5755.02","5755.02","5755.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1916.85","1500.35","2020.9","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","7019.4","6524.04","10710.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","2317.36","2317.36","2317.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1541.29","1541.29","1541.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","16693.87","11017.87","22942.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2191.48","2191.48","6122.87","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","9344.54","9344.54","9344.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","10331.28","8765.04","10831.28","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","10985.14","8255.78","11282.66","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3042.48","2870.47","6007.85","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4854.37","4126.2","9020.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2883.1","2744.11","3111.61","43","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2973.33","2762.89","4745.45","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6923.41","6315.37","10369.87","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2633.47","2191.48","4011.19","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9285.58","9285.58","9285.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","7528.12","7528.12","7528.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2957.79","2537.62","3402.48","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","11132.32","11132.32","11132.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","11897","11706.67","15105.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2880.78","2880.78","2975.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7610.46","7610.46","7610.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","18894.08","17313.4","31805.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","17342.23","17342.23","17342.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","10402.28","10402.28","14927.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","14833.92","13094.79","15964.82","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","16380.14","14135.62","16858.13","60","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6086.49","5841.73","8773.5","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4664.31","4402.89","7504.21","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5664.02","5664.02","5664.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","9337.51","4564","13700","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4458.57","4448.77","7632.16","45","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4558","4323.68","8953.88","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8931.17","6691.4","13336.47","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6086.49","4252.93","9251.53","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9009.94","8920.02","14056.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","4487.37","3995.76","6851.3","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","19944.95","16847.2","28157.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4876.49","4876.49","4876.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","21043.79","21043.79","21043.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","17895.09","17895.09","17895.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12560.28","12560.28","12560.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","34539.9","34539.9","42508.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","26779.62","26779.62","26779.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","28840.12","26341.67","29040.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","27509.89","24880.69","30250.34","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12682.05","12682.05","12682.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","8676.67","8676.67","10534.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","10022.47","10022.47","10022.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","8667.36","8222.53","12127.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10618.06","8656.03","13173.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8507.33","7892.8","8507.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","14615.08","10455.61","21196.74","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","17891.03","17891.03","17891.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","8236.28","8236.28","8236.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","21639","21639","21639","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10527.18","10527.18","10527.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","21639","21639","21639","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Urology and Related Services","5376","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","31388.34","31388.34","31388.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","7294.39","7294.39","7294.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Urology and Related Services","5377","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","63216.58","62558.02","65721.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1450.83","1450.83","1450.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","19342.32","19342.32","19435.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","27340.17","27340.17","27340.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","18959.16","18959.16","18959.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","17579.82","17579.82","17579.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","15593.43","15593.43","15593.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","18640.79","18640.79","18640.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","18834.77","18834.77","18834.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 8 Urology and Related Services","5378","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1588.98","1436.85","3256.84","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","4457.17","3305.07","7774.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","3563.71","3563.71","3563.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1410.39","1067.02","2613.78","89","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3779.01","3779.01","3779.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1295.15","917.7","5163.09","47","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1594.38","1429.4","2504.76","78","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1009.14","667.84","1538.13","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2042","1792","4678","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1925","1925","1925","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1426.45","938.24","3056.15","71","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1508.77","1508.77","1508.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1691.48","1473.49","2343.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1128.68","759.69","1651.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1391.25","577.8","2526.2","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","286.91","275.38","679.29","352","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","443.06","15.89","590.74","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","537.01","271.27","1167.83","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","595.06","460.72","658.1","73","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","144.71","144.71","144.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","411.79","196.69","487.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1103.36","542.67","1339.37","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","895.6","413.42","1038.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","109.26","109.26","109.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","609.1","609.1","609.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","286.91","275.38","651.98","632","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","153.61","153.61","192.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","353","298.5","605.76","103","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","314.4","294.75","1193.75","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","375","375","522","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","237.99","237.99","237.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1454.88","1408","1645.7","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1108.95","678.88","1743.34","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","297.74","285.77","676.58","134","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","306.93","303.19","420.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","300.61","216.05","497.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","260.26","260.26","260.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1059.33","1059.33","1478","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","238.53","238.53","238.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1831.64","1831.64","1831.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3044.34","3044.34","3044.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","841.9","841.9","841.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","260.26","249.79","376.6","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","270.08","259.22","270.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","350.05","350.05","350.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","8069.55","8069.55","8069.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","15611.5","13995.88","18054.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2783.9","2489.21","5389.58","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","6771.79","3532.94","7964.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","9485.11","7740.47","9985.11","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","9335.98","7870.43","10401.23","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2729.38","2729.38","2729.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5384.87","5384.87","5384.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4564","3473.56","7337","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2623.42","2623.42","2623.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","10203.32","10203.32","10203.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2779.54","2489.21","4152.59","45","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6975.99","5470.88","10460.69","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2716.17","2716.17","2716.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7138.19","7138.19","9688.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","3397.45","3397.45","3397.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","12739","12739","12739","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","11157.3","9868.73","12397","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2691.39","2572.78","3606.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6923.73","6923.73","6923.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","19792.41","19792.41","19792.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5799.39","4201.1","6063.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","14853.15","12911.47","15938.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4500.46","4452.53","5641.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","15502.63","15502.63","15502.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7043.73","7043.73","7043.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4512.72","4512.72","4512.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8124.79","7322.44","11714.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4393.04","4393.04","6994.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6042.36","5809.38","8005.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","9241.73","9241.73","9241.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","8733.04","8733.04","8733.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","4349.66","4349.66","4349.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","12490.51","12490.51","12490.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4260.56","4260.56","4260.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","15651.76","15651.76","15651.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","13372.69","13372.69","13372.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","808.93","808.93","1977.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","4104.84","4104.84","4104.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6138.14","4289.98","20949.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1575.95","1575.95","1575.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3933.34","3933.34","3933.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10265.63","10265.63","10265.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5670.44","5670.44","9128","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1897.89","808.93","2356.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","5268.61","4236.8","19333.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1569.79","1569.79","1569.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","5339.36","5339.36","5339.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","26741.25","26741.25","26741.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11663.15","11663.15","11663.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","20068.14","18089.78","22507.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10578.63","10578.63","10578.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5989.6","5989.6","5989.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","9485.08","9485.08","9485.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7503.52","7503.52","7644.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4665.01","4665.01","4665.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22413.96","22413.96","22413.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","8903.5","8903.5","8903.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12447.26","12447.26","12447.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","702.62","702.62","702.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","7252.59","7252.59","7252.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","746.51","558.89","777.79","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","739.19","482.86","1549.56","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","289.84","264.84","477.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1771.46","1771.46","1771.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","620.95","620.95","620.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","978.62","978.62","978.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","777.79","558.89","861.45","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","295.69","295.69","295.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","321.76","175","1470.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","315.75","315.75","315.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","165.73","165.73","215.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","774.68","358.63","807.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","696.3","696.3","696.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4685.4","2905.74","12312.72","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1270.57","1063.64","2007.42","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","1931.87","1931.87","1931.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1852.16","1464.66","4256.9","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1929.28","1612.37","2265.47","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","394.59","291.69","988.36","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3395.65","3395.65","3395.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3790.53","3319.85","7410.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","226.45","226.45","2101.85","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1108.2","1063.64","1287.17","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","342.46","342.46","3548.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1559.33","937.5","5586.53","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2858.23","2858.23","2858.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2210.63","2210.63","2210.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","533.4","231.51","815.25","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","3064.5","3064.5","3251.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5208","5208","5208","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2807.82","2807.82","2807.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4534.45","4534.45","4534.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4747.97","4747.97","4747.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2721.86","1436.12","4368.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3068.55","3068.55","3068.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1147.72","848.14","1861.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3106.65","3106.65","3106.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3990.44","3990.44","3990.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1353.62","1353.62","1353.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2240.71","1266.14","4600.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","555.73","531.23","980.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","663.48","663.48","663.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5248.5","5248.5","5248.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","29680.92","29680.92","29680.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","11162.74","11162.74","11162.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","11250.08","11250.08","11250.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4632.95","4632.95","4632.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4089.62","4089.62","4089.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2688.97","2688.97","2688.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3378.86","3378.86","3378.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8509.26","8509.26","8509.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Neurostimulator and Related Procedures","5461","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6045.66","6045.66","6045.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","20610.4","20610.4","20610.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6244.44","6244.44","6244.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5969.89","5969.89","5969.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8690.44","8690.44","8690.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","6271.04","6271.04","6271.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9018.38","9018.38","9018.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Neurostimulator and Related Procedures","5462","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","34781.02","34266.38","37144.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4899.19","4899.19","4899.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","12183.83","12183.83","12183.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","33651.16","33651.16","33651.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","9850.7","9850.7","9850.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","11790.52","11790.52","11790.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8126.8","1788","13394.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8690.44","8690.44","8690.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","4965.05","4965.05","4965.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","17904.01","17904.01","17904.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","10639.77","10639.77","10639.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Neurostimulator and Related Procedures","5463","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","27009.33","27009.33","28162.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","66494.3","66494.3","66494.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","26650.79","26650.79","26650.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","20227","20227","20227","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","27009.33","27009.33","27009.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","22769.84","22769.84","22769.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","21155.32","21155.32","21155.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Neurostimulator and Related Procedures","5464","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","55941.19","55941.19","63681.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","18968.52","18968.52","18968.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","27578.16","27578.16","28681.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","64590.74","61005.65","77842.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","29482.57","28297.84","29531.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","93334.61","93334.61","93334.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","30217.95","29666.8","41032.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","28929.3","28929.3","29027.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","28949.95","28949.95","28949.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","26138.52","26138.52","26138.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","27009.33","17119","27009.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","23952.47","23952.47","28098.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Neurostimulator and Related Procedures","5465","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","48540.99","48540.99","48540.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18175.09","17836.64","18189.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","52957.01","52957.01","52957.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","44624.86","44624.86","44624.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","17114.71","16985.55","17501.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","28383.8","28383.8","28383.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","16882.7","16882.7","17034.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","15835.79","15835.79","15835.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16843.98","16843.98","16843.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17696.32","17466.03","17836.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","15702.8","13891.99","16538.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","55075.1","55075.1","55075.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Implantation of Drug Infusion Device","5471","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1043.02","1043.02","1043.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1430.41","994.36","1685.71","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1966.22","1518.32","2772.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","628.02","513.22","721.25","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","252.3","252.3","650.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1127.98","1127.97","1351.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","211.94","211.94","352.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1685.71","255.3","1756.34","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","699.27","637.32","2899.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","636.8","631.9","893.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","676.67","676.67","676.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","428.6","178.23","810.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","3399","3399","3399","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1720.4","1720.4","1792.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laser Eye Procedures","5481","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","662.91","662.91","662.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","22003.06","22003.06","22003.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2409.08","2409.08","3765.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","7460.99","7460.99","7460.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6341.85","5222.69","7460.99","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1917.01","1777.23","2409.08","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","9956","9956","9956","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1757.16","1712.49","4757.5","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","11017.4","11017.4","11017.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2409.08","2409.08","3613.62","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1882.82","1741.45","4071.84","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8968","6513.28","11357.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7484.09","5600.44","8662.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","9246.43","8512.52","9428.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1830.34","1280.48","2240.84","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2499.99","2499.99","2499.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","29257.39","29257.39","29257.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4516.36","4506.96","8348.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","8270.24","8270.24","10898.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","12910.05","9358.54","13160.05","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3575.92","3555.99","3943.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","11370.2","9867.68","12241.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3436.21","3251.71","3877.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6166.02","4843.83","8237.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3521.07","3521.07","5573.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8698","4526.34","10616.96","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","5821.37","5821.37","5821.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3529.09","3162.01","5765.94","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","18953.1","18953.1","18953.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8663.26","8663.26","8663.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Intraocular Procedures","5492","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","16754.05","13298.9","17608.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5057.39","4670.29","7420.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","15903.77","15903.77","16003.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5950.8","5950.8","5950.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","8291.2","8291.2","10383.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4665","4665","4665","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4755.26","4506.96","8348.23","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4631.17","4631.17","8290.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8944.54","8944.54","12861.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5069.46","5069.46","5069.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","27157.5","27157.5","27157.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Intraocular Procedures","5493","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1544.75","1544.75","1544.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","222.84","159.3","626.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","873","873","873","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1372","1372","1372","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","389.91","389.91","389.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","378","274.86","412.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","541.16","541.16","541.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","275.8","219.98","377.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","361.57","361.57","361.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","231.25","231.25","231.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1166.89","1166.89","1166.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures","5501","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4037.12","4037.12","4037.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1007.74","1007.74","1007.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","492.47","492.47","492.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1188.69","1188.69","1188.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","167.54","167.54","192.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1528.16","1528.16","1528.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","378.8","378.8","378.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Extraocular, Repair, and Plastic Eye Procedures","5502","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","10548.29","10548.29","10548.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2331.75","2331.75","2331.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2665.78","2521.4","3921.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6868.64","4830.68","7631.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","7026.51","6105.47","7157.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","13639","13639","13639","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","17335.3","17335.3","17335.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1807.5","1718.23","3193.48","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1908.17","113.2","2235.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","6048.76","532","9995.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2430.69","2077.35","3649.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","10135.19","10135.19","10807.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2024.99","1784.89","2183.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","10920.45","10920.45","10920.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","10573.62","10573.62","10573.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2879.03","2879.03","2879.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","11986.14","8635.3","12336.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6353.48","6353.48","6353.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","11842.61","11842.61","11842.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7577.51","7577.51","7577.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","10632.72","7803.32","27413.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4413.12","3766.22","8698","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","12355.7","12355.7","12355.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3350.47","3350.47","3350.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","17187","17187","17187","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Extraocular, Repair, and Plastic Eye Procedures","5504","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","739.8","149.26","1565.32","143","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","634.43","272.49","1194.69","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","398.31","398.31","403.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","271.35","201.61","502.79","692","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","118.52","77.51","260.39","313","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","243.57","180.98","383.09","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","260.5","205.91","449.41","204","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","71.71","6.41","152","168","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","123.86","115.28","526.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","687.19","338.45","1327.99","107","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","704.77","144.53","925.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","99.45","45.66","122.58","103","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","2177.01","2177.01","2177.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","76.18","76.18","76.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","116.26","77.51","260.39","541","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","64.26","0.73","127.02","246","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","383","149.6","477","652","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","378","156.8","471","116","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","379","205","473","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","69.21","43.19","198.44","206","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","566.1","232.9","1088","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","544","218.4","1280","90","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","120.65","80.43","275.42","117","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","1082.32","1082.32","1082.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","227.99","227.99","227.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","255.82","168.52","866.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","882","353.6","2013","185","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","559.5","222.5","1066.35","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","307.88","97.88","493.87","1073","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","154.62","105.21","398.2","531","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","312.27","218.59","437.18","63","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","293.96","250.79","565.97","318","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","104.23","1.33","146.24","588","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","281.38","190.96","598.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","737.35","448.31","1274.69","207","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","551.26","401.16","1296.96","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","102.5","53.5","213.43","356","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","1599.1","1599.1","1599.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","67.8","67.8","67.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","154.62","109.61","382.19","914","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","97.17","18.2","101.91","447","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","402","247","789.6","918","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","396","206","695","206","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","398","257.5","839","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","99.51","75.01","114.23","449","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","758.86","403.19","1365","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","755","288","1552","151","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","160.46","104.91","396.62","172","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","1394.85","1394.85","1394.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","389.78","389.78","420.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","194.78","194.78","194.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2354.96","1152.22","4438.01","81","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1496.53","248.14","2217.97","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1128.06","1128.06","1128.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","672.13","512.22","1356.61","575","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","334.15","239.88","447.07","227","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","673.36","354.9","1586.46","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","616.9","121.27","786.32","177","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","177.94","138.92","324.03","194","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","599.94","599.94","599.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1349.21","809.53","2025.93","100","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","984.25","825.78","1717.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","183.97","134.97","286.47","183","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","334.15","239.88","501.23","363","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","184.57","133.28","334.15","152","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1203","620.25","1788","427","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","965","436.8","2062","58","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1340","788.7","3304","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","189.99","25.29","374.34","263","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2140.3","966.8","2450","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1674.78","707","2916.88","70","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","361.3","346.76","679.03","64","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","2479.93","2479.93","2479.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1963.53","1963.53","1963.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2589","1812.3","3571.49","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","23791.65","23791.65","23791.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","774.63","774.63","774.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1721.9","1284.31","1797.59","177","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","681.76","654.34","1392.52","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","1478.74","1127.04","1793.66","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1614.46","853.13","1721.9","60","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","439.43","150.33","667.04","144","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2464.25","2464.25","2464.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2164.4","1731.52","5108.06","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","1847.28","1847.28","1847.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","401.06","401.06","652.67","166","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","3960.82","3960.82","3960.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","681.76","654.34","975.38","112","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","440.02","418.66","679.02","125","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1111","518","1634","127","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1082","522.83","23361.3","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1145","1145","1536","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","501.97","312.16","2500.52","83","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","833","729","6846","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","810","648","12412.49","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","707.49","679.03","1796.85","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","774.63","774.63","4394.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4247.37","4247.37","4247.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2499.53","705","6335.63","69","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1299.44","568.7","2284.54","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2177.57","2177.57","2177.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","495","320.8","1209.9","434","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","447.07","162.04","573.92","146","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","610.65","261.37","1277.7","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","447.72","226.73","1093.17","112","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","133.43","69.28","426.49","111","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","919.78","919.78","919.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1184.44","490.2","2704.42","78","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","3902.62","2067.94","4878.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","100.86","44.18","171.58","133","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","447.07","162.04","550.83","239","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","135.93","86.61","332.24","99","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","770.41","310.5","2653.6","267","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","817","352","2774.4","63","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1076.6","671.2","2643.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","168.41","133.27","407.16","110","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1178","272","2506","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1160.25","262.4","2506","63","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","463.94","168.16","571.62","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","728.89","728.89","728.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","179.52","179.52","179.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1704.89","1704.89","1704.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","3823.2","901.08","6677.25","214","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","2451.75","817.85","4998.87","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1651.81","1651.81","2472.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","973.19","673.1","1750.64","1352","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","573.92","550.83","743.87","317","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","786.53","431.47","1309.86","97","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","897.24","286.46","1829.86","432","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","279.27","11.95","536.49","371","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1617.62","1395.64","1648.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2040.14","1080.1","3739.66","216","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","2824.21","1219.08","3496.89","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","25.7","25.7","515.78","573","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","500","500","500","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","561.93","465.81","701.45","563","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","61.55","60.62","342.24","477","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1354","630.4","3142","824","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1307.58","546.4","3028.61","180","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1145.36","291.2","3481","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","285.18","123.48","598.99","409","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2213.81","935.53","4709.23","93","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","2140.3","765","4686.88","172","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","583.13","483.38","843.31","106","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","2432.82","2432.82","3105.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","393.04","329.87","3113.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1651.68","1429.88","3651.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","3229.73","2921.51","6848.35","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","3711.04","3711.04","3711.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7237.93","7237.93","7237.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2584.52","1809.18","7449.87","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","681.76","585.47","2039.72","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","8113.36","3890.7","9915.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2470.29","1736.78","5011.76","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","774.4","628.8","2587.69","45","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2086.26","2086.26","2086.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2312.38","1336.34","8373.48","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","714.64","621.68","2261.57","68","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","936.15","654.34","2632.04","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","603.26","457.82","2111.73","53","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1459.06","754.24","6816.2","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1303.39","383","7268.1","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2002.43","2002.43","2002.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","789.27","621","2523.86","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1119","1119","1872.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1239.05","707.49","3748.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","5627.99","5627.99","5627.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging with Contrast","5573","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","994.32","994.32","994.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","6823.91","6823.91","6823.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2254.28","2139.5","10453.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","536.14","514.58","769.04","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","1179.96","1179.96","2457.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1261.93","945.92","2305.1","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1314.52","742.09","2487.93","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","75.36","6.76","838.37","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2408.31","1368.11","4677.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","6279.71","6279.71","6279.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","160.13","68.79","488.15","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","536.14","514.58","738.11","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","274.13","104.22","385.09","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1631","849","3517","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1321.6","873.6","2601","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1985.03","1985.03","1985.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","376.01","292.71","562.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1438.4","1274","3964.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","556.37","534","765.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","1127.56","1127.56","1127.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","2062.81","2062.81","2062.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2645.42","1691.1","4761.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","1788.83","1788.83","1788.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1572.28","895.3","1926.9","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1510.85","948.24","1858.73","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1130.7","514.58","1321.33","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","399.62","140.49","1114.15","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2190.74","1127.41","2368.22","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","1894.58","1894.58","1894.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","285.14","200.28","817.59","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","626.13","536.14","1321.33","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","410.99","234.45","715.99","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1477","924.5","2750","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1929.2","1179","2617","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","890","890","890","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","453.3","302.78","862.02","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1749","1399.2","2067.74","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1371.19","1316.05","1393.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2272.02","2272.02","2272.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1245.93","1245.93","1245.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","6866.13","3685.36","7636","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1268.19","1268.19","3868.68","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","3150.3","2135.32","4270.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3371.75","2589","8328.43","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4020.63","3286.69","7825.46","78","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1023.68","892.5","2771.46","87","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3565.74","2256.84","5017.24","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","939.72","939.72","2340.79","102","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1321.33","1268.19","3100.71","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","966.7","966.7","2126.24","71","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3268.28","1344.76","8150.78","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2622","1507.26","3496","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2071.02","2071.02","2071.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1230.49","1010.87","3297.74","52","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2292.3","1599","5381.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","2192.94","1749","6885","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1371.19","1316.05","3736.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","5218.26","5218.26","5218.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2060.48","2060.48","2060.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","7318.94","7201.54","13945.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","4374.39","4374.39","4374.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1945.24","1945.24","1945.24","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","4193.47","2096.74","4671.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","4234.99","3432.06","4484.99","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4671.78","3737.43","16552","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1136.07","1082","6199.48","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5534.82","4981.93","5651.44","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1396.37","1102.37","6134.36","64","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1945.24","1945.24","1945.24","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1106.25","1103.52","5092.75","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3470.4","1955.51","3856","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","3851.13","2892","3856","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","3871","3871","3871","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1189.11","1135.21","5242.55","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","8459.02","8459.02","8459.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","8459.02","6767.22","8459.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2018.64","2018.64","2018.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","5151.66","5151.66","5151.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Nuclear Medicine and Related Services","5594","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","389.88","389.88","389.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","434.34","405.19","434.34","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","365.59","365.59","365.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","230.42","104.11","230.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","416.96","416.96","3111.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","797.54","797.54","797.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","239.1","226.58","589.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","278.1","278.1","502","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","209.68","101.38","209.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","380.91","365.59","408.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","205.65","205.65","205.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1123","1123","1784","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","172.81","172.81","172.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","830.12","830.12","830.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Therapeutic Radiation Treatment Preparation","5611","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2109.86","2109.86","5374.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2206.79","1028","14767.88","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","247.85","247.85","2483.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","413.35","358.81","843.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1149.64","1149.64","9309.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1599.48","1599.48","1599.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","352.82","282.26","1660.73","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","279.52","108.3","472.39","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2122.22","1226.4","9074.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","264.76","247.85","4136.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2363.2","2363.2","2954","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","490.32","490.32","676.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","6244","6244","6244","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","3568","3568","3568","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","23818.5","23818.5","23818.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","5872.55","5872.55","5872.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","7560.11","6476.59","11214.53","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2194.02","1846.9","3092.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2249.73","1934.42","5148.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","7430.16","6230.52","10555.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","17810.56","17810.56","17810.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2028.96","869.25","4027.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2213.42","1846.9","3821.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","9286","9286","9286","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2381.14","2381.14","2381.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","16628.94","16628.94","16628.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1991.07","1695.83","2849.48","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","5360.81","5360.81","5360.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","6419","6419","6419","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2405.41","2405.41","2405.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","3030.54","3030.54","3030.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","7695","7695","7695","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Radiation Therapy","5621","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3072.11","1550.27","7780.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","8501.96","8501.96","8501.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","10294.45","3720.4","14853.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","13942.96","3840.73","22801.55","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2871.37","1135.16","6183.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","20943.05","8014.94","21359.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2266.39","507.89","6608.85","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","14226","4161.75","24480","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1407.56","502","5875.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2169.47","1600.14","8503.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","6412.18","4446.98","15483.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","10623","10623","10623","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","592.52","592.52","6100.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","33004","33004","33004","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","11596","11596","11596","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","33464.76","27948","85932","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","24613.26","24613.26","24613.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","24322.06","9917.27","32134.27","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","26717.17","10007.88","36994.03","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8889.48","2321.52","12139.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7539.86","3662.26","10395.64","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7314.58","7314.58","31594.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","19433.93","19433.93","44763.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6003","3986.76","9370.86","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9779.07","2154.99","12433.9","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7913.43","3950.47","10241.12","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","39040","4934.1","74496","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","25389","990","76167","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","21885.19","21885.19","195607.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","6793.65","1952.11","9698.89","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","14592.24","14592.24","22761.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","12838","8028","26593","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4072.68","4072.68","7911.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2475.58","2475.58","2475.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Radiation Therapy","5624","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","89064.81","89064.81","89064.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9900.33","9900.33","10066.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","5156.13","5156.13","5156.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","14352.62","11922.6","31810.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7477.69","3985.84","10648.51","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","27988.56","27988.56","33953.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","65888.3","65888.3","83750.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","35966.76","35966.76","35966.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","6467.43","2810.11","10135.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","48886","27554.42","56740","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9187.79","6991.31","10537.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10340.23","3893.52","12110.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","49233","49233","49233","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","4540.95","3995.31","7173.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5957.05","5957.05","6233.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","25441.9","25441.9","25441.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","8834.03","8834.03","8834.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","22128","22128","22128","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","31684.82","31684.82","31684.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5996.54","5996.54","5996.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","20622.66","20622.66","20622.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15317.09","15317.09","15317.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5821.91","5821.91","5821.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 7 Radiation Therapy","5627","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","271.81","271.81","271.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","25855.5","16685.42","73365.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2864.63","2864.63","2864.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2953.06","2640.02","97003.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","93789.25","11457.89","100203.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","946.08","946.08","946.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","607.14","465.42","61430.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","21615.2","21615.2","21615.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","37783.9","37783.9","37783.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2440","2395","4667.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2405","2405","2405","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","946.08","946.08","946.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","39908.19","3366.99","61605.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","44295","44295","44295","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","43394","43394","43394","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2158.34","2158.34","2158.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7.49","7.49","7.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","51.5","51.5","51.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","15487","15487","15487","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8165.95","6307","8283.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","50503.55","50503.55","50503.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","256.93","198.54","488.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","13926.63","13926.63","13926.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","560.59","489.66","133488.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","560.59","433.56","77659.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","167.96","155.04","23658.74","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","492.95","492.95","492.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","238.76","85.86","573.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","165.16","165.16","23399.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6531.52","6531.52","6531.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","5574.91","934.15","22121.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","388.45","388.45","388.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","973.16","973.16","973.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","160.35","148.01","171.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","4971.94","4971.94","4971.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","401.71","401.71","401.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","687.99","687.99","687.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","57.5","57.5","57.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","27586.35","4103.52","42851.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","435.28","201.65","1411.72","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1827.24","1067.85","80252.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","352.58","352.58","1790.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1999.22","1999.22","1999.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4697.98","4697.98","5220","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","353.15","346.69","1200.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4164.74","563.18","9967.01","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","343.33","308.41","23331.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","10121.72","332.15","16702.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","719","719","719","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","447.5","333.73","1636.18","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","335.8","335.8","335.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","26982","26982","31282.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","10502.05","10502.05","10502.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","600.48","600.48","600.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Pathology","5674","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","23475.71","16421.83","34495.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3980.27","3980.27","3980.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1659.87","891.77","2920.77","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","5924.93","2528.44","7774.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","6783.56","1807.36","114654.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","8361.56","2473.02","9269.97","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2610.75","1813.48","4279.31","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","895.35","895.35","895.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","3785.54","2957.47","8913.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","9635.13","9635.13","9635.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2551.87","1849.12","10153.61","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1147.91","371.73","2276.2","47","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2442.14","1470.95","6935.03","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","7749","787.42","19918.57","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","44272.79","12094.75","46242.37","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","23788.28","23788.28","23788.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2687.61","1350.1","6457.85","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","6846","3139","11138.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1469","996.61","2673.37","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","7810","7810","7810","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3738.36","3738.36","3738.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4565.02","1206.38","18283.9","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","4633.52","4633.52","4633.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","285.76","75.02","2672.22","95","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","6119.07","1080.2","14292.25","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","4969.23","224.05","20542.86","162","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2422.53","126.31","6247.06","271","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3491.6","223.52","12370.31","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","6202.78","283.85","11441.41","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","187.27","187.27","187.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3067.78","909.77","12459.5","322","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1372.11","75.02","4567.33","164","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1992.77","67.92","5041.25","411","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3717.53","481","10644.84","153","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","4768.08","315.75","11898.7","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","7678","4407.07","7678","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2557.14","1203.4","6966.07","175","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","841.51","97.17","4653.26","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","523.18","39","8710.61","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","301.86","191.02","1758.32","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","402.15","402.15","402.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1841.33","1841.33","1841.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2895.75","671.25","28634.91","84","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1026.73","821.39","12619.15","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1185.96","286.91","8713.94","293","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","938.52","378.48","13637.24","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","5947.19","600.52","18191.55","174","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","5710.05","631.73","23162.23","691","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1804.24","206.52","5989.08","301","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","362.8","362.8","362.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1421.07","783.72","11885.89","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","1611.33","502.07","1722.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1733.49","162.45","8652.26","435","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1235.64","275.38","6153.73","575","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1525.24","201.09","6970.43","364","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3985.77","353.77","14836.3","637","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","6693.83","599.05","22215.7","115","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","10098.94","1418.93","22925.16","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1580.62","197.15","4945.71","214","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1370.89","384.21","17264.45","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","913.75","360.9","10840.75","68","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1230.69","258.17","7889.52","99","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","586.04","586.04","1489.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2453.48","2453.48","2453.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","15559.68","125","124105.47","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","20156.54","20156.54","36564.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1395.58","744.77","7371.99","114","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","3105.69","1193.96","24359.47","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","6651.65","2792.75","106675.06","58","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","8704.07","1913.36","57045.92","138","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1961.35","325.11","7480.88","97","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5021.79","810.78","27487.45","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2576.79","365.48","13130.08","99","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1801.43","587.28","25800.88","240","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1494.23","478.63","7551.48","132","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","9589.07","2534.18","54717.54","227","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","12203.7","1514.34","66092.31","75","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","10108.22","10108.21","23096.99","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","1467.5","207.51","36249.8","63","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","18331.08","666.4","32946.68","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3656.85","1448.23","18518.98","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","35888.81","35888.81","35888.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","841.62","588.5","1308.85","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","490.78","490.78","490.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","222.58","175.72","248.17","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","367.54","367.54","617.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","417.64","217.67","491.34","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","435.05","124.8","511.82","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","113.43","55.36","153.99","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","330","330","330","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","635.78","386.94","1048.47","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","715.5","715.5","715.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","101.79","90.41","150.79","71","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","213.62","168.65","238.19","106","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","66.03","54.76","149.33","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","712.8","212","1062","81","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","366","313.33","759.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","469.99","469.99","522.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","122.98","97.41","154.35","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","801","624","2296.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","946.4","720.9","2232.07","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","230.98","230.98","257.53","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","409.9","409.9","409.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1551.6","891.42","2461.5","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1107.39","419.52","1251.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","309.08","198.65","519.16","79","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","722.91","640.08","937.32","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","782.34","218.37","977.92","54","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","897.32","616.07","1018.67","165","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","305.22","227.93","331.93","108","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","616.54","616.54","616.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1326.03","885.87","1781.86","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","982.25","982.25","982.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","251.12","231.16","300.12","121","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","309.08","190.66","364.18","176","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","213.91","213.91","297.21","114","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","837","375.2","1062","166","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","564.75","230.1","929","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","862","770.4","1095","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","244.76","242.39","326.77","80","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1698.3","1464.61","2232.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1340.06","548","2228","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","328.14","160.46","483.38","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","521.29","521.29","521.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","579.09","579.09","579.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2157.06","2052.34","3085.47","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1816.86","1636.5","5018.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4876.84","4876.84","4876.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","670.95","274.52","2693.28","60","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2190.81","2190.81","2495.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1666.32","3.54","3572.16","79","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","1735.76","1450.55","5639.1","103","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","520.08","482.54","727.3","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5897.36","5897.36","5897.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","753","753","1986.68","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","413.39","380.4","762.51","65","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1664.49","286.04","3050.43","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","506.42","405.94","746.07","78","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","670.87","586","9702.56","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","596","439.6","11931.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","504.42","504.42","630.53","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","696.27","481.63","1791.21","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1119","506.1","3754.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3053.45","1502.36","3740.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3610.69","3610.69","3610.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Diagnostic Tests and Related Services","5723","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1694.38","1694.38","1694.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","2305.38","2031.53","4431","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","2390.02","2390.02","2390.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2556.05","2236.54","3195.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2662.57","2021.84","3328.21","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1069.22","1069.22","1114.03","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","610.95","610.11","759.25","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","2743.75","2195","5487.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","862.95","568.95","882.55","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1069.22","927.91","1114.03","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","887.73","776.83","887.73","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1640","737.08","2281","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1412","605.86","2397","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","903","799.67","1003.67","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","3749","1119","3749","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1109.57","1109.57","1156.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2246.81","2246.81","3749","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Diagnostic Tests and Related Services","5724","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","37708.45","37708.45","37708.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","236.28","236.28","243.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","12169.98","12169.98","12169.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","532.05","532.05","532.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","154","154","154","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","391.1","391.1","391.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","334.98","81.82","502.48","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","294.82","86.45","513.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","847.11","98.62","1324.41","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","577.34","88.41","7209.69","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","57.34","28.67","246.24","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","369.3","369.3","369.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","12.43","12.43","72.04","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","95.7","81.82","430.7","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","115.65","29.97","243.54","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","165.64","160.27","414.1","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","191.15","95.58","386.74","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","161.9","33.06","244.24","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","346","346","346","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","580","232","696","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","305.77","118.76","787.5","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","300.79","175.4","883.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","37.77","36.25","286.91","86","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","163.94","130.81","174.41","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","158.55","130.82","442.25","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","165.16","140.75","194.3","153","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","46.58","33.72","193.68","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","99.66","99.66","99.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","284.03","227.22","786.97","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","216.08","216.08","216.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","45.81","24.51","98.25","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","175.06","175.06","175.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","37.77","5.4","281.81","192","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","45.35","36.15","59.47","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","187","149.6","343.06","145","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","197","157.6","469.33","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","481.63","198","764.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","44.52","6.59","58.61","80","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","294.1","198.52","356.49","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","336","268.8","1036.97","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","39.19","37.62","304.7","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","115.77","115.77","115.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","256.03","256.03","256.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","425.79","9.91","42318.19","72","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","198.63","11.03","26285.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","48.85","48.85","48.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","33","8.16","7175.48","125","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","381.45","264.96","72037.79","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","384.81","9.43","73976.12","95","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","421.68","21.76","80212.91","287","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","126.35","9.43","23658.74","216","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","149.12","149.12","398.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","136","38.82","31279.81","52","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","244.7","244.7","34714.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","124.23","10.8","23203.12","293","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","351.07","351.07","351.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","395.48","80.89","23355.42","87","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","123.03","15.43","23331.26","147","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","12726.59","14.17","29769.63","144","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1541.29","85.48","35545.46","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","36685.55","20705.86","62582.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","120.62","15.46","22617.36","174","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","136.56","10.23","14751.9","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","50","10.23","16841.5","52","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","21.2","10.23","862.81","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","57789.8","57789.8","57789.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","48.85","32.74","8884.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","842.69","842.69","842.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","240.5","240.5","240.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","7320.52","7320.52","7320.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","243.27","243.27","243.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","4966.87","4966.87","4966.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","252.45","252.45","252.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Minor Procedures","5735","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","121.99","121.99","121.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","52.16","52.16","52.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","34.9","34.9","34.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","117.11","117.11","117.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","487.81","487.81","487.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","23203.12","23203.12","23203.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","73.8","56.67","133.38","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","28.48","28.48","35.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","52.16","50.06","281.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","81","81","81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","30236.43","30236.43","30236.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","871.2","871.2","871.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Electronic Analysis of Devices","5741","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1327.69","379.34","2332.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","189.18","189.18","354.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1743.12","217.89","2614.68","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","2697.6","562","5040","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2149.65","562","5339","84","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1175.3","123.92","2603.23","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1057.14","352.38","3932.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","606.75","96.85","2060.65","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1045.7","209.14","1961.01","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1113.5","218.9","2452.8","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","747.41","160.52","2206.93","47","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1157.7","1157.7","1303.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1013.04","1013.04","1042","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","692.72","226.12","1649.48","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","2040","408","3876","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","2388","944","3184","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2604.36","2604.36","2821.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4769.97","3615.2","17122.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","46.37","46.37","46.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1579.34","1579.34","1579.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1865.79","1555.06","2985.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2140.7","1462.02","4819.15","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","347.41","254.31","1083.97","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","7548.61","7548.61","53419.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","3258.21","3258.21","3258.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","513.09","513.09","1041.55","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","541.27","541.27","979.59","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1151.2","584.04","3723","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1179.51","905.32","1284.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1115.54","1115.54","1419","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","1352","1352","1352","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","612.33","473.74","1463.72","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","925.65","925.65","1395.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","5180","5180","5180","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1279.01","1279.01","1332.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","21742.74","21742.74","21742.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","20190.3","20190.3","20190.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","199.35","126.31","325.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","124.21","99.36","23203.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4813.08","4813.08","7394.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","17816.23","17816.23","17816.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3449.97","3449.97","8632.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17.93","17.93","17.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","24046.28","24046.28","24046.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","65.17","65.17","65.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3173.2","3173.2","3173.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","13066.24","13066.24","13066.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2111.42","2111.42","4237.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3365.17","3365.17","3365.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventilation Initiation and Management","5801","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","47.76","20.44","82.76","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","18.03","18.03","83.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","161.4","31.43","292.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","22.77","22.77","22.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","5","5","67.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","40","20","60","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","70","60","426","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Manipulation Therapy","5811","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","643.02","643.02","643.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Health and Behavior Services","5821","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","32.57","32.57","32.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, morphine (fresenius)","9211","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","6626.72","6626.72","6626.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Flotufolastat f18 diag 1 mci","9254","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4326.35","4326.35","4326.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","1218.25","1218.25","1218.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine, nos, 0.5mg","9290","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","17746.11","17746.11","17746.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5315.79","5315.79","5315.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, clindamycin phosp 300mg","9291","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7300.6","7300.6","7300.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, esmolol hcl, 10mg","9363","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","22021.6","22021.6","22021.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, nitroglycerin, 5 mg","9404","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","628.61","628.61","628.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, releuko 1 mcg","9447","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3267.62","3267.62","3267.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Frozen plasma, pooled, sd","9509","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","14161.15","14161.15","14161.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","3494.97","3494.97","3494.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6072.15","6072.15","6072.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2160.39","2160.39","2160.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3892.76","2178.58","4061.52","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","66.11","66.11","66.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","586.26","586.26","586.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1555.64","1555.64","2176.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","707.33","421.12","1505.21","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","1195.21","1195.21","1195.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","2586.33","2586.33","2586.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","714.3","714.3","714.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3342.65","3342.65","3342.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Plasma, frz between 8-24hour","9513","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1250.64","1250.64","1250.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","2872.89","2872.89","5757.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","430.55","430.55","430.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1687.88","1687.88","1687.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","982.61","897.17","4688.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","8704.16","7860.76","11352.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1051.65","1051.65","1051.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","3921.44","3921.44","5237.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","1861.87","1861.87","1861.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","14861.07","14861.07","14861.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1234.57","1074.75","12205.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","3217.24","3217.24","14367.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","6048.32","3195.07","26371.93","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1470.85","1031.39","6375.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","5204.62","5204.62","13470.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1371.75","896.55","1991.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3594.95","1410","5021.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","3378.11","1295.17","18784.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2008.62","1004.31","7797.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2748.02","1492.26","4475.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","16203.26","16203.26","16203.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","13971.62","13971.62","13971.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","16457.94","16457.94","16457.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1780.56","1646.48","2472.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1483.98","1483.98","1483.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","232.2","166.5","285.52","108","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","161.42","133.2","166.5","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","77.19","77.19","231.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","281.81","199.02","320.01","368","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","75.68","75.68","75.68","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","113.04","113.04","113.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","254.56","254.56","254.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","180.82","180.82","180.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","281.81","199.06","293.62","701","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","68.54","24.99","442.12","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","293.62","281.4","562.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2619.91","2619.91","2619.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","252.15","201.72","280","72","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","252.15","176.51","252.15","126","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","292.45","187.32","471.86","150","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","196.08","196.08","196.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","73.19","73.19","74.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","77.19","77.19","154.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","360.53","20.96","2284.16","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","87.12","87.12","626.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","33.04","3.71","395.45","140","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","9.09","7.06","18.18","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","8.83","7.06","33.73","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","27.36","5.12","193.6","79","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","28.15","5.25","148.33","124","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","267.69","267.69","267.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","26.9","7.57","273.08","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","392.57","392.57","392.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","28.31","5.16","183.54","74","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","452.2","452.2","452.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","258.94","43.57","626.66","84","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8.91","4.29","120.04","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","90.5","13.43","2007.01","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","364.62","84.05","371.62","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","259.6","259.6","703.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","27.23","5.02","121.42","96","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","49.88","7.49","756.46","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","14.72","7.05","1167.36","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","47.99","6.78","375.96","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","1173.63","1173.63","1173.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","261.46","261.46","261.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","1000.06","314.97","3034.45","237","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","770.28","277.19","1711.42","51","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","881.67","467.64","1393.08","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","413.19","88.35","896.28","981","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","358.52","138.43","1006.54","105","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","532.76","183.07","1267.71","830","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","522.45","171.91","1294.51","1715","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","146.33","52.72","356.4","727","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","229.24","83.82","291.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","1045.36","402.28","2988.16","376","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","856.7","469.44","2000.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","196.63","68.32","403.02","581","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","415.24","96.31","841.13","2189","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","224.31","72.56","485.67","987","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","383.44","115.81","986.08","1596","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","290.06","171.7","1167.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","326.99","120.78","906.47","119","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","229.55","80.16","535.52","490","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","1409.39","482","4013.78","95","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","1487.2","348","4950","248","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","428.78","102.32","841.8","310","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","350.89","278.16","2986.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","55.44","55.44","55.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","642.75","414.79","711.31","251","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","414.79","388.65","414.79","69","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","242.01","232.01","249.02","1769","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","97.97","97.97","102.07","273","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","216.47","216.47","222.75","131","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","232.01","232.01","238.74","845","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","113.95","113.95","117.27","543","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","537.34","503.48","537.34","255","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","408.79","383.03","537.34","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","112.06","107.48","115.3","559","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","728.45","728.45","728.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","97.97","59.66","97.97","607","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","110.96","108.79","114.18","516","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","244","228","244","1656","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","240","228","240","276","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","241","241","241","80","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","111.95","76.15","117.54","302","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","492","492","504","73","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","492","492","504","184","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","101.66","101.66","105.92","76","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","488.49","488.49","488.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","192.31","192.31","192.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mammography Services","N804","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","13547","13547","13547","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","192.63","192.63","192.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Durable Medical Equipment","N805","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","300.15","240.12","718.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","353.92","331.7","538.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","913.61","913.61","913.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","145.45","145.45","145.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","158.6","156.59","174.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","390.05","390.05","390.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","413.19","413.19","413.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","191.17","160.92","205.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","133.45","133.45","133.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Medicine","N809","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","442.41","442.41","442.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","609.75","214.85","792.65","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","400.27","393.49","494.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","208.92","208.92","239.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","84.04","6.41","124.67","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","509.75","428.87","640.8","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","387.8","387.8","487.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","77.24","23.14","106.44","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","383","383","477","127","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","447","378","471","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","473","473","473","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","109.56","85.99","177.33","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","504","504","504","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","492","393.6","492","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","105.92","101.66","105.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","105.78","105.78","105.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","5.25","5.25","5.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","99.52","99.52","99.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2853.86","2853.86","2853.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","30.38","30.38","30.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All OP services (%BC): 47.7] [OP Surgery  (%BC): 47.7] [Observation (%BC): 47.7] [Emergency Department (%BC): 47.7] [Occupational Therapy (%BC): 47.7] [Physical Therapy (%BC): 47.7] [Respiratory Services/Therapy  (%BC): 47.7] [Speech Therapy (%BC): 47.7] [All Other OP (%BC): 47.7]","2766.16","2159.13","3452.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Aetna","All Commercial Plans","","","[OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs (%BC): 75] [Other Outpatient Implant (%BC): 75] [All Other OP (%BC): 75]","4736.98","2243.41","5929.52","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","561.93","561.93","742.03","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","11.95","11.95","11.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 296.56]","1168.29","1168.29","1168.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1567.68","1567.68","1567.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 308.91]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","","","[Lesser Than Charges paid at %: 100] [Laboratory Fee Schedule: FEE SCHEDULE] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): 277.30]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5220] [Cardiac Cath (%BC): 62.6] [Observation (%BC): 62.6 Maximum Reimbursement 4462] [Emergency Department (%BC): 72.2] [Chemotherapy (%BC): 62.6] [Nuclear Medicine (%BC): 62.6] [Radiation Therapy  (%BC): 62.6] [CT Scan OP ($): FEE SCHEDULE] [MRI OP ($): FEE SCHEDULE] [Imaging Services (%BC): 62.6] [Mammography-Diagnostic (%BC): 62.6] [Mammography-Screening (%BC): 62.6] [Positron Emission Tomography (%BC): 62.6] [Radiology (%BC): 62.6] [Ultrasound Imaging (%BC): 62.6] [Laboratory Fee Schedule: FEE SCHEDULE] [OP ECT Mental Health ($): 753] [Other Outpatient Implant (%BC): 73.3] [All Other OP (%BC): 62.6]","4008.79","980.71","4467.72","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 431] [OP ECT Mental Health ($): 753] [All Other OP (%BC): 47.7]","3072.58","3072.58","3072.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","First Health","Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All OP services (%BC): 93] [OP Surgery  (%BC): 93] [Observation (%BC): 93] [Emergency Department (%BC): 93] [Occupational Therapy (%BC): 93] [Physical Therapy (%BC): 93] [Respiratory Services/Therapy  (%BC): 93] [Speech Therapy (%BC): 93] [All Other OP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[All OP services (%BC): 47.9] [OP Surgery  (%BC): 47.9] [Observation (%BC): 47.9] [Emergency Department (%BC): 47.9] [Occupational Therapy (%BC): 47.9] [Physical Therapy (%BC): 47.9] [Respiratory Services/Therapy  (%BC): 47.9] [Speech Therapy (%BC): 47.9] [All Other OP (%BC): 47.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All OP services (%BC): 74] [OP Surgery  (%BC): 74] [Observation (%BC): 74] [Emergency Department (%BC): 74] [Occupational Therapy (%BC): 74] [Physical Therapy (%BC): 74] [Respiratory Services/Therapy  (%BC): 74] [Speech Therapy (%BC): 74] [All Other OP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Multiplan","Phcs Ppo","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Optum","Transplant","","","[Transplants: Lessor of billed charges or 465% of Medicare]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","585.47","561.93","712.19","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 27.5] [Cardiac Cath (%BC): 39.6] [Observation (%BC): 47.6] [ED Level 1--99281 ($): 452] [ED Level 2--99282 ($): 452] [ED Level 3--99283 ($): 814] [ED Level 4--99284 ($): 2174] [ED Level 5--99285 ($): 4980] [Critical Care-99291 ($): 11267] [Radiology (%BC): 36.2] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 36.2] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 27.5]","2386.13","1445.35","2550.41","94","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","95.85","46.85","561.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 31.4] [Cardiac Cath (%BC): 33.6] [Observation (%BC): 54.1] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 796] [ED Level 4--99284 ($): 2128] [ED Level 5--99285 ($): 4875] [Critical Care-99291 ($): 11030] [Radiology (%BC): 41.1] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 41.1] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 31.4]","2204.41","1183.2","2943.33","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 37.6] [Cardiac Cath (%BC): 52.0] [Observation (%BC): 36.2] [ED Level 1--99281 ($): 442] [ED Level 2--99282 ($): 442] [ED Level 3--99283 ($): 795] [ED Level 4--99284 ($): 2122] [ED Level 5--99285 ($): 4861] [Critical Care-99291 ($): 10995] [Radiology (%BC): 51.4] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory (%BC): 51.4] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 51.4]","2585.48","1278.47","3572.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Mental Health-Intensive ($): 208] [Mental Health-Partial Hospitalization ($): 416] [APC ($): FEE SCHEDULE]","770.03","770.03","770.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5790] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 138244] [Insertion of Permanent Pacemaker ($): 45084] [PTCA w/ Stent ($): 39642] [PTCA w/non Drug Eluting Stent ($): 36886] [PTCA w/out stent ($): 31373] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1184] [ED Level 2--99282 ($): 1184] [ED Level 3--99283 ($): 3552] [ED Level 4--99284 ($): 5920] [ED Level 5--99285 ($): 5920] [Critical Care-99291 ($): 9191] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 17227] [Electrophysiology and Mapping Studies ($): 27559] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1500] [MRI OP ($): 2769] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10290 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2426]","400","250","2518","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5226] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 125655] [Insertion of Permanent Pacemaker ($): 41044] [PTCA w/ Stent ($): 36037] [PTCA w/non Drug Eluting Stent ($): 33527] [PTCA w/out stent ($): 28517] [Stereotactic Radiosurgery ($): 37770] [Stereotactic Radiosurgery-Fractionated ($): 14157] [Observation ($): 7035] [ED Level 1--99281 ($): 1075] [ED Level 2--99282 ($): 1075] [ED Level 3--99283 ($): 3225] [ED Level 4--99284 ($): 5380] [ED Level 5--99285 ($): 5380] [Critical Care-99291 ($): 8354] [Urgent Care ($): 402] [Cardiac Rehabilitation Therapy ($): 204] [Cardiac Stress Test ($): 820] [Cardiology ($): 1119] [Echocardiology ($): 833] [EKG/ECG ($): 346] [Electrophysiology Ablation ($): 15654] [Electrophysiology and Mapping Studies ($): 25050] [Holter Monitor/Telemetry ($): 425] [Peripheral Vascular Lab ($): 1010] [EEG ($): 874] [EMG ($): 402] [MEG ($): 4632] [Neuropsychological Testing and Biofeedback ($): 1210] [Sleep Studies-Attended ($): 3749] [Sleep Studies-Unattended ($): 801] [Chemotherapy ($): 612] [Nuclear Medicine ($): 1798] [Oncology ($): 2206] [Radiation Therapy ($): 917] [CT Scan OP ($): 1365] [MRI OP ($): 2518] [Imaging Services ($): 582] [Mammography-Diagnostic ($): 252] [Mammography-Screening ($): 252] [Positron Emission Tomography ($): 8687] [Radiology ($): 320] [Ultrasound Imaging ($): 776] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 1108] [Peritoneal Dialysis, CAPD, and CCPD ($): 373] [Occupational Therapy ($): 174] [Physical Therapy ($): 174] [Resp. Services/Therapy ($): 144] [Speech Therapy ($): 174] [Mental Health-Intensive ($): 215] [Mental Health-Partial Hospitalization ($): 430] [OP High Cost Drugs ($): 0 Charge Threshold 10095 (%BC): 45] [Ambulance--Air ($): 11456] [Hyperbarics ($): 501] [IV Therapy ($): 412] [Pulmonary Function ($): 573] [Pulmonary Rehabilitation ($): 174] [Trauma ($): 2430]","2016.63","380.66","2518","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","607.56","607.56","607.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[OP Surgery  (%BC): 57] [Observation (%BC): 57] [Emergency Department (%BC): 57] [Occupational Therapy (%BC): 57] [Physical Therapy (%BC): 57] [Respiratory Services/Therapy  (%BC): 57] [Speech Therapy (%BC): 57] [All Other OP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","facility","outpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Or Per Minute Level 3","01502883","CDM","360","RC","","","facility","both","","","","120","60","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacu Phase I First Hr","01722759","CDM","710","RC","","","facility","both","","","","2628","1314","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","0270","CDM","270","RC","","","facility","both","","","","829.19","414.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","0272","CDM","272","RC","","","facility","both","","","","479.9","239.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","0278","CDM","278","RC","","","facility","both","","","","2204.9","1102.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Renal Art/Vein Duplx-Bilat","03751021","CDM","921","RC","","","facility","both","","","","3319","1659.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Barium Enema","03800335","CDM","320","RC","","","facility","both","","","","2236","1118","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj For Vcug Or Cystogram","03800342","CDM","320","RC","","","facility","both","","","","1389","694.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagram","03800366","CDM","320","RC","","","facility","both","","","","764","382","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroscopy Only","03800373","CDM","320","RC","","","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Upper G.I. (Ugi)","03800377","CDM","320","RC","","","facility","both","","","","2363","1181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ugi With Small Bowel","03800378","CDM","320","RC","","","facility","both","","","","2803","1401.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulse Doppler Repeat Fetal","03800402","CDM","320","RC","76827","HCPCS","facility","both","","","","1630","815","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vcug","03800439","CDM","320","RC","","","facility","both","","","","2221","1110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gi Tube Placement Fluoro","03800463","CDM","320","RC","","","facility","both","","","","1259","629.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Survey - Genetics","03800487","CDM","320","RC","","","facility","both","","","","1954","977","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech Video Swallow","03800544","CDM","320","RC","","","facility","both","","","","1366","683","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Abdominal Complete","03810357","CDM","402","RC","","","facility","both","","","","2512","1256","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Abdominal Ltd","03810358","CDM","402","RC","","","facility","both","","","","1167","583.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Retroperitoneal (Complete)","03810361","CDM","402","RC","","","facility","both","","","","2247","1123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Retroperitoneal Limited","03810362","CDM","402","RC","","","facility","both","","","","1590","795","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Spine","03810552","CDM","402","RC","","","facility","both","","","","1725","862.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound - Hip(Manipulation)","03810558","CDM","402","RC","","","facility","both","","","","1464","732","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Pylorus","03810560","CDM","402","RC","","","facility","both","","","","1895","947.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Portable Renal Ultrasound","03810586","CDM","402","RC","","","facility","both","","","","2199","1099.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Head Sngh","03810588","CDM","402","RC","","","facility","both","","","","1298","649","","","","","","","","","","","","","Gross Charge Type: Standard"
"Renal Scan","03820003","CDM","341","RC","","","facility","both","","","","5430","2715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chkd Transcath Pulmonary Valve","03820006","CDM","270","RC","","","facility","both","","","","107588.25","53794.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chkd Implant Tcat Pulm Vlv Perq","03820007","CDM","481","RC","33477","HCPCS","facility","both","","","","49869","24934.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chkd Transcath Delivery System","03820008","CDM","270","RC","","","facility","both","","","","27712.13","13856.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vascular Flow Study","03820010","CDM","341","RC","","","facility","both","","","","1463","731.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Dup Abd/Pelvis Retro","03820015","CDM","350","RC","","","facility","both","","","","1653","826.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hepatobiliary Scan","03820019","CDM","341","RC","","","facility","both","","","","2853","1426.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastric Emptying Scan","03820036","CDM","341","RC","","","facility","both","","","","3789","1894.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Head W/O","03830002","CDM","351","RC","","","facility","both","","","","3774","1887","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Chest W/O","03830019","CDM","350","RC","","","facility","both","","","","4522","2261","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cta Contrast W & W/O","03830021","CDM","350","RC","","","facility","both","","","","6489","3244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Abd Wet","03830034","CDM","350","RC","","","facility","both","","","","4238","2119","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Cranio-Facial Dry","03830041","CDM","350","RC","","","facility","both","","","","5138","2569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Cor/Sag/Recon/3D","03830043","CDM","350","RC","","","facility","both","","","","1908","954","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Brain W/O","03841004","CDM","611","RC","","","facility","both","","","","6955","3477.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Brain W/Wo","03841006","CDM","611","RC","","","facility","both","","","","9494","4747","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Abdomen 2 Views","03841007","CDM","320","RC","","","facility","both","","","","873","436.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Chest","03841008","CDM","402","RC","","","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Lower Extremity","03841012","CDM","402","RC","","","facility","both","","","","1174","587","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tas Congenital Car Anomal","03841013","CDM","481","RC","33741","HCPCS","facility","both","","","","5604","2802","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sp Cath Super / Inferior Vena Cava","03841014","CDM","481","RC","36010","HCPCS","facility","both","","","","3820","1910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Balo Angiop 1St Vein","03841019","CDM","481","RC","37248","HCPCS","facility","both","","","","6749","3374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venogram Caval Super","03841020","CDM","320","RC","75827","HCPCS","facility","both","","","","3472","1736","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Valvuloplasty Ao","03841021","CDM","480","RC","92986","HCPCS","facility","both","","","","12037","6018.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Valvuloplasty Mitral","03841022","CDM","480","RC","92987","HCPCS","facility","both","","","","13863","6931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pb Valvuloplasty; Pulmon Valve","03841023","CDM","480","RC","92990","HCPCS","facility","both","","","","19433","9716.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Drug Admin & Hemodynmic Meas","03841024","CDM","481","RC","93463","HCPCS","facility","both","","","","3702","1851","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Inject R Ventr / Atrail Angio","03841026","CDM","481","RC","93566","HCPCS","facility","both","","","","3712","1856","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Inject S Uprvlv Aortography","03841027","CDM","481","RC","93567","HCPCS","facility","both","","","","3932","1966","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Inject Pulm Art Hrt Cath","03841028","CDM","481","RC","93568","HCPCS","facility","both","","","","4818","2409","","","","","","","","","","","","","Gross Charge Type: Standard"
"R&L Hrt Cath Chd Nml Nt Cnj","03841029","CDM","481","RC","93596","HCPCS","facility","both","","","","25024","12512","","","","","","","","","","","","","Gross Charge Type: Standard"
"R&L Hrt Cath Chd Abnl Nt Cnj","03841030","CDM","481","RC","93597","HCPCS","facility","both","","","","25024","12512","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sp Cath Vein First Order Branch","03841031","CDM","481","RC","36011","HCPCS","facility","both","","","","5310","2655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Venous","03841032","CDM","481","RC","37241","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Artery","03841033","CDM","481","RC","37242","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Balo Angiop 1St Artery","03841034","CDM","481","RC","37246","HCPCS","facility","both","","","","6749","3374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd Inject L Ventr / Atrail Angio","03841035","CDM","481","RC","93565","HCPCS","facility","both","","","","3712","1856","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Drg Cgen C-Cathj Slctv Opacification S&I","03841036","CDM","481","RC","93564","HCPCS","facility","both","","","","3938","1969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Trluml Pulmonary Art Balloon Angiop 1 Vsl","03841037","CDM","481","RC","92997","HCPCS","facility","both","","","","15013","7506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Ecls Insj Of Prph Cannula Birth-5 Yrs Perq","03841038","CDM","481","RC","33951","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Ecls Insj Of Prph Cannula 6 Yrs&Older Perq","03841039","CDM","481","RC","33952","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Videofluoroscopy","04040741","CDM","320","RC","","","facility","both","","","","637","318.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Videofluoroscopy Consult","04040825","CDM","320","RC","","","facility","both","","","","334","167","","","","","","","","","","","","","Gross Charge Type: Standard"
"General Anesth Set Up","04122728","CDM","370","RC","","","facility","both","","","","833","416.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gen Anesthesia Per Minute","04122730","CDM","370","RC","","","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Holter Monitor - 24Hr","04553074","CDM","480","RC","","","facility","both","","","","1417","708.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiology Portable Chg","04553113","CDM","402","RC","","","facility","both","","","","519","259.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Echo","04553114","CDM","480","RC","76825","HCPCS","facility","both","","","","2285","1142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Holter Scan Report","04553115","CDM","480","RC","","","facility","both","","","","415","207.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Holter Hook Up","04553116","CDM","480","RC","93225","HCPCS","facility","both","","","","1831","915.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tte,Congenital,Complete","04553117","CDM","402","RC","93303","HCPCS","facility","both","","","","2979","1489.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tte,Congential,Limited","04553118","CDM","480","RC","93304","HCPCS","facility","both","","","","1776","888","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tte,Noncong Comp Fu/Limited","04553120","CDM","480","RC","93306","HCPCS","facility","both","","","","4953","2476.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Color Flow Doppler","04583073","CDM","480","RC","93325","HCPCS","facility","both","","","","1425","712.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiac Doppler Ultrasound","04583078","CDM","480","RC","93320","HCPCS","facility","both","","","","1684","842","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiac Doppler Limited","04583080","CDM","480","RC","93321","HCPCS","facility","both","","","","982","491","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Tracing Only","04583106","CDM","730","RC","","","facility","both","","","","689","344.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnsc Intrv Stnt-Int;Vn","04590066","CDM","481","RC","37238","HCPCS","facility","both","","","","19364","9682","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rt Hc Cong Nml Nat Conn","04599176","CDM","481","RC","93593","HCPCS","facility","both","","","","24434","12217","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","100230","CDM","270","RC","","","facility","both","","","","126.5","63.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","100234","CDM","270","RC","","","facility","both","","","","90.81","45.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10187","CDM","270","RC","","","facility","both","","","","71.67","35.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","101903","CDM","270","RC","","","facility","both","","","","1507.74","753.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","101906","CDM","270","RC","","","facility","both","","","","622.13","311.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102147","CDM","270","RC","","","facility","both","","","","989","494.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102212","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102225","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102226","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102236","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102356","CDM","278","RC","C1713","HCPCS","facility","both","","","","2044.9","1022.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102357","CDM","278","RC","C1713","HCPCS","facility","both","","","","2044.9","1022.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102358","CDM","278","RC","C1713","HCPCS","facility","both","","","","2044.9","1022.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102572","CDM","270","RC","","","facility","both","","","","62.21","31.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102573","CDM","270","RC","","","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","102715","CDM","270","RC","","","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","103626","CDM","270","RC","","","facility","both","","","","361.77","180.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","103627","CDM","270","RC","","","facility","both","","","","385.99","193","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","103628","CDM","270","RC","","","facility","both","","","","350.83","175.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","103629","CDM","270","RC","","","facility","both","","","","602.6","301.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","103781","CDM","270","RC","","","facility","both","","","","55.06","27.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","103782","CDM","270","RC","","","facility","both","","","","55.06","27.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10387","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intermediate Eye Exam","10400003","CDM","510","RC","92012","HCPCS","facility","both","","","","305","152.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Quant Perimetr Gvf/Hvf Uni/Bil","10400007","CDM","510","RC","92082","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Static/Kinetic Hvf Uni/Bil","10400008","CDM","510","RC","92083","HCPCS","facility","both","","","","326","163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluorescein Angiography","10400015","CDM","920","RC","92235","HCPCS","facility","both","","","","673","336.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fundus Photos","10400020","CDM","920","RC","92250","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Ocular Photography","10400021","CDM","920","RC","92285","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ophth A-Scan Biometry W/Comput","10400022","CDM","402","RC","76519","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ophth B-Scan W/Image  Document","10400024","CDM","402","RC","76512","HCPCS","facility","both","","","","674","337","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopy-One Eyelid","10400100","CDM","761","RC","67810","HCPCS","facility","both","","","","2880","1440","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc Photos","10400101","CDM","920","RC","92250","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Color Vision Testing","10400103","CDM","920","RC","92283","HCPCS","facility","both","","","","192","96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneal Topogra Mapping","10400106","CDM","920","RC","92025","HCPCS","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fit Contact Lens Occ Surf Dis","10400109","CDM","920","RC","92071","HCPCS","facility","both","","","","254","127","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fit Contact Lens Keratoconus","10400110","CDM","920","RC","92072","HCPCS","facility","both","","","","254","127","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removl Fb Conjunct Superficial","10400150","CDM","761","RC","65205","HCPCS","facility","both","","","","797","398.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Fb Xtrnl Eye Embed Scjncl/Scleral Nonperfor","10400151","CDM","761","RC","65210","HCPCS","facility","both","","","","821","410.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Fb Cornea W/Burr","10400152","CDM","761","RC","65220","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intravitreal Inj Medictn 1 Eye","10400155","CDM","761","RC","67028","HCPCS","facility","both","","","","1289","644.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Focal/Grid Laser","10400156","CDM","761","RC","67210","HCPCS","facility","both","","","","1799","899.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prf Laser","10400157","CDM","761","RC","67228","HCPCS","facility","both","","","","1799","899.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Tenon""""s Injection""","10400158","CDM","761","RC","67515","HCPCS","facility","both","","","","1097","548.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tarsorrhaphy Severing","10400159","CDM","761","RC","67710","HCPCS","facility","both","","","","2977","1488.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repr Trichiasi Epilatn-Forceps","10400161","CDM","761","RC","67820","HCPCS","facility","both","","","","381","190.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eyelid Lesion Excisn W/O Close","10400162","CDM","761","RC","67840","HCPCS","facility","both","","","","2977","1488.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Eyelid Closure","10400163","CDM","761","RC","67875","HCPCS","facility","both","","","","3832","1916","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Eyelid Wound","10400164","CDM","761","RC","67930","HCPCS","facility","both","","","","6138","3069","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conjunctiva Biopsy- 1 Eye","10400165","CDM","761","RC","68100","HCPCS","facility","both","","","","2148","1074","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punctal Plug Insertion -1 Eye","10400166","CDM","761","RC","68761","HCPCS","facility","both","","","","255","127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneal Pachymetry Us,Uni/Bil","10400167","CDM","402","RC","76514","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comprehensive Eye Exam","10400169","CDM","510","RC","92014","HCPCS","facility","both","","","","342","171","","","","","","","","","","","","","Gross Charge Type: Standard"
"Refraction Only","10400170","CDM","999","RC","92015","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gonioscopy","10400171","CDM","920","RC","92020","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Fb Cornea W/Bur-Bilat","10400178","CDM","761","RC","65220","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intravitreal Inj Medictn-2 Eyes","10400180","CDM","761","RC","67028","HCPCS","facility","both","","","","1289","644.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punctal Plug Insertion-2 Eyes","10400186","CDM","761","RC","68761","HCPCS","facility","both","","","","382","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cont Lens-1Eyes-Excp Aphak","10400188","CDM","999","RC","92310","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iridoplasty","10400191","CDM","761","RC","66762","HCPCS","facility","both","","","","1525","762.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ectropion Repair","10400192","CDM","761","RC","67917","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closure Of Lacrimal","10400200","CDM","761","RC","68760","HCPCS","facility","both","","","","1940","970","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cover Eye W/ Membrane","10400201","CDM","761","RC","65778","HCPCS","facility","both","","","","2678","1339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amniotic Membrane","10400202","CDM","278","RC","V2790","HCPCS","facility","both","","","","1881","940.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conjunctivoplasty","10400203","CDM","761","RC","68399","HCPCS","facility","both","","","","2583","1291.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prob Of Lac Can W Or W_O Irrig","10400204","CDM","761","RC","68840","HCPCS","facility","both","","","","1377","688.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Tear Ducts","10400205","CDM","761","RC","68700","HCPCS","facility","both","","","","3383","1691.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blephartmy Drain Abscess","10400206","CDM","761","RC","67700","HCPCS","facility","both","","","","1510","755","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Nasolacrimal Duct","10400207","CDM","761","RC","68815","HCPCS","facility","both","","","","3448","1724","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Eyelid Wound","10400208","CDM","761","RC","67935","HCPCS","facility","both","","","","6138","3069","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Detach Retina","10400209","CDM","360","RC","67105","HCPCS","facility","both","","","","3611","1805.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Surgery Eye Strand Lt","10400210","CDM","360","RC","67031","HCPCS","facility","both","","","","2783","1391.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Srep F/E/N/L/Mm; 2.5Cm/<","10400212","CDM","369","RC","12011","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Repair F/E/E/N/L/M 2.6Cm-5.0 Cm","10400215","CDM","761","RC","12013","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Ocular Implant","10400216","CDM","761","RC","65175","HCPCS","facility","both","","","","10380","5190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incise/Drain Eyelid Lining","10400217","CDM","761","RC","68020","HCPCS","facility","both","","","","2542","1271","","","","","","","","","","","","","Gross Charge Type: Standard"
"Follow-Up Surgery Of Eye","10400218","CDM","761","RC","66250","HCPCS","facility","both","","","","6289","3144.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Eyelid Foreign Body","10400219","CDM","761","RC","67938","HCPCS","facility","both","","","","1762","881","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Eye Wound","10400220","CDM","761","RC","65275","HCPCS","facility","both","","","","10391","5195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Upper Eyelid","10400221","CDM","369","RC","15822","HCPCS","facility","both","","","","6533","3266.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ciliary Transsleral Therapy","10400222","CDM","761","RC","66710","HCPCS","facility","both","","","","3652","1826","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Skin Tags","10400224","CDM","761","RC","11200","HCPCS","facility","both","","","","643","321.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Eyelid","10400225","CDM","761","RC","67880","HCPCS","facility","both","","","","2014","1007","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Entropion Excision Tarsal Wedge","10400226","CDM","761","RC","67923","HCPCS","facility","both","","","","4866","2433","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Blpos Conjunctivo-Tarso-Musc-Levator Rescj","10400227","CDM","761","RC","67908","HCPCS","facility","both","","","","4866","2433","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Upper Eyelid","10400228","CDM","510","RC","15823","HCPCS","facility","both","","","","7167","3583.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Layr Closr Face=<2.5Cm","10400229","CDM","510","RC","12051","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Eyelid Lesion","10400230","CDM","510","RC","67800","HCPCS","facility","both","","","","1313","656.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr E/N/E/L 10 Sq Cm/<","10400231","CDM","510","RC","14060","HCPCS","facility","both","","","","6156","3078","","","","","","","","","","","","","Gross Charge Type: Standard"
"Canthoplasty","10400232","CDM","510","RC","67950","HCPCS","facility","both","","","","3833","1916.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenervation Face Unilat","10400233","CDM","510","RC","64612","HCPCS","facility","both","","","","605","302.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Of Chalazion:Mult Diff Lid","10400234","CDM","510","RC","67805","HCPCS","facility","both","","","","2876","1438","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Into Skin Lesions=<7","10400235","CDM","510","RC","11900","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Face/Ears/Eyelids/Nose/Lips/Mucosa 0.6-1.0 Cm","10400236","CDM","510","RC","11311","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prob Nasolacrimal Duct Irrigat","10400237","CDM","510","RC","68810","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temp Artery Biopsy","10400238","CDM","510","RC","37609","HCPCS","facility","both","","","","9378","4689","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg </=0.5Cm","10400239","CDM","510","RC","11440","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 0.6-1 Cm","10400240","CDM","510","RC","11441","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 1.1-2 Cm","10400241","CDM","510","RC","11442","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face -Mm Malig+Marg 0.5<","10400242","CDM","510","RC","11640","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Malig+Marg 0.6-1","10400243","CDM","510","RC","11641","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm-Malig+Marg 1.1-2","10400244","CDM","510","RC","11642","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Face/Ears/Eyelids/Nose/Lips/Mucosa 0.5 Cm/<","10400245","CDM","510","RC","11310","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Medial Canthopexy Separate Procedure","10400248","CDM","510","RC","21280","HCPCS","facility","both","","","","7622","3811","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explore/Biopsy Eye Socket","10400249","CDM","510","RC","67400","HCPCS","facility","both","","","","8039","4019.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Eyelid Lesions","10400250","CDM","510","RC","67801","HCPCS","facility","both","","","","1969","984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Eyelid Lesion","10400251","CDM","510","RC","67850","HCPCS","facility","both","","","","2264","1132","","","","","","","","","","","","","Gross Charge Type: Standard"
"Constj Intermargin Adhes/Tarsor/Canthor W/Trpos","10400252","CDM","510","RC","67882","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Blpos Conjunctivo-Tarso-Musc-Levator Rescj","10400253","CDM","510","RC","67908","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduction Overcorrection Ptosis","10400254","CDM","510","RC","67909","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Ectropion Suture","10400255","CDM","510","RC","67914","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Ectropion Excision Tarsal Wedge","10400256","CDM","510","RC","67916","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Entropion Suture","10400257","CDM","510","RC","67921","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision & Repair Eyelid < One-Fourth Lid Margin","10400258","CDM","510","RC","67961","HCPCS","facility","both","","","","4866","2433","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rcnstj Eyelid Full Thickness Second Stage","10400259","CDM","510","RC","67975","HCPCS","facility","both","","","","4866","2433","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conjunctivoplasty W/Grf/Xtnsv Rearrangement","10400260","CDM","510","RC","68320","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision Drainage Lacrimal Sac","10400261","CDM","510","RC","68420","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snip Incision Lacrimal Punctum","10400262","CDM","510","RC","68440","HCPCS","facility","both","","","","636","318","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Lacrimal Gland","10400263","CDM","510","RC","68510","HCPCS","facility","both","","","","2804","1402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Fb/Dacryolith Lacrimal Passages","10400264","CDM","510","RC","68530","HCPCS","facility","both","","","","636","318","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilation Lacrimal Punctum W/Wo Irrgation","10400265","CDM","510","RC","68801","HCPCS","facility","both","","","","660","330","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Lacrimal System","10400266","CDM","510","RC","68899","HCPCS","facility","both","","","","636","318","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Single Les","10400267","CDM","510","RC","11102","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","10400268","CDM","510","RC","11104","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Single Les","10400269","CDM","510","RC","11106","HCPCS","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Ea Sep/Addl","10400270","CDM","510","RC","11103","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Sep/Addl","10400271","CDM","510","RC","11105","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Ea Sep/Addl","10400272","CDM","510","RC","11107","HCPCS","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subconjunctival Injection","10400273","CDM","761","RC","68200","HCPCS","facility","both","","","","894","447","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Eyelashes","10402223","CDM","761","RC","67825","HCPCS","facility","both","","","","841","420.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104049","CDM","270","RC","","","facility","both","","","","152.95","76.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104288","CDM","270","RC","","","facility","both","","","","5035","2517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104307","CDM","270","RC","","","facility","both","","","","256.73","128.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104566","CDM","278","RC","C1713","HCPCS","facility","both","","","","9019.3","4509.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104657","CDM","270","RC","","","facility","both","","","","207.74","103.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104658","CDM","270","RC","","","facility","both","","","","207.74","103.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104700","CDM","270","RC","","","facility","both","","","","264.7","132.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104707","CDM","270","RC","","","facility","both","","","","415.76","207.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104708","CDM","270","RC","","","facility","both","","","","524.4","262.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104712","CDM","270","RC","","","facility","both","","","","3678.4","1839.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104804","CDM","272","RC","C1884","HCPCS","facility","both","","","","2850","1425","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","104906","CDM","270","RC","","","facility","both","","","","892.7","446.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105160","CDM","270","RC","","","facility","both","","","","234","117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105245","CDM","270","RC","","","facility","both","","","","51.43","25.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105260","CDM","276","RC","V2787","HCPCS","facility","both","","","","545","272.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105585","CDM","270","RC","","","facility","both","","","","342.93","171.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105591","CDM","270","RC","","","facility","both","","","","139.44","69.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105592","CDM","270","RC","","","facility","both","","","","184.8","92.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105593","CDM","270","RC","","","facility","both","","","","123.91","61.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105598","CDM","278","RC","C1813","HCPCS","facility","both","","","","4962.8","2481.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105601","CDM","278","RC","C1813","HCPCS","facility","both","","","","24350.4","12175.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105737","CDM","270","RC","","","facility","both","","","","308.38","154.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105757","CDM","278","RC","C1776","HCPCS","facility","both","","","","1599.78","799.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105871","CDM","270","RC","","","facility","both","","","","5.65","2.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105899","CDM","272","RC","C1729","HCPCS","facility","both","","","","23.69","11.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","105901","CDM","272","RC","C1729","HCPCS","facility","both","","","","23.69","11.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","106244","CDM","270","RC","","","facility","both","","","","2.57","1.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","106245","CDM","270","RC","","","facility","both","","","","6.26","3.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","106259","CDM","270","RC","","","facility","both","","","","1446.12","723.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","106417","CDM","278","RC","C1713","HCPCS","facility","both","","","","1098.58","549.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107128","CDM","278","RC","C1769","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107129","CDM","272","RC","C1769","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107352","CDM","272","RC","C1893","HCPCS","facility","both","","","","132.67","66.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10736","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107365","CDM","270","RC","","","facility","both","","","","1061.88","530.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107367","CDM","270","RC","","","facility","both","","","","1116.88","558.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10737","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107465","CDM","270","RC","","","facility","both","","","","72.23","36.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107475","CDM","270","RC","","","facility","both","","","","174.8","87.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107489","CDM","270","RC","","","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107601","CDM","270","RC","","","facility","both","","","","807.02","403.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10772","CDM","270","RC","","","facility","both","","","","216.66","108.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10776","CDM","270","RC","","","facility","both","","","","259.97","129.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10779","CDM","270","RC","","","facility","both","","","","308.18","154.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107812","CDM","270","RC","L8000","HCPCS","facility","both","","","","73.37","36.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","107813","CDM","270","RC","L8000","HCPCS","facility","both","","","","73.37","36.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10787","CDM","270","RC","","","facility","both","","","","466.31","233.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108275","CDM","270","RC","","","facility","both","","","","203.82","101.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108276","CDM","270","RC","C2626","HCPCS","facility","both","","","","1348.84","674.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108277","CDM","272","RC","C1893","HCPCS","facility","both","","","","132.67","66.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108550","CDM","270","RC","","","facility","both","","","","478.4","239.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108552","CDM","270","RC","","","facility","both","","","","397.62","198.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108640","CDM","278","RC","C1713","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108732","CDM","270","RC","","","facility","both","","","","1993.1","996.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","108844","CDM","270","RC","","","facility","both","","","","6462.47","3231.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","109062","CDM","270","RC","","","facility","both","","","","7809.68","3904.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","109362","CDM","278","RC","C1776","HCPCS","facility","both","","","","2166.3","1083.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","109522","CDM","270","RC","","","facility","both","","","","88","44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10955","CDM","270","RC","","","facility","both","","","","475.55","237.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","109577","CDM","270","RC","","","facility","both","","","","4275","2137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","109578","CDM","270","RC","","","facility","both","","","","4275","2137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10966","CDM","270","RC","","","facility","both","","","","1510.86","755.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","10974","CDM","270","RC","","","facility","both","","","","297.07","148.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1125","CDM","272","RC","C1769","HCPCS","facility","both","","","","256.76","128.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11300","CDM","270","RC","","","facility","both","","","","7.62","3.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11302","CDM","270","RC","","","facility","both","","","","50.31","25.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11322","CDM","270","RC","","","facility","both","","","","90.53","45.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11326","CDM","270","RC","","","facility","both","","","","90.53","45.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11348","CDM","270","RC","","","facility","both","","","","177.33","88.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11358","CDM","270","RC","","","facility","both","","","","23.44","11.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11375","CDM","270","RC","","","facility","both","","","","9.8","4.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11376","CDM","270","RC","","","facility","both","","","","9.8","4.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11381","CDM","270","RC","","","facility","both","","","","51.67","25.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11382","CDM","270","RC","","","facility","both","","","","5.19","2.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11383","CDM","270","RC","","","facility","both","","","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11384","CDM","270","RC","","","facility","both","","","","5.29","2.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11387","CDM","270","RC","","","facility","both","","","","5.61","2.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11394","CDM","270","RC","","","facility","both","","","","39.39","19.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11395","CDM","270","RC","","","facility","both","","","","39.03","19.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11396","CDM","270","RC","","","facility","both","","","","26.99","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11397","CDM","270","RC","","","facility","both","","","","27.21","13.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11398","CDM","270","RC","","","facility","both","","","","5.64","2.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11402","CDM","270","RC","","","facility","both","","","","5.71","2.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11403","CDM","270","RC","","","facility","both","","","","5.76","2.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11404","CDM","270","RC","","","facility","both","","","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11407","CDM","270","RC","","","facility","both","","","","5.51","2.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11408","CDM","270","RC","","","facility","both","","","","5.17","2.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11410","CDM","270","RC","","","facility","both","","","","5.29","2.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11412","CDM","270","RC","","","facility","both","","","","5.17","2.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11413","CDM","270","RC","","","facility","both","","","","7.41","3.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11417","CDM","270","RC","","","facility","both","","","","38.43","19.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11419","CDM","270","RC","","","facility","both","","","","26.69","13.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11420","CDM","270","RC","","","facility","both","","","","5.66","2.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11424","CDM","270","RC","","","facility","both","","","","6.51","3.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","114240","CDM","278","RC","L8603","HCPCS","facility","both","","","","2195.35","1097.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11429","CDM","270","RC","","","facility","both","","","","7.43","3.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11430","CDM","270","RC","","","facility","both","","","","13.83","6.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11434","CDM","270","RC","","","facility","both","","","","38.72","19.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11437","CDM","270","RC","","","facility","both","","","","26.27","13.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11438","CDM","270","RC","","","facility","both","","","","5.54","2.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11439","CDM","270","RC","","","facility","both","","","","5.18","2.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11440","CDM","270","RC","","","facility","both","","","","7.27","3.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11441","CDM","270","RC","","","facility","both","","","","5.44","2.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11446","CDM","270","RC","","","facility","both","","","","8.14","4.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11448","CDM","270","RC","","","facility","both","","","","5.34","2.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11450","CDM","270","RC","","","facility","both","","","","5.33","2.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","114504","CDM","278","RC","C1776","HCPCS","facility","both","","","","2422.5","1211.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11451","CDM","270","RC","","","facility","both","","","","7.28","3.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","114517","CDM","278","RC","C1776","HCPCS","facility","both","","","","2668.8","1334.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11452","CDM","270","RC","","","facility","both","","","","13.93","6.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11456","CDM","270","RC","","","facility","both","","","","13.68","6.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","114572","CDM","270","RC","","","facility","both","","","","137.31","68.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11458","CDM","270","RC","","","facility","both","","","","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11460","CDM","270","RC","","","facility","both","","","","15.02","7.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11462","CDM","270","RC","","","facility","both","","","","15.02","7.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","114650","CDM","272","RC","C1769","HCPCS","facility","both","","","","1702.27","851.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11469","CDM","270","RC","","","facility","both","","","","15.16","7.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11470","CDM","270","RC","","","facility","both","","","","15.15","7.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11471","CDM","270","RC","","","facility","both","","","","15.16","7.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11473","CDM","270","RC","","","facility","both","","","","15.16","7.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11478","CDM","270","RC","","","facility","both","","","","48.91","24.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11483","CDM","270","RC","","","facility","both","","","","46.75","23.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11486","CDM","270","RC","","","facility","both","","","","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","114918","CDM","270","RC","","","facility","both","","","","1870.4","935.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115021","CDM","278","RC","C1876","HCPCS","facility","both","","","","3119.8","1559.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115397","CDM","278","RC","C1713","HCPCS","facility","both","","","","1600.11","800.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115432","CDM","270","RC","","","facility","both","","","","190.69","95.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11544","CDM","270","RC","","","facility","both","","","","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11546","CDM","270","RC","","","facility","both","","","","46.4","23.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115469","CDM","270","RC","","","facility","both","","","","154.1","77.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115471","CDM","270","RC","","","facility","both","","","","386.4","193.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115479","CDM","270","RC","","","facility","both","","","","661.2","330.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11548","CDM","270","RC","","","facility","both","","","","38.89","19.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115480","CDM","270","RC","","","facility","both","","","","605.59","302.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115481","CDM","270","RC","","","facility","both","","","","661.2","330.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115483","CDM","270","RC","","","facility","both","","","","233.56","116.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115485","CDM","270","RC","","","facility","both","","","","813.97","406.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115494","CDM","270","RC","","","facility","both","","","","1487.2","743.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115496","CDM","270","RC","","","facility","both","","","","1806.67","903.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115497","CDM","270","RC","","","facility","both","","","","1487.2","743.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11553","CDM","270","RC","","","facility","both","","","","39.46","19.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115572","CDM","278","RC","C1713","HCPCS","facility","both","","","","1019.13","509.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11570","CDM","270","RC","","","facility","both","","","","194.45","97.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11573","CDM","270","RC","","","facility","both","","","","17.68","8.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115771","CDM","278","RC","C1713","HCPCS","facility","both","","","","1492.47","746.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115772","CDM","278","RC","C1713","HCPCS","facility","both","","","","1751.36","875.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","115801","CDM","278","RC","C1713","HCPCS","facility","both","","","","1737.24","868.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11588","CDM","270","RC","","","facility","both","","","","9.03","4.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11594","CDM","270","RC","","","facility","both","","","","14.93","7.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11598","CDM","270","RC","","","facility","both","","","","14.82","7.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11600","CDM","270","RC","","","facility","both","","","","14.89","7.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116068","CDM","278","RC","C1713","HCPCS","facility","both","","","","1872.05","936.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11612","CDM","270","RC","","","facility","both","","","","53.72","26.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116121","CDM","270","RC","","","facility","both","","","","427.57","213.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116125","CDM","270","RC","","","facility","both","","","","427.57","213.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116129","CDM","270","RC","","","facility","both","","","","373.75","186.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11616","CDM","270","RC","","","facility","both","","","","10.05","5.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116179","CDM","270","RC","","","facility","both","","","","687.91","343.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11619","CDM","270","RC","","","facility","both","","","","13.44","6.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116197","CDM","272","RC","A6258","HCPCS","facility","both","","","","27.57","13.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11623","CDM","270","RC","","","facility","both","","","","13.83","6.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11627","CDM","270","RC","","","facility","both","","","","10.39","5.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11628","CDM","270","RC","","","facility","both","","","","13.83","6.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11630","CDM","270","RC","","","facility","both","","","","6.55","3.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11631","CDM","270","RC","","","facility","both","","","","6.55","3.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116322","CDM","270","RC","","","facility","both","","","","11.18","5.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116323","CDM","270","RC","","","facility","both","","","","11.18","5.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11633","CDM","270","RC","","","facility","both","","","","14.38","7.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116331","CDM","270","RC","C2626","HCPCS","facility","both","","","","769.12","384.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11636","CDM","270","RC","","","facility","both","","","","15.02","7.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11637","CDM","270","RC","","","facility","both","","","","15.02","7.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11641","CDM","270","RC","","","facility","both","","","","12.83","6.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116419","CDM","278","RC","C1713","HCPCS","facility","both","","","","553.06","276.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11642","CDM","270","RC","","","facility","both","","","","12.83","6.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116420","CDM","278","RC","C1713","HCPCS","facility","both","","","","553.27","276.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116421","CDM","278","RC","C1713","HCPCS","facility","both","","","","553.06","276.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116427","CDM","278","RC","C1781","HCPCS","facility","both","","","","1780.02","890.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116428","CDM","278","RC","C1713","HCPCS","facility","both","","","","140.06","70.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116430","CDM","278","RC","C1713","HCPCS","facility","both","","","","166.06","83.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116441","CDM","278","RC","C1713","HCPCS","facility","both","","","","927.73","463.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116445","CDM","278","RC","C1713","HCPCS","facility","both","","","","1986.85","993.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116446","CDM","278","RC","C1713","HCPCS","facility","both","","","","1986.85","993.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11646","CDM","270","RC","","","facility","both","","","","15.16","7.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116461","CDM","278","RC","C1713","HCPCS","facility","both","","","","179.77","89.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116463","CDM","278","RC","C1713","HCPCS","facility","both","","","","216.71","108.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116465","CDM","278","RC","C1713","HCPCS","facility","both","","","","179.77","89.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116469","CDM","278","RC","C1713","HCPCS","facility","both","","","","179.77","89.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116488","CDM","272","RC","C1769","HCPCS","facility","both","","","","179.4","89.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11650","CDM","270","RC","","","facility","both","","","","13.82","6.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11651","CDM","270","RC","","","facility","both","","","","13.82","6.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116514","CDM","278","RC","C1713","HCPCS","facility","both","","","","1492.47","746.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11658","CDM","270","RC","","","facility","both","","","","12.85","6.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116617","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116639","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11665","CDM","270","RC","","","facility","both","","","","53.29","26.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11666","CDM","270","RC","","","facility","both","","","","54.67","27.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116661","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116663","CDM","272","RC","C1729","HCPCS","facility","both","","","","169.68","84.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11667","CDM","270","RC","","","facility","both","","","","44.19","22.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11669","CDM","270","RC","","","facility","both","","","","54.45","27.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11679","CDM","270","RC","","","facility","both","","","","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116857","CDM","272","RC","C1725","HCPCS","facility","both","","","","791.2","395.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116869","CDM","272","RC","C1729","HCPCS","facility","both","","","","55.91","27.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","116870","CDM","272","RC","C1729","HCPCS","facility","both","","","","56.72","28.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11694","CDM","270","RC","","","facility","both","","","","10.2","5.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11695","CDM","270","RC","","","facility","both","","","","10.2","5.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11696","CDM","270","RC","","","facility","both","","","","10.1","5.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11700","CDM","270","RC","","","facility","both","","","","10.36","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11701","CDM","270","RC","","","facility","both","","","","10.73","5.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11702","CDM","270","RC","","","facility","both","","","","11.76","5.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11703","CDM","270","RC","","","facility","both","","","","10.85","5.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117049","CDM","278","RC","C1781","HCPCS","facility","both","","","","506","253","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117051","CDM","270","RC","","","facility","both","","","","113.1","56.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117054","CDM","270","RC","","","facility","both","","","","385.84","192.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117055","CDM","270","RC","","","facility","both","","","","300.14","150.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11707","CDM","270","RC","","","facility","both","","","","10.75","5.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117075","CDM","272","RC","C1769","HCPCS","facility","both","","","","1365","682.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11708","CDM","270","RC","","","facility","both","","","","10.87","5.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11710","CDM","270","RC","","","facility","both","","","","21.45","10.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117100","CDM","278","RC","C1776","HCPCS","facility","both","","","","3135","1567.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117101","CDM","278","RC","C1776","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117104","CDM","278","RC","C1713","HCPCS","facility","both","","","","1751.5","875.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117105","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117107","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117108","CDM","278","RC","C1776","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117109","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117111","CDM","278","RC","C1776","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117118","CDM","278","RC","C1776","HCPCS","facility","both","","","","1820","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11712","CDM","270","RC","","","facility","both","","","","20.58","10.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117163","CDM","278","RC","C1713","HCPCS","facility","both","","","","171.12","85.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117164","CDM","278","RC","C1713","HCPCS","facility","both","","","","171.12","85.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117167","CDM","278","RC","C1713","HCPCS","facility","both","","","","171.12","85.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117168","CDM","278","RC","C1713","HCPCS","facility","both","","","","171.12","85.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117172","CDM","278","RC","C1713","HCPCS","facility","both","","","","171.12","85.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117183","CDM","270","RC","","","facility","both","","","","524.4","262.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117184","CDM","270","RC","","","facility","both","","","","416.15","208.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11721","CDM","270","RC","","","facility","both","","","","21.06","10.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117217","CDM","270","RC","","","facility","both","","","","76.67","38.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11723","CDM","270","RC","","","facility","both","","","","20.77","10.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11724","CDM","270","RC","","","facility","both","","","","10.76","5.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11725","CDM","270","RC","","","facility","both","","","","53.92","26.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11729","CDM","270","RC","","","facility","both","","","","20.98","10.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11741","CDM","270","RC","","","facility","both","","","","10.1","5.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11749","CDM","270","RC","","","facility","both","","","","23.25","11.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117578","CDM","270","RC","","","facility","both","","","","897.31","448.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117582","CDM","278","RC","C1815","HCPCS","facility","both","","","","24574.85","12287.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117583","CDM","278","RC","C1815","HCPCS","facility","both","","","","28371.18","14185.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117584","CDM","278","RC","C1815","HCPCS","facility","both","","","","11716.16","5858.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","117587","CDM","270","RC","","","facility","both","","","","2360.37","1180.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11759","CDM","270","RC","","","facility","both","","","","20.65","10.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11762","CDM","270","RC","","","facility","both","","","","53.92","26.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11778","CDM","270","RC","","","facility","both","","","","7.02","3.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11795","CDM","270","RC","","","facility","both","","","","42.73","21.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11796","CDM","270","RC","","","facility","both","","","","37.21","18.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11797","CDM","270","RC","","","facility","both","","","","42.76","21.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11798","CDM","270","RC","","","facility","both","","","","37.21","18.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11799","CDM","270","RC","","","facility","both","","","","6.2","3.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11806","CDM","270","RC","","","facility","both","","","","37.21","18.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11807","CDM","270","RC","","","facility","both","","","","52.41","26.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","118107","CDM","270","RC","","","facility","both","","","","129.25","64.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11812","CDM","270","RC","","","facility","both","","","","69.98","34.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11819","CDM","270","RC","","","facility","both","","","","20.33","10.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11820","CDM","270","RC","","","facility","both","","","","20.33","10.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11824","CDM","270","RC","","","facility","both","","","","13.73","6.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11826","CDM","270","RC","","","facility","both","","","","15.5","7.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11830","CDM","270","RC","","","facility","both","","","","15.48","7.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11831","CDM","270","RC","","","facility","both","","","","67.8","33.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","118311","CDM","278","RC","C1713","HCPCS","facility","both","","","","4207.34","2103.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11832","CDM","270","RC","","","facility","both","","","","9.4","4.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11835","CDM","270","RC","","","facility","both","","","","10.16","5.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11836","CDM","270","RC","","","facility","both","","","","8.78","4.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11838","CDM","270","RC","","","facility","both","","","","9.81","4.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11840","CDM","270","RC","","","facility","both","","","","8.87","4.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11850","CDM","270","RC","","","facility","both","","","","66.96","33.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11853","CDM","270","RC","","","facility","both","","","","21.75","10.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11858","CDM","270","RC","","","facility","both","","","","11.87","5.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11860","CDM","270","RC","","","facility","both","","","","22.07","11.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","118650","CDM","278","RC","C1750","HCPCS","facility","both","","","","2090","1045","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","118651","CDM","278","RC","C1750","HCPCS","facility","both","","","","4560","2280","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","118652","CDM","272","RC","C1893","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11866","CDM","270","RC","","","facility","both","","","","22.75","11.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11867","CDM","270","RC","","","facility","both","","","","73.26","36.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11871","CDM","270","RC","","","facility","both","","","","10.58","5.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11872","CDM","270","RC","","","facility","both","","","","33.99","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11875","CDM","270","RC","","","facility","both","","","","21.16","10.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11878","CDM","270","RC","","","facility","both","","","","90.3","45.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11882","CDM","270","RC","","","facility","both","","","","8.73","4.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11883","CDM","270","RC","","","facility","both","","","","12.46","6.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11886","CDM","270","RC","","","facility","both","","","","8.3","4.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11891","CDM","270","RC","","","facility","both","","","","15.82","7.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11892","CDM","270","RC","","","facility","both","","","","8.8","4.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11895","CDM","270","RC","","","facility","both","","","","8.87","4.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11897","CDM","270","RC","","","facility","both","","","","26.31","13.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11898","CDM","270","RC","","","facility","both","","","","21.37","10.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11899","CDM","270","RC","","","facility","both","","","","20.78","10.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11900","CDM","270","RC","","","facility","both","","","","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11901","CDM","270","RC","","","facility","both","","","","11.17","5.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11903","CDM","270","RC","","","facility","both","","","","20.69","10.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11904","CDM","270","RC","","","facility","both","","","","20.72","10.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11907","CDM","270","RC","","","facility","both","","","","9.7","4.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11908","CDM","270","RC","","","facility","both","","","","19.81","9.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11910","CDM","270","RC","","","facility","both","","","","26.54","13.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11912","CDM","270","RC","","","facility","both","","","","20.99","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11913","CDM","270","RC","","","facility","both","","","","19.2","9.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11914","CDM","270","RC","","","facility","both","","","","19.64","9.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11917","CDM","270","RC","","","facility","both","","","","206.82","103.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11918","CDM","270","RC","","","facility","both","","","","20.48","10.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11919","CDM","270","RC","","","facility","both","","","","20.5","10.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11920","CDM","270","RC","","","facility","both","","","","21.04","10.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11922","CDM","270","RC","","","facility","both","","","","21.3","10.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11923","CDM","270","RC","","","facility","both","","","","17.19","8.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11924","CDM","270","RC","","","facility","both","","","","19.94","9.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11925","CDM","270","RC","","","facility","both","","","","52.17","26.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11926","CDM","270","RC","","","facility","both","","","","51.91","25.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11931","CDM","270","RC","","","facility","both","","","","55.72","27.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11935","CDM","270","RC","","","facility","both","","","","20.48","10.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11936","CDM","270","RC","","","facility","both","","","","61.11","30.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11938","CDM","270","RC","","","facility","both","","","","219.15","109.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11940","CDM","270","RC","","","facility","both","","","","21.72","10.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11941","CDM","270","RC","","","facility","both","","","","21.37","10.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11942","CDM","270","RC","","","facility","both","","","","54.78","27.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11943","CDM","270","RC","","","facility","both","","","","21.11","10.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11944","CDM","270","RC","","","facility","both","","","","20.71","10.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11945","CDM","270","RC","","","facility","both","","","","54.78","27.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11946","CDM","270","RC","","","facility","both","","","","62.02","31.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11947","CDM","270","RC","","","facility","both","","","","60.59","30.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11953","CDM","270","RC","","","facility","both","","","","247.96","123.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11955","CDM","270","RC","","","facility","both","","","","61.48","30.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11957","CDM","270","RC","","","facility","both","","","","64.17","32.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11967","CDM","270","RC","","","facility","both","","","","4.9","2.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11968","CDM","270","RC","","","facility","both","","","","4.45","2.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11969","CDM","270","RC","","","facility","both","","","","12.4","6.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11970","CDM","270","RC","","","facility","both","","","","3.26","1.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11974","CDM","270","RC","","","facility","both","","","","5.16","2.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11975","CDM","270","RC","","","facility","both","","","","8.49","4.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11976","CDM","270","RC","","","facility","both","","","","4.37","2.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11977","CDM","270","RC","","","facility","both","","","","5.62","2.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11978","CDM","270","RC","","","facility","both","","","","5.67","2.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11979","CDM","270","RC","","","facility","both","","","","12.4","6.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11981","CDM","270","RC","","","facility","both","","","","12.4","6.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11985","CDM","270","RC","","","facility","both","","","","6.52","3.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","119854","CDM","270","RC","","","facility","both","","","","59.19","29.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11986","CDM","270","RC","","","facility","both","","","","10.3","5.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11987","CDM","270","RC","","","facility","both","","","","30.48","15.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11988","CDM","270","RC","","","facility","both","","","","30.28","15.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11991","CDM","270","RC","","","facility","both","","","","4.37","2.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","119965","CDM","270","RC","","","facility","both","","","","30.34","15.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11997","CDM","270","RC","","","facility","both","","","","6.12","3.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","11998","CDM","270","RC","","","facility","both","","","","33.78","16.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120010","CDM","270","RC","","","facility","both","","","","294.18","147.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120012","CDM","270","RC","","","facility","both","","","","74.75","37.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120013","CDM","270","RC","","","facility","both","","","","198.38","99.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12004","CDM","270","RC","","","facility","both","","","","7.2","3.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12005","CDM","270","RC","","","facility","both","","","","10.44","5.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120050","CDM","270","RC","","","facility","both","","","","116.1","58.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12011","CDM","270","RC","","","facility","both","","","","40.52","20.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12012","CDM","270","RC","","","facility","both","","","","20.65","10.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12036","CDM","270","RC","","","facility","both","","","","40.49","20.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12047","CDM","270","RC","","","facility","both","","","","148.65","74.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12060","CDM","270","RC","","","facility","both","","","","47.1","23.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120692","CDM","272","RC","C1769","HCPCS","facility","both","","","","808.68","404.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120775","CDM","270","RC","","","facility","both","","","","17.23","8.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1208","CDM","270","RC","","","facility","both","","","","21.76","10.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12080","CDM","270","RC","","","facility","both","","","","21.37","10.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120805","CDM","270","RC","","","facility","both","","","","191.89","95.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120806","CDM","272","RC","C1769","HCPCS","facility","both","","","","382.43","191.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","120808","CDM","270","RC","C1750","HCPCS","facility","both","","","","740.97","370.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12103","CDM","270","RC","","","facility","both","","","","11.29","5.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12104","CDM","270","RC","","","facility","both","","","","35.8","17.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12114","CDM","270","RC","","","facility","both","","","","4.49","2.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12115","CDM","270","RC","","","facility","both","","","","21.63","10.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12116","CDM","270","RC","","","facility","both","","","","6.48","3.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12117","CDM","270","RC","","","facility","both","","","","15.02","7.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12118","CDM","270","RC","","","facility","both","","","","5.83","2.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121190","CDM","270","RC","","","facility","both","","","","153.71","76.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12120","CDM","270","RC","","","facility","both","","","","39.47","19.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12121","CDM","270","RC","","","facility","both","","","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12127","CDM","270","RC","","","facility","both","","","","13.58","6.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12135","CDM","270","RC","","","facility","both","","","","11.02","5.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12148","CDM","270","RC","","","facility","both","","","","256.73","128.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12153","CDM","270","RC","","","facility","both","","","","39.25","19.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121557","CDM","278","RC","C1772","HCPCS","facility","both","","","","22084.09","11042.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12156","CDM","270","RC","","","facility","both","","","","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12158","CDM","270","RC","","","facility","both","","","","21.53","10.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121616","CDM","272","RC","C1729","HCPCS","facility","both","","","","97.68","48.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121649","CDM","278","RC","C1713","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12168","CDM","270","RC","","","facility","both","","","","185.22","92.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121706","CDM","270","RC","","","facility","both","","","","87.63","43.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121707","CDM","270","RC","","","facility","both","","","","87.63","43.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121709","CDM","270","RC","","","facility","both","","","","87.63","43.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121710","CDM","270","RC","","","facility","both","","","","87.63","43.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121759","CDM","270","RC","","","facility","both","","","","132.38","66.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121833","CDM","270","RC","","","facility","both","","","","22.46","11.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121854","CDM","270","RC","","","facility","both","","","","2694.39","1347.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121873","CDM","270","RC","","","facility","both","","","","488.81","244.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","121874","CDM","270","RC","","","facility","both","","","","408.08","204.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","122226","CDM","272","RC","C1725","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","122236","CDM","278","RC","C1768","HCPCS","facility","both","","","","3473.2","1736.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12300","CDM","270","RC","","","facility","both","","","","19.08","9.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","124786","CDM","278","RC","Q4104","HCPCS","facility","both","","","","149.17","74.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","125034","CDM","272","RC","C1729","HCPCS","facility","both","","","","83.97","41.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","125062","CDM","270","RC","","","facility","both","","","","363.35","181.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","125215","CDM","270","RC","","","facility","both","","","","53.31","26.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","125236","CDM","270","RC","","","facility","both","","","","1697.4","848.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","125518","CDM","278","RC","Q4104","HCPCS","facility","both","","","","52.4","26.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","125621","CDM","270","RC","","","facility","both","","","","230.94","115.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126403","CDM","278","RC","C1776","HCPCS","facility","both","","","","3908.3","1954.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126465","CDM","278","RC","C1771","HCPCS","facility","both","","","","3592.08","1796.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126470","CDM","270","RC","","","facility","both","","","","93.9","46.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126514","CDM","270","RC","","","facility","both","","","","134.09","67.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126548","CDM","270","RC","","","facility","both","","","","201.66","100.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1267","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12672","CDM","270","RC","","","facility","both","","","","74.58","37.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126897","CDM","270","RC","","","facility","both","","","","110.61","55.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126908","CDM","270","RC","","","facility","both","","","","1418.33","709.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126909","CDM","270","RC","","","facility","both","","","","1489.64","744.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126910","CDM","270","RC","","","facility","both","","","","1489.63","744.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126911","CDM","270","RC","","","facility","both","","","","1489.63","744.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12692","CDM","270","RC","","","facility","both","","","","5.02","2.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12694","CDM","270","RC","","","facility","both","","","","6.35","3.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126940","CDM","276","RC","V2632","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","126968","CDM","270","RC","","","facility","both","","","","230.67","115.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12709","CDM","270","RC","","","facility","both","","","","2.71","1.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12714","CDM","272","RC","A6223","HCPCS","facility","both","","","","2.99","1.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12720","CDM","270","RC","","","facility","both","","","","138.94","69.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127633","CDM","270","RC","","","facility","both","","","","1976","988","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127635","CDM","270","RC","","","facility","both","","","","1319.63","659.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127666","CDM","278","RC","C1776","HCPCS","facility","both","","","","4736.93","2368.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127691","CDM","270","RC","","","facility","both","","","","84.23","42.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127716","CDM","278","RC","C1713","HCPCS","facility","both","","","","584.43","292.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127717","CDM","278","RC","C1713","HCPCS","facility","both","","","","584.43","292.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127718","CDM","278","RC","C1713","HCPCS","facility","both","","","","584.43","292.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127765","CDM","278","RC","C1789","HCPCS","facility","both","","","","2041","1020.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12780","CDM","270","RC","","","facility","both","","","","78.85","39.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","127876","CDM","278","RC","C1767","HCPCS","facility","both","","","","37430","18715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12795","CDM","270","RC","","","facility","both","","","","17.84","8.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12796","CDM","270","RC","","","facility","both","","","","6.44","3.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12799","CDM","270","RC","","","facility","both","","","","21.91","10.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12807","CDM","270","RC","","","facility","both","","","","80.5","40.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","128097","CDM","278","RC","C1763","HCPCS","facility","both","","","","2044.9","1022.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","128099","CDM","278","RC","C1763","HCPCS","facility","both","","","","2044.9","1022.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","128183","CDM","270","RC","","","facility","both","","","","697.14","348.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","128184","CDM","278","RC","C1713","HCPCS","facility","both","","","","402.84","201.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12841","CDM","270","RC","","","facility","both","","","","19.27","9.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12844","CDM","270","RC","","","facility","both","","","","27.57","13.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12855","CDM","270","RC","","","facility","both","","","","18.05","9.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12863","CDM","272","RC","A6254","HCPCS","facility","both","","","","2.01","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","128661","CDM","270","RC","","","facility","both","","","","147.78","73.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","128663","CDM","270","RC","","","facility","both","","","","157.32","78.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12870","CDM","278","RC","C1762","HCPCS","facility","both","","","","53.21","26.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12871","CDM","270","RC","C1713","HCPCS","facility","both","","","","297.85","148.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12890","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","129310","CDM","270","RC","","","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","129313","CDM","270","RC","","","facility","both","","","","1716.03","858.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12933","CDM","272","RC","C1887","HCPCS","facility","both","","","","60.14","30.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12937","CDM","278","RC","C1751","HCPCS","facility","both","","","","63.48","31.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12940","CDM","272","RC","C1887","HCPCS","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","129425","CDM","278","RC","C1776","HCPCS","facility","both","","","","7448","3724","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12947","CDM","270","RC","","","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","129652","CDM","270","RC","","","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","12998","CDM","270","RC","","","facility","both","","","","1232.8","616.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130264","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13059","CDM","270","RC","","","facility","both","","","","147.98","73.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130624","CDM","270","RC","","","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130744","CDM","278","RC","C1768","HCPCS","facility","both","","","","4383.87","2191.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130775","CDM","270","RC","","","facility","both","","","","35.39","17.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130776","CDM","270","RC","","","facility","both","","","","32.35","16.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130778","CDM","270","RC","","","facility","both","","","","51.83","25.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","130779","CDM","270","RC","","","facility","both","","","","47.12","23.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13104","CDM","270","RC","","","facility","both","","","","82.11","41.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13113","CDM","270","RC","","","facility","both","","","","43.67","21.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","131495","CDM","278","RC","C1757","HCPCS","facility","both","","","","5478.94","2739.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13159","CDM","270","RC","C1729","HCPCS","facility","both","","","","1173","586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","131784","CDM","278","RC","C1781","HCPCS","facility","both","","","","224.48","112.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1318","CDM","270","RC","","","facility","both","","","","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","131930","CDM","270","RC","","","facility","both","","","","1362.2","681.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","131943","CDM","270","RC","B4087","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","131945","CDM","270","RC","","","facility","both","","","","562.35","281.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132203","CDM","270","RC","","","facility","both","","","","2643.74","1321.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132627","CDM","278","RC","C1713","HCPCS","facility","both","","","","2316.23","1158.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13266","CDM","270","RC","","","facility","both","","","","59.25","29.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132675","CDM","278","RC","C1713","HCPCS","facility","both","","","","107.27","53.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132676","CDM","278","RC","C1713","HCPCS","facility","both","","","","107.27","53.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132677","CDM","278","RC","C1713","HCPCS","facility","both","","","","107.27","53.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132702","CDM","278","RC","C1713","HCPCS","facility","both","","","","495.51","247.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132714","CDM","278","RC","C1713","HCPCS","facility","both","","","","495.51","247.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13272","CDM","270","RC","","","facility","both","","","","81.88","40.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","132853","CDM","270","RC","","","facility","both","","","","1353.09","676.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133335","CDM","278","RC","C1874","HCPCS","facility","both","","","","4734.72","2367.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133339","CDM","278","RC","C1817","HCPCS","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13339","CDM","272","RC","C1769","HCPCS","facility","both","","","","104.42","52.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133569","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133622","CDM","278","RC","C1713","HCPCS","facility","both","","","","2093.16","1046.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133623","CDM","278","RC","C1713","HCPCS","facility","both","","","","2093.16","1046.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133629","CDM","278","RC","C1713","HCPCS","facility","both","","","","2093.16","1046.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133634","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133635","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133636","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133637","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133638","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133639","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133640","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","133641","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1339","CDM","270","RC","","","facility","both","","","","476.33","238.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13438","CDM","278","RC","C1713","HCPCS","facility","both","","","","91.54","45.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134393","CDM","270","RC","","","facility","both","","","","650.76","325.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134414","CDM","270","RC","","","facility","both","","","","632.5","316.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134422","CDM","270","RC","","","facility","both","","","","23.11","11.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134426","CDM","270","RC","","","facility","both","","","","1932","966","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134428","CDM","270","RC","","","facility","both","","","","1541","770.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134451","CDM","270","RC","","","facility","both","","","","2094.79","1047.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13451","CDM","270","RC","","","facility","both","","","","11.75","5.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134789","CDM","278","RC","C1776","HCPCS","facility","both","","","","3230.82","1615.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134863","CDM","278","RC","C1768","HCPCS","facility","both","","","","1065.76","532.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","134980","CDM","270","RC","","","facility","both","","","","250.7","125.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135005","CDM","278","RC","C1788","HCPCS","facility","both","","","","1320.2","660.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135233","CDM","272","RC","C1887","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135234","CDM","272","RC","C1769","HCPCS","facility","both","","","","815.29","407.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135235","CDM","272","RC","C1769","HCPCS","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13533","CDM","272","RC","C1769","HCPCS","facility","both","","","","53.74","26.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13553","CDM","272","RC","C1769","HCPCS","facility","both","","","","143.23","71.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135534","CDM","278","RC","C1713","HCPCS","facility","both","","","","2000.17","1000.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135536","CDM","278","RC","C1713","HCPCS","facility","both","","","","1947.08","973.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135556","CDM","278","RC","C1713","HCPCS","facility","both","","","","263.35","131.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135560","CDM","278","RC","C1713","HCPCS","facility","both","","","","263.35","131.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135700","CDM","278","RC","C1713","HCPCS","facility","both","","","","2181","1090.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135727","CDM","270","RC","","","facility","both","","","","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135728","CDM","270","RC","","","facility","both","","","","22.31","11.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135852","CDM","270","RC","","","facility","both","","","","1504.08","752.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135867","CDM","272","RC","C1769","HCPCS","facility","both","","","","47.15","23.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135877","CDM","272","RC","C1729","HCPCS","facility","both","","","","295.92","147.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13590","CDM","272","RC","C1769","HCPCS","facility","both","","","","263.26","131.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135960","CDM","278","RC","C1713","HCPCS","facility","both","","","","998.2","499.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135964","CDM","270","RC","","","facility","both","","","","692.78","346.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","135965","CDM","270","RC","","","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13613","CDM","278","RC","C1713","HCPCS","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","136257","CDM","270","RC","","","facility","both","","","","518.65","259.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","136258","CDM","270","RC","","","facility","both","","","","514.69","257.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","136315","CDM","278","RC","C1713","HCPCS","facility","both","","","","263.35","131.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13669","CDM","270","RC","","","facility","both","","","","23.37","11.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137066","CDM","270","RC","","","facility","both","","","","178.6","89.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137069","CDM","270","RC","","","facility","both","","","","95.82","47.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137073","CDM","270","RC","","","facility","both","","","","498.48","249.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137078","CDM","270","RC","","","facility","both","","","","1328.36","664.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13708","CDM","270","RC","","","facility","both","","","","166.98","83.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137087","CDM","270","RC","","","facility","both","","","","1068.79","534.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137165","CDM","272","RC","C1773","HCPCS","facility","both","","","","1476.92","738.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137166","CDM","272","RC","C1773","HCPCS","facility","both","","","","1476.92","738.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137167","CDM","272","RC","C1773","HCPCS","facility","both","","","","1651.91","825.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137242","CDM","278","RC","C1713","HCPCS","facility","both","","","","7220","3610","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137540","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137689","CDM","270","RC","","","facility","both","","","","7.92","3.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","137766","CDM","278","RC","C1762","HCPCS","facility","both","","","","2612.5","1306.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138","CDM","270","RC","","","facility","both","","","","6.92","3.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138051","CDM","278","RC","C1713","HCPCS","facility","both","","","","551.94","275.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138054","CDM","278","RC","C1713","HCPCS","facility","both","","","","625.6","312.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138055","CDM","278","RC","C1713","HCPCS","facility","both","","","","625.6","312.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138056","CDM","278","RC","C1713","HCPCS","facility","both","","","","625.6","312.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138062","CDM","278","RC","C1713","HCPCS","facility","both","","","","740.6","370.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138266","CDM","270","RC","","","facility","both","","","","272.67","136.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","138283","CDM","270","RC","","","facility","both","","","","126.5","63.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13836","CDM","270","RC","","","facility","both","","","","39.17","19.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13931","CDM","270","RC","","","facility","both","","","","3.41","1.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13934","CDM","270","RC","","","facility","both","","","","26.6","13.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13935","CDM","270","RC","","","facility","both","","","","3.52","1.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13936","CDM","270","RC","","","facility","both","","","","5.52","2.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13938","CDM","270","RC","","","facility","both","","","","21.19","10.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13941","CDM","270","RC","","","facility","both","","","","409.13","204.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13955","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13976","CDM","270","RC","","","facility","both","","","","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13984","CDM","270","RC","","","facility","both","","","","12.47","6.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13988","CDM","272","RC","C1729","HCPCS","facility","both","","","","17.52","8.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","13995","CDM","272","RC","C1729","HCPCS","facility","both","","","","16.43","8.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14012","CDM","270","RC","","","facility","both","","","","19.85","9.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14037","CDM","270","RC","","","facility","both","","","","13.48","6.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14042","CDM","270","RC","","","facility","both","","","","18.12","9.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14049","CDM","270","RC","","","facility","both","","","","14.18","7.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14055","CDM","270","RC","L3260","HCPCS","facility","both","","","","18.12","9.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14085","CDM","270","RC","","","facility","both","","","","31.48","15.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14094","CDM","270","RC","","","facility","both","","","","23.25","11.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14103","CDM","270","RC","","","facility","both","","","","58.23","29.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14108","CDM","270","RC","","","facility","both","","","","19.74","9.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14109","CDM","270","RC","","","facility","both","","","","56.53","28.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141148","CDM","278","RC","C1776","HCPCS","facility","both","","","","12329.1","6164.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141150","CDM","278","RC","C1776","HCPCS","facility","both","","","","4626.01","2313","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141313","CDM","278","RC","C1776","HCPCS","facility","both","","","","3361.18","1680.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141347","CDM","278","RC","C1776","HCPCS","facility","both","","","","3186.41","1593.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141396","CDM","278","RC","C1776","HCPCS","facility","both","","","","4214.2","2107.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141416","CDM","272","RC","C1769","HCPCS","facility","both","","","","1853.34","926.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141418","CDM","270","RC","","","facility","both","","","","287.09","143.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141510","CDM","278","RC","C1874","HCPCS","facility","both","","","","4501.12","2250.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141584","CDM","270","RC","","","facility","both","","","","53.43","26.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141587","CDM","270","RC","","","facility","both","","","","137.89","68.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141614","CDM","270","RC","","","facility","both","","","","57.5","28.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1417","CDM","270","RC","","","facility","both","","","","4.96","2.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14173","CDM","270","RC","","","facility","both","","","","51.49","25.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141790","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141873","CDM","270","RC","","","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","141888","CDM","272","RC","C1729","HCPCS","facility","both","","","","71.24","35.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142059","CDM","270","RC","","","facility","both","","","","37.46","18.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142060","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142064","CDM","270","RC","","","facility","both","","","","19.44","9.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142065","CDM","270","RC","","","facility","both","","","","5.39","2.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142068","CDM","270","RC","","","facility","both","","","","5.73","2.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142108","CDM","270","RC","","","facility","both","","","","40.98","20.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142120","CDM","270","RC","","","facility","both","","","","58.6","29.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142129","CDM","270","RC","","","facility","both","","","","430.1","215.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142143","CDM","270","RC","","","facility","both","","","","25.76","12.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142147","CDM","270","RC","","","facility","both","","","","110.98","55.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142158","CDM","270","RC","","","facility","both","","","","239.2","119.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142159","CDM","270","RC","","","facility","both","","","","124.2","62.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142163","CDM","270","RC","","","facility","both","","","","233.88","116.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142166","CDM","270","RC","","","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142167","CDM","270","RC","","","facility","both","","","","78.2","39.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14224","CDM","270","RC","B4082","HCPCS","facility","both","","","","26.59","13.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14226","CDM","270","RC","B4082","HCPCS","facility","both","","","","26.59","13.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14270","CDM","270","RC","","","facility","both","","","","11.73","5.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142714","CDM","278","RC","C1713","HCPCS","facility","both","","","","460.16","230.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14273","CDM","278","RC","C1781","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142731","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14278","CDM","270","RC","","","facility","both","","","","23.6","11.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142823","CDM","278","RC","C1887","HCPCS","facility","both","","","","1417.57","708.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142948","CDM","270","RC","","","facility","both","","","","261.76","130.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","142977","CDM","270","RC","","","facility","both","","","","1065.36","532.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143021","CDM","278","RC","C1713","HCPCS","facility","both","","","","1437.23","718.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143045","CDM","278","RC","C1713","HCPCS","facility","both","","","","2248.66","1124.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14305","CDM","270","RC","C1729","HCPCS","facility","both","","","","28.29","14.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143059","CDM","270","RC","","","facility","both","","","","86.35","43.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14306","CDM","270","RC","","","facility","both","","","","27.73","13.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14308","CDM","270","RC","","","facility","both","","","","28.5","14.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14314","CDM","270","RC","","","facility","both","","","","8.03","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14319","CDM","270","RC","","","facility","both","","","","20.19","10.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14320","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14322","CDM","270","RC","","","facility","both","","","","24.68","12.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14334","CDM","270","RC","","","facility","both","","","","11.55","5.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14335","CDM","270","RC","","","facility","both","","","","20.65","10.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143398","CDM","270","RC","","","facility","both","","","","22.74","11.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14341","CDM","270","RC","","","facility","both","","","","18.03","9.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14342","CDM","270","RC","","","facility","both","","","","103.04","51.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14345","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14349","CDM","270","RC","","","facility","both","","","","14.47","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14352","CDM","270","RC","","","facility","both","","","","14.47","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143540","CDM","270","RC","","","facility","both","","","","516.67","258.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143543","CDM","270","RC","","","facility","both","","","","734.16","367.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143544","CDM","270","RC","","","facility","both","","","","640.37","320.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143549","CDM","278","RC","C1713","HCPCS","facility","both","","","","209.48","104.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143551","CDM","278","RC","C1713","HCPCS","facility","both","","","","208.75","104.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143555","CDM","278","RC","C1713","HCPCS","facility","both","","","","208.56","104.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143557","CDM","278","RC","C1713","HCPCS","facility","both","","","","208.56","104.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143604","CDM","278","RC","C1713","HCPCS","facility","both","","","","390.12","195.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143610","CDM","278","RC","C1713","HCPCS","facility","both","","","","481.62","240.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143614","CDM","278","RC","C1713","HCPCS","facility","both","","","","481.62","240.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143616","CDM","278","RC","C1713","HCPCS","facility","both","","","","481.62","240.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14363","CDM","270","RC","","","facility","both","","","","9.01","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143634","CDM","278","RC","C1713","HCPCS","facility","both","","","","1126.36","563.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143641","CDM","278","RC","C1713","HCPCS","facility","both","","","","1097.84","548.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143643","CDM","278","RC","C1713","HCPCS","facility","both","","","","1284.23","642.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143815","CDM","278","RC","C1713","HCPCS","facility","both","","","","390.12","195.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143879","CDM","270","RC","","","facility","both","","","","1536.4","768.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143951","CDM","270","RC","","","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","143959","CDM","270","RC","","","facility","both","","","","702.88","351.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14402","CDM","270","RC","","","facility","both","","","","51.77","25.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14445","CDM","270","RC","","","facility","both","","","","9.85","4.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14449","CDM","270","RC","","","facility","both","","","","8.79","4.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14463","CDM","272","RC","C1729","HCPCS","facility","both","","","","54.51","27.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","144786","CDM","270","RC","","","facility","both","","","","2225.8","1112.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14512","CDM","270","RC","","","facility","both","","","","3.34","1.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14529","CDM","270","RC","","","facility","both","","","","3.4","1.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1454","CDM","270","RC","","","facility","both","","","","26.47","13.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14544","CDM","270","RC","","","facility","both","","","","318.64","159.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14547","CDM","270","RC","","","facility","both","","","","170.8","85.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","145580","CDM","270","RC","","","facility","both","","","","27.38","13.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","145596","CDM","270","RC","","","facility","both","","","","3135","1567.5","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","145871","CDM","278","RC","C1752","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","14610","CDM","270","RC","","","facility","both","","","","27.23","13.62","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","1462","CDM","270","RC","","","facility","both","","","","142.55","71.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14620","CDM","270","RC","","","facility","both","","","","9.3","4.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14622","CDM","270","RC","","","facility","both","","","","12.76","6.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14628","CDM","270","RC","","","facility","both","","","","3.13","1.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146280","CDM","278","RC","C1876","HCPCS","facility","both","","","","1404","702","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14629","CDM","270","RC","","","facility","both","","","","8.04","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146291","CDM","278","RC","C1874","HCPCS","facility","both","","","","1404","702","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14631","CDM","270","RC","","","facility","both","","","","459.86","229.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14637","CDM","270","RC","","","facility","both","","","","2.75","1.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14643","CDM","270","RC","","","facility","both","","","","291.6","145.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14649","CDM","270","RC","","","facility","both","","","","34.27","17.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14651","CDM","270","RC","","","facility","both","","","","35.51","17.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14652","CDM","270","RC","","","facility","both","","","","67.17","33.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14653","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14660","CDM","270","RC","","","facility","both","","","","4.14","2.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146752","CDM","270","RC","","","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146758","CDM","278","RC","V2785","HCPCS","facility","both","","","","6718.4","3359.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146761","CDM","278","RC","V2785","HCPCS","facility","both","","","","6718.4","3359.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146782","CDM","270","RC","","","facility","both","","","","121.9","60.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146785","CDM","270","RC","","","facility","both","","","","58.68","29.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146787","CDM","272","RC","C1769","HCPCS","facility","both","","","","784.23","392.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146788","CDM","272","RC","C1769","HCPCS","facility","both","","","","784.23","392.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146901","CDM","278","RC","C1874","HCPCS","facility","both","","","","4501.12","2250.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146902","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146923","CDM","270","RC","","","facility","both","","","","76.43","38.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146932","CDM","270","RC","","","facility","both","","","","575","287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146935","CDM","270","RC","","","facility","both","","","","9.61","4.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","146947","CDM","270","RC","","","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14695","CDM","270","RC","","","facility","both","","","","11.27","5.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147037","CDM","270","RC","","","facility","both","","","","24.76","12.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147038","CDM","270","RC","","","facility","both","","","","21.37","10.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147052","CDM","270","RC","","","facility","both","","","","1251.84","625.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147055","CDM","270","RC","","","facility","both","","","","1686.31","843.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147152","CDM","272","RC","C1893","HCPCS","facility","both","","","","1173","586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147298","CDM","278","RC","C1874","HCPCS","facility","both","","","","17057.25","8528.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147331","CDM","278","RC","C1874","HCPCS","facility","both","","","","8507.25","4253.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147334","CDM","278","RC","C1874","HCPCS","facility","both","","","","8421.75","4210.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147335","CDM","278","RC","C1874","HCPCS","facility","both","","","","7652.25","3826.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147336","CDM","278","RC","C1874","HCPCS","facility","both","","","","7951.5","3975.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147337","CDM","278","RC","C1874","HCPCS","facility","both","","","","8507.25","4253.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147338","CDM","278","RC","C1874","HCPCS","facility","both","","","","7652.25","3826.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147339","CDM","278","RC","C1874","HCPCS","facility","both","","","","8421.75","4210.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147341","CDM","278","RC","C1874","HCPCS","facility","both","","","","8293.5","4146.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","147427","CDM","270","RC","","","facility","both","","","","302.82","151.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14766","CDM","278","RC","C1762","HCPCS","facility","both","","","","63.97","31.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14768","CDM","278","RC","C1762","HCPCS","facility","both","","","","81.48","40.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14775","CDM","270","RC","","","facility","both","","","","124.2","62.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14818","CDM","272","RC","C1751","HCPCS","facility","both","","","","1181.4","590.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148264","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148311","CDM","278","RC","C1713","HCPCS","facility","both","","","","1461.08","730.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148312","CDM","278","RC","C1713","HCPCS","facility","both","","","","1461.08","730.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148381","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148382","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148392","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148393","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148394","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148528","CDM","270","RC","","","facility","both","","","","1843.1","921.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148541","CDM","272","RC","A6259","HCPCS","facility","both","","","","7.71","3.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148853","CDM","278","RC","C1751","HCPCS","facility","both","","","","553.56","276.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148921","CDM","272","RC","C1769","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148922","CDM","278","RC","C1713","HCPCS","facility","both","","","","2652.4","1326.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148934","CDM","270","RC","","","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","148937","CDM","270","RC","","","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149036","CDM","278","RC","C1768","HCPCS","facility","both","","","","2233.07","1116.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149137","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149139","CDM","270","RC","","","facility","both","","","","298.15","149.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149140","CDM","270","RC","C2626","HCPCS","facility","both","","","","126.96","63.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149142","CDM","270","RC","C2626","HCPCS","facility","both","","","","591.26","295.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149143","CDM","270","RC","C2626","HCPCS","facility","both","","","","2173.6","1086.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149151","CDM","270","RC","","","facility","both","","","","1681.16","840.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149152","CDM","270","RC","","","facility","both","","","","2242.78","1121.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149246","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149253","CDM","270","RC","","","facility","both","","","","2067.92","1033.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149257","CDM","270","RC","","","facility","both","","","","82.85","41.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149260","CDM","270","RC","","","facility","both","","","","1810.99","905.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149263","CDM","270","RC","","","facility","both","","","","2219.85","1109.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149552","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149559","CDM","270","RC","","","facility","both","","","","40.94","20.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14956","CDM","270","RC","","","facility","both","","","","22.63","11.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14957","CDM","270","RC","","","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149599","CDM","270","RC","","","facility","both","","","","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14960","CDM","270","RC","","","facility","both","","","","19.82","9.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149631","CDM","270","RC","","","facility","both","","","","752.51","376.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","14965","CDM","270","RC","","","facility","both","","","","374.56","187.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149699","CDM","270","RC","","","facility","both","","","","782","391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149701","CDM","278","RC","C1713","HCPCS","facility","both","","","","1380","690","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149711","CDM","270","RC","","","facility","both","","","","805","402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149718","CDM","270","RC","","","facility","both","","","","1316.16","658.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149734","CDM","270","RC","","","facility","both","","","","549.24","274.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149737","CDM","270","RC","C1758","HCPCS","facility","both","","","","892.4","446.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149738","CDM","270","RC","C1758","HCPCS","facility","both","","","","760.17","380.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149750","CDM","270","RC","","","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149751","CDM","270","RC","","","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149752","CDM","270","RC","","","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149753","CDM","278","RC","C1778","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149862","CDM","270","RC","","","facility","both","","","","726.8","363.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149867","CDM","272","RC","C1769","HCPCS","facility","both","","","","784.23","392.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149868","CDM","270","RC","B4087","HCPCS","facility","both","","","","636.55","318.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","149883","CDM","270","RC","","","facility","both","","","","757.68","378.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15004","CDM","272","RC","C1729","HCPCS","facility","both","","","","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150052","CDM","270","RC","","","facility","both","","","","201.57","100.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150053","CDM","270","RC","","","facility","both","","","","268.14","134.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15006","CDM","272","RC","C1729","HCPCS","facility","both","","","","5.47","2.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150060","CDM","270","RC","","","facility","both","","","","6.31","3.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150062","CDM","270","RC","","","facility","both","","","","147.66","73.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150063","CDM","270","RC","","","facility","both","","","","1738.48","869.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150064","CDM","278","RC","C1776","HCPCS","facility","both","","","","2422.5","1211.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150074","CDM","270","RC","","","facility","both","","","","1574.26","787.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15009","CDM","272","RC","C1729","HCPCS","facility","both","","","","13.27","6.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150098","CDM","278","RC","C1776","HCPCS","facility","both","","","","8946.25","4473.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150099","CDM","278","RC","C1776","HCPCS","facility","both","","","","8946.25","4473.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150106","CDM","278","RC","C1776","HCPCS","facility","both","","","","4029.1","2014.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150112","CDM","278","RC","C1776","HCPCS","facility","both","","","","2212.21","1106.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15013","CDM","270","RC","","","facility","both","","","","30.09","15.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15015","CDM","270","RC","","","facility","both","","","","31.12","15.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15017","CDM","270","RC","","","facility","both","","","","33.23","16.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15018","CDM","270","RC","","","facility","both","","","","379.5","189.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150257","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150265","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150268","CDM","278","RC","C1713","HCPCS","facility","both","","","","2093.16","1046.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150276","CDM","270","RC","","","facility","both","","","","166.2","83.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150283","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150288","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150293","CDM","278","RC","C1776","HCPCS","facility","both","","","","4029.1","2014.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150299","CDM","270","RC","","","facility","both","","","","901.6","450.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150339","CDM","278","RC","C1776","HCPCS","facility","both","","","","10738.8","5369.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150344","CDM","270","RC","","","facility","both","","","","647.83","323.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150345","CDM","270","RC","","","facility","both","","","","647.83","323.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","150472","CDM","270","RC","","","facility","both","","","","1283.4","641.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15063","CDM","272","RC","C1729","HCPCS","facility","both","","","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15070","CDM","272","RC","B4082","HCPCS","facility","both","","","","16.1","8.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15081","CDM","270","RC","","","facility","both","","","","894.64","447.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15125","CDM","270","RC","","","facility","both","","","","40.34","20.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151281","CDM","278","RC","C1781","HCPCS","facility","both","","","","967.84","483.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151286","CDM","278","RC","C1781","HCPCS","facility","both","","","","1443.43","721.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151287","CDM","278","RC","C1781","HCPCS","facility","both","","","","1903.44","951.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151288","CDM","278","RC","C1781","HCPCS","facility","both","","","","1541","770.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151290","CDM","278","RC","C1781","HCPCS","facility","both","","","","1518","759","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151291","CDM","278","RC","C1781","HCPCS","facility","both","","","","1668.38","834.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151292","CDM","278","RC","C1781","HCPCS","facility","both","","","","2185","1092.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151345","CDM","270","RC","","","facility","both","","","","520.26","260.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151349","CDM","270","RC","","","facility","both","","","","1111.31","555.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151376","CDM","270","RC","","","facility","both","","","","467.36","233.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151379","CDM","270","RC","","","facility","both","","","","555.68","277.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151380","CDM","270","RC","","","facility","both","","","","592.48","296.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151540","CDM","270","RC","","","facility","both","","","","154.13","77.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151595","CDM","278","RC","C1751","HCPCS","facility","both","","","","299","149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151645","CDM","270","RC","","","facility","both","","","","939.06","469.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151669","CDM","278","RC","Q4121","HCPCS","facility","both","","","","61.59","30.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151677","CDM","270","RC","","","facility","both","","","","114.45","57.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151679","CDM","270","RC","C1894","HCPCS","facility","both","","","","1026.44","513.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151746","CDM","270","RC","","","facility","both","","","","717.85","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151747","CDM","270","RC","","","facility","both","","","","1371.94","685.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151748","CDM","270","RC","","","facility","both","","","","2169.87","1084.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151749","CDM","270","RC","","","facility","both","","","","2097.65","1048.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151750","CDM","270","RC","","","facility","both","","","","1587.74","793.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151752","CDM","270","RC","","","facility","both","","","","1453.74","726.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151753","CDM","270","RC","","","facility","both","","","","1335.54","667.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151754","CDM","270","RC","","","facility","both","","","","2280.82","1140.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151755","CDM","270","RC","","","facility","both","","","","1618.97","809.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151756","CDM","270","RC","","","facility","both","","","","1588.94","794.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151758","CDM","270","RC","","","facility","both","","","","1687.69","843.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15176","CDM","270","RC","","","facility","both","","","","40.65","20.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151760","CDM","270","RC","","","facility","both","","","","2172.3","1086.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151761","CDM","270","RC","","","facility","both","","","","2001.71","1000.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151769","CDM","270","RC","","","facility","both","","","","939.06","469.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151779","CDM","278","RC","C1776","HCPCS","facility","both","","","","3088.26","1544.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151803","CDM","278","RC","C1776","HCPCS","facility","both","","","","3088.26","1544.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151884","CDM","278","RC","C1713","HCPCS","facility","both","","","","1119.46","559.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151885","CDM","278","RC","C1713","HCPCS","facility","both","","","","1119.46","559.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151887","CDM","278","RC","C1713","HCPCS","facility","both","","","","1040.32","520.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151889","CDM","278","RC","C1713","HCPCS","facility","both","","","","961.17","480.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151898","CDM","278","RC","C1713","HCPCS","facility","both","","","","3061.74","1530.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","151900","CDM","278","RC","C1713","HCPCS","facility","both","","","","965.17","482.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15204","CDM","270","RC","","","facility","both","","","","8.45","4.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15206","CDM","270","RC","","","facility","both","","","","8.02","4.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152131","CDM","278","RC","C1751","HCPCS","facility","both","","","","71.07","35.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152134","CDM","270","RC","","","facility","both","","","","9.2","4.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152136","CDM","270","RC","","","facility","both","","","","118.13","59.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152169","CDM","278","RC","C1713","HCPCS","facility","both","","","","5330.26","2665.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152170","CDM","278","RC","C1713","HCPCS","facility","both","","","","3695.5","1847.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152181","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152189","CDM","278","RC","C1713","HCPCS","facility","both","","","","550.02","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152201","CDM","270","RC","","","facility","both","","","","1958.9","979.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152229","CDM","272","RC","C1887","HCPCS","facility","both","","","","910.46","455.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15224","CDM","272","RC","C1729","HCPCS","facility","both","","","","10.35","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152280","CDM","272","RC","C1725","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152288","CDM","272","RC","C1725","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152292","CDM","272","RC","C1725","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152314","CDM","270","RC","","","facility","both","","","","9.59","4.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152384","CDM","278","RC","C1713","HCPCS","facility","both","","","","590.56","295.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15239","CDM","270","RC","L1830","HCPCS","facility","both","","","","51.47","25.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152393","CDM","278","RC","C1713","HCPCS","facility","both","","","","2729.6","1364.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152419","CDM","278","RC","C1713","HCPCS","facility","both","","","","590.56","295.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152420","CDM","278","RC","C1713","HCPCS","facility","both","","","","587.7","293.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152421","CDM","278","RC","C1713","HCPCS","facility","both","","","","574.54","287.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152450","CDM","270","RC","","","facility","both","","","","123.46","61.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152451","CDM","270","RC","","","facility","both","","","","361.35","180.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152452","CDM","270","RC","","","facility","both","","","","67.42","33.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152454","CDM","270","RC","","","facility","both","","","","235.83","117.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152455","CDM","270","RC","","","facility","both","","","","163.17","81.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152456","CDM","270","RC","","","facility","both","","","","176.23","88.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152457","CDM","270","RC","","","facility","both","","","","177.49","88.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152458","CDM","270","RC","","","facility","both","","","","203.45","101.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152459","CDM","270","RC","","","facility","both","","","","164.51","82.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152460","CDM","270","RC","","","facility","both","","","","111.97","55.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152463","CDM","270","RC","","","facility","both","","","","129.54","64.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152464","CDM","270","RC","","","facility","both","","","","201.18","100.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152470","CDM","270","RC","","","facility","both","","","","16.79","8.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15253","CDM","270","RC","","","facility","both","","","","16.4","8.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152952","CDM","270","RC","","","facility","both","","","","594.32","297.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","152953","CDM","270","RC","","","facility","both","","","","516.67","258.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee - Heel Stick","15300100","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153039","CDM","278","RC","C1725","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15306","CDM","272","RC","A6224","HCPCS","facility","both","","","","3.08","1.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153076","CDM","272","RC","C1725","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153220","CDM","278","RC","C1752","HCPCS","facility","both","","","","734.39","367.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15326","CDM","272","RC","A6223","HCPCS","facility","both","","","","3.01","1.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15330","CDM","272","RC","A6223","HCPCS","facility","both","","","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153319","CDM","278","RC","C1760","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153320","CDM","278","RC","C1760","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15334","CDM","272","RC","A6222","HCPCS","facility","both","","","","2.11","1.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153360","CDM","270","RC","","","facility","both","","","","1161.38","580.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153368","CDM","270","RC","","","facility","both","","","","518.47","259.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153372","CDM","278","RC","C1776","HCPCS","facility","both","","","","1404.93","702.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153433","CDM","278","RC","C1713","HCPCS","facility","both","","","","1424.8","712.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153434","CDM","278","RC","C1713","HCPCS","facility","both","","","","2036.89","1018.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153473","CDM","278","RC","C1713","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15348","CDM","270","RC","","","facility","both","","","","5.49","2.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153541","CDM","270","RC","","","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153544","CDM","270","RC","","","facility","both","","","","440.85","220.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153545","CDM","270","RC","","","facility","both","","","","440.85","220.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153546","CDM","270","RC","","","facility","both","","","","440.85","220.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153549","CDM","270","RC","","","facility","both","","","","214.87","107.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153552","CDM","270","RC","","","facility","both","","","","1471.57","735.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153561","CDM","278","RC","C1713","HCPCS","facility","both","","","","1424.8","712.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153568","CDM","270","RC","","","facility","both","","","","2093.8","1046.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153571","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.4","227.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153574","CDM","272","RC","C1725","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153595","CDM","270","RC","","","facility","both","","","","409.7","204.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15360","CDM","270","RC","","","facility","both","","","","11.68","5.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153680","CDM","270","RC","","","facility","both","","","","108.25","54.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153681","CDM","270","RC","","","facility","both","","","","109.32","54.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153711","CDM","270","RC","","","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153720","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153721","CDM","270","RC","","","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153760","CDM","278","RC","C1763","HCPCS","facility","both","","","","6175","3087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","153763","CDM","270","RC","","","facility","both","","","","526.93","263.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15391","CDM","272","RC","C1757","HCPCS","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15408","CDM","270","RC","","","facility","both","","","","13.85","6.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15421","CDM","270","RC","","","facility","both","","","","5.68","2.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15422","CDM","270","RC","","","facility","both","","","","26.54","13.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154265","CDM","270","RC","","","facility","both","","","","1307.86","653.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15427","CDM","270","RC","","","facility","both","","","","105.69","52.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15428","CDM","270","RC","","","facility","both","","","","3.81","1.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15433","CDM","270","RC","","","facility","both","","","","8.05","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154330","CDM","278","RC","C1776","HCPCS","facility","both","","","","3271.14","1635.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15434","CDM","270","RC","","","facility","both","","","","434.19","217.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15436","CDM","270","RC","","","facility","both","","","","11.35","5.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154726","CDM","278","RC","C1776","HCPCS","facility","both","","","","2345.07","1172.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154727","CDM","278","RC","C1713","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15475","CDM","270","RC","","","facility","both","","","","9.52","4.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15478","CDM","270","RC","","","facility","both","","","","24.3","12.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15481","CDM","270","RC","","","facility","both","","","","118.6","59.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154831","CDM","272","RC","C1725","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154858","CDM","272","RC","C1725","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154862","CDM","278","RC","C1725","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15487","CDM","270","RC","","","facility","both","","","","2.68","1.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154886","CDM","272","RC","C1725","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","154900","CDM","272","RC","C1725","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","155069","CDM","270","RC","","","facility","both","","","","29.54","14.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15525","CDM","270","RC","","","facility","both","","","","24.56","12.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15548","CDM","270","RC","","","facility","both","","","","4.22","2.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15572","CDM","270","RC","","","facility","both","","","","8.52","4.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15574","CDM","270","RC","","","facility","both","","","","8.51","4.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15578","CDM","270","RC","","","facility","both","","","","7.39","3.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15580","CDM","270","RC","","","facility","both","","","","8.05","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15582","CDM","270","RC","","","facility","both","","","","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15583","CDM","270","RC","","","facility","both","","","","407.17","203.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15585","CDM","270","RC","","","facility","both","","","","15.2","7.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15590","CDM","270","RC","","","facility","both","","","","20.83","10.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15591","CDM","270","RC","","","facility","both","","","","3.44","1.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15594","CDM","270","RC","","","facility","both","","","","2.53","1.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","155943","CDM","272","RC","C1729","HCPCS","facility","both","","","","68.66","34.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","155944","CDM","272","RC","C1773","HCPCS","facility","both","","","","1473.33","736.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","155992","CDM","270","RC","","","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156011","CDM","272","RC","C1782","HCPCS","facility","both","","","","2181.27","1090.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156022","CDM","270","RC","C1782","HCPCS","facility","both","","","","2284.59","1142.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156023","CDM","270","RC","","","facility","both","","","","1545.6","772.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156073","CDM","270","RC","","","facility","both","","","","15.49","7.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156197","CDM","270","RC","","","facility","both","","","","26.36","13.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156198","CDM","270","RC","","","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156199","CDM","270","RC","","","facility","both","","","","25.76","12.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156202","CDM","278","RC","C1713","HCPCS","facility","both","","","","2288","1144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156203","CDM","278","RC","C1713","HCPCS","facility","both","","","","2280","1140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156204","CDM","278","RC","C1713","HCPCS","facility","both","","","","4180","2090","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156206","CDM","278","RC","L8610","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15627","CDM","272","RC","C1729","HCPCS","facility","both","","","","13.17","6.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15639","CDM","270","RC","","","facility","both","","","","151.77","75.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156441","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156442","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156449","CDM","270","RC","","","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156456","CDM","278","RC","C1713","HCPCS","facility","both","","","","579.12","289.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156457","CDM","278","RC","C1713","HCPCS","facility","both","","","","574.54","287.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156527","CDM","270","RC","C1887","HCPCS","facility","both","","","","910.46","455.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","156597","CDM","270","RC","","","facility","both","","","","67.58","33.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157014","CDM","270","RC","","","facility","both","","","","20.13","10.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157023","CDM","270","RC","","","facility","both","","","","1596.57","798.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157024","CDM","270","RC","","","facility","both","","","","1294.42","647.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157046","CDM","278","RC","C1782","HCPCS","facility","both","","","","1635.27","817.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157189","CDM","278","RC","C1729","HCPCS","facility","both","","","","677.18","338.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157192","CDM","278","RC","C1769","HCPCS","facility","both","","","","1504.2","752.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15721","CDM","270","RC","","","facility","both","","","","69.05","34.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157220","CDM","270","RC","","","facility","both","","","","177.7","88.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157299","CDM","270","RC","","","facility","both","","","","41.86","20.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157362","CDM","278","RC","C1776","HCPCS","facility","both","","","","2201.29","1100.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157367","CDM","278","RC","C1776","HCPCS","facility","both","","","","2104.83","1052.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157378","CDM","270","RC","","","facility","both","","","","168.9","84.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157408","CDM","278","RC","C1776","HCPCS","facility","both","","","","2030.21","1015.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157409","CDM","278","RC","C1776","HCPCS","facility","both","","","","2345.07","1172.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157411","CDM","278","RC","C1776","HCPCS","facility","both","","","","2345.07","1172.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157508","CDM","278","RC","C1776","HCPCS","facility","both","","","","1971.06","985.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157530","CDM","270","RC","","","facility","both","","","","233.15","116.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157531","CDM","270","RC","","","facility","both","","","","463.45","231.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157567","CDM","270","RC","","","facility","both","","","","614.13","307.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157570","CDM","270","RC","","","facility","both","","","","1520.54","760.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157571","CDM","270","RC","","","facility","both","","","","1629.47","814.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157586","CDM","270","RC","","","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15762","CDM","270","RC","","","facility","both","","","","23.17","11.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157651","CDM","272","RC","C1894","HCPCS","facility","both","","","","722.38","361.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157656","CDM","270","RC","","","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157662","CDM","270","RC","","","facility","both","","","","1084.68","542.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157663","CDM","270","RC","C1713","HCPCS","facility","both","","","","1084.68","542.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15770","CDM","270","RC","","","facility","both","","","","17.71","8.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157813","CDM","270","RC","","","facility","both","","","","427.57","213.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15782","CDM","270","RC","","","facility","both","","","","8.03","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15787","CDM","270","RC","","","facility","both","","","","241.18","120.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15788","CDM","270","RC","","","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157902","CDM","270","RC","","","facility","both","","","","1507.48","753.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15791","CDM","270","RC","","","facility","both","","","","8.2","4.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157921","CDM","278","RC","C1776","HCPCS","facility","both","","","","2345.07","1172.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157933","CDM","270","RC","","","facility","both","","","","78.2","39.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157936","CDM","270","RC","","","facility","both","","","","860.2","430.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157957","CDM","278","RC","C1776","HCPCS","facility","both","","","","2017.47","1008.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157958","CDM","278","RC","C1776","HCPCS","facility","both","","","","2017.47","1008.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","157965","CDM","278","RC","C1776","HCPCS","facility","both","","","","1971.06","985.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15803","CDM","270","RC","","","facility","both","","","","9.2","4.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15808","CDM","270","RC","","","facility","both","","","","80.91","40.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15811","CDM","270","RC","","","facility","both","","","","6.1","3.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15831","CDM","270","RC","","","facility","both","","","","143.75","71.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15849","CDM","270","RC","","","facility","both","","","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15860","CDM","270","RC","","","facility","both","","","","5.52","2.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15864","CDM","270","RC","","","facility","both","","","","56.98","28.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","158776","CDM","270","RC","","","facility","both","","","","200.38","100.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","158780","CDM","278","RC","C1768","HCPCS","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15911","CDM","272","RC","C1729","HCPCS","facility","both","","","","13.17","6.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159136","CDM","270","RC","","","facility","both","","","","100.6","50.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15914","CDM","270","RC","L1830","HCPCS","facility","both","","","","59.02","29.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159145","CDM","270","RC","","","facility","both","","","","125.38","62.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159148","CDM","270","RC","","","facility","both","","","","125.74","62.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159150","CDM","270","RC","","","facility","both","","","","88.32","44.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159201","CDM","270","RC","","","facility","both","","","","89.37","44.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15934","CDM","270","RC","","","facility","both","","","","107.53","53.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15940","CDM","270","RC","","","facility","both","","","","66.74","33.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159405","CDM","278","RC","Q4104","HCPCS","facility","both","","","","180.19","90.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159406","CDM","278","RC","Q4104","HCPCS","facility","both","","","","63.5","31.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159409","CDM","278","RC","C9356","HCPCS","facility","both","","","","157.76","78.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15943","CDM","272","RC","A6258","HCPCS","facility","both","","","","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159521","CDM","270","RC","C1713","HCPCS","facility","both","","","","300.88","150.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15961","CDM","270","RC","","","facility","both","","","","24.73","12.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1597","CDM","270","RC","","","facility","both","","","","310.96","155.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159728","CDM","278","RC","C1776","HCPCS","facility","both","","","","1707.24","853.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15973","CDM","270","RC","","","facility","both","","","","253.6","126.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159746","CDM","278","RC","C1776","HCPCS","facility","both","","","","7327.24","3663.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15975","CDM","270","RC","L0120","HCPCS","facility","both","","","","17.2","8.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15984","CDM","270","RC","","","facility","both","","","","85.1","42.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","15987","CDM","270","RC","","","facility","both","","","","87.4","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159945","CDM","272","RC","C1894","HCPCS","facility","both","","","","390.08","195.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159967","CDM","278","RC","C1776","HCPCS","facility","both","","","","7327.24","3663.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159979","CDM","278","RC","Q4118","HCPCS","facility","both","","","","1364.48","682.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","159980","CDM","278","RC","Q4118","HCPCS","facility","both","","","","4.86","2.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16001","CDM","270","RC","","","facility","both","","","","54.93","27.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16017","CDM","270","RC","","","facility","both","","","","3.03","1.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16018","CDM","272","RC","C1729","HCPCS","facility","both","","","","41.22","20.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16020","CDM","272","RC","C1729","HCPCS","facility","both","","","","41.59","20.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16022","CDM","272","RC","C1729","HCPCS","facility","both","","","","41.22","20.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16025","CDM","272","RC","C1729","HCPCS","facility","both","","","","41.22","20.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160273","CDM","270","RC","","","facility","both","","","","6.47","3.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160274","CDM","270","RC","","","facility","both","","","","4.59","2.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160321","CDM","278","RC","Q4100","HCPCS","facility","both","","","","897.87","448.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16035","CDM","272","RC","C1729","HCPCS","facility","both","","","","73.68","36.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160364","CDM","270","RC","","","facility","both","","","","39.19","19.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160369","CDM","270","RC","","","facility","both","","","","2069.6","1034.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160408","CDM","278","RC","C1713","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","160498","CDM","278","RC","C1713","HCPCS","facility","both","","","","32.2","16.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16057","CDM","278","RC","C1713","HCPCS","facility","both","","","","225.4","112.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16088","CDM","270","RC","","","facility","both","","","","30.9","15.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16100","CDM","270","RC","","","facility","both","","","","27.07","13.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16112","CDM","270","RC","","","facility","both","","","","11.59","5.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16114","CDM","270","RC","","","facility","both","","","","12.67","6.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16116","CDM","272","RC","C1729","HCPCS","facility","both","","","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16117","CDM","272","RC","C1729","HCPCS","facility","both","","","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16119","CDM","272","RC","C1729","HCPCS","facility","both","","","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16121","CDM","272","RC","C1729","HCPCS","facility","both","","","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16123","CDM","272","RC","C1729","HCPCS","facility","both","","","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16142","CDM","272","RC","C1751","HCPCS","facility","both","","","","12.56","6.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1618","CDM","270","RC","","","facility","both","","","","61.92","30.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16197","CDM","270","RC","","","facility","both","","","","62.28","31.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16198","CDM","270","RC","","","facility","both","","","","70.4","35.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16199","CDM","270","RC","","","facility","both","","","","49.02","24.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1621","CDM","278","RC","C1781","HCPCS","facility","both","","","","667.92","333.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16224","CDM","270","RC","","","facility","both","","","","60.54","30.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16233","CDM","270","RC","","","facility","both","","","","60.54","30.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1633","CDM","270","RC","","","facility","both","","","","18.77","9.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16341","CDM","270","RC","","","facility","both","","","","346.69","173.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16364","CDM","270","RC","","","facility","both","","","","4.86","2.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16393","CDM","270","RC","","","facility","both","","","","4.19","2.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16396","CDM","270","RC","","","facility","both","","","","62.72","31.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16458","CDM","270","RC","","","facility","both","","","","71.3","35.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16459","CDM","272","RC","C1729","HCPCS","facility","both","","","","3.8","1.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16476","CDM","270","RC","","","facility","both","","","","60.54","30.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","164848","CDM","270","RC","","","facility","both","","","","89.38","44.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","164849","CDM","270","RC","","","facility","both","","","","89.38","44.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16494","CDM","272","RC","C1729","HCPCS","facility","both","","","","41.52","20.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","164941","CDM","270","RC","","","facility","both","","","","173.39","86.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16504","CDM","270","RC","","","facility","both","","","","5.03","2.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16506","CDM","270","RC","","","facility","both","","","","10.7","5.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16510","CDM","270","RC","","","facility","both","","","","180.35","90.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","165324","CDM","270","RC","","","facility","both","","","","431.15","215.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","165359","CDM","270","RC","","","facility","both","","","","745.08","372.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16542","CDM","270","RC","L1830","HCPCS","facility","both","","","","53.36","26.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16557","CDM","272","RC","C1765","HCPCS","facility","both","","","","1225.15","612.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16559","CDM","270","RC","","","facility","both","","","","64.4","32.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16563","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1658","CDM","270","RC","","","facility","both","","","","153.13","76.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16597","CDM","270","RC","","","facility","both","","","","20.35","10.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16621","CDM","270","RC","","","facility","both","","","","11.73","5.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167057","CDM","278","RC","C1713","HCPCS","facility","both","","","","2210","1105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167085","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167086","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167087","CDM","270","RC","","","facility","both","","","","2206.44","1103.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167093","CDM","270","RC","","","facility","both","","","","197.8","98.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167130","CDM","278","RC","C1713","HCPCS","facility","both","","","","878.6","439.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167135","CDM","278","RC","C1713","HCPCS","facility","both","","","","878.6","439.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167137","CDM","270","RC","","","facility","both","","","","1228.2","614.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167202","CDM","278","RC","C1713","HCPCS","facility","both","","","","1716.72","858.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16727","CDM","270","RC","","","facility","both","","","","12.92","6.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167270","CDM","278","RC","C1713","HCPCS","facility","both","","","","878.6","439.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","167314","CDM","278","RC","C1751","HCPCS","facility","both","","","","1840","920","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16759","CDM","270","RC","","","facility","both","","","","10.06","5.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16761","CDM","270","RC","","","facility","both","","","","10.36","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16775","CDM","270","RC","","","facility","both","","","","5.55","2.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","16846","CDM","270","RC","C1755","HCPCS","facility","both","","","","40.89","20.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","168708","CDM","270","RC","","","facility","both","","","","797.04","398.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","168709","CDM","270","RC","","","facility","both","","","","909.65","454.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","168777","CDM","270","RC","","","facility","both","","","","1020.1","510.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","168778","CDM","270","RC","","","facility","both","","","","740.78","370.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","168844","CDM","272","RC","C1769","HCPCS","facility","both","","","","939.14","469.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169081","CDM","278","RC","C2617","HCPCS","facility","both","","","","1155.43","577.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169082","CDM","278","RC","C2617","HCPCS","facility","both","","","","1155.43","577.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169086","CDM","270","RC","","","facility","both","","","","218.5","109.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169196","CDM","278","RC","C1781","HCPCS","facility","both","","","","1483.04","741.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169321","CDM","270","RC","","","facility","both","","","","1362.4","681.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169510","CDM","278","RC","C1874","HCPCS","facility","both","","","","7425.2","3712.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169715","CDM","278","RC","C1776","HCPCS","facility","both","","","","6662.46","3331.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169717","CDM","278","RC","C1776","HCPCS","facility","both","","","","6662.46","3331.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169738","CDM","278","RC","C1776","HCPCS","facility","both","","","","5416.67","2708.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169745","CDM","278","RC","C1776","HCPCS","facility","both","","","","5416.67","2708.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169959","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169962","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169970","CDM","270","RC","","","facility","both","","","","132.8","66.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169971","CDM","270","RC","","","facility","both","","","","156.54","78.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169972","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169973","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169974","CDM","270","RC","","","facility","both","","","","103.45","51.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169976","CDM","270","RC","","","facility","both","","","","1547","773.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","169978","CDM","270","RC","","","facility","both","","","","382.72","191.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170076","CDM","270","RC","","","facility","both","","","","73.6","36.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1701","CDM","270","RC","","","facility","both","","","","202.4","101.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170107","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170108","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170146","CDM","270","RC","","","facility","both","","","","6.48","3.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170147","CDM","270","RC","","","facility","both","","","","7.62","3.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170148","CDM","270","RC","","","facility","both","","","","8.05","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170149","CDM","270","RC","","","facility","both","","","","9.64","4.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170150","CDM","270","RC","","","facility","both","","","","10.66","5.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170509","CDM","278","RC","C1713","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170510","CDM","278","RC","C1713","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170604","CDM","270","RC","B4087","HCPCS","facility","both","","","","127.33","63.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170612","CDM","270","RC","","","facility","both","","","","118.04","59.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170614","CDM","270","RC","","","facility","both","","","","118.04","59.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170615","CDM","270","RC","","","facility","both","","","","118.04","59.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170624","CDM","270","RC","C2617","HCPCS","facility","both","","","","1426","713","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170628","CDM","270","RC","","","facility","both","","","","642.16","321.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170645","CDM","270","RC","","","facility","both","","","","1559.48","779.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","170651","CDM","270","RC","","","facility","both","","","","1426","713","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171035","CDM","270","RC","","","facility","both","","","","171.56","85.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171050","CDM","278","RC","C1776","HCPCS","facility","both","","","","3209.82","1604.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171051","CDM","278","RC","C1713","HCPCS","facility","both","","","","786.6","393.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171084","CDM","270","RC","","","facility","both","","","","725.33","362.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171098","CDM","278","RC","C1713","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171101","CDM","278","RC","C1713","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171114","CDM","278","RC","C1776","HCPCS","facility","both","","","","1579.5","789.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171479","CDM","270","RC","","","facility","both","","","","1004.64","502.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171567","CDM","278","RC","C1713","HCPCS","facility","both","","","","574.54","287.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171949","CDM","278","RC","C1771","HCPCS","facility","both","","","","1999.56","999.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171965","CDM","270","RC","","","facility","both","","","","2140.38","1070.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171970","CDM","270","RC","","","facility","both","","","","187.91","93.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","171984","CDM","270","RC","","","facility","both","","","","82.57","41.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172070","CDM","278","RC","C1713","HCPCS","facility","both","","","","3912.33","1956.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172086","CDM","278","RC","C1713","HCPCS","facility","both","","","","2156.08","1078.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172087","CDM","278","RC","C1713","HCPCS","facility","both","","","","2587.78","1293.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172091","CDM","278","RC","C1713","HCPCS","facility","both","","","","2424.19","1212.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172137","CDM","278","RC","C1713","HCPCS","facility","both","","","","347.21","173.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172138","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172139","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172140","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172150","CDM","278","RC","C1713","HCPCS","facility","both","","","","347.21","173.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172152","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172154","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172159","CDM","278","RC","C1713","HCPCS","facility","both","","","","588.03","294.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172160","CDM","278","RC","C1713","HCPCS","facility","both","","","","580","290","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172161","CDM","278","RC","C1713","HCPCS","facility","both","","","","583.6","291.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172162","CDM","278","RC","C1713","HCPCS","facility","both","","","","574.54","287.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172170","CDM","270","RC","","","facility","both","","","","211.6","105.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172184","CDM","278","RC","C1713","HCPCS","facility","both","","","","2424.19","1212.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172189","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172190","CDM","278","RC","C1713","HCPCS","facility","both","","","","257.62","128.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172192","CDM","278","RC","C1713","HCPCS","facility","both","","","","184.83","92.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172194","CDM","278","RC","C1713","HCPCS","facility","both","","","","599.1","299.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172196","CDM","278","RC","C1713","HCPCS","facility","both","","","","586.42","293.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172207","CDM","270","RC","","","facility","both","","","","280.37","140.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172212","CDM","278","RC","C1713","HCPCS","facility","both","","","","1586.54","793.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172425","CDM","272","RC","C1894","HCPCS","facility","both","","","","522.33","261.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172478","CDM","272","RC","C1894","HCPCS","facility","both","","","","522.33","261.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172479","CDM","272","RC","C1894","HCPCS","facility","both","","","","522.33","261.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172507","CDM","278","RC","C1874","HCPCS","facility","both","","","","7087","3543.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172509","CDM","278","RC","C1874","HCPCS","facility","both","","","","7654.15","3827.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172516","CDM","272","RC","C1894","HCPCS","facility","both","","","","390.08","195.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172518","CDM","272","RC","C1894","HCPCS","facility","both","","","","390.08","195.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172520","CDM","278","RC","C1713","HCPCS","facility","both","","","","892.07","446.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172545","CDM","270","RC","","","facility","both","","","","707.26","353.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172546","CDM","270","RC","","","facility","both","","","","239.09","119.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172617","CDM","270","RC","","","facility","both","","","","134.17","67.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172744","CDM","270","RC","","","facility","both","","","","1465.87","732.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172958","CDM","278","RC","C1781","HCPCS","facility","both","","","","2226.8","1113.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172960","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","172966","CDM","278","RC","C1771","HCPCS","facility","both","","","","2817.7","1408.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173005","CDM","278","RC","C1781","HCPCS","facility","both","","","","2281.5","1140.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173041","CDM","270","RC","","","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173793","CDM","272","RC","C1894","HCPCS","facility","both","","","","1481.2","740.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173795","CDM","272","RC","C1894","HCPCS","facility","both","","","","1481.2","740.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173796","CDM","272","RC","C1894","HCPCS","facility","both","","","","1936.6","968.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173798","CDM","272","RC","C1894","HCPCS","facility","both","","","","1936.6","968.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","173837","CDM","272","RC","C1725","HCPCS","facility","both","","","","2116","1058","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174005","CDM","278","RC","C1788","HCPCS","facility","both","","","","1752.6","876.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174471","CDM","278","RC","C1760","HCPCS","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174472","CDM","278","RC","C1760","HCPCS","facility","both","","","","1368.5","684.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174510","CDM","272","RC","C1753","HCPCS","facility","both","","","","2314","1157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174989","CDM","270","RC","","","facility","both","","","","961.31","480.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174991","CDM","270","RC","","","facility","both","","","","195.82","97.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","174998","CDM","270","RC","","","facility","both","","","","81.74","40.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175416","CDM","270","RC","","","facility","both","","","","64.29","32.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175474","CDM","278","RC","C1713","HCPCS","facility","both","","","","2145","1072.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175475","CDM","278","RC","C1713","HCPCS","facility","both","","","","2145","1072.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175486","CDM","278","RC","C1713","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175517","CDM","270","RC","","","facility","both","","","","96.64","48.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175519","CDM","270","RC","","","facility","both","","","","220.8","110.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175605","CDM","270","RC","","","facility","both","","","","264.55","132.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175609","CDM","270","RC","","","facility","both","","","","118.04","59.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175670","CDM","278","RC","C1750","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175671","CDM","278","RC","C1750","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175675","CDM","278","RC","C1750","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1757","CDM","270","RC","","","facility","both","","","","36.8","18.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175812","CDM","270","RC","","","facility","both","","","","188.97","94.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175813","CDM","270","RC","","","facility","both","","","","387.85","193.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","175884","CDM","270","RC","","","facility","both","","","","78.19","39.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176253","CDM","270","RC","","","facility","both","","","","189.84","94.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176331","CDM","270","RC","","","facility","both","","","","9.3","4.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176346","CDM","270","RC","","","facility","both","","","","1028.75","514.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176351","CDM","278","RC","C1713","HCPCS","facility","both","","","","829.65","414.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176352","CDM","278","RC","C1713","HCPCS","facility","both","","","","596.99","298.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176353","CDM","278","RC","C1713","HCPCS","facility","both","","","","598.64","299.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176354","CDM","278","RC","C1713","HCPCS","facility","both","","","","152.35","76.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176359","CDM","278","RC","C1713","HCPCS","facility","both","","","","579.14","289.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176361","CDM","278","RC","C1713","HCPCS","facility","both","","","","1001.84","500.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176477","CDM","270","RC","","","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176481","CDM","270","RC","","","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176482","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176484","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176485","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176486","CDM","270","RC","","","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176487","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176488","CDM","270","RC","","","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176493","CDM","270","RC","","","facility","both","","","","1299.51","649.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176495","CDM","270","RC","","","facility","both","","","","1365.26","682.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176498","CDM","270","RC","","","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176518","CDM","270","RC","","","facility","both","","","","9.48","4.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176519","CDM","270","RC","","","facility","both","","","","19.62","9.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176523","CDM","270","RC","","","facility","both","","","","21.16","10.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176560","CDM","270","RC","","","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17681","CDM","270","RC","","","facility","both","","","","431.03","215.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176838","CDM","270","RC","","","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176839","CDM","270","RC","","","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176849","CDM","270","RC","","","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","176869","CDM","270","RC","","","facility","both","","","","1660.6","830.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177011","CDM","270","RC","C1729","HCPCS","facility","both","","","","788.9","394.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177012","CDM","270","RC","C1729","HCPCS","facility","both","","","","805","402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17707","CDM","270","RC","","","facility","both","","","","1127.74","563.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177180","CDM","270","RC","C1887","HCPCS","facility","both","","","","723.72","361.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177183","CDM","270","RC","","","facility","both","","","","1019.34","509.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177315","CDM","278","RC","C2617","HCPCS","facility","both","","","","246.97","123.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177352","CDM","270","RC","","","facility","both","","","","101.43","50.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177353","CDM","270","RC","","","facility","both","","","","177.66","88.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177412","CDM","270","RC","","","facility","both","","","","86.42","43.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177413","CDM","270","RC","","","facility","both","","","","2099.73","1049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177491","CDM","270","RC","","","facility","both","","","","5.69","2.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177601","CDM","278","RC","C1874","HCPCS","facility","both","","","","19228","9614","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177615","CDM","278","RC","C1874","HCPCS","facility","both","","","","6935","3467.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177616","CDM","278","RC","C1874","HCPCS","facility","both","","","","6935","3467.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177635","CDM","278","RC","C1874","HCPCS","facility","both","","","","2070","1035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177636","CDM","278","RC","C1874","HCPCS","facility","both","","","","2295.4","1147.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177675","CDM","278","RC","C1713","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177754","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177779","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177781","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1778","CDM","270","RC","","","facility","both","","","","1570.14","785.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177840","CDM","270","RC","","","facility","both","","","","77.31","38.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177940","CDM","278","RC","C1713","HCPCS","facility","both","","","","332.3","166.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177955","CDM","270","RC","","","facility","both","","","","455.37","227.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177965","CDM","270","RC","","","facility","both","","","","1497","748.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177968","CDM","270","RC","","","facility","both","","","","330.71","165.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177969","CDM","270","RC","","","facility","both","","","","318.32","159.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177977","CDM","270","RC","","","facility","both","","","","24.41","12.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","177987","CDM","272","RC","C1769","HCPCS","facility","both","","","","506","253","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178060","CDM","270","RC","","","facility","both","","","","149.5","74.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178156","CDM","272","RC","C1887","HCPCS","facility","both","","","","2568.8","1284.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178186","CDM","270","RC","","","facility","both","","","","1067.45","533.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178213","CDM","276","RC","V2787","HCPCS","facility","both","","","","545","272.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178245","CDM","278","RC","C1713","HCPCS","facility","both","","","","11.67","5.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17825","CDM","270","RC","","","facility","both","","","","15.02","7.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17829","CDM","270","RC","","","facility","both","","","","10.41","5.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17830","CDM","270","RC","","","facility","both","","","","12.11","6.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17835","CDM","270","RC","","","facility","both","","","","5.16","2.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178350","CDM","278","RC","C1776","HCPCS","facility","both","","","","3460.15","1730.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178365","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17837","CDM","270","RC","","","facility","both","","","","10.08","5.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","17838","CDM","270","RC","","","facility","both","","","","30.24","15.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178383","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178384","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178391","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178393","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178395","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178400","CDM","278","RC","C1776","HCPCS","facility","both","","","","3027.33","1513.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178505","CDM","270","RC","","","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178521","CDM","278","RC","C1713","HCPCS","facility","both","","","","4686.92","2343.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178530","CDM","278","RC","C1713","HCPCS","facility","both","","","","782","391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178832","CDM","270","RC","","","facility","both","","","","363.4","181.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178852","CDM","270","RC","","","facility","both","","","","437","218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178853","CDM","270","RC","","","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","178975","CDM","270","RC","","","facility","both","","","","88.92","44.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179005","CDM","270","RC","","","facility","both","","","","118.04","59.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179008","CDM","270","RC","","","facility","both","","","","122.27","61.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179009","CDM","270","RC","","","facility","both","","","","119.78","59.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179022","CDM","270","RC","","","facility","both","","","","1918.5","959.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179043","CDM","270","RC","C1887","HCPCS","facility","both","","","","144.74","72.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179052","CDM","270","RC","","","facility","both","","","","367.86","183.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179103","CDM","270","RC","","","facility","both","","","","613.09","306.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179104","CDM","270","RC","","","facility","both","","","","544.59","272.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179107","CDM","270","RC","","","facility","both","","","","6479.3","3239.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179122","CDM","278","RC","C1713","HCPCS","facility","both","","","","4111.6","2055.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179150","CDM","278","RC","C1776","HCPCS","facility","both","","","","5286.66","2643.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179315","CDM","270","RC","L1830","HCPCS","facility","both","","","","86.89","43.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179385","CDM","278","RC","C1713","HCPCS","facility","both","","","","1900.57","950.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179386","CDM","278","RC","C1713","HCPCS","facility","both","","","","1989.94","994.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179517","CDM","270","RC","","","facility","both","","","","253","126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179532","CDM","272","RC","C1769","HCPCS","facility","both","","","","784.23","392.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179543","CDM","270","RC","","","facility","both","","","","213.16","106.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179859","CDM","270","RC","","","facility","both","","","","221.35","110.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179877","CDM","270","RC","","","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179951","CDM","270","RC","","","facility","both","","","","1135.25","567.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179963","CDM","270","RC","","","facility","both","","","","1639.72","819.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179964","CDM","270","RC","","","facility","both","","","","1046.73","523.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179972","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179973","CDM","278","RC","C2625","HCPCS","facility","both","","","","600.67","300.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179974","CDM","270","RC","","","facility","both","","","","1981.22","990.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179976","CDM","272","RC","C1769","HCPCS","facility","both","","","","459.08","229.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","179992","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180000","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180001","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180002","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180003","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180005","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180006","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180010","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180012","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180013","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180015","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180016","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180017","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180018","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180020","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.14","305.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180023","CDM","278","RC","C1713","HCPCS","facility","both","","","","2530.34","1265.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180026","CDM","278","RC","C1713","HCPCS","facility","both","","","","2557.93","1278.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180034","CDM","278","RC","C1713","HCPCS","facility","both","","","","3428.97","1714.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180036","CDM","278","RC","C1713","HCPCS","facility","both","","","","2530.34","1265.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180055","CDM","270","RC","","","facility","both","","","","1476.8","738.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180069","CDM","270","RC","","","facility","both","","","","128.48","64.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180100","CDM","270","RC","C1781","HCPCS","facility","both","","","","1333.41","666.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180276","CDM","278","RC","C1781","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180315","CDM","272","RC","C1725","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180366","CDM","272","RC","C1782","HCPCS","facility","both","","","","2026.03","1013.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180388","CDM","278","RC","C1874","HCPCS","facility","both","","","","2570.46","1285.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180389","CDM","278","RC","C1874","HCPCS","facility","both","","","","2570.46","1285.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180397","CDM","278","RC","C1789","HCPCS","facility","both","","","","2707.5","1353.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180432","CDM","278","RC","C1755","HCPCS","facility","both","","","","2211.78","1105.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180882","CDM","270","RC","","","facility","both","","","","108.1","54.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180883","CDM","270","RC","","","facility","both","","","","225.4","112.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180887","CDM","270","RC","","","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180892","CDM","278","RC","C1771","HCPCS","facility","both","","","","3267.11","1633.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180895","CDM","278","RC","C1713","HCPCS","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180896","CDM","278","RC","C1713","HCPCS","facility","both","","","","3230","1615","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180897","CDM","278","RC","C1713","HCPCS","facility","both","","","","5605","2802.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","180930","CDM","278","RC","C1778","HCPCS","facility","both","","","","3657.5","1828.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182005","CDM","270","RC","","","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182009","CDM","270","RC","","","facility","both","","","","15.33","7.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182038","CDM","270","RC","","","facility","both","","","","973.82","486.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182051","CDM","270","RC","","","facility","both","","","","68.2","34.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182055","CDM","270","RC","","","facility","both","","","","15.62","7.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182058","CDM","270","RC","","","facility","both","","","","8.01","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182060","CDM","270","RC","","","facility","both","","","","8.01","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182061","CDM","270","RC","","","facility","both","","","","8.01","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182245","CDM","270","RC","","","facility","both","","","","2116.37","1058.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182263","CDM","270","RC","","","facility","both","","","","68.77","34.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182340","CDM","270","RC","","","facility","both","","","","735.26","367.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182632","CDM","272","RC","C1729","HCPCS","facility","both","","","","45.54","22.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182635","CDM","270","RC","","","facility","both","","","","334.74","167.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182642","CDM","270","RC","","","facility","both","","","","62.68","31.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182643","CDM","270","RC","","","facility","both","","","","62.68","31.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182651","CDM","270","RC","","","facility","both","","","","84.78","42.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182754","CDM","272","RC","C1769","HCPCS","facility","both","","","","271.4","135.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182766","CDM","270","RC","","","facility","both","","","","79.93","39.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182792","CDM","270","RC","","","facility","both","","","","211.6","105.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182826","CDM","278","RC","C1725","HCPCS","facility","both","","","","2464.05","1232.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182880","CDM","270","RC","","","facility","both","","","","2054","1027","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182881","CDM","270","RC","","","facility","both","","","","2054","1027","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182886","CDM","270","RC","","","facility","both","","","","2548","1274","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182887","CDM","270","RC","","","facility","both","","","","2375","1187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","182888","CDM","270","RC","","","facility","both","","","","2375","1187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183018","CDM","270","RC","","","facility","both","","","","891.35","445.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183020","CDM","270","RC","","","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183022","CDM","270","RC","","","facility","both","","","","244.94","122.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183024","CDM","270","RC","","","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183027","CDM","278","RC","C1713","HCPCS","facility","both","","","","1938","969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183341","CDM","270","RC","","","facility","both","","","","313.48","156.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183375","CDM","278","RC","C1781","HCPCS","facility","both","","","","1961.84","980.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183381","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","183382","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184098","CDM","270","RC","","","facility","both","","","","20.66","10.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184446","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184587","CDM","272","RC","C1729","HCPCS","facility","both","","","","148.03","74.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184589","CDM","270","RC","","","facility","both","","","","727.53","363.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184606","CDM","270","RC","","","facility","both","","","","523.09","261.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184638","CDM","278","RC","C2617","HCPCS","facility","both","","","","246.97","123.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184649","CDM","270","RC","","","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184650","CDM","270","RC","","","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184659","CDM","270","RC","","","facility","both","","","","1995","997.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184695","CDM","270","RC","","","facility","both","","","","1752.6","876.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184724","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184761","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184762","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184766","CDM","270","RC","","","facility","both","","","","1957.42","978.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184885","CDM","270","RC","","","facility","both","","","","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184900","CDM","270","RC","","","facility","both","","","","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","184906","CDM","270","RC","","","facility","both","","","","7.34","3.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185147","CDM","278","RC","C1713","HCPCS","facility","both","","","","538.89","269.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185148","CDM","270","RC","","","facility","both","","","","675.51","337.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185149","CDM","278","RC","C1713","HCPCS","facility","both","","","","908.27","454.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185174","CDM","270","RC","","","facility","both","","","","976.35","488.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185235","CDM","270","RC","","","facility","both","","","","441.22","220.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185329","CDM","272","RC","C1753","HCPCS","facility","both","","","","3790.5","1895.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185330","CDM","270","RC","C1776","HCPCS","facility","both","","","","445.13","222.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185353","CDM","278","RC","C1713","HCPCS","facility","both","","","","395.89","197.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185354","CDM","278","RC","C1713","HCPCS","facility","both","","","","382.09","191.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185356","CDM","278","RC","C1713","HCPCS","facility","both","","","","409.4","204.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185360","CDM","270","RC","","","facility","both","","","","431.48","215.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185361","CDM","270","RC","","","facility","both","","","","431.48","215.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185362","CDM","270","RC","","","facility","both","","","","339.02","169.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185363","CDM","270","RC","","","facility","both","","","","400.66","200.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185371","CDM","278","RC","C1713","HCPCS","facility","both","","","","2020.2","1010.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185372","CDM","278","RC","C1713","HCPCS","facility","both","","","","1994.2","997.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185373","CDM","278","RC","C1713","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185375","CDM","278","RC","C1713","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185391","CDM","278","RC","C1713","HCPCS","facility","both","","","","103.04","51.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185393","CDM","278","RC","C1713","HCPCS","facility","both","","","","400.2","200.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185394","CDM","278","RC","C1713","HCPCS","facility","both","","","","400.2","200.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185396","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185398","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185404","CDM","278","RC","C1713","HCPCS","facility","both","","","","409.4","204.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185405","CDM","278","RC","C1713","HCPCS","facility","both","","","","409.4","204.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185407","CDM","278","RC","C1713","HCPCS","facility","both","","","","401.33","200.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185409","CDM","278","RC","C1713","HCPCS","facility","both","","","","382.09","191.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185410","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185411","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185419","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185420","CDM","278","RC","C1713","HCPCS","facility","both","","","","393.06","196.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185421","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185422","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185477","CDM","270","RC","","","facility","both","","","","152.49","76.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185481","CDM","270","RC","","","facility","both","","","","1421.16","710.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185485","CDM","270","RC","","","facility","both","","","","2960.2","1480.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185506","CDM","278","RC","C1713","HCPCS","facility","both","","","","119.6","59.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185523","CDM","278","RC","C1713","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185531","CDM","278","RC","C1713","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185637","CDM","270","RC","","","facility","both","","","","158.7","79.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185710","CDM","270","RC","","","facility","both","","","","156.4","78.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185726","CDM","270","RC","C1729","HCPCS","facility","both","","","","53.22","26.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185732","CDM","270","RC","","","facility","both","","","","2001","1000.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185758","CDM","278","RC","C1713","HCPCS","facility","both","","","","1540.08","770.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185777","CDM","270","RC","","","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","18581","CDM","270","RC","","","facility","both","","","","241.07","120.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","18582","CDM","270","RC","","","facility","both","","","","130.35","65.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185829","CDM","270","RC","","","facility","both","","","","248.4","124.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","185870","CDM","270","RC","","","facility","both","","","","872.85","436.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186302","CDM","270","RC","","","facility","both","","","","770.91","385.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186306","CDM","270","RC","","","facility","both","","","","1256.23","628.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186322","CDM","270","RC","","","facility","both","","","","114.46","57.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186592","CDM","270","RC","","","facility","both","","","","299","149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186593","CDM","270","RC","","","facility","both","","","","300.48","150.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186603","CDM","270","RC","","","facility","both","","","","104.74","52.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186617","CDM","270","RC","","","facility","both","","","","1918.8","959.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186682","CDM","278","RC","C1781","HCPCS","facility","both","","","","3612.47","1806.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186683","CDM","278","RC","C1781","HCPCS","facility","both","","","","7355.55","3677.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186801","CDM","270","RC","","","facility","both","","","","735.08","367.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186807","CDM","270","RC","","","facility","both","","","","2176.46","1088.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186810","CDM","278","RC","C1713","HCPCS","facility","both","","","","1725","862.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186866","CDM","270","RC","","","facility","both","","","","366.16","183.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186870","CDM","278","RC","C1781","HCPCS","facility","both","","","","1221.67","610.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186872","CDM","270","RC","","","facility","both","","","","2070","1035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186873","CDM","270","RC","","","facility","both","","","","5.66","2.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186878","CDM","270","RC","","","facility","both","","","","198.06","99.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186880","CDM","270","RC","","","facility","both","","","","1588.6","794.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186886","CDM","270","RC","","","facility","both","","","","1182.2","591.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186900","CDM","278","RC","C1713","HCPCS","facility","both","","","","612.15","306.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","186997","CDM","270","RC","","","facility","both","","","","285.29","142.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187040","CDM","272","RC","C1757","HCPCS","facility","both","","","","248.4","124.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187055","CDM","272","RC","C1729","HCPCS","facility","both","","","","48.48","24.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187161","CDM","270","RC","","","facility","both","","","","314.82","157.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187196","CDM","270","RC","","","facility","both","","","","53.51","26.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187232","CDM","270","RC","","","facility","both","","","","2120.43","1060.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187233","CDM","270","RC","","","facility","both","","","","1318.35","659.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187234","CDM","270","RC","","","facility","both","","","","2120.43","1060.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187617","CDM","278","RC","C1776","HCPCS","facility","both","","","","2070","1035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187665","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187668","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187883","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","18789","CDM","270","RC","","","facility","both","","","","121.99","61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","18790","CDM","270","RC","","","facility","both","","","","126.94","63.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","187935","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","18795","CDM","270","RC","","","facility","both","","","","446.2","223.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","188772","CDM","278","RC","C1768","HCPCS","facility","both","","","","2422.5","1211.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","188950","CDM","270","RC","","","facility","both","","","","2115.79","1057.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189099","CDM","270","RC","","","facility","both","","","","46.59","23.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189178","CDM","270","RC","","","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189187","CDM","270","RC","","","facility","both","","","","1794.08","897.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189217","CDM","278","RC","C1874","HCPCS","facility","both","","","","5462.5","2731.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189369","CDM","272","RC","C1725","HCPCS","facility","both","","","","736","368","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189379","CDM","278","RC","C1725","HCPCS","facility","both","","","","736","368","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189380","CDM","272","RC","C1725","HCPCS","facility","both","","","","736","368","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189381","CDM","272","RC","C1725","HCPCS","facility","both","","","","1219","609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189408","CDM","278","RC","C1713","HCPCS","facility","both","","","","119.6","59.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189425","CDM","278","RC","C1713","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189614","CDM","270","RC","","","facility","both","","","","341.78","170.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","189626","CDM","270","RC","","","facility","both","","","","2694.2","1347.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190252","CDM","270","RC","","","facility","both","","","","155.65","77.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190253","CDM","270","RC","","","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190254","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190277","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190846","CDM","270","RC","","","facility","both","","","","372.05","186.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19089","CDM","272","RC","C1729","HCPCS","facility","both","","","","37.05","18.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190891","CDM","270","RC","","","facility","both","","","","399.37","199.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190894","CDM","270","RC","","","facility","both","","","","1764.8","882.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19090","CDM","272","RC","C1729","HCPCS","facility","both","","","","42.45","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190909","CDM","270","RC","","","facility","both","","","","67.75","33.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19091","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.35","21.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190911","CDM","278","RC","C1768","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190928","CDM","270","RC","","","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","190954","CDM","270","RC","","","facility","both","","","","11.58","5.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191007","CDM","270","RC","","","facility","both","","","","639.4","319.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191009","CDM","270","RC","","","facility","both","","","","48.08","24.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191051","CDM","270","RC","","","facility","both","","","","709.32","354.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191052","CDM","270","RC","","","facility","both","","","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191099","CDM","278","RC","C1713","HCPCS","facility","both","","","","1982.46","991.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191102","CDM","270","RC","","","facility","both","","","","987.53","493.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191152","CDM","272","RC","C1894","HCPCS","facility","both","","","","1434.28","717.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191155","CDM","270","RC","","","facility","both","","","","18.86","9.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191156","CDM","270","RC","","","facility","both","","","","68.54","34.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191157","CDM","270","RC","","","facility","both","","","","75.9","37.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191243","CDM","272","RC","C1769","HCPCS","facility","both","","","","139.29","69.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191346","CDM","270","RC","","","facility","both","","","","4740.5","2370.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191348","CDM","270","RC","","","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","191833","CDM","270","RC","","","facility","both","","","","2327","1163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192001","CDM","272","RC","C1769","HCPCS","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192007","CDM","272","RC","C1769","HCPCS","facility","both","","","","182.62","91.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192447","CDM","270","RC","","","facility","both","","","","37.77","18.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192486","CDM","270","RC","","","facility","both","","","","230.69","115.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192505","CDM","270","RC","","","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192506","CDM","270","RC","C1713","HCPCS","facility","both","","","","915.4","457.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192509","CDM","270","RC","C1713","HCPCS","facility","both","","","","938.4","469.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192510","CDM","270","RC","C1713","HCPCS","facility","both","","","","938.4","469.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192528","CDM","270","RC","","","facility","both","","","","216.2","108.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192533","CDM","270","RC","C1713","HCPCS","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192534","CDM","270","RC","","","facility","both","","","","105.8","52.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192535","CDM","270","RC","","","facility","both","","","","1145.4","572.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192538","CDM","270","RC","","","facility","both","","","","312.29","156.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192541","CDM","270","RC","","","facility","both","","","","188.6","94.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192544","CDM","270","RC","","","facility","both","","","","1833","916.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192545","CDM","270","RC","","","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192641","CDM","270","RC","","","facility","both","","","","86.02","43.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192653","CDM","272","RC","C1729","HCPCS","facility","both","","","","54.97","27.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192654","CDM","272","RC","C1729","HCPCS","facility","both","","","","55.57","27.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","192715","CDM","270","RC","","","facility","both","","","","92.19","46.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1931","CDM","272","RC","C1729","HCPCS","facility","both","","","","49.58","24.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193110","CDM","270","RC","","","facility","both","","","","100.39","50.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193111","CDM","270","RC","","","facility","both","","","","92.69","46.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193113","CDM","270","RC","","","facility","both","","","","387.21","193.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1932","CDM","272","RC","C1729","HCPCS","facility","both","","","","49.84","24.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193410","CDM","270","RC","","","facility","both","","","","818.8","409.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193412","CDM","270","RC","","","facility","both","","","","1127","563.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193434","CDM","270","RC","","","facility","both","","","","1867.6","933.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193451","CDM","270","RC","","","facility","both","","","","204.93","102.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193497","CDM","272","RC","C1769","HCPCS","facility","both","","","","1504.2","752.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193606","CDM","270","RC","","","facility","both","","","","80.41","40.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193608","CDM","270","RC","","","facility","both","","","","1309.63","654.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19361","CDM","270","RC","","","facility","both","","","","85.1","42.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193617","CDM","272","RC","C1726","HCPCS","facility","both","","","","2373.28","1186.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193618","CDM","272","RC","C1726","HCPCS","facility","both","","","","2373.28","1186.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","193625","CDM","270","RC","","","facility","both","","","","861.12","430.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19398","CDM","270","RC","","","facility","both","","","","16.76","8.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194136","CDM","270","RC","","","facility","both","","","","814.2","407.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194142","CDM","270","RC","","","facility","both","","","","289.56","144.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194143","CDM","270","RC","","","facility","both","","","","284.73","142.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194155","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194250","CDM","270","RC","","","facility","both","","","","59.69","29.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194251","CDM","270","RC","","","facility","both","","","","410.78","205.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194290","CDM","270","RC","","","facility","both","","","","1831.44","915.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194292","CDM","270","RC","","","facility","both","","","","2117.99","1059","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","1949","CDM","270","RC","","","facility","both","","","","725.19","362.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194922","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194949","CDM","270","RC","","","facility","both","","","","22.46","11.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194950","CDM","270","RC","C1729","HCPCS","facility","both","","","","22.46","11.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194954","CDM","270","RC","","","facility","both","","","","164.85","82.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","194966","CDM","270","RC","","","facility","both","","","","28.27","14.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","195286","CDM","272","RC","C1887","HCPCS","facility","both","","","","2405","1202.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196073","CDM","272","RC","C1887","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196083","CDM","278","RC","C1788","HCPCS","facility","both","","","","1050.64","525.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196125","CDM","270","RC","","","facility","both","","","","717.85","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196126","CDM","270","RC","","","facility","both","","","","717.85","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196127","CDM","270","RC","","","facility","both","","","","717.85","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196129","CDM","270","RC","","","facility","both","","","","717.85","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196130","CDM","270","RC","","","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196131","CDM","270","RC","","","facility","both","","","","1507.48","753.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196132","CDM","270","RC","","","facility","both","","","","1507.48","753.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196140","CDM","270","RC","","","facility","both","","","","316","158","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196309","CDM","278","RC","C1713","HCPCS","facility","both","","","","1821.6","910.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196310","CDM","278","RC","C1713","HCPCS","facility","both","","","","323.84","161.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196311","CDM","270","RC","","","facility","both","","","","2151.43","1075.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196312","CDM","278","RC","C2631","HCPCS","facility","both","","","","1834.69","917.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196313","CDM","270","RC","","","facility","both","","","","105.25","52.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196339","CDM","278","RC","Q4150","HCPCS","facility","both","","","","461.5","230.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196560","CDM","270","RC","","","facility","both","","","","42.43","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196564","CDM","270","RC","","","facility","both","","","","1489.63","744.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196568","CDM","270","RC","","","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196592","CDM","278","RC","C1713","HCPCS","facility","both","","","","1610","805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196629","CDM","270","RC","","","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196630","CDM","270","RC","","","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196713","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196715","CDM","270","RC","","","facility","both","","","","4740.5","2370.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196726","CDM","270","RC","","","facility","both","","","","45.08","22.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196727","CDM","270","RC","","","facility","both","","","","15.74","7.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196728","CDM","270","RC","","","facility","both","","","","45.53","22.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196729","CDM","270","RC","","","facility","both","","","","418.79","209.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196730","CDM","270","RC","","","facility","both","","","","168.77","84.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196909","CDM","272","RC","C1769","HCPCS","facility","both","","","","694.61","347.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","196994","CDM","270","RC","","","facility","both","","","","1455.09","727.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19711","CDM","270","RC","C1729","HCPCS","facility","both","","","","1192.93","596.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19763","CDM","270","RC","","","facility","both","","","","379.16","189.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","198","CDM","270","RC","","","facility","both","","","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19833","CDM","270","RC","","","facility","both","","","","48.97","24.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19834","CDM","270","RC","","","facility","both","","","","20.17","10.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19842","CDM","270","RC","","","facility","both","","","","7.49","3.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19859","CDM","270","RC","","","facility","both","","","","5.18","2.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","198699","CDM","278","RC","C1751","HCPCS","facility","both","","","","253","126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","198703","CDM","278","RC","C1751","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","198715","CDM","270","RC","","","facility","both","","","","2136.56","1068.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","199262","CDM","270","RC","","","facility","both","","","","680.8","340.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","199267","CDM","270","RC","","","facility","both","","","","1334","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","199452","CDM","270","RC","","","facility","both","","","","549.42","274.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","199453","CDM","270","RC","","","facility","both","","","","198.38","99.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","199454","CDM","270","RC","","","facility","both","","","","209.3","104.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19950","CDM","270","RC","","","facility","both","","","","18.89","9.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","19960","CDM","270","RC","","","facility","both","","","","16.71","8.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20009","CDM","270","RC","","","facility","both","","","","183.78","91.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200119","CDM","270","RC","","","facility","both","","","","149.87","74.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20016","CDM","270","RC","","","facility","both","","","","523.02","261.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200168","CDM","270","RC","","","facility","both","","","","183.95","91.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200195","CDM","270","RC","","","facility","both","","","","182.14","91.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20024","CDM","270","RC","","","facility","both","","","","56.53","28.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200525","CDM","270","RC","","","facility","both","","","","3401","1700.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200569","CDM","276","RC","V2787","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200859","CDM","278","RC","C2631","HCPCS","facility","both","","","","1644.9","822.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200874","CDM","270","RC","","","facility","both","","","","1256.23","628.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200875","CDM","270","RC","","","facility","both","","","","690.93","345.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200878","CDM","272","RC","C1894","HCPCS","facility","both","","","","192.32","96.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200888","CDM","270","RC","","","facility","both","","","","246.33","123.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","200962","CDM","270","RC","","","facility","both","","","","1789.4","894.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sickle Cell Prep","20100001","CDM","300","RC","85660","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hct","20100004","CDM","300","RC","85014","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Wbc Count","20100005","CDM","300","RC","85048","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blood Ct, Platelet, Automated","20100008","CDM","300","RC","85049","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Reticulocyte Count","20100009","CDM","300","RC","85046","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sed Rate, Automated","20100010","CDM","300","RC","85652","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fibrinogen","20100017","CDM","300","RC","85384","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ptt","20100020","CDM","300","RC","85730","HCPCS","facility","both","","","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Eos Count","20100025","CDM","300","RC","85048","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Factor Ii Assay","20100026","CDM","300","RC","85210","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Factor V Assay","20100031","CDM","300","RC","85220","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Inhibitor Titer","20100033","CDM","300","RC","85335","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Malaria","20100039","CDM","300","RC","87207","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lap","20100042","CDM","300","RC","85540","HCPCS","facility","both","","","","288","144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Kleihauer-Betke","20100060","CDM","300","RC","85460","HCPCS","facility","both","","","","541","270.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ristocetin Aggreg","20100068","CDM","300","RC","85576","HCPCS","facility","both","","","","397","198.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Reptilase","20100071","CDM","300","RC","85635","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thrombin Time","20100072","CDM","300","RC","85670","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Plasminogen","20100074","CDM","300","RC","85420","HCPCS","facility","both","","","","502","251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Antithrombin Iii","20100075","CDM","300","RC","85300","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Factor Vii Assay","20100107","CDM","300","RC","85230","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Factor Viii Assay","20100108","CDM","300","RC","85240","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Factor Ix Assay","20100109","CDM","300","RC","85250","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Factor X Assay","20100110","CDM","300","RC","85260","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Factor Xi Assay","20100111","CDM","300","RC","85270","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Factor Xii Assay","20100112","CDM","300","RC","85280","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Factor Xiii Assay","20100113","CDM","300","RC","85290","HCPCS","facility","both","","","","163","81.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fletcher Factor","20100114","CDM","300","RC","85292","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fitzgerald Factor","20100115","CDM","300","RC","85293","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pt 1:1 Mix W/Normal","20100122","CDM","300","RC","85611","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ptt 1:1 W/Normal","20100123","CDM","300","RC","85732","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vonwillebrand Factor","20100126","CDM","300","RC","85245","HCPCS","facility","both","","","","288","144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hematocrit-Spun","20100147","CDM","300","RC","85013","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fibrinogen Antigen","20100152","CDM","300","RC","85385","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Eos Smear","20100161","CDM","300","RC","89190","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Adamts13 Activity","20100300","CDM","300","RC","85397","HCPCS","facility","both","","","","754","377","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Stain, Inclusion Bodies","20100813","CDM","300","RC","87207","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein C Antigen","20100831","CDM","300","RC","85302","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein C Functional","20100832","CDM","300","RC","85303","HCPCS","facility","both","","","","118","59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Body Fluid Diff","20100836","CDM","300","RC","89051","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cbc Without Diff","20100837","CDM","300","RC","85027","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cbc With Diff","20100839","CDM","300","RC","85025","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csf Profile","20100849","CDM","300","RC","89051","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Aggregation-Adp","20100861","CDM","300","RC","85576","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Aggregation-Adp 1:4","20100862","CDM","300","RC","85576","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Aggregation-Collagen","20100863","CDM","300","RC","85576","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Aggregation-Epinephri","20100864","CDM","300","RC","85576","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Plat Aggregation-Aracadonic Ac","20100865","CDM","300","RC","85576","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pt/Inr","20100866","CDM","300","RC","85610","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H.Pylori Biopsy Screen","20100868","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hgb","20100874","CDM","300","RC","85018","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Smear - Giemsa/Gram Stain","20100876","CDM","300","RC","87205","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Antibody Indirect","20100877","CDM","300","RC","86022","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Antibody Direct","20100879","CDM","300","RC","86023","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl G6Pd Quant(Lc)","20100909","CDM","300","RC","82955","HCPCS","facility","both","","","","192","96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl In Situ Hybrid (Fish) Init","20101000","CDM","300","RC","88365","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl In Situ Hybrid (Fish) Ea Add't","20101001","CDM","300","RC","88364","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl In Situ Hybrid (Fish) Multi","20101002","CDM","300","RC","88366","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Morph Analysis,Ea Multiplex","20101004","CDM","300","RC","88374","HCPCS","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Morph Analysis, Man Each Add't","20101005","CDM","300","RC","88369","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Morph Analysis, Man Ea Multi","20101006","CDM","300","RC","88377","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pf 4 By Elisa","20101170","CDM","300","RC","83520","HCPCS","facility","both","","","","268","134","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Path Review For Crystals","20101180","CDM","300","RC","89060","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cebpa Mutation Analysis","20101501","CDM","310","RC","81218","HCPCS","facility","both","","","","851","425.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult F/Chrom: Lymphocytes","20101640","CDM","311","RC","88230","HCPCS","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult F/Chrom: Skin Or Other","20101641","CDM","311","RC","88233","HCPCS","facility","both","","","","2304","1152","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult F/Chrom: Amniotic Fluid","20101642","CDM","310","RC","88235","HCPCS","facility","both","","","","629","314.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult F/Chrom: Bone Marrow","20101643","CDM","311","RC","88237","HCPCS","facility","both","","","","1913","956.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult F/Chrom: Other","20101644","CDM","311","RC","88239","HCPCS","facility","both","","","","1660","830","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ct 5 Cells: 1 Karyo W/Banding","20101646","CDM","311","RC","88261","HCPCS","facility","both","","","","2133","1066.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ct Cells: 1 Karyo W/Banding","20101650","CDM","311","RC","88269","HCPCS","facility","both","","","","2003","1001.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Additional Karyotypes: Each","20101651","CDM","311","RC","88280","HCPCS","facility","both","","","","582","291","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Additional Cells Counted: Each","20101653","CDM","311","RC","88285","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Factor X Act. Unfrac","20101656","CDM","300","RC","85520","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Factor X Act. Lmwh","20101657","CDM","300","RC","85520","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytogenetic Dna Probe","20101660","CDM","311","RC","88271","HCPCS","facility","both","","","","686","343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chrom In Situ,10-30 Cells","20101662","CDM","311","RC","88273","HCPCS","facility","both","","","","395","197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Interphase In Situ,100-300 Cel","20101664","CDM","311","RC","88275","HCPCS","facility","both","","","","422","211","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fish Hematologic Manual","20101667","CDM","310","RC","88368","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fish Hematologic Add'tl Manual","20101668","CDM","310","RC","88368","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rsv Pcr-Each Probe","20101700","CDM","300","RC","87634","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bv Panel","20101721","CDM","300","RC","87801","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Calr Mutation Analysis","20101723","CDM","310","RC","81219","HCPCS","facility","both","","","","1005","502.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl P2Y12 Assay","20101724","CDM","300","RC","85576","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Russell Viper Screen-Dilute","20101740","CDM","300","RC","85613","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Russell Viper Confirm-Dilute","20101741","CDM","300","RC","85613","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha 2 Antiplasmin","20101742","CDM","300","RC","85410","HCPCS","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Analyze 20-25 Cells","20101743","CDM","310","RC","88264","HCPCS","facility","both","","","","1785","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Absolute Neutrophil","20101744","CDM","300","RC","85048","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag,Ctc-Assay For Tumor A","20101749","CDM","300","RC","86316","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cgh Microarray Analysis","20101760","CDM","310","RC","81229","HCPCS","facility","both","","","","3827","1913.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag,Hbv Quant","20101801","CDM","300","RC","87517","HCPCS","facility","both","","","","382","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Sma Carrier Testing","20101821","CDM","310","RC","81329","HCPCS","facility","both","","","","693","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heparin Agg-Low","20101900","CDM","300","RC","85576","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heparin Agg-High","20101901","CDM","300","RC","85576","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Activated Protein C","20102015","CDM","300","RC","85307","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Synovial Fluid Cell Ct/Diff","20102016","CDM","300","RC","89051","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Plat Agg - Pfa Col Adp","20102017","CDM","300","RC","85576","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Plat Agg - Pfa Col Epi","20102018","CDM","300","RC","85576","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Plasminogen Activator Inhibito","20102019","CDM","300","RC","85415","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl D-Dimer Quantitation","20102373","CDM","300","RC","85379","HCPCS","facility","both","","","","313","156.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Protein S - Total","20102375","CDM","300","RC","85305","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Protein S Activity(Free)","20102376","CDM","300","RC","85306","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urovysion Probe Ea-Automated","20102397","CDM","310","RC","88121","HCPCS","facility","both","","","","1586","793","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytogenetic Probe Subtelomeres","20102405","CDM","311","RC","88271","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Anti-Thrombin Iii Antigen","20102409","CDM","300","RC","85301","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Macroscopic Exam And Prep","20102460","CDM","300","RC","88387","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lamellar Body Counts","20102500","CDM","300","RC","83664","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hexagonal Phase Phospholipid","20102501","CDM","300","RC","85598","HCPCS","facility","both","","","","721","360.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anti-Xa Fondaparinux","20102502","CDM","300","RC","85520","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  Lc-Prostate Cancer Gene3(Pca3)","20102550","CDM","310","RC","81313","HCPCS","facility","both","","","","547","273.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Cystic Fibrosis 97","20103000","CDM","310","RC","81220","HCPCS","facility","both","","","","2796","1398","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Jak2 Exon 14","20104004","CDM","310","RC","81270","HCPCS","facility","both","","","","723","361.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Factor V","20104008","CDM","310","RC","81241","HCPCS","facility","both","","","","782","391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Ptg","20104009","CDM","310","RC","81240","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag Cf","20104010","CDM","310","RC","81220","HCPCS","facility","both","","","","7029","3514.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Microarray-Snp","20104011","CDM","310","RC","81229","HCPCS","facility","both","","","","5820","2910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Tay-Sachs Dna Analysis","20104012","CDM","310","RC","81255","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla B*1502 Screen","20104016","CDM","310","RC","81381","HCPCS","facility","both","","","","520","260","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Celiac Hla Dq2 Assoc","20104017","CDM","310","RC","81377","HCPCS","facility","both","","","","412","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Narcolepsy Evaluation","20104019","CDM","310","RC","81383","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Brc/Abl Major Quant Pcr, S/O","20104020","CDM","300","RC","81206","HCPCS","facility","both","","","","502","251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Bcr/Abl Quant Pcr","20104021","CDM","310","RC","81479","HCPCS","facility","both","","","","551","275.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hered Hemochromatosis Pcr","20104022","CDM","310","RC","81256","HCPCS","facility","both","","","","227","113.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cytochrome P450 2C19 Genoty","20104023","CDM","310","RC","81225","HCPCS","facility","both","","","","866","433","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cytochrome P450 2D6 Genotyp","20104024","CDM","310","RC","81226","HCPCS","facility","both","","","","1108","554","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-B-Thalassemia Hbb Fgs","20104025","CDM","310","RC","81364","HCPCS","facility","both","","","","1395","697.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Alpha Thalassemia","20104026","CDM","310","RC","81257","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Fragile X","20104027","CDM","310","RC","81243","HCPCS","facility","both","","","","611","305.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-C-Kit Mutation In Tumors","20104028","CDM","310","RC","81272","HCPCS","facility","both","","","","1757","878.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla Typing A,B,C (Ir)","20104031","CDM","310","RC","81372","HCPCS","facility","both","","","","1178","589","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Jak2 Exon 12 Mutation Analy","20104034","CDM","310","RC","81279","HCPCS","facility","both","","","","1066","533","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla B27 Disease Association","20104050","CDM","310","RC","81374","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla B 5701","20104051","CDM","310","RC","81381","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Fbn-1 Marfan Syndrome Fgs","20104054","CDM","310","RC","81408","HCPCS","facility","both","","","","5713","2856.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Flt3 Idt & D835 Var Det Pcr","20104060","CDM","310","RC","81479","HCPCS","facility","both","","","","478","239","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Pml-Rara Transcript Detect","20104064","CDM","310","RC","81315","HCPCS","facility","both","","","","1211","605.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Teg Koalin Analysis","20107001","CDM","300","RC","85347","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Teg Koalin Analysis","20107002","CDM","300","RC","85384","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Teg Koalin Analysis","20107003","CDM","300","RC","85384","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Teg Koalin Analysis","20107004","CDM","300","RC","85576","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Teg Koalin Analysis","20107005","CDM","300","RC","85390","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Mapping Adp And Aa/Teg","20107007","CDM","300","RC","85576","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Mapping Adp And Aa/Teg","20107008","CDM","300","RC","85576","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Mapping Adp And Aa/Teg","20107009","CDM","300","RC","85576","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Il28B Polymorphism","20107901","CDM","310","RC","81283","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Igvh Somatic Hypermutation","20107903","CDM","310","RC","81263","HCPCS","facility","both","","","","1868","934","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Men2: Ret Gene Sequencing","20107904","CDM","310","RC","81405","HCPCS","facility","both","","","","791","395.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Bcr-Abl1 Kinase Domain Mut","20107905","CDM","310","RC","81170","HCPCS","facility","both","","","","2259","1129.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Maternal Cell Contamination","20107906","CDM","310","RC","81265","HCPCS","facility","both","","","","347","173.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Men1 Gene, Seq Analysis","20107907","CDM","310","RC","81405","HCPCS","facility","both","","","","3403","1701.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Respiratory Viral Pnl","20107909","CDM","300","RC","0225U","HCPCS","facility","both","","","","1722","861","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amnisure","20107910","CDM","300","RC","84112","HCPCS","facility","both","","","","120","60","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Eos Smear Urine","20107911","CDM","300","RC","87205","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Alpha1-Antitrypsin Defic","20107912","CDM","310","RC","81332","HCPCS","facility","both","","","","468","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytogenetic Interp","20109500","CDM","300","RC","G0452","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Mpl Mutation Analysis","20109501","CDM","310","RC","81338","HCPCS","facility","both","","","","1264","632","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Mefv Fgs","20109701","CDM","310","RC","81404","HCPCS","facility","both","","","","1979","989.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Brca1/2 Comp Analysis","20109711","CDM","310","RC","81162","HCPCS","facility","both","","","","4897","2448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol-Diag Braf Mutation","20110003","CDM","310","RC","81210","HCPCS","facility","both","","","","617","308.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol-Diag Egfr Mutation","20110004","CDM","310","RC","81235","HCPCS","facility","both","","","","882","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag - Extended Kras","20110005","CDM","310","RC","81479","HCPCS","facility","both","","","","718","359","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl - Mol Diag-Snrpn Ube3A, Ma","20110008","CDM","310","RC","81331","HCPCS","facility","both","","","","765","382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zlc Adamts-13 Antibody Rflx","20110011","CDM","300","RC","83520","HCPCS","facility","both","","","","462","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201265","CDM","270","RC","","","facility","both","","","","104.23","52.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fecal Wbcs","20130004","CDM","300","RC","89055","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Semen Analysis-Motility/Presence","20130006","CDM","300","RC","89321","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bronch. Lav Cell Ct/Diff","20130010","CDM","300","RC","89051","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc Fragile X Dna Prenatal","20130034","CDM","310","RC","81243","HCPCS","facility","both","","","","343","171.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl - Lc Gla Full Gene Sequencing","20130037","CDM","310","RC","81405","HCPCS","facility","both","","","","1968","984","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Dpd 5-Fluorouracil Toxicity","20130047","CDM","310","RC","81232","HCPCS","facility","both","","","","539","269.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Asprin Assay","20130048","CDM","300","RC","85576","HCPCS","facility","both","","","","360","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult: Blood","20130050","CDM","311","RC","88230","HCPCS","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ct 15-20 : 2 Karyo +Band Bld","20130051","CDM","311","RC","88262","HCPCS","facility","both","","","","2021","1010.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult: Blood  Hi Res","20130052","CDM","311","RC","88230","HCPCS","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ct15-20: 2Karyo+Band","20130053","CDM","311","RC","88262","HCPCS","facility","both","","","","2021","1010.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Addt'l High Resolution Blood","20130054","CDM","311","RC","88289","HCPCS","facility","both","","","","490","245","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cult: Skin Other","20130055","CDM","311","RC","88233","HCPCS","facility","both","","","","2304","1152","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Kras Mutation By Snapshot","20130079","CDM","310","RC","81276","HCPCS","facility","both","","","","545","272.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Nras Mutation By Pcr Snpsht","20130080","CDM","310","RC","81479","HCPCS","facility","both","","","","1193","596.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla Drb1,3,4,5,Dqb1 (Ir)","20130082","CDM","310","RC","81375","HCPCS","facility","both","","","","388","194","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla-A (Ir)","20130083","CDM","310","RC","81373","HCPCS","facility","both","","","","420","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla-B (Ir)","20130084","CDM","310","RC","81373","HCPCS","facility","both","","","","420","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Npm1 Mutation Analysis","20130100","CDM","310","RC","81310","HCPCS","facility","both","","","","673","336.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Jak2 V617F,Rfx Calr/E12/Mpl","20130101","CDM","310","RC","81270","HCPCS","facility","both","","","","528","264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cah 21-Hydroxylase (Cyp21)","20130105","CDM","310","RC","81402","HCPCS","facility","both","","","","820","410","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cystic Fibrosis Mutation 97","20130108","CDM","310","RC","81220","HCPCS","facility","both","","","","519","259.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Factor V Leiden Mutation","20130109","CDM","310","RC","81241","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cystic Fibrosis Profile","20130110","CDM","310","RC","81220","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ct 15-20: 2 Karyo+Band Sk/Oth","20130156","CDM","311","RC","88262","HCPCS","facility","both","","","","2021","1010.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc Vistaseq Hereditary Cancer","20130157","CDM","310","RC","81432","HCPCS","facility","both","","","","5521","2760.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Solid Tumor Dna Only","20130158","CDM","310","RC","81445","HCPCS","facility","both","","","","1971","985.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo-Oncoheme Ngs","20130159","CDM","310","RC","81450","HCPCS","facility","both","","","","4684","2342","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Opmd Dna Test","20130160","CDM","310","RC","81312","HCPCS","facility","both","","","","1311","655.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Notch1 Mutation Analysi","20130161","CDM","310","RC","81407","HCPCS","facility","both","","","","1693","846.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Sma Diagnostic Test","20130163","CDM","310","RC","81329","HCPCS","facility","both","","","","1202","601","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Infertility-Male,Y Deletion","20130165","CDM","310","RC","81479","HCPCS","facility","both","","","","371","185.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Chromosome Breakage Study","20130166","CDM","311","RC","88230","HCPCS","facility","both","","","","261","130.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Chromosome Breakage Study","20130167","CDM","311","RC","88248","HCPCS","facility","both","","","","359","179.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Chromosome Breakage Study","20130168","CDM","311","RC","88249","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Qual Jak2 V617F Mutation","20130169","CDM","310","RC","81270","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Wilson Disease Atp7B Fgs","20130170","CDM","310","RC","81406","HCPCS","facility","both","","","","2574","1287","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Il28B Polymorphism","20130172","CDM","310","RC","81335","HCPCS","facility","both","","","","746","373","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-P53 Mutation Analysis","20130173","CDM","310","RC","81352","HCPCS","facility","both","","","","1271","635.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Apo E Genotyping Cardiorisk","20130177","CDM","310","RC","81401","HCPCS","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Athena Notch3 Dna Seq","20130179","CDM","310","RC","81479","HCPCS","facility","both","","","","5210","2605","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Ugt1A1 Irinotecan Toxicity","20130182","CDM","310","RC","81350","HCPCS","facility","both","","","","697","348.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Epi Procolon Septin 9 Gene","20130183","CDM","310","RC","81327","HCPCS","facility","both","","","","347","173.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Nras Mutation Analy","20130187","CDM","310","RC","81479","HCPCS","facility","both","","","","733","366.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Gjb2 Fgs - Connexin 26, S/O","20130188","CDM","310","RC","81252","HCPCS","facility","both","","","","1173","586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Von Hippel-Lindau Dis Fgs","20130189","CDM","310","RC","81404","HCPCS","facility","both","","","","1110","555","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Nras Exon 4 Mutation","20130199","CDM","310","RC","81403","HCPCS","facility","both","","","","649","324.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Egfr Mutation Analysis","20130201","CDM","310","RC","81235","HCPCS","facility","both","","","","675","337.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Ras Raf Panel","20130202","CDM","310","RC","81479","HCPCS","facility","both","","","","2065","1032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Braf Mutation Analysis","20130207","CDM","310","RC","81210","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag - Macrodisection","20130208","CDM","310","RC","88387","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Sma Carrier Test Smn1","20130210","CDM","310","RC","81329","HCPCS","facility","both","","","","291","145.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Billing Correction Sendouts-Snvmc","20130216","CDM","300","RC","","","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Ntrk","20130311","CDM","310","RC","81194","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Braf Ngs","20130312","CDM","310","RC","81479","HCPCS","facility","both","","","","535","267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag-Fgfr","20130313","CDM","310","RC","81404","HCPCS","facility","both","","","","707","353.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl-Neogen-Kras Mutation Analysis","20130314","CDM","310","RC","81479","HCPCS","facility","both","","","","739","369.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Ar-Drug Panel Umb Cord Qual","20130315","CDM","300","RC","80307","HCPCS","facility","both","","","","284","142","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Ar-Thc Umb Cord Tissue Qual, S/O","20130316","CDM","300","RC","G0480","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Lymphocyte Clonality Panel","20130317","CDM","310","RC","81479","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mycoplasma Genitalium","20130318","CDM","300","RC","87563","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mycoplasma Hominis","20130319","CDM","300","RC","87798","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ureaplasma Spp","20130320","CDM","300","RC","87798","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81263 Cll, Igvh Mutation Status, Cell Based, S/O","20130322","CDM","310","RC","81263","HCPCS","facility","both","","","","322","161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gd-Custom Panel","20130323","CDM","310","RC","81479","HCPCS","facility","both","","","","6372","3186","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Br-Onkosight Myeloid Diso. Pnl","20130324","CDM","310","RC","81450","HCPCS","facility","both","","","","1665","832.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Br-Onkosight Aml Panel","20130325","CDM","310","RC","81450","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Neotype Lung Tumor Profile","20130326","CDM","310","RC","81479","HCPCS","facility","both","","","","5054","2527","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Neotype Brain Tumor Profil","20130327","CDM","310","RC","81479","HCPCS","facility","both","","","","5597","2798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Wilson Disease Atp7B Seq.","20130328","CDM","310","RC","81406","HCPCS","facility","both","","","","1978","989","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tp53 Somatic Mutation, Prognostic, S/O","20130329","CDM","310","RC","81352","HCPCS","facility","both","","","","970","485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Leukovantage Mpns","20130330","CDM","310","RC","81450","HCPCS","facility","both","","","","4080","2040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Mlh1 Prom Methlataion Anal","20130333","CDM","310","RC","81288","HCPCS","facility","both","","","","620","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi-Mpl Mutation","20130334","CDM","310","RC","81338","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi-Calreticulin","20130335","CDM","310","RC","81219","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi-B Cell Igk Gene Rearangemt","20130336","CDM","310","RC","81264","HCPCS","facility","both","","","","834","417","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi-B Cell Igh Gene Rearangemt","20130337","CDM","310","RC","81261","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi Jak2 V617F Mutation Detect","20130338","CDM","310","RC","81270","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo-Transthyretin (Ttr Fgs)","20130339","CDM","310","RC","81404","HCPCS","facility","both","","","","1386","693","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Neotype Myeloid Diso Prfil","20130340","CDM","310","RC","81450","HCPCS","facility","both","","","","4311","2155.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Limb Gridle Musc Dys Adv Ev","20130341","CDM","310","RC","81443","HCPCS","facility","both","","","","5899","2949.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bcr-Abl1 Quantitative","20130342","CDM","310","RC","81479","HCPCS","facility","both","","","","445","222.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc Drug Profile 14 Ua Monitor","20130345","CDM","300","RC","80307","HCPCS","facility","both","","","","202","101","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gtc-Hematology Profile","20130346","CDM","310","RC","81479","HCPCS","facility","both","","","","3488","1744","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pdgfra Mutation Analysis","20130347","CDM","310","RC","81314","HCPCS","facility","both","","","","944","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi - Idh1 & Idh2 Mutations","20131346","CDM","310","RC","81479","HCPCS","facility","both","","","","768","384","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi - Flt3 Mutation","20131347","CDM","310","RC","81479","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi T-Cell Recep Gamma Gene Re","20131348","CDM","310","RC","81342","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc Hpa-1A (Pla1 Plt Ag) Genoty","20131349","CDM","310","RC","81105","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi T-Cell Recep Beta Gene Rea","20131350","CDM","310","RC","81340","HCPCS","facility","both","","","","727","363.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Meconium Drug 10 Panel","20131351","CDM","300","RC","80307","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Cebpa Mutation Analysis","20131352","CDM","310","RC","81218","HCPCS","facility","both","","","","505","252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu- Npm(Exon 12) Mut Cell-Base","20131353","CDM","310","RC","81310","HCPCS","facility","both","","","","537","268.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi - Myd88","20131354","CDM","310","RC","81479","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo- Pik3Ca Ldt Mutation Analy","20131355","CDM","310","RC","81309","HCPCS","facility","both","","","","767","383.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myd88, Mutation Analysis, S/O","20131356","CDM","310","RC","81305","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Caredx Allosure Kidney Process","20131357","CDM","300","RC","84999","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Stone Analysis","20131358","CDM","300","RC","82365","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csi-Npm1 Mutation","20131359","CDM","310","RC","81310","HCPCS","facility","both","","","","535","267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Idh1 Idh2 Mutation Analysis","20131360","CDM","310","RC","81479","HCPCS","facility","both","","","","1134","567","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Mgmt Gene Methylation Assay","20131361","CDM","310","RC","81287","HCPCS","facility","both","","","","1180","590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Neotype Aml Prognostic","20131362","CDM","310","RC","81450","HCPCS","facility","both","","","","2536","1268","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Myd88 Mutation Analysis","20131363","CDM","310","RC","81305","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-T-Cell Receptor Gamma Gene","20131364","CDM","310","RC","81342","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Jak2 Exon 12 Mutation","20131365","CDM","310","RC","81479","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Umhs-Cebpa Mutation Detection","20131366","CDM","310","RC","81218","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) T-Cell Clonality Panel, S/O","20131367","CDM","310","RC","81479","HCPCS","facility","both","","","","615","307.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Colorectal Tumor Profile","20131368","CDM","310","RC","81479","HCPCS","facility","both","","","","3164","1582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo-Pompe Disease, Full Gene","20131369","CDM","310","RC","81406","HCPCS","facility","both","","","","4394","2197","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-T-Cell Receptor Beta Gene","20131370","CDM","310","RC","81340","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Umhs-Kit Mutation For Gist","20131371","CDM","310","RC","81272","HCPCS","facility","both","","","","1005","502.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid Antibody","20131372","CDM","300","RC","86328","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Hydrocodone Confirm, Urine, S/O","20131373","CDM","300","RC","G0480","HCPCS","facility","both","","","","117","58.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Kit D816 Mutation Analysis","20131374","CDM","310","RC","81273","HCPCS","facility","both","","","","844","422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo-Dpyd Fgs","20131375","CDM","310","RC","81232","HCPCS","facility","both","","","","1549","774.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo-Ugt1A1 Fgs","20131376","CDM","310","RC","81350","HCPCS","facility","both","","","","1711","855.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Brcassure Comp Analysis","20131377","CDM","310","RC","81162","HCPCS","facility","both","","","","3007","1503.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Complete Hnpp Evaluation","20131378","CDM","310","RC","81479","HCPCS","facility","both","","","","2952","1476","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-B-Cell Gene Rearrangement","20131379","CDM","310","RC","81479","HCPCS","facility","both","","","","722","361","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Lab","20131380","CDM","300","RC","U0005","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Br-Onkosight Mds Panel","20131381","CDM","310","RC","81450","HCPCS","facility","both","","","","1586","793","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Sept9 Dna Squencing Test","20131382","CDM","310","RC","81479","HCPCS","facility","both","","","","1477","738.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ver-Vwf Fgs","20131385","CDM","310","RC","81408","HCPCS","facility","both","","","","2199","1099.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mach-Ahus Genetic Panel","20131386","CDM","310","RC","81443","HCPCS","facility","both","","","","4699","2349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 Plus Anti-Sae1","20131387","CDM","300","RC","83520","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Anti-Pl-7 Ab","20131388","CDM","300","RC","83516","HCPCS","facility","both","","","","128","64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Anti-Cn-1A Ab (Nt5C1A) Ibm","20131389","CDM","300","RC","83516","HCPCS","facility","both","","","","307","153.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cu Index","20131390","CDM","300","RC","86352","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Anti-Pl-12 Ab","20131391","CDM","300","RC","83516","HCPCS","facility","both","","","","128","64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Cxcr4 Mutation Analysis","20131392","CDM","310","RC","81479","HCPCS","facility","both","","","","637","318.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Estradiol, Free-Serum","20131393","CDM","300","RC","82681","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Fungal Panel-Coccidioides Ab","20131394","CDM","300","RC","86635","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Fungal Panel-Blastomyces Ab","20131395","CDM","300","RC","86612","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Fungal Panel-Histoplasma Ab","20131396","CDM","300","RC","86698","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Fungal Panel-Aspergillus Flavus Ab","20131397","CDM","300","RC","86606","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Fungal Panel-Aspergillus Fumigatus Ab","20131398","CDM","300","RC","86606","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Fungal Panel-Aspergillus Niger Ab","20131399","CDM","300","RC","86606","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Phospholipase A2 Receptor","20131400","CDM","300","RC","83516","HCPCS","facility","both","","","","322","161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Lead,Blood, Filter Paper","20131401","CDM","300","RC","83655","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Intelligen(R) Myeloid","20131402","CDM","310","RC","81450","HCPCS","facility","both","","","","4036","2018","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Fmi) Foundationone Cdx, S/O","20131403","CDM","310","RC","0037U","HCPCS","facility","both","","","","3515","1757.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogenomics-Breast Tumor Profile","20131405","CDM","310","RC","81479","HCPCS","facility","both","","","","2116","1058","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla A,B,C,Drb1 Profile","20131406","CDM","310","RC","81378","HCPCS","facility","both","","","","2191","1095.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Neotype Pancreas Tumor Profile","20131407","CDM","310","RC","81479","HCPCS","facility","both","","","","2564","1282","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Tert Promoter Mutation Analysis","20131408","CDM","310","RC","81345","HCPCS","facility","both","","","","322","161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mgmt Promoter Methylation Analysis","20131409","CDM","310","RC","81287","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Idh1 And Idh2 Mutations Analysis (Bi-Directional Seq)","20131410","CDM","310","RC","81479","HCPCS","facility","both","","","","419","209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Inhibitor Titer Fix","20131411","CDM","300","RC","85335","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla B 58:01","20131412","CDM","310","RC","81381","HCPCS","facility","both","","","","546","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Aire Gene Autoimmune Polyglandular Syndrome Type 1","20131413","CDM","310","RC","81406","HCPCS","facility","both","","","","1386","693","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131414","CDM","300","RC","86651","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131415","CDM","300","RC","86651","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131416","CDM","300","RC","86652","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131417","CDM","300","RC","86652","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131418","CDM","300","RC","86653","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131419","CDM","300","RC","86653","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131420","CDM","300","RC","86654","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Arboviral Antibodies, Ifa","20131421","CDM","300","RC","86654","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gtc - Hematology Profile Plus","20131422","CDM","310","RC","81479","HCPCS","facility","both","","","","3707","1853.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mol Diag - Oncomine Precision Assay","20131423","CDM","310","RC","81445","HCPCS","facility","both","","","","2775","1387.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup - Microstellite Instability By Pcr","20131424","CDM","310","RC","81301","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl - Lsu - Immunofluorescence Staining","20131425","CDM","300","RC","88346","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lsu - Immunofluorescence Staining","20131426","CDM","300","RC","88350","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup - Mog Igg, Reflexed","20131427","CDM","300","RC","86256","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup - Mog Igg","20131428","CDM","300","RC","86255","HCPCS","facility","both","","","","352","176","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl-Lc - Anti-Tysabri Ab","20131429","CDM","300","RC","83516","HCPCS","facility","both","","","","322","161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Athena - Lrp4 Autoantibody","20131430","CDM","300","RC","86255","HCPCS","facility","both","","","","1219","609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Omega Check (Epa + Dpa + Dha)","20131431","CDM","300","RC","82542","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Hepatitis B Surface Antigen, Quant, Monitor","20131432","CDM","300","RC","82397","HCPCS","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Rituximab And Anti-Rituximab Antibody","20131433","CDM","300","RC","80299","HCPCS","facility","both","","","","352","176","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Rituximab And Anti-Rituximab Antibody","20131434","CDM","300","RC","82397","HCPCS","facility","both","","","","303","151.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Pneumocystis Jiroveci Qpcr Bal","20131435","CDM","300","RC","87799","HCPCS","facility","both","","","","352","176","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Thc Wb","20131436","CDM","300","RC","80307","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Thc Wb, Reflexed","20131437","CDM","300","RC","80307","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Ustekinumab And Anti-Ustekinumab Antibody","20131438","CDM","300","RC","80299","HCPCS","facility","both","","","","334","167","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Ustekinumab And Anti-Ustekinumab Antibody","20131439","CDM","300","RC","82397","HCPCS","facility","both","","","","287","143.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo - 2, 3 Dinor 11 Beta - Prostaglandin F2 Alpha","20131440","CDM","300","RC","84150","HCPCS","facility","both","","","","437","218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Hiv-2 Qualitative Rna, Diagnostic","20131441","CDM","300","RC","87538","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Alpha-Gal Panel Allergen Spec Ige Recomb","20131442","CDM","300","RC","86008","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Alpha-Gal Panel Immunoglobulin E, Total","20131443","CDM","300","RC","82785","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Mthfr Pcr","20131444","CDM","310","RC","81291","HCPCS","facility","both","","","","128","64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Wu - Myeloid Gene Panel By Ngs","20131445","CDM","310","RC","81479","HCPCS","facility","both","","","","1320","660","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Ri Ab Western Blot","20131446","CDM","300","RC","84181","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Ri Ab Titer","20131447","CDM","300","RC","86256","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Rickettsia (Typhus Fever) Igg Titer","20131448","CDM","300","RC","86757","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Rickettsia (Typhus Fever) Igm Titer","20131449","CDM","300","RC","86757","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Rmsf Igg Titer","20131450","CDM","300","RC","86757","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Autoantibody Hu (Western Blot)","20131451","CDM","300","RC","84181","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hu Antibody Titer","20131452","CDM","300","RC","86256","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Yo Antibody Titer","20131453","CDM","300","RC","86256","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Autoantibody Yo (Western Blot)","20131454","CDM","300","RC","84181","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Endomysial Antibody Titer","20131455","CDM","300","RC","86256","HCPCS","facility","both","","","","78","39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Dna (Ds) Antibody Titer","20131456","CDM","300","RC","86256","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Sensory Motor Neuropathy Panel","20131457","CDM","300","RC","83520","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Rmsf Igm Titer","20131458","CDM","300","RC","86757","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Rickettsial Disease Panel","20131459","CDM","300","RC","86638","HCPCS","facility","both","","","","431","215.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Neisseria Meningitidis Igg Vaccine","20131460","CDM","300","RC","86317","HCPCS","facility","both","","","","119","59.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Jc Virus Stratified","20131461","CDM","300","RC","86711","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Echinococcus Igg Western Blot","20131462","CDM","300","RC","86682","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ma - Flcn Full Gene Analysis","20131463","CDM","310","RC","81479","HCPCS","facility","both","","","","1976","988","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-T Pallidum Screening Cascade","20131464","CDM","300","RC","86780","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Rpr, Reflex","20131465","CDM","300","RC","86592","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Rpr, Quant Reflex","20131466","CDM","300","RC","86593","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ebv Plasma","20131467","CDM","300","RC","87799","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Musk Antibody Test","20131468","CDM","300","RC","83519","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hiv-1 Integrase Genotype","20131469","CDM","300","RC","87906","HCPCS","facility","both","","","","114","57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hiv-1 Genotype (Rti, Pi, Integrase)","20131470","CDM","300","RC","87900","HCPCS","facility","both","","","","56","28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hiv-1 Genotype (Rti, Pi, Integrase)","20131471","CDM","300","RC","87901","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hiv-1 Genotype (Rti, Pi, Integrase)","20131472","CDM","300","RC","87906","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ma - Foxl2 Mutation Analysis, Tumor","20131473","CDM","310","RC","81479","HCPCS","facility","both","","","","1729","864.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hiv-1 Genotype","20131474","CDM","300","RC","87900","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Hiv-1 Genotype","20131475","CDM","300","RC","87901","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Athena - Gfap (Alexander Disease) Sequencing Test","20131476","CDM","310","RC","81405","HCPCS","facility","both","","","","2295","1147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Von Willebrand Factor Ag","20131477","CDM","300","RC","85246","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Q Fever Lgg Phase I Titer","20131478","CDM","300","RC","86757","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Q Fever Igg Phase Ii Titer","20131479","CDM","300","RC","86757","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Q Fever Igm Phase Ii Titer","20131480","CDM","300","RC","86757","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Q Fever Igm Phase I Titer","20131481","CDM","300","RC","86757","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Pancreatitis Three-Gene Profile","20131482","CDM","310","RC","81479","HCPCS","facility","both","","","","3822","1911","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - T-Cell Receptor Beta Gene Rearrangement","20131483","CDM","310","RC","81340","HCPCS","facility","both","","","","296","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gh - Oncotype Dx Breast Cancer Assay","20131484","CDM","310","RC","81519","HCPCS","facility","both","","","","4635","2317.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alcohol, Methyl, S/O","20131485","CDM","300","RC","G0480","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Body Fluid Ph","20131486","CDM","300","RC","83986","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Ethylene Glycol","20131487","CDM","300","RC","82693","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alcohol, Isopropyl, S/O","20131488","CDM","300","RC","G0480","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alcohol, Ethyl Glc, S/O","20131489","CDM","300","RC","G0480","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Methotrexate","20131490","CDM","300","RC","80204","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc- Factor V Leiden With Rfx R2","20131491","CDM","310","RC","81241","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Factor Ii Mutation","20131492","CDM","310","RC","81240","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Ahus Genetic Analysis","20131493","CDM","310","RC","81479","HCPCS","facility","both","","","","2175","1087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neo-Brca 1/2 Mutation Analysis For Tumors","20131494","CDM","310","RC","81163","HCPCS","facility","both","","","","665","332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Mthfr, Dna Mutation Analysis","20131495","CDM","310","RC","81291","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Caris-Mi Profile","20131496","CDM","310","RC","81479","HCPCS","facility","both","","","","2935","1467.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Acetylcholine Receptor","20131497","CDM","300","RC","83519","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Voltage-Gated Calcium","20131498","CDM","300","RC","86596","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Paraneoplastic Ifa","20131499","CDM","300","RC","86255","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Alpha 3 Ab","20131500","CDM","300","RC","83519","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Vgcc Type N Ab","20131501","CDM","300","RC","86596","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Vgkc Antibody","20131502","CDM","300","RC","83519","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Striated Muscle Antibody","20131503","CDM","300","RC","86255","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Anti-Striated Muscle Ab T","20131504","CDM","300","RC","86256","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Paraneop Ab, Cba-Ifa","20131505","CDM","300","RC","86255","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Anna 3 Ab, Titer","20131506","CDM","300","RC","86256","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Pca 2 Ab, Titer","20131507","CDM","300","RC","86256","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86043 Acetylcholine Receptor Modulating Antibody, S/O","20131508","CDM","302","RC","86043","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Paraneoplastic Ab, Lb","20131509","CDM","300","RC","84182","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Paraneoplastic Ab, Lb","20131510","CDM","300","RC","86341","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu - Aquaporin-4 Ab (Igg),Cba","20131511","CDM","300","RC","86255","HCPCS","facility","both","","","","265","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vzv Lesion Pcr","20131512","CDM","300","RC","87798","HCPCS","facility","both","","","","78","39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vzv Pcr Csf","20131513","CDM","300","RC","87798","HCPCS","facility","both","","","","78","39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Myasthenia Gravis Panel 2 With Reflex To Musk Antibody","20131514","CDM","300","RC","83519","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Striated Muscle Ab Titer","20131515","CDM","300","RC","86256","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Qu-Musk Antibody Test Reflex Myasthenia Gravis Panel","20131516","CDM","300","RC","83519","HCPCS","facility","both","","","","670","335","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Hemophagocytic Lymphohistocytosis (Hlh) Genetic Analysis, S/O","20131517","CDM","310","RC","81479","HCPCS","facility","both","","","","2175","1087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Neotype Lymphoma Profile, S/O","20131518","CDM","310","RC","81450","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Microsatellite Instability By Pcr, S/O","20131519","CDM","310","RC","81301","HCPCS","facility","both","","","","497","248.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Vdrl Csf, S/O","20131520","CDM","300","RC","86592","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Muscle Biopsy Panel, S/O","20131521","CDM","310","RC","G0416","HCPCS","facility","both","","","","880","440","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Muscle Biopsy Panel, S/O","20131522","CDM","310","RC","88313","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Muscle Biopsy Panel, S/O","20131523","CDM","310","RC","88314","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Muscle Biopsy Panel, S/O","20131524","CDM","310","RC","88319","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Muscle Biopsy Panel, S/O","20131525","CDM","310","RC","88348","HCPCS","facility","both","","","","830","415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Nerve Biopsy Panel, S/O","20131526","CDM","310","RC","G0416","HCPCS","facility","both","","","","329","164.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Nerve Biopsy Panel, S/O","20131527","CDM","310","RC","88313","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Nerve Biopsy Panel, S/O","20131528","CDM","310","RC","88348","HCPCS","facility","both","","","","311","155.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Vectra, S/O","20131529","CDM","300","RC","81490","HCPCS","facility","both","","","","1004","502","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Hnpcc: Msh6 (Known Mutation), S/O","20131530","CDM","310","RC","81299","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ha) Molar Pregnancy Comprehensive Consultation, S/O","20131531","CDM","310","RC","88323","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ha) Molar Pregnancy Comprehensive Consultation, S/O","20131532","CDM","310","RC","88342","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ha) Molar Pregnancy Comprehensive Consultation, S/O","20131533","CDM","310","RC","88377","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ark) Nerve Biopsy Panel, S/O","20131534","CDM","310","RC","88362","HCPCS","facility","both","","","","134","67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Igh Clonality/Mrd By Ngs, S/O","20131535","CDM","310","RC","81263","HCPCS","facility","both","","","","425","212.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Neotype Cll Profile, S/O","20131536","CDM","310","RC","81479","HCPCS","facility","both","","","","515","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Neotype Dna & Rna Profile Brain W Mgmt, S/O","20131537","CDM","310","RC","81479","HCPCS","facility","both","","","","1253","626.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Neotype Dna & Rna Profile Brain W Mgmt, S/O","20131538","CDM","310","RC","88377","HCPCS","facility","both","","","","134","67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Neotype Dna & Rna Profile Brain W Mgmt, S/O","20131539","CDM","310","RC","88360","HCPCS","facility","both","","","","909","454.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) Neotype Dna & Rna Profile Brain W Mgmt, S/O","20131540","CDM","310","RC","81287","HCPCS","facility","both","","","","781","390.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Strep Pneumo Antigen Urine, S/O","20131541","CDM","306","RC","87899","HCPCS","facility","both","","","","162","81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Susceptibility, Yeast, Comprehensive Panel, S/O","20131542","CDM","306","RC","87186","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Thygenext, S/O","20131543","CDM","310","RC","0245U","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Thyramir Thyroid Mirna Classifier, S/O","20131544","CDM","310","RC","0018U","HCPCS","facility","both","","","","2015","1007.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Myeloid Ngs Panel","20131545","CDM","310","RC","81479","HCPCS","facility","both","","","","2437","1218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Calcium-Sensing Receptor (Casr) Gene Sequencing Analysis, S/O","20131546","CDM","310","RC","81405","HCPCS","facility","both","","","","1215","607.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Strongyloides, Igg Antibody, Qualitative, Eia, S/O","20131547","CDM","302","RC","86682","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) Nerve Fiber Density, S/O","20131548","CDM","310","RC","88342","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) Nerve Fiber Density, S/O","20131549","CDM","310","RC","G0416","HCPCS","facility","both","","","","873","436.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) Nerve Fiber Density, S/O","20131550","CDM","310","RC","88356","HCPCS","facility","both","","","","319","159.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) Nerve Fiber Density, S/O","20131551","CDM","310","RC","88313","HCPCS","facility","both","","","","77","38.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84066 Prostatic Acid Phosphatase (Pap), S/O","20132000","CDM","301","RC","84066","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Acth, Plasma, S/O","20132001","CDM","301","RC","82024","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ova& Parasites, Stool Concentrate &Permanent Smear, S/O","20132002","CDM","306","RC","87177","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Delta-Aminolevulinic Acid, Random Urine, S/O","20132003","CDM","301","RC","82135","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Albumin, Csf, S/O","20132004","CDM","301","RC","82042","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldolase, S/O","20132005","CDM","301","RC","82085","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alkaline Phosphatase Isoenzymes, S/O","20132006","CDM","301","RC","84075","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alkaline Phosphatase Isoenzymes, S/O","20132007","CDM","301","RC","84080","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-Fetoprotein,Af W/Rfl To Ache/Fetal Hgb, S/O","20132008","CDM","301","RC","82106","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-1-Antitrypsin Quantitation, S/O","20132009","CDM","301","RC","82103","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamines, Quantitative, Urine, S/O","20132010","CDM","301","RC","G0480","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dnase-B Antibody, S/O","20132011","CDM","302","RC","86215","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Glomerular Basement Membrane Antibody (Igg), S/O","20132012","CDM","301","RC","83520","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mitochondrial Antibody W/Refl Titer, S/O","20132013","CDM","302","RC","86255","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myocardial Antibody Screen With Reflex To Titer, S/O","20132014","CDM","302","RC","86255","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Actin Antibody (Igg), S/O","20132016","CDM","302","RC","86015","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B12, S/O","20132017","CDM","301","RC","82607","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Anti-Streptolysin O, S/O","20132018","CDM","302","RC","86060","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Striated Muscle Antibody, S/O","20132019","CDM","302","RC","86255","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Anti-Thyroglobulin Antibo, S/O","20132020","CDM","302","RC","86800","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Arsenic, Blood, S/O","20132021","CDM","301","RC","82175","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nortriptyline, S/O","20132022","CDM","301","RC","G0480","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C1 Inhibitor, Functional, S/O","20132023","CDM","302","RC","86161","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Lab","20132024","CDM","301","RC","84022","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C1 Esterase Inhibitor, Protein, S/O","20132025","CDM","302","RC","86160","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cadmium, Blood, S/O","20132026","CDM","301","RC","82300","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Carotene, S/O","20132027","CDM","301","RC","82380","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ceruloplasmin, S/O","20132028","CDM","301","RC","82390","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Ii Activity,Clotting, S/O","20132029","CDM","305","RC","85210","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Clonazepam, S/O","20132030","CDM","301","RC","G0480","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor V Activity,Clotting, S/O","20132031","CDM","305","RC","85220","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cobalt, Serum/Plasma, S/O","20132032","CDM","301","RC","83018","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Vii Activity,Clotting, S/O","20132033","CDM","305","RC","85230","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cold Hemagglutinins, S/O","20132034","CDM","302","RC","86157","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor X Activity,Clotting, S/O","20132035","CDM","305","RC","85260","HCPCS","facility","both","","","","42","21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Xi Activity,Clotting, S/O","20132036","CDM","305","RC","85270","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Xii Activity,Clotting, S/O","20132037","CDM","305","RC","85280","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Copper, S/O","20132038","CDM","301","RC","82525","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C-Peptide, S/O","20132039","CDM","301","RC","84681","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryofibrinogen, S/O","20132040","CDM","301","RC","82585","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin, Qualitative Analysis, S/O","20132041","CDM","301","RC","84165","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin, Qualitative Analysis, S/O","20132042","CDM","302","RC","86334","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin, Qualitative Analysis, S/O","20132043","CDM","301","RC","82595","HCPCS","facility","both","","","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cyanide, Blood, S/O","20132050","CDM","301","RC","82600","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Meperidine, Gc/Ms, Serum, S/O","20132051","CDM","301","RC","G0480","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Desipramine, S/O","20132052","CDM","301","RC","G0480","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amitriptyline, S/O","20132053","CDM","301","RC","G0480","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Erythropoietin (Epo), S/O","20132054","CDM","301","RC","82668","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Estrogen, Total, Serum, S/O","20132055","CDM","301","RC","82672","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alcohol, Ethyl, S/O","20132056","CDM","301","RC","G0480","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nonesterified Fatty Acids (Free Fatty Acids), S/O","20132057","CDM","301","RC","82725","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fecal Lipids, Total, S/O","20132058","CDM","301","RC","82710","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Furosemide, Serum/Plasma, S/O","20132059","CDM","301","RC","80299","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Folate, Rbc, S/O","20132060","CDM","301","RC","82747","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-1-Acid Glycoprotein, S/O","20132061","CDM","301","RC","82985","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Gastrin, S/O","20132062","CDM","301","RC","82941","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Glucose-6-Phosphate Dehydrogenase,(G-6-Pd), Quant, S/O","20132063","CDM","301","RC","82955","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hemoglobin, Free, Plasma, S/O","20132064","CDM","301","RC","83051","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Glucagon, S/O","20132065","CDM","301","RC","82943","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Growth Hormone(Gh), S/O","20132066","CDM","301","RC","83003","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 5 Hiaa, 24 Hour Urine, W/O Creatinine, S/O","20132067","CDM","301","RC","83497","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Homovanillic Acid, 24H Urine, S/O","20132068","CDM","301","RC","83150","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hepatitis Be Antigen, S/O","20132069","CDM","306","RC","87350","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hepatitis Be Antibody, S/O","20132070","CDM","302","RC","86707","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Insulin, S/O","20132071","CDM","301","RC","83525","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Haloperidol, S/O","20132072","CDM","301","RC","80173","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Intrinsic Factor Blocking Antibody, S/O","20132073","CDM","302","RC","86340","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alcohol, Isopropyl, S/O","20132074","CDM","301","RC","G0480","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead (Venous), S/O","20132075","CDM","301","RC","83655","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead, Urine, S/O","20132076","CDM","301","RC","82570","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead, Urine, S/O","20132077","CDM","301","RC","83655","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lidocaine, S/O","20132078","CDM","301","RC","80176","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Complement, Total (Ch50), S/O","20132079","CDM","302","RC","86162","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Magnesium, Rbc, S/O","20132080","CDM","302","RC","86005","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Magnesium, Rbc, S/O","20132081","CDM","301","RC","83735","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Manganese, Blood, S/O","20132082","CDM","301","RC","83785","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Meprobamate, S/O","20132083","CDM","301","RC","G0480","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mercury, S/O","20132084","CDM","301","RC","83825","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alcohol,Methyl, S/O","20132085","CDM","301","RC","G0480","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myoglobin, Urine, S/O","20132086","CDM","301","RC","83874","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myelin Basic Protein, S/O","20132087","CDM","301","RC","83873","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cadmium, Random Urine (Includes Mcg/L), S/O","20132088","CDM","301","RC","82300","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cadmium, Random Urine (Includes Mcg/L), S/O","20132089","CDM","301","RC","82570","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oligoclonal Bands (Igg), Csf, S/O","20132090","CDM","301","RC","83916","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Angiotensin Converting Enzyme, S/O","20132091","CDM","301","RC","82164","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Culture,Virus, Body, S/O","20132092","CDM","301","RC","82784","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Culture,Virus, Body, S/O","20132093","CDM","301","RC","84157","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Culture,Virus, Body, S/O","20132094","CDM","301","RC","84166","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Culture,Virus, Body, S/O","20132095","CDM","302","RC","86335","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Culture,Virus, Body, S/O","20132096","CDM","306","RC","87252","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Paraldehyde And Metabolite, Serum/Plasma, S/O","20132097","CDM","301","RC","80299","HCPCS","facility","both","","","","81","40.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rotavirus Antigen Detection, Eia, S/O","20132098","CDM","306","RC","87425","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phospholipids, S/O","20132099","CDM","301","RC","84311","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132100","CDM","301","RC","82040","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132101","CDM","301","RC","82247","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132102","CDM","301","RC","82310","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132103","CDM","301","RC","82374","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132104","CDM","301","RC","82435","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132105","CDM","301","RC","82565","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132106","CDM","301","RC","82947","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132107","CDM","301","RC","84075","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132108","CDM","301","RC","84100","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132109","CDM","301","RC","84132","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132110","CDM","301","RC","84155","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132111","CDM","301","RC","84295","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132112","CDM","301","RC","84450","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132113","CDM","301","RC","84520","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132114","CDM","301","RC","84550","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132115","CDM","305","RC","85007","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132116","CDM","305","RC","85014","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132117","CDM","305","RC","85018","HCPCS","facility","both","","","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, 24 Hr Ur, S/O","20132118","CDM","301","RC","84110","HCPCS","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphyrins, Fractionated, Quantitative,24-Hr Urine, S/O","20132119","CDM","301","RC","84120","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Procainamide, S/O","20132120","CDM","301","RC","80192","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein Total And Protein Electrophoresis, Csf, S/O","20132121","CDM","301","RC","84157","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein Total And Protein Electrophoresis, Csf, S/O","20132122","CDM","301","RC","84166","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Primidone And Phenobarbital, S/O","20132123","CDM","301","RC","80184","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Primidone And Phenobarbital, S/O","20132124","CDM","301","RC","80188","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Proinsulin, S/O","20132125","CDM","301","RC","84206","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84210 Pyruvic Acid (Pyruvate), Blood, S/O","20132126","CDM","301","RC","84210","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Quinidine, S/O","20132127","CDM","306","RC","87254","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Quinidine, S/O","20132128","CDM","301","RC","80194","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Retinol Binding Protein, S/O","20132129","CDM","302","RC","86320","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Retinol Binding Protein, S/O","20132130","CDM","301","RC","83883","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ethylene Glycol, S/O","20132131","CDM","301","RC","82693","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Serotonin, Blood, S/O","20132132","CDM","301","RC","84260","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Doxepin, S/O","20132133","CDM","301","RC","80299","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amylase Isoenzymes, S/O","20132134","CDM","301","RC","82150","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Beta-2 Microglobulin, Ser, S/O","20132135","CDM","301","RC","82232","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-1-Antitrypsin (Aat) Phenotype, S/O","20132136","CDM","301","RC","82104","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) T3 Uptake, S/O","20132137","CDM","301","RC","84479","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlorpromazine, S/O","20132138","CDM","301","RC","G0480","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Imipramine, S/O","20132139","CDM","301","RC","G0480","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Viscosity, Serum, S/O","20132140","CDM","305","RC","85810","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vasoactive Intestinal Polypeptide (Vip), Plasma, S/O","20132141","CDM","301","RC","84586","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin A (Retinol), S/O","20132142","CDM","301","RC","84590","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B6, Plasma, S/O","20132143","CDM","301","RC","84207","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin C, S/O","20132144","CDM","301","RC","82180","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin E (Tocopherol), S/O","20132145","CDM","301","RC","84446","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Coumadin, S/O","20132146","CDM","301","RC","80299","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Candida Antibody, Immunodiffusion, S/O","20132147","CDM","302","RC","86628","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zinc, S/O","20132148","CDM","301","RC","84630","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zinc Protoporphyrin (Zpp), S/O","20132149","CDM","301","RC","84202","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Manganese, Serum, S/O","20132150","CDM","301","RC","83785","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tryptophan, S/O","20132151","CDM","301","RC","82131","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Osmolality, Feces, S/O","20132152","CDM","301","RC","84999","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Complement Component C1Q, S/O","20132153","CDM","306","RC","87230","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Complement Component C1Q, S/O","20132154","CDM","302","RC","86160","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ph, Feces, S/O","20132155","CDM","301","RC","83986","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 5-Hydroxyindoleacetic Acid(5-Hiaa), Random Ur W/Cr, S/O","20132156","CDM","301","RC","82570","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 5-Hydroxyindoleacetic Acid(5-Hiaa), Random Ur W/Cr, S/O","20132157","CDM","301","RC","83497","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82570 Vma (Vanillylmandelic Acid), Random Urine, S/O","20132158","CDM","301","RC","82570","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84585 Vma (Vanillylmandelic Acid), Random Urine, S/O","20132159","CDM","301","RC","84585","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Clozapine, S/O","20132160","CDM","301","RC","80159","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Risperidone And Metabolite, S/O","20132161","CDM","301","RC","G0480","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sweet Potato (F54) Ige, S/O","20132162","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Anchovy (F313) Ige, S/O","20132163","CDM","302","RC","86003","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus Culture With Reflex To Typing, S/O","20132164","CDM","306","RC","87255","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Green Bean (F315) Ige**, S/O","20132165","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Varicella Zoster Virus Culture, Rapid Method, S/O","20132166","CDM","306","RC","87254","HCPCS","facility","both","","","","83","41.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nutmeg (Rf282) Ige**, S/O","20132167","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aluminum, S/O","20132168","CDM","301","RC","82108","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bicarbonate, Urine, S/O","20132169","CDM","301","RC","82374","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Valproic Acid, Free, S/O","20132170","CDM","301","RC","80165","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Potassium, Rbc, S/O","20132171","CDM","301","RC","84132","HCPCS","facility","both","","","","78","39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromium, Plasma, S/O","20132172","CDM","301","RC","82495","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Gabapentin, S/O","20132173","CDM","301","RC","80171","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igg, Csf, S/O","20132174","CDM","301","RC","82784","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nickel, Serum/Plasma, S/O","20132175","CDM","301","RC","83885","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Trazodone, Serum, S/O","20132176","CDM","301","RC","80299","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tetanus Antitoxoid, S/O","20132177","CDM","302","RC","86774","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Diphtheria Antitoxoid, S/O","20132178","CDM","302","RC","86648","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Copper, 24 Hour Urine, S/O","20132179","CDM","301","RC","82525","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Copper, 24 Hour Urine, S/O","20132180","CDM","301","RC","82570","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Von Willebrand Factor Antigen, S/O","20132181","CDM","305","RC","85246","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mexiletine, Serum/Plasma, S/O","20132182","CDM","301","RC","80299","HCPCS","facility","both","","","","88","44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha 2-Antiplasmin, S/O","20132183","CDM","305","RC","85410","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha 2-Antiplasmin, S/O","20132184","CDM","302","RC","86003","HCPCS","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hepatitis D Virus (Hdv) Antibody, Total, S/O","20132185","CDM","302","RC","86692","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B1 (Thiamine), Blood Lc/Ms/Ms, S/O","20132186","CDM","301","RC","84425","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Maternal Serum Afp, S/O","20132187","CDM","301","RC","82105","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroid Peroxidase Antibody, S/O","20132188","CDM","302","RC","86376","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ibuprofen, Serum/Plasma, S/O","20132189","CDM","301","RC","80299","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydia Trachomatis Antibody (Igm), S/O","20132190","CDM","302","RC","86632","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein S, Total Antigen, S/O","20132191","CDM","305","RC","85305","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Von Willebrand Antigen,Multimeric Analysis, S/O","20132192","CDM","305","RC","85247","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nickel, Random Urine, S/O","20132193","CDM","301","RC","82570","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nickel, Random Urine, S/O","20132194","CDM","301","RC","83885","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Apolipoprotein A1, S/O","20132195","CDM","301","RC","82172","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Apolipoprotein B, S/O","20132196","CDM","301","RC","82172","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Flecainide, S/O","20132197","CDM","301","RC","80181","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ph, Body Fluid, S/O","20132198","CDM","301","RC","83986","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxalate, Serum/Plasma, S/O","20132199","CDM","301","RC","83945","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Immunoglobulin G Subclass4, S/O","20132200","CDM","301","RC","82787","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Selenium, S/O","20132201","CDM","301","RC","84255","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Arsenic, Serum/Plasma, S/O","20132202","CDM","305","RC","85610","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Arsenic, Serum/Plasma, S/O","20132203","CDM","301","RC","82175","HCPCS","facility","both","","","","56","28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromium, Blood, S/O","20132204","CDM","301","RC","82495","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Selenium, Blood, S/O","20132205","CDM","301","RC","84255","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Selenium, Blood, S/O","20132206","CDM","301","RC","84255","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zinc, Rbc, S/O","20132207","CDM","301","RC","84630","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rickettsia(Rmsf) Abs, S/O","20132208","CDM","302","RC","86757","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epstein-Barr Virus Antibody Panel, S/O","20132209","CDM","302","RC","86664","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epstein-Barr Virus Antibody Panel, S/O","20132210","CDM","302","RC","86665","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hsv 1/2 Igg,Type Specific, S/O","20132211","CDM","302","RC","86695","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hsv 1/2 Igg,Type Specific, S/O","20132212","CDM","302","RC","86696","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aureobasidium Pullulans (M12) Ige, S/O","20132213","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Apolipoprotein Evaluation, S/O","20132214","CDM","301","RC","82172","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroid Panel, S/O","20132215","CDM","301","RC","84436","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroid Panel, S/O","20132216","CDM","301","RC","84479","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Multiple Sclerosis Panel 2, S/O","20132217","CDM","301","RC","82040","HCPCS","facility","both","","","","4","2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Multiple Sclerosis Panel 2, S/O","20132218","CDM","301","RC","82042","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Multiple Sclerosis Panel 2, S/O","20132219","CDM","301","RC","82784","HCPCS","facility","both","","","","4","2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Multiple Sclerosis Panel 2, S/O","20132220","CDM","301","RC","83873","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Multiple Sclerosis Panel 2, S/O","20132221","CDM","301","RC","83916","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 1, S/O","20132222","CDM","302","RC","86355","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 1, S/O","20132223","CDM","302","RC","86357","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 1, S/O","20132224","CDM","302","RC","86359","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 1, S/O","20132225","CDM","302","RC","86360","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Volatiles, S/O","20132226","CDM","301","RC","G0480","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroid Peroxidase And Thyroglobulin Antibodies, S/O","20132227","CDM","302","RC","86376","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroid Peroxidase And Thyroglobulin Antibodies, S/O","20132228","CDM","302","RC","86800","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel, Random Urine, S/O","20132229","CDM","301","RC","82175","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel, Random Urine, S/O","20132230","CDM","301","RC","82570","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel, Random Urine, S/O","20132231","CDM","301","RC","83655","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel, Random Urine, S/O","20132232","CDM","301","RC","83825","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igg Synthesis Rate/Index, Csf, S/O","20132233","CDM","301","RC","82040","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igg Synthesis Rate/Index, Csf, S/O","20132255","CDM","301","RC","82042","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igg Synthesis Rate/Index, Csf, S/O","20132256","CDM","301","RC","82784","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel (Venous), S/O","20132257","CDM","301","RC","82175","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel (Venous), S/O","20132258","CDM","301","RC","83655","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Panel (Venous), S/O","20132259","CDM","301","RC","83825","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Coxsackie B (1-6) Antibodies, Serum, S/O","20132260","CDM","302","RC","86658","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Parainfluenza Virus Ab (Types 1,2 And 3),Serum, S/O","20132261","CDM","302","RC","86790","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sjogren's Antibodies (Ss-A,Ss-B), S/O","20132262","CDM","302","RC","86235","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cholinesterase, Serum, With Dibucaine Inhibition, S/O","20132263","CDM","301","RC","82480","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cholinesterase, Serum, With Dibucaine Inhibition, S/O","20132264","CDM","301","RC","82638","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Afb Progressive Id, Probe, S/O","20132265","CDM","306","RC","87555","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Titanium, Blood, S/O","20132266","CDM","301","RC","83018","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fructosamine, S/O","20132267","CDM","301","RC","82985","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 17 Hydroxypregnenolone, S/O","20132268","CDM","301","RC","84143","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fluoxetine, S/O","20132269","CDM","301","RC","80299","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Barbiturates, Urine, S/O","20132270","CDM","301","RC","G0480","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methadone, Urine, S/O","20132271","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epstein-Barr Virusviralcapsid Antigen (Vca)Ab(Igm), S/O","20132272","CDM","302","RC","86665","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epstein-Barr Virusviralcapsidantigen (Vca)Ab(Igg), S/O","20132273","CDM","302","RC","86665","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bupropion And Metabolite, Serum/Plasma, S/O","20132274","CDM","301","RC","G0480","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lyme Disease Antibodies (Igg, Igm), Immunoblot, S/O","20132275","CDM","302","RC","86617","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha Subunit, S/O","20132276","CDM","301","RC","83520","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Varicella-Zoster Virus Antibody (Igm), S/O","20132277","CDM","302","RC","86787","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myeloperoxidase Antibody, S/O","20132278","CDM","302","RC","86021","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Potassium , Feces, S/O","20132279","CDM","301","RC","84311","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sodium, Feces, S/O","20132280","CDM","301","RC","84302","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thallium, Urine, S/O","20132281","CDM","301","RC","82570","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thallium, Urine, S/O","20132282","CDM","301","RC","83018","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Parvovirus B19  Antibodies (Igg, Igm), S/O","20132283","CDM","302","RC","86747","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Torch Panel, Convalenscent, S/O","20132284","CDM","302","RC","86644","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Torch Panel, Convalenscent, S/O","20132285","CDM","302","RC","86695","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Torch Panel, Convalenscent, S/O","20132286","CDM","302","RC","86696","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Torch Panel, Convalenscent, S/O","20132287","CDM","302","RC","86762","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Torch Panel, Convalenscent, S/O","20132288","CDM","302","RC","86777","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Torch Panel, Convalenscent, S/O","20132289","CDM","302","RC","86778","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sureswab(R) Advanced Vaginitis Plus, Tma, S/O","20132290","CDM","310","RC","81513","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sureswab(R) Advanced Vaginitis Plus, Tma, S/O","20132291","CDM","306","RC","87481","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sureswab(R) Advanced Vaginitis Plus, Tma, S/O","20132292","CDM","306","RC","87491","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sureswab(R) Advanced Vaginitis Plus, Tma, S/O","20132293","CDM","306","RC","87591","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sureswab(R) Advanced Vaginitis Plus, Tma, S/O","20132294","CDM","306","RC","87661","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ri Ab Screen W/Reflex To Titer And Western Blot, S/O","20132295","CDM","302","RC","86255","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thrombin-Antithrombin (Tat) Complex, S/O","20132296","CDM","301","RC","83520","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Prostaglandins, Urine, S/O","20132297","CDM","301","RC","84150","HCPCS","facility","both","","","","340","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epstein Barr Virus, Dna, S/O","20132298","CDM","306","RC","87799","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cytosolic 5?-Nucleotidase 1A (Cn-1A) Antibody, S/O","20132299","CDM","301","RC","83516","HCPCS","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Saccharomyces Cerevisiae Antibody (Asca) (Iga), S/O","20132300","CDM","302","RC","86671","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pancreastatin, S/O","20132301","CDM","301","RC","83520","HCPCS","facility","both","","","","135","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cytomegalovirus Dna,Qual, S/O","20132302","CDM","306","RC","87496","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Beta-2 Transferrin, S/O","20132303","CDM","302","RC","86335","HCPCS","facility","both","","","","165","82.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mycophenolic Acid Lc/Ms/Ms, S/O","20132304","CDM","301","RC","80180","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor X Activity, Chromogenic, S/O","20132305","CDM","305","RC","85260","HCPCS","facility","both","","","","142","71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxycodone And Metabolite Total, Urine, S/O","20132306","CDM","301","RC","G0480","HCPCS","facility","both","","","","78","39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Citric Acid, Random Urine, S/O","20132307","CDM","301","RC","82507","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Citric Acid, Random Urine, S/O","20132308","CDM","301","RC","82570","HCPCS","facility","both","","","","4","2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bartonella Dna, Real-Time Pcr, S/O","20132309","CDM","306","RC","87471","HCPCS","facility","both","","","","234","117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Kappa/Lambda Light Chains, Free With Ratio, Urine, S/O","20132310","CDM","301","RC","83521","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Kappa/Lambda Light Chains, S/O","20132311","CDM","301","RC","83520","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fatty Acid Panel, Essential (C12-C22), Serum, S/O","20132312","CDM","301","RC","82542","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fatty Acid Panel, Essential (C12-C22), Serum, S/O","20132313","CDM","301","RC","82725","HCPCS","facility","both","","","","124","62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromium, Urine, S/O","20132314","CDM","301","RC","82495","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromium, Urine, S/O","20132315","CDM","301","RC","82570","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Citric Acid, 24-Hour Urine Without Creatinine, S/O","20132316","CDM","301","RC","82507","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxalic Acid, 24-Hour Urine Without Creatinine, S/O","20132317","CDM","301","RC","83945","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Clobazam  And Metabolite, Serum/Plasma, S/O","20132318","CDM","301","RC","80299","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zika Virus Igm Ab Capture (Mac), Elisa, S/O","20132319","CDM","302","RC","86794","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Marijuana, Confirmation By Gcms, Blood, S/O","20132320","CDM","301","RC","G0480","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Marijuana, Confirmation, Serum, S/O","20132321","CDM","301","RC","G0480","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Xiii Functional, S/O","20132322","CDM","305","RC","85290","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vascular Endothelial Growth Factor (Vegf), Elisa, S/O","20132323","CDM","301","RC","83520","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Acylcarnitine, Plasma, S/O","20132324","CDM","301","RC","82017","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cortisol, Free, 24-Hour Urine, S/O","20132325","CDM","301","RC","82530","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cortisol, Free, 24-Hour Urine, S/O","20132326","CDM","301","RC","82570","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromosome Analysis, Chorionic Villus Sample, S/O","20132327","CDM","311","RC","88235","HCPCS","facility","both","","","","196","98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromosome Analysis, Chorionic Villus Sample, S/O","20132328","CDM","311","RC","88267","HCPCS","facility","both","","","","265","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromosome Analysis, Chorionic Villus Sample, S/O","20132329","CDM","311","RC","88280","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86022 Serotonin Releasing Assay (Sra), Unfractionated Heparin, S/O","20132330","CDM","302","RC","86022","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pancreatic Elastase-1, S/O","20132331","CDM","301","RC","82653","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bile Acids, Total, S/O","20132332","CDM","301","RC","82239","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Helicobacter Pylori, Urea Breath Test, S/O","20132333","CDM","301","RC","83013","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Metanephrines, Fractionated,Lc/Ms/Ms,24-Hour Urine, S/O","20132334","CDM","301","RC","83835","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Benzodiazepine, Confirmation, Urine, S/O","20132335","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Liver Kidney Microsome (Lkm-1) Antibody (Igg), S/O","20132336","CDM","302","RC","86376","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hepatitis E Antibodies (Igg, Igm), S/O","20132337","CDM","302","RC","86790","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mvista? Blastomyces Ag Quantitative Eia, S/O","20132338","CDM","306","RC","87449","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Parietal Cell Ab, Elisa, S/O","20132339","CDM","301","RC","83516","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Copper, Random Urine, S/O","20132340","CDM","301","RC","82525","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Copper, Random Urine, S/O","20132341","CDM","301","RC","82570","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86430 Rheumatoid Factor Screen W/Reflex To Titer, Synovial Fld, S/O","20132342","CDM","302","RC","86430","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Immune Cell Function, S/O","20132343","CDM","302","RC","86352","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) D-Lactate, Plasma, S/O","20132344","CDM","301","RC","83605","HCPCS","facility","both","","","","366","183","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Afb Cult&Smear Prog Tb/Mai Probes,Id&Tb/Mai Sens, S/O","20132345","CDM","306","RC","87015","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Afb Cult&Smear Prog Tb/Mai Probes,Id&Tb/Mai Sens, S/O","20132346","CDM","306","RC","87116","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Afb Cult&Smear Prog Tb/Mai Probes,Id&Tb/Mai Sens, S/O","20132347","CDM","306","RC","87206","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Qn Thyroglobulin Without Thyroglobulin Antibodies, S/O","20132348","CDM","301","RC","84432","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rheumatoid Factor (Iga), S/O","20132349","CDM","301","RC","83520","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiates, Confirmation, Urine, S/O","20132350","CDM","301","RC","G0480","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiates, Confirmation, Urine, S/O","20132351","CDM","301","RC","G0480","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zap-70, S/O","20132352","CDM","311","RC","88184","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zap-70, S/O","20132353","CDM","311","RC","88185","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) First Trimester Screen, Hyperglycosylated Hcg, S/O","20132354","CDM","310","RC","81508","HCPCS","facility","both","","","","218","109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Desmoglein Antibodies (1 And 3), S/O","20132355","CDM","301","RC","83520","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Prolactin, Total And Monomeric, S/O","20132356","CDM","301","RC","84146","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sequential Integrated Screen, Part 1, S/O","20132357","CDM","310","RC","81508","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sequential Integrated Screen, Part 2, S/O","20132358","CDM","310","RC","81511","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) First Trimester Screen, Hcg, S/O","20132359","CDM","310","RC","81508","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Serum Integrated Screen, Part 1, S/O","20132360","CDM","310","RC","00000","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Serum Integrated Screen, Part 2, S/O","20132361","CDM","310","RC","81511","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lacosamide, S/O","20132362","CDM","301","RC","80235","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fungitell(R) (1-3)-B-D Glucan Assay, S/O","20132363","CDM","306","RC","87449","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igf I, Lc/Ms, S/O","20132364","CDM","301","RC","84305","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rufinamide, S/O","20132365","CDM","301","RC","80210","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Buprenorphine, Quantitative, Urine, S/O","20132366","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Osteocalcin, N-Mid, S/O","20132367","CDM","301","RC","83937","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Jc Polyoma Virus Dna,R/T, S/O","20132368","CDM","306","RC","87798","HCPCS","facility","both","","","","148","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sureswab?,?Candidiasis, Pcr, S/O","20132369","CDM","306","RC","87481","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) He4, Ovarian Cancer Monitoring, S/O","20132370","CDM","302","RC","86305","HCPCS","facility","both","","","","177","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zinc, Random Urine, S/O","20132371","CDM","301","RC","82570","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zinc, Random Urine, S/O","20132372","CDM","301","RC","84630","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydia/Gc, Rna, Tma, Rectal, S/O","20132373","CDM","306","RC","87491","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydia/Gc, Rna, Tma, Rectal, S/O","20132374","CDM","306","RC","87591","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86790 Chikungunya Igg Titration, S/O","20132375","CDM","302","RC","86790","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroglobulin, Fine Needle Aspirate, S/O","20132376","CDM","301","RC","84432","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pth, Intact, Fine Needle Aspirate, S/O","20132377","CDM","301","RC","83970","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Iodine,  Serum/Plasma, S/O","20132378","CDM","301","RC","82542","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Iodine, Random Urine, S/O","20132379","CDM","301","RC","82542","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Iodine,24-Hr Urine, S/O","20132380","CDM","301","RC","82542","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Procollagen Type I Intact N Terminal Propeptide, S/O","20132381","CDM","301","RC","83519","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Quetiapine, Blood, S/O","20132382","CDM","301","RC","80299","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hbv Dna, Qnt Pcr W/Reflex, S/O","20132383","CDM","306","RC","87517","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Calprotectin, Stool, S/O","20132384","CDM","301","RC","83993","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone/Plasma Renin Activity Ratio, Lc/Ms/Ms, S/O","20132385","CDM","301","RC","82088","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone/Plasma Renin Activity Ratio, Lc/Ms/Ms, S/O","20132386","CDM","301","RC","84244","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Plasma Renin Activity, Lc/Ms/Ms, S/O","20132387","CDM","301","RC","84244","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Streptococcus Pneumoniae Igg Ab(23 Serotypes),Maid, S/O","20132388","CDM","302","RC","86317","HCPCS","facility","both","","","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Carbohydrate-Deficient Transferrin (Alcohol Use), S/O","20132389","CDM","301","RC","82373","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Carbohydrate-Deficient Transferrin (Alcohol Use), S/O","20132390","CDM","301","RC","84466","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Treponema Pallidum Ab Csf, S/O","20132391","CDM","302","RC","86780","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Neurokinin A (Substance K, S/O","20132392","CDM","301","RC","83519","HCPCS","facility","both","","","","265","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Selenium Rbc, S/O","20132393","CDM","301","RC","84255","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hla Typing For Celiac, S/O","20132394","CDM","300","RC","81376","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hla Typing For Celiac, S/O","20132395","CDM","310","RC","81382","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus 1/2 (Igg), W/Refl Hsv-2 Inhib, S/O","20132396","CDM","302","RC","86695","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus 1/2 (Igg), W/Refl Hsv-2 Inhib, S/O","20132397","CDM","302","RC","86696","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus 2 (Igg),W/Refl Hsv-2 Inhib, S/O","20132398","CDM","302","RC","86696","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 17-Hydroxyprogest Lcmsms, S/O","20132399","CDM","301","RC","83498","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone, Lc/Ms/Ms, S/O","20132400","CDM","301","RC","82088","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Androstenedione, S/O","20132401","CDM","301","RC","82157","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Jc Polyoma Virus Dna,, S/O","20132402","CDM","306","RC","87798","HCPCS","facility","both","","","","163","81.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Wa1 Igg Antibody,Ifa, S/O","20132403","CDM","302","RC","86753","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Kappa/Lambda Light Chains, Total, W/Calc, 24Hr Ur, S/O","20132404","CDM","301","RC","83883","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Anaplasma Phagocytophilum Dna, Ql Real-Time Pcr, S/O","20132405","CDM","306","RC","87798","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Collagen Type I C-Telopep, S/O","20132406","CDM","301","RC","82523","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tricyclics By Hplc, Identification & Quantitation, S/O","20132407","CDM","301","RC","G0480","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tricyclics By Hplc, Identification & Quantitation, S/O","20132408","CDM","301","RC","G0480","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tricyclics By Hplc, Identification & Quantitation, S/O","20132409","CDM","301","RC","G0480","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cytomegalovirus, Rapid Culture, S/O","20132410","CDM","306","RC","87254","HCPCS","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Saccharomyces Cerevisiae Antibodies(Asca)(Igg,Iga), S/O","20132411","CDM","302","RC","86671","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C3A Desarg Fragment, S/O","20132412","CDM","302","RC","86161","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adenosine Deaminase, Pleural Fluid, S/O","20132413","CDM","301","RC","84311","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adenosine Deaminase, Peritoneal Fluid, S/O","20132414","CDM","301","RC","84311","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adenosine Deaminase, Csf, S/O","20132415","CDM","301","RC","84311","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fentanyl And Metabolite, Blood, S/O","20132416","CDM","301","RC","G0480","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rheumatoid Factor (Igm), S/O","20132417","CDM","301","RC","83520","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bartonella Antibody Panel, Ifa (Csf), S/O","20132418","CDM","302","RC","86611","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor V Activity And Human Inhibitor, S/O","20132419","CDM","305","RC","85220","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor V Activity And Human Inhibitor, S/O","20132420","CDM","305","RC","85335","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone/Cortisol Ratio, 2 Sites, S/O","20132421","CDM","301","RC","82088","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone/Cortisol Ratio, 2 Sites, S/O","20132422","CDM","301","RC","82533","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone/Cortisol Ratio, 3 Sites, S/O","20132423","CDM","301","RC","82088","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aldosterone/Cortisol Ratio, 3 Sites, S/O","20132424","CDM","301","RC","82533","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tpmt Activity, S/O","20132425","CDM","301","RC","82657","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86366 Musk Antibody Test, S/O","20132426","CDM","302","RC","86366","HCPCS","facility","both","","","","465","232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Leflunomide Metabolite, S/O","20132427","CDM","301","RC","80193","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pregabalin, S/O","20132428","CDM","301","RC","80299","HCPCS","facility","both","","","","117","58.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Everolimus, Lc/Ms/Ms, Blood, S/O","20132429","CDM","301","RC","80169","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Flunitrazepam And Metabolites, Quantitative, Urine, S/O","20132430","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Carbamazepine Free, S/O","20132431","CDM","301","RC","80157","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ganglioside Gm-1 Antibody (Igg), Eia, S/O","20132432","CDM","301","RC","83520","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fish, Egfr, S/O","20132433","CDM","310","RC","88365","HCPCS","facility","both","","","","278","139","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tysabri? Antibody Test, S/O","20132434","CDM","301","RC","83516","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-Fetoprotein (Afp) And Afp-L3, S/O","20132435","CDM","301","RC","82107","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Metanephrines, Lc/Ms/Ms, S/O","20132436","CDM","301","RC","83835","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nk Cells, Lgls (Cd57), S/O","20132437","CDM","302","RC","86357","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tramadol Screen With Reflex To Confirmation, Urine, S/O","20132438","CDM","301","RC","80307","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Virus 6 Dna, Quant, S/O","20132439","CDM","306","RC","87533","HCPCS","facility","both","","","","220","110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mycobacterium Avium Complex, Mic Panel, S/O","20132440","CDM","306","RC","87186","HCPCS","facility","both","","","","81","40.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Coenzyme Q10, S/O","20132441","CDM","301","RC","82542","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cd57, Cd3, Cd8, Flow Cytometry, S/O","20132442","CDM","302","RC","86356","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cd57, Cd3, Cd8, Flow Cytometry, S/O","20132443","CDM","302","RC","86359","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dhea, Unconjugated, S/O","20132444","CDM","301","RC","82626","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cortisol, Lc/Ms, Saliva, S/O","20132445","CDM","301","RC","82530","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aspergillus Antibodies, Immunodiffusion, Serum, S/O","20132446","CDM","302","RC","86606","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) M. Pneumoniae Ab (Igm), S/O","20132447","CDM","302","RC","86738","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lamotrigine, S/O","20132448","CDM","301","RC","80175","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead (Venous), Osha And Zinc Protoporphyrin Eval, S/O","20132449","CDM","301","RC","83655","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead (Venous), Osha And Zinc Protoporphyrin Eval, S/O","20132450","CDM","301","RC","84202","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thioridazine And Metabolite, Serum/Plasma, S/O","20132451","CDM","301","RC","G0480","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Estrone, S/O","20132452","CDM","301","RC","82679","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Gulf Flounder (F147) Ige, S/O","20132453","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86041 Acetylcholine Receptor Binding Antibody, S/O","20132454","CDM","302","RC","86041","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Yellow Dock Weed (Rw23) Ige, S/O","20132455","CDM","302","RC","86003","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dexamethasone, S/O","20132456","CDM","301","RC","80299","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Isohemagglutinin Titer, S/O","20132457","CDM","300","RC","86886","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Serotonin, Serum, S/O","20132458","CDM","301","RC","84260","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Clomipramine, S/O","20132459","CDM","301","RC","80299","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aspergillus Fumigatus (M3) Igg, S/O","20132460","CDM","302","RC","86001","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sulfatide Autoantibody Test, S/O","20132461","CDM","301","RC","83520","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Estradiol, Ultrasensitive, Lc/Ms, S/O","20132462","CDM","301","RC","82670","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Quad Screen, S/O","20132463","CDM","310","RC","81511","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mitochondria M2 Antibody (Igg), Eia, S/O","20132464","CDM","302","RC","86381","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tiagabine, Serum/Plasma, S/O","20132465","CDM","301","RC","80199","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mitotane, Serum/Plasma, S/O","20132466","CDM","301","RC","80299","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Glycosaminoglycans, Urine (Gags), S/O","20132467","CDM","301","RC","82542","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Glycosaminoglycans, Urine (Gags), S/O","20132468","CDM","301","RC","83864","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryptococcus Antibody, S/O","20132469","CDM","302","RC","86403","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 11-Deoxycortisol, S/O","20132470","CDM","301","RC","82634","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tsi (Thyroid Stimulating Immunoglobulin), S/O","20132471","CDM","301","RC","84445","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sex Hormone Binding Globulin, S/O","20132472","CDM","301","RC","84270","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Calcitonin, S/O","20132473","CDM","301","RC","82308","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Topiramate, S/O","20132474","CDM","301","RC","80201","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pregnenolone, Lc/Ms, S/O","20132475","CDM","301","RC","84140","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Homocysteine, S/O","20132476","CDM","301","RC","83090","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Group # 3, S/O","20132477","CDM","301","RC","82175","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Group # 3, S/O","20132478","CDM","301","RC","82300","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Group # 3, S/O","20132479","CDM","301","RC","83655","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Heavy Metals Group # 3, S/O","20132480","CDM","301","RC","83825","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rabies Rffit Serology Report End Point, S/O","20132481","CDM","302","RC","86790","HCPCS","facility","both","","","","118","59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Diphenhydramine, Serum/Plasma, S/O","20132482","CDM","301","RC","80299","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Voltage-Gated Calcium, S/O","20132483","CDM","301","RC","83519","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mycoplasma Pneumoniae Antibodies (Igg, Igm), S/O","20132484","CDM","302","RC","86738","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Proteinase-3 Antibody, S/O","20132485","CDM","302","RC","86021","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cysticercus Antibody, Elisa (Serum), S/O","20132486","CDM","302","RC","86682","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epstein Barr Virus Dna,Qualitative Real-Time Pcr, S/O","20132487","CDM","306","RC","87798","HCPCS","facility","both","","","","77","38.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Iga Subclasses, S/O","20132488","CDM","301","RC","82784","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Iga Subclasses, S/O","20132489","CDM","301","RC","82787","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bartonella Species Ab(Igg, Igm) W/Reflex To Titers, S/O","20132490","CDM","302","RC","86611","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Measles Antibody (Igm), S/O","20132491","CDM","302","RC","86765","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ehrlichia Chaffeen Ab G/M, S/O","20132492","CDM","302","RC","86666","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Babesia Microti Antibodies (Igg, Igm), S/O","20132493","CDM","302","RC","86753","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C1Q Ab (Igg), S/O","20132494","CDM","301","RC","83516","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Schistosoma Igg Antibody, Fmi (Serum), S/O","20132495","CDM","302","RC","86682","HCPCS","facility","both","","","","67","33.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Strongyloides Antibody, S/O","20132496","CDM","302","RC","86682","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igf Binding Protein-3, S/O","20132497","CDM","301","RC","83520","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Anaplasma Phagocytophilum Antibodies (Igg, Igm), S/O","20132498","CDM","302","RC","86666","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hiv 1 Rna, Qn Pcr W/Reflex To Genotype, S/O","20132499","CDM","306","RC","87536","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Legionella Pneumophila Antigen, Dfa, S/O","20132500","CDM","306","RC","87278","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pth-Related Protein (Pth-Rp), S/O","20132501","CDM","301","RC","83519","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Somatostatin, S/O","20132502","CDM","301","RC","84307","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tryptase, S/O","20132503","CDM","301","RC","83520","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tumor Necrosis Factor-Alpha, Highly Sensitive, S/O","20132504","CDM","301","RC","83520","HCPCS","facility","both","","","","93","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lipoprotein (A), S/O","20132505","CDM","301","RC","83695","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Angiotensin Converting Enzyme (Ace), Csf, S/O","20132506","CDM","301","RC","82164","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Helicobacter Pylori Antigen, Eia , Stool, S/O","20132507","CDM","306","RC","87338","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hexosaminidase A And Total, Serum, S/O","20132508","CDM","301","RC","83080","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Glutamic Acid Decarboxylase-65 Antibody, S/O","20132509","CDM","302","RC","86341","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methylmalonic Acid, S/O","20132510","CDM","301","RC","83921","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Estriol, Serum, S/O","20132511","CDM","301","RC","82677","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Candida Albicans Antibody (Igg), S/O","20132512","CDM","302","RC","86628","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Entamoeba Histolytica Antigen, Eia, S/O","20132513","CDM","306","RC","87337","HCPCS","facility","both","","","","49","24.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Haemophilus Influenzae Type B Antibody (Igg), S/O","20132517","CDM","302","RC","86684","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Francisella Tularensis Ab, S/O","20132518","CDM","302","RC","86000","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Quetiapine, Serum/Plasma, S/O","20132519","CDM","301","RC","80299","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Estradiol, Free, S/O","20132520","CDM","301","RC","82670","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Estradiol, Free, S/O","20132521","CDM","301","RC","82681","HCPCS","facility","both","","","","73","36.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Testosterone, Free (Dialysis) And Total, Ms, S/O","20132522","CDM","301","RC","84402","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Testosterone, Free (Dialysis) And Total, Ms, S/O","20132523","CDM","301","RC","84403","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Htlv I/Ii Antibody,W/Reflex To Confirmatory Assay, S/O","20132524","CDM","302","RC","86790","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amino Acid Analysis, Lc/Ms, Urine, S/O","20132525","CDM","301","RC","82139","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amino Acid Analysis, Lc/Ms, Urine, S/O","20132526","CDM","301","RC","82570","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adalimumab Level/Ada, Ibd, S/O","20132527","CDM","301","RC","80145","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adalimumab Level/Ada, Ibd, S/O","20132528","CDM","301","RC","83520","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Infliximab Level/Ada, Ibd, S/O","20132530","CDM","301","RC","80230","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Infliximab Level/Ada, Ibd, S/O","20132531","CDM","301","RC","83520","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Levetiracetam, S/O","20132532","CDM","301","RC","80177","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus, Type 1/2 Ag, Dfa, S/O","20132533","CDM","306","RC","87273","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus, Type 1/2 Ag, Dfa, S/O","20132534","CDM","306","RC","87274","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B2 (Riboflavin), Plasma, S/O","20132535","CDM","301","RC","84252","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 2, S/O","20132536","CDM","302","RC","86355","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 2, S/O","20132537","CDM","302","RC","86359","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lymphocyte Subset Panel 2, S/O","20132538","CDM","302","RC","86360","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead, 24-Hour Urine, S/O","20132539","CDM","301","RC","83655","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mercury, 24-Hour Urine, S/O","20132540","CDM","301","RC","83825","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vedolizumab Quantitation With Antibodies, Serum, S/O","20132541","CDM","301","RC","80280","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vedolizumab Quantitation With Antibodies, Serum, S/O","20132542","CDM","301","RC","82397","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Plasminogen Activator Inhibitor (Pai-1) Antigen, S/O","20132543","CDM","305","RC","85415","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mumps Virus Antibody (Igm), S/O","20132544","CDM","302","RC","86735","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hexagonal Phase Confirmation, S/O","20132545","CDM","305","RC","85598","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hepatitis E Antibody (Igg), S/O","20132546","CDM","302","RC","86790","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin K, S/O","20132547","CDM","301","RC","84597","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Histamine, Plasma, S/O","20132548","CDM","301","RC","83088","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igf Binding Protein-1 (Igfbp-1), S/O","20132549","CDM","301","RC","83519","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphyrins, Fractionated, Quantitative, Random Ur, S/O","20132550","CDM","301","RC","84120","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) West Nile Virus Antibodies (Igg, Igm), Serum, S/O","20132551","CDM","302","RC","86788","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) West Nile Virus Antibodies (Igg, Igm), Serum, S/O","20132552","CDM","302","RC","86789","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) West Nile Virus Antibodies (Igg, Igm), Csf, S/O","20132553","CDM","302","RC","86788","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) West Nile Virus Antibodies (Igg, Igm), Csf, S/O","20132554","CDM","302","RC","86789","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxcarbazepine Metabolite, S/O","20132555","CDM","301","RC","80183","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amiodarone, S/O","20132556","CDM","301","RC","80151","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hsp-70 Antibody (Anti-68 Kd Antigen), S/O","20132557","CDM","301","RC","84181","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Immune Complex, C1Q, S/O","20132558","CDM","302","RC","86332","HCPCS","facility","both","","","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hu Ab Screen W/Reflex To Titer And Western Blot, S/O","20132559","CDM","302","RC","86255","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Histone Antibodies, S/O","20132560","CDM","301","RC","83516","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Q Fever (Coxiella Burnetii)Ab (Igg,M)W/Refl Titers, S/O","20132561","CDM","302","RC","86638","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Epidermal Antibodies With Reflex To Titers, S/O","20132562","CDM","302","RC","86255","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydophila Pneumoniae Antibodies (Igg,Iga,Igm), S/O","20132563","CDM","302","RC","86631","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydophila Pneumoniae Antibodies (Igg,Iga,Igm), S/O","20132564","CDM","302","RC","86632","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Respiratory Syncytial Virus Antibody, Serum, S/O","20132565","CDM","302","RC","86756","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thallium, 24-Hour Urine, S/O","20132566","CDM","301","RC","83018","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydia/Chlamydophila Antibody Panel 1 (Igg), S/O","20132567","CDM","302","RC","86631","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82166 Anti-Mullerian Hormone (Amh), Male, S/O","20132568","CDM","301","RC","82166","HCPCS","facility","both","","","","117","58.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82166 Anti-Mullerian Hormone (Amh), Female, S/O","20132569","CDM","301","RC","82166","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Citric Acid, Serum, S/O","20132570","CDM","301","RC","82507","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Babesia Microti Dna, Real-Time Pcr, S/O","20132571","CDM","306","RC","87798","HCPCS","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin Scr W/Refl To Cryoglobulin Panel, S/O","20132572","CDM","301","RC","82595","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83520 Mag Antibody (Igm), Eia, S/O","20132573","CDM","301","RC","83520","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86003 American Cockroach (I206) Ige, S/O","20132574","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Echovirus Antibodies, Csf, S/O","20132575","CDM","302","RC","86658","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Reticulin Iga Screen With Reflex To Titer, S/O","20132576","CDM","302","RC","86255","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-Galactosidase, Leukocytes, S/O","20132577","CDM","301","RC","82657","HCPCS","facility","both","","","","469","234.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Gamma-Hydroxybutyric Acid Screen, Urine, S/O","20132578","CDM","301","RC","80307","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80307 Gamma-Hydroxybutyric Acid Screen, Serum/Plasma, S/O","20132579","CDM","301","RC","80307","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Reptilase Clotting Time, S/O","20132580","CDM","305","RC","85635","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fibrinogen Antigen, Nephelometry, S/O","20132581","CDM","305","RC","85385","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80321 Drug Monitor, Phosphatidylethanol, B, S/O","20132582","CDM","301","RC","G0480","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zonisamide, S/O","20132583","CDM","301","RC","80203","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87506 Gastrointestinal Pathogen Panel, Real-Time Pcr, S/O","20132584","CDM","302","RC","87506","HCPCS","facility","both","","","","233","116.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cholinesterase, Serum, S/O","20132585","CDM","301","RC","82480","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 14-3-3 Protein, Csf (Prion Disease), S/O","20132586","CDM","300","RC","0035U","HCPCS","facility","both","","","","632","316","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 14-3-3 Protein, Csf (Prion Disease), S/O","20132587","CDM","301","RC","83520","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hop (Fruit Cone) (Humulus Lupus) (F324) Ige**, S/O","20132588","CDM","302","RC","86003","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Catfish Ige, S/O","20132589","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Trypsin, S/O","20132590","CDM","301","RC","83519","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Trab (Tsh Receptor Binding Antibody), S/O","20132591","CDM","301","RC","83520","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Total Glutathione, S/O","20132592","CDM","301","RC","82978","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead, Capillary, S/O","20132593","CDM","301","RC","83655","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead And Zinc Protoporphyrin Evaluation, S/O","20132594","CDM","301","RC","83655","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lead And Zinc Protoporphyrin Evaluation, S/O","20132595","CDM","301","RC","84202","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hmgcr Ab (Igg), S/O","20132596","CDM","301","RC","82397","HCPCS","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 21-Hydroxylase Antibody, S/O","20132597","CDM","301","RC","83516","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phospholipase A2 Receptor (Pla2R) Antibody, Elisa, S/O","20132598","CDM","301","RC","83520","HCPCS","facility","both","","","","271","135.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pdm Test 01, S/O","20132599","CDM","301","RC","80307","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pdm Test 01, S/O","20132600","CDM","301","RC","80307","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cholinesterase , Serum, Plasma, Rbc, S/O","20132601","CDM","301","RC","82480","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cholinesterase , Serum, Plasma, Rbc, S/O","20132602","CDM","301","RC","82482","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Csf Igg/Albumin Ratio, S/O","20132603","CDM","301","RC","82042","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Csf Igg/Albumin Ratio, S/O","20132604","CDM","301","RC","82784","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha 1 Antitrypsin (Aat) Qn And Phenotype, S/O","20132605","CDM","301","RC","82103","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha 1 Antitrypsin (Aat) Qn And Phenotype, S/O","20132606","CDM","301","RC","82104","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) N-Methylhistamine, 24 Hour, Urine, S/O","20132607","CDM","301","RC","82542","HCPCS","facility","both","","","","223","111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) N-Methylhistamine, 24 Hour, Urine, S/O","20132608","CDM","301","RC","82570","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Viii Inhibitor Pnl, S/O","20132609","CDM","305","RC","85240","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Viii Inhibitor Pnl, S/O","20132610","CDM","305","RC","85335","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Xiii Screen, S/O","20132611","CDM","305","RC","85291","HCPCS","facility","both","","","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) N-Telopeptide Serum, S/O","20132612","CDM","301","RC","82523","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Prostaglandins D2, Serum Or Plasma, S/O","20132613","CDM","301","RC","84150","HCPCS","facility","both","","","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydia-Gc, Rna, Tma, Throat, S/O","20132614","CDM","306","RC","87491","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydia-Gc, Rna, Tma, Throat, S/O","20132615","CDM","306","RC","87591","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Olanzapine, S/O","20132616","CDM","301","RC","80299","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Carnitine, S/O","20132617","CDM","301","RC","82379","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86790 Chikungunya Ab (Igg, Igm) W/Rflx To Titers, S/O","20132618","CDM","302","RC","86790","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Reticulin Iga Titer, S/O","20132619","CDM","302","RC","86256","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chronic Urticaria Panel 3, S/O","20132620","CDM","301","RC","83520","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chronic Urticaria Panel 3, S/O","20132621","CDM","302","RC","86343","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Von Willebrand Screen, S/O","20132622","CDM","305","RC","85240","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Von Willebrand Screen, S/O","20132623","CDM","305","RC","85245","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Von Willebrand Screen, S/O","20132624","CDM","305","RC","85246","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Von Willebrand Screen, S/O","20132625","CDM","305","RC","85730","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Syphilis Antibody Cascading Reflex, S/O","20132626","CDM","302","RC","86780","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Leptin, S/O","20132627","CDM","301","RC","83520","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aquaporin-4 (Aqp4) (Nmo-Igg) Antibody, S/O","20132628","CDM","302","RC","86052","HCPCS","facility","both","","","","655","327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Severe Combined Immunodeficiency (Scid) Panel, S/O","20132629","CDM","305","RC","85025","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Severe Combined Immunodeficiency (Scid) Panel, S/O","20132630","CDM","302","RC","86355","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Severe Combined Immunodeficiency (Scid) Panel, S/O","20132631","CDM","302","RC","86356","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Severe Combined Immunodeficiency (Scid) Panel, S/O","20132632","CDM","302","RC","86357","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Severe Combined Immunodeficiency (Scid) Panel, S/O","20132633","CDM","302","RC","86359","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Severe Combined Immunodeficiency (Scid) Panel, S/O","20132634","CDM","302","RC","86361","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dihydrotestosterone, S/O","20132635","CDM","301","RC","82642","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Nicotine And Cotinine, Lc/Ms/Ms, Serum/Plasma, S/O","20132636","CDM","301","RC","G0480","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nicotine And Cotinine, Urine, S/O","20132637","CDM","301","RC","G0480","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroglobulin, Lc/Ms/Ms, S/O","20132638","CDM","301","RC","84432","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Diazepam And Metabolite, S/O","20132639","CDM","301","RC","G0480","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Factor Viii Antigen, S/O","20132640","CDM","305","RC","85244","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Leptospira Antibody, Igm, S/O","20132641","CDM","302","RC","86720","HCPCS","facility","both","","","","135","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rivaroxaban, S/O","20132642","CDM","301","RC","80299","HCPCS","facility","both","","","","163","81.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B3, S/O","20132643","CDM","301","RC","84591","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B5 (Pantothenic Acid), S/O","20132644","CDM","301","RC","84591","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Soluble Transferrin Receptor, S/O","20132645","CDM","301","RC","84238","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methylmalonic Acid Gc/Ms/Ms, Urine, S/O","20132646","CDM","301","RC","82570","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methylmalonic Acid Gc/Ms/Ms, Urine, S/O","20132647","CDM","301","RC","83921","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dabigatran With Reflex To Thrombin Time, S/O","20132648","CDM","301","RC","80299","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlordiazepoxide And Metabolites, S/O","20132649","CDM","301","RC","G0480","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Human Transforming Growth Factor Beta 1 (Tgf-B1), S/O","20132650","CDM","301","RC","83520","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mdma/Mda Screen With Confirmation, Urine, S/O","20132651","CDM","301","RC","80307","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rabies Rffit Screen, S/O","20132652","CDM","302","RC","86382","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 14-3-3 Eta Protein, S/O","20132653","CDM","301","RC","83520","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rheumatoid Arthritis Diagnostic Identra(R) Pnl 2, S/O","20132654","CDM","301","RC","83520","HCPCS","facility","both","","","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rheumatoid Arthritis Diagnostic Identra(R) Pnl 2, S/O","20132655","CDM","302","RC","86200","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rheumatoid Arthritis Diagnostic Identra(R) Pnl 2, S/O","20132656","CDM","302","RC","86431","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hemoglobin, Free, Serum, S/O","20132657","CDM","301","RC","84311","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Platelet Antibody, Direct (Igg), S/O","20132658","CDM","302","RC","86023","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thiopurine Metabolites, S/O","20132659","CDM","301","RC","80299","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Paliperidone, S/O","20132660","CDM","301","RC","80299","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Androsterone, Serum, S/O","20132661","CDM","301","RC","82160","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fluphenazine, Serum/Plasma, S/O","20132662","CDM","301","RC","G0480","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Nmda Receptor Antibody Test, S/O","20132663","CDM","302","RC","86255","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Caspr2 Antibody Test, S/O","20132664","CDM","302","RC","86255","HCPCS","facility","both","","","","226","113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lgi1 Antibody Test, S/O","20132665","CDM","302","RC","86255","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Leishmania Antibody (Igg), S/O","20132666","CDM","302","RC","86717","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Liver Fibrosis, Fibrotest-Actitest Panel, S/O","20132667","CDM","310","RC","81596","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Questassured? 25-Hydroxyvitamin D (D2, D3), S/O","20132668","CDM","301","RC","82306","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Zinc Transporter 8 (Znt8) Antibody, S/O","20132669","CDM","302","RC","86341","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitor, Synthetic Cannabinoids, W/Conf, U, S/O","20132670","CDM","301","RC","80307","HCPCS","facility","both","","","","42","21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dengue Fever Antibodies (Igg,Igm), S/O","20132671","CDM","302","RC","86790","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pcb Panel, Congeners, Serum/Plasma, S/O","20132672","CDM","301","RC","82441","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein S Activity, Antigen, Total And Free, S/O","20132673","CDM","305","RC","85305","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein S Activity, Antigen, Total And Free, S/O","20132674","CDM","305","RC","85306","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Early Sjogren's Syndrome, S/O","20132675","CDM","301","RC","83520","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vgkc Antibody, S/O","20132676","CDM","301","RC","83519","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Itraconazole, S/O","20132677","CDM","301","RC","80189","HCPCS","facility","both","","","","73","36.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lp-Pla2 Activity, S/O","20132678","CDM","301","RC","83698","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Comprehensive Drug Screen, Umbilical Cord Tissue, S/O","20132679","CDM","301","RC","80307","HCPCS","facility","both","","","","198","99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 18-Hydroxycorticosterone, S/O","20132680","CDM","301","RC","82542","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Flucytosine, Serum/Plasma, S/O","20132681","CDM","301","RC","80299","HCPCS","facility","both","","","","190","95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Streptomycin, Level, S/O","20132682","CDM","301","RC","80299","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Isoniazid, Level, S/O","20132683","CDM","301","RC","80299","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cyclospora And Isospora Examination, S/O","20132684","CDM","306","RC","87015","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cyclospora And Isospora Examination, S/O","20132685","CDM","306","RC","87207","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phenosense(R), S/O","20132686","CDM","306","RC","87903","HCPCS","facility","both","","","","1217","608.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phenosense(R), S/O","20132687","CDM","306","RC","87904","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxalic Acid, Random Urine, S/O","20132688","CDM","301","RC","82570","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxalic Acid, Random Urine, S/O","20132689","CDM","301","RC","83945","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cystine, 24-Hour Urine, S/O","20132690","CDM","301","RC","82131","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84105 Phosphate, 24 Hour Urine (W/O Creatinine), S/O","20132691","CDM","301","RC","84105","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cocaine And Metabolites, Confirmation, S/P/B, S/O","20132692","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adamts13 Activity With Reflex To Inhibitor, S/O","20132693","CDM","305","RC","85397","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Viral Respiratory, Rapid Culture With Reflex, S/O","20132694","CDM","306","RC","87254","HCPCS","facility","both","","","","56","28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Metanephrines, Fractionated, Lc/Ms/Ms, Random Ur, S/O","20132695","CDM","301","RC","82570","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Metanephrines, Fractionated, Lc/Ms/Ms, Random Ur, S/O","20132696","CDM","301","RC","83835","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiates, Confirmation, Urine, S/O","20132697","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiates, Confirmation, Urine, S/O","20132698","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adiponectin, S/O","20132699","CDM","301","RC","83520","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Helicobacter Pylori Culture, S/O","20132700","CDM","306","RC","87081","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Helicobacter Pylori Culture, S/O","20132701","CDM","306","RC","87205","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lactoferrin, Quantitative, Stool, S/O","20132702","CDM","301","RC","83631","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cytomegalovirus, Rapid Culture, S/O","20132703","CDM","306","RC","87254","HCPCS","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Smooth Muscle Actin W/ Interp, S/O","20132704","CDM","310","RC","88342","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Magnesium, 24 Hour Urine, (W/O Creatinine), Aa, S/O","20132705","CDM","301","RC","83735","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ethosuximide, S/O","20132706","CDM","301","RC","80168","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cotton Seed (K83) Ige, S/O","20132707","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hackberry, Ige*, S/O","20132708","CDM","302","RC","86003","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Basil (Rf269) Ige, S/O","20132709","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Blueberry (Rf288) Ige**, S/O","20132710","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Raspberry (Rf 343) Ige **, S/O","20132711","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cinnamon (Rf220) Ige, S/O","20132712","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Clove (Rf268) Ige, S/O","20132713","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ginger (F270) Ige, S/O","20132714","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87254 Enterovirus Culture, S/O","20132715","CDM","306","RC","87254","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Marijuana Metabolite, Quantitative, Urine, S/O","20132716","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rat Urine Protein (E74) Ige, S/O","20132717","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Herpes Simplex Virus Culture, S/O","20132718","CDM","306","RC","87255","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pine Nut (Rf253) Ige, S/O","20132719","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Coffee (Rf221) Ige, S/O","20132720","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dill (Rf277) Ige, S/O","20132721","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pepper (Unripe) (Rf263) Ige, S/O","20132722","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oregano (Rf283) Ige, S/O","20132723","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Swordfish (Rf312) Ige**, S/O","20132724","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyme (Rf273) Ige, S/O","20132725","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Watermelon (Rf329) Ige**, S/O","20132726","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Careless Weed (Amaranthus Palmeri) Ige, S/O","20132727","CDM","302","RC","86003","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Virginia Live Oak (Rt218) Ige, S/O","20132728","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phenytoin, Free, S/O","20132729","CDM","301","RC","80186","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Catecholamines, Fract, 24 Hour Urine W/O Creat, S/O","20132730","CDM","301","RC","82384","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vanilla (Rf234) Ige, S/O","20132731","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methadone, Quantitation, Serum, S/O","20132732","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Sweet Gum (Rt211) Ige, S/O","20132733","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Parvovirus B19 Dna, Qualitative Real-Time Pcr, S/O","20132734","CDM","306","RC","87798","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cocaine, Confirmation By Gcms, Meconium, S/O","20132735","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Marijuana, Confirmation, Meconium, S/O","20132736","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamines, Confirmation  Meconium, S/O","20132737","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Microsporidia Exam, S/O","20132738","CDM","306","RC","87207","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Influenza A And B Culture, Rapid Method, S/O","20132739","CDM","306","RC","87254","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Oxycodone, Confirmation, Urine, S/O","20132740","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Red Snapper, Ige*, S/O","20132741","CDM","302","RC","86003","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86003 Macadamia Nut (Rf345) Ige, S/O","20132742","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin B7 (Biotin), S/O","20132743","CDM","301","RC","84591","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Whitefish, Ige*, S/O","20132744","CDM","302","RC","86003","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Parasite Identification, Worm, S/O","20132745","CDM","306","RC","87169","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tracp, Ihc With Interpretation, S/O","20132746","CDM","310","RC","88342","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tracp, Ihc Without Interpretation, S/O","20132747","CDM","310","RC","88342","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dhea Sulfate, S/O","20132748","CDM","301","RC","82627","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Disopyramide, S/O","20132749","CDM","301","RC","80299","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Digitoxin, Serum/Plasma, S/O","20132750","CDM","301","RC","80299","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pinworm Examination, S/O","20132751","CDM","306","RC","87172","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Panel 5, Meconium, S/O","20132752","CDM","301","RC","80307","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Antiadrenal Antibody Screen With Reflex To Titer, S/O","20132753","CDM","302","RC","86255","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Beta-2-Microglobulin, Urine, S/O","20132754","CDM","301","RC","82232","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Histamine, 24-Hour Urine, S/O","20132755","CDM","301","RC","83088","HCPCS","facility","both","","","","61","30.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein C Antigen, S/O","20132756","CDM","305","RC","85302","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Antithrombin Iii Antigen, S/O","20132757","CDM","305","RC","85301","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bordetella Pertussis/Parapertussis Culture, S/O","20132758","CDM","306","RC","87081","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Igd, Serum, S/O","20132759","CDM","301","RC","82784","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cocaine Metabolites, Urine, S/O","20132760","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rabies Vaccine Response End-Point Titer, S/O","20132761","CDM","302","RC","86382","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Homovanillic Acid(Hva), Random Urine, S/O","20132762","CDM","301","RC","82570","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Homovanillic Acid(Hva), Random Urine, S/O","20132763","CDM","301","RC","83150","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tea (Rf222) Ige**, S/O","20132764","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ova& Parasites, Stool Concentrate &Permanent Smear, S/O","20132765","CDM","306","RC","87177","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ova& Parasites, Stool Concentrate &Permanent Smear, S/O","20132766","CDM","306","RC","87209","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adenovirus Antibody, Serum, S/O","20132767","CDM","302","RC","86603","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Legionella Culture, S/O","20132768","CDM","306","RC","87081","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydiae Species, Culture, S/O","20132769","CDM","306","RC","87110","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chlamydiae Species, Culture, S/O","20132770","CDM","306","RC","87140","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pentobarbital, S/O","20132771","CDM","301","RC","G0480","HCPCS","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tramadol (Ultram) Gcms, Urine, S/O","20132772","CDM","301","RC","G0480","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Influenza A And B Ab, Serum, S/O","20132773","CDM","302","RC","86710","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Barbiturates, Confirmation, Serum, S/O","20132774","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Immunoglobulin G Subclasses Panel, S/O","20132775","CDM","301","RC","82784","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Immunoglobulin G Subclasses Panel, S/O","20132776","CDM","301","RC","82787","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Scabies Examination, S/O","20132777","CDM","306","RC","87220","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tbg (Thyroxine Binding Globulin), S/O","20132778","CDM","301","RC","84442","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mycoplasma Hominis/Ureaplasma Culture, S/O","20132779","CDM","306","RC","87109","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein C, Activity And Antigen, S/O","20132780","CDM","305","RC","85302","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein C, Activity And Antigen, S/O","20132781","CDM","305","RC","85303","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thiocyanate, S/O","20132782","CDM","301","RC","84430","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mushroom (Rf212) Ige, S/O","20132783","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vma, 24H Urine W/O Creat, S/O","20132784","CDM","301","RC","84585","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Coumadin, S/O","20132785","CDM","301","RC","80299","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Galactose-Alpha-1,3-Galactose (Alpha-Gal) Ige, S/O","20132786","CDM","302","RC","86003","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cytochrome P450 2D6 Genotype, S/O","20132787","CDM","310","RC","81226","HCPCS","facility","both","","","","222","111","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-Globin Gene Sequencing, S/O O","20132788","CDM","310","RC","81259","HCPCS","facility","both","","","","461","230.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cytochrome P450 2C9 Genotype, S/O","20132789","CDM","310","RC","81227","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Plasminogen Activator Inhibitor-1 4G/5G, S/O","20132790","CDM","310","RC","81400","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Y Chromosome Microdeletion, Dna Analysis, S/O","20132791","CDM","310","RC","81403","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Beta-Globin Complete, S/O","20132792","CDM","310","RC","81364","HCPCS","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pml-Rara T(15;17), Quantitative Rt-Pcr, S/O","20132793","CDM","310","RC","81315","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Dihydropyrimidine Dehydro, S/O","20132794","CDM","310","RC","81232","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81170 Abl Kinase Domain Mutation In Cml, Cell-Based, S/O","20132795","CDM","310","RC","81170","HCPCS","facility","both","","","","264","132","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Accutype(R) Warfarin, S/O","20132796","CDM","310","RC","81479","HCPCS","facility","both","","","","515","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hla-A29 Determination, S/O","20132797","CDM","310","RC","81374","HCPCS","facility","both","","","","190","95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hla-B51 Determination, S/O","20132798","CDM","310","RC","81374","HCPCS","facility","both","","","","190","95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Accutype(R)Cp, Clopidogrel Cyp2C19 Genotype, S/O","20132799","CDM","310","RC","81225","HCPCS","facility","both","","","","288","144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hla-B*5701 Typing, S/O","20132800","CDM","310","RC","81381","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C-Kit Mutation Analysis, Cell-Based, S/O","20132801","CDM","310","RC","81272","HCPCS","facility","both","","","","330","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81401 Cardio Iq Apoe Genotype, S/O","20132802","CDM","310","RC","81401","HCPCS","facility","both","","","","293","146.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Tay-Sachs Disease Mutation Analysis, S/O","20132803","CDM","310","RC","81255","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) B-Cell Clonality Panel (Igh.Igk), Pcr, S/O","20132804","CDM","310","RC","81479","HCPCS","facility","both","","","","522","261","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Brca Panel (Brca1, Brca2), S/O","20132805","CDM","310","RC","81162","HCPCS","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Calreticulin (Calr) Mutation Analysis, S/O","20132806","CDM","310","RC","81479","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mpl Mutation Analysis, S/O","20132807","CDM","310","RC","81479","HCPCS","facility","both","","","","165","82.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) B. Henselae Igg Titer, S/O","20132808","CDM","302","RC","86611","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) B. Quintana Igg Titer, S/O","20132809","CDM","302","RC","86611","HCPCS","facility","both","","","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) B. Henselae Igm Titer, S/O","20132810","CDM","302","RC","86611","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) B. Quintana Igm Titer, S/O","20132811","CDM","302","RC","86611","HCPCS","facility","both","","","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myocardial Antibody Titer, S/O","20132812","CDM","302","RC","86256","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Adamts13 Inhibitor, S/O","20132813","CDM","305","RC","85335","HCPCS","facility","both","","","","235","117.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Vitamin D, 1, 25-Dihydroxy, Lc/Ms/Ms, S/O","20132814","CDM","301","RC","82652","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Anca Screen With Reflex To Anca Titer, S/O","20132815","CDM","302","RC","86036","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hepatitis A  Antibody, Total, S/O","20132816","CDM","302","RC","86708","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phencyclidine, Urine, S/O","20132817","CDM","301","RC","G0480","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C-Anca Titier, S/O","20132818","CDM","302","RC","86021","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) P-Anca Titier, S/O","20132819","CDM","302","RC","86021","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Atypical P-Anca Titier, S/O","20132820","CDM","302","RC","86021","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroid Cancer Monitoring, S/O","20132821","CDM","302","RC","86800","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Thyroglobulin, S/O","20132822","CDM","302","RC","84432","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Gamma-Hydroxybutyric Acid Confirmation, Urine, S/O","20132823","CDM","301","RC","82570","HCPCS","facility","both","","","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Gamma-Hydroxybutyric Acid Confirmation, Urine, S/O","20132824","CDM","301","RC","83921","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Specific Gravity Confirmation, Urine, S/O","20132825","CDM","307","RC","81099","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamine, Confirmation, Gc/Ms, Urine, S/O","20132826","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamine, Confirmation, Gc/Ms, Urine, S/O","20132827","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alkaline Phosphatase, Bone Specific, S/O","20132828","CDM","301","RC","84075","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chronic Urticaria Panel, S/O","20132829","CDM","301","RC","84443","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chronic Urticaria Panel, S/O","20132830","CDM","302","RC","86343","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chronic Urticaria Panel, S/O","20132831","CDM","302","RC","86376","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chronic Urticaria Panel, S/O","20132832","CDM","302","RC","86800","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Rapid Respiratory Virus, S/O","20132833","CDM","306","RC","87140","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin Reflex, S/O","20132834","CDM","302","RC","86329","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin Reflex, S/O","20132835","CDM","302","RC","86334","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cryoglobulin Reflex, S/O","20132836","CDM","302","RC","86431","HCPCS","facility","both","","","","14","7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86042 Acetylcholine Receptor Blocking Antibody, S/O","20132837","CDM","302","RC","86042","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aquaporin 4 Antibody, Titer, Serum, S/O","20132838","CDM","302","RC","86052","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hsv Typing, S/O","20132839","CDM","306","RC","87140","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Flt3 Mutation Analysis, S/O","20132840","CDM","310","RC","81479","HCPCS","facility","both","","","","365","182.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pain Management, S/O","20132841","CDM","301","RC","80307","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pain Management, S/O","20132842","CDM","301","RC","80307","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pain Management, S/O","20132843","CDM","301","RC","80307","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pain Management, S/O","20132844","CDM","301","RC","G0480","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Buprenorphine And Naloxone, Quantitative, Urine, S/O","20132845","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Buprenorphine And Naloxone, Quantitative, Urine, S/O","20132846","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Fentanyl, Quantitative, Urine Reflex, S/O","20132847","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Amphetamines, Quantitative, Urine, S/O","20132848","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Methamphetamine D/L Isomers, Urine, S/O","20132849","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Barbiturates, Quantitative, Urine, S/O","20132850","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Benzodiazepines, Quantitative, Urine, S/O","20132851","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Cocaine Metabolite, Quantitative, Urine, S/O","20132852","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Methadone Metabolite, Quantitative, Urine, S/O","20132853","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Marijuana Metabolite, Quantitative, Urine, S/O","20132854","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Opiates Expanded, Quantitative, Urine, S/O","20132855","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Monitoring, Opiates Expanded, Quantitative, Urine, S/O","20132856","CDM","301","RC","G0480","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Ca 27.29, S/O","20132857","CDM","302","RC","86300","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Protein S Activity, S/O","20132858","CDM","305","RC","85306","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hla-B27 Dna Typing, S/O","20132859","CDM","310","RC","81374","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Chromogranin A, Lc/Ms/Ms, S/O","20132860","CDM","302","RC","86316","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Advanced Lipid Panel, Cardio Iq (Our Nmr Lipoprotein Profile), S/O","20132861","CDM","301","RC","80061","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Advanced Lipid Panel, Cardio Iq (Our Nmr Lipoprotein Profile), S/O","20132862","CDM","301","RC","82172","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Advanced Lipid Panel, Cardio Iq (Our Nmr Lipoprotein Profile), S/O","20132863","CDM","301","RC","83695","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Advanced Lipid Panel, Cardio Iq (Our Nmr Lipoprotein Profile), S/O","20132864","CDM","301","RC","83704","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cardio Iq Direct Ldl, S/O","20132865","CDM","301","RC","83721","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Insulin, Free, S/O","20132866","CDM","301","RC","83527","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hereditary Hemochromatosis Dna Mutation Analysis, S/O","20132867","CDM","310","RC","81256","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Monkeypox Virus Dna, Qual Rt Pcr, S/O","20132868","CDM","306","RC","87593","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hypersensitivity Pneumonitis Screen, S/O","20132869","CDM","302","RC","86331","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hypersensitivity Pneumonitis Screen, S/O","20132870","CDM","302","RC","86606","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hypersensitivity Pneumonitis Screen, S/O","20132871","CDM","302","RC","86609","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Htlv 1&2 Antibody Screen, S/O","20132872","CDM","302","RC","86790","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Mycoplasma Antibodies Igg, S/O","20132873","CDM","302","RC","86738","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aspergillus Antigen, Eia, Bal, S/O","20132874","CDM","302","RC","87305","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aspergillus Antigen, Eia, Serum, S/O","20132875","CDM","302","RC","87305","HCPCS","facility","both","","","","120","60","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Stone Analysis Without Image, S/O","20132876","CDM","301","RC","82365","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Paroxysmal Nocturnal Hemoglobinuria (Pnh) W/Flaer (High Sensitivity), S/O","20132877","CDM","310","RC","88184","HCPCS","facility","both","","","","199","99.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Paroxysmal Nocturnal Hemoglobinuria (Pnh) W/Flaer (High Sensitivity), S/O","20132878","CDM","310","RC","88185","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Paroxysmal Nocturnal Hemoglobinuria (Pnh) W/Flaer (High Sensitivity), S/O","20132879","CDM","310","RC","88187","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Brucella Ab Agglutination, S/O","20132880","CDM","302","RC","86622","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Inflammatory Bowel Disease Differentiation Panel, S/O","20132881","CDM","302","RC","86021","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Inflammatory Bowel Disease Differentiation Panel, S/O","20132882","CDM","302","RC","86036","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Inflammatory Bowel Disease Differentiation Panel, S/O","20132883","CDM","302","RC","86671","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) C-Anca Titer, S/O","20132884","CDM","302","RC","86037","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) P-Anca Titer, S/O","20132885","CDM","302","RC","86037","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Atypical P-Anca Titer, S/O","20132886","CDM","302","RC","86037","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Extended Myositis Specific Antibody (Msa) Panel, S/O","20132887","CDM","301","RC","83516","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Extended Myositis Specific Antibody (Msa) Panel, S/O","20132888","CDM","301","RC","83520","HCPCS","facility","both","","","","305","152.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Extended Myositis Specific Antibody (Msa) Panel, S/O","20132889","CDM","301","RC","84182","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Extended Myositis Specific Antibody (Msa) Panel, S/O","20132890","CDM","302","RC","86235","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myositis Specific 11 Antibody Panel, S/O","20132892","CDM","302","RC","86235","HCPCS","facility","both","","","","22","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 5'Nucleotidase, S/O","20132893","CDM","301","RC","83915","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aquaporin-4 (Aqp4) (Nmo-Igg) Antibody With Reflex To Titer, Csf, S/O","20132894","CDM","302","RC","86052","HCPCS","facility","both","","","","365","182.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Aquaporin 4 Titer, S/O","20132895","CDM","302","RC","86052","HCPCS","facility","both","","","","800","400","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Brucella Antibodies (Igg, Igm), Eia With Reflex To Agglutination, S/O","20132896","CDM","302","RC","86622","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) E Histolytica Ab Igg, S/O","20132897","CDM","302","RC","86753","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu)  Nijmegen Assay, S/O","20132898","CDM","305","RC","85335","HCPCS","facility","both","","","","122","61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Donor, Hiv/Hcv/Hbv Nat Procleix ( R) With Reflexes, S/O","20132899","CDM","302","RC","87801","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Donor Hiv-1 Nat, S/O","20132900","CDM","306","RC","87535","HCPCS","facility","both","","","","241","120.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Donor Hcv Nat, S/O","20132901","CDM","306","RC","87521","HCPCS","facility","both","","","","241","120.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Donor, Hbv Discrimin, S/O","20132902","CDM","306","RC","87516","HCPCS","facility","both","","","","241","120.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cystatin C W/ Glomerular Filtration Rate, Estimated (Egfr), S/O","20132903","CDM","301","RC","82610","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Testosterone, Free, Bioavailable And Total, Ms, S/O","20132905","CDM","301","RC","82040","HCPCS","facility","both","","","","4","2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Histamine Release (Chronic Urticaria), S/O","20132910","CDM","302","RC","86343","HCPCS","facility","both","","","","106","53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Bordetella Pertussis Toxin (Pt) Antibodies (Igg, Iga), Maid, S/O","20132911","CDM","302","RC","86615","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) P190 Bcr-Abl1, S/O","20132912","CDM","310","RC","81207","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) P210 Bcr-Abl1, S/O","20132913","CDM","310","RC","81206","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Collagen Cross-Linked N-Telopeptide (Ntx), Urine, S/O","20132914","CDM","301","RC","82523","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Collagen Cross-Linked N-Telopeptide (Ntx), Urine, S/O","20132915","CDM","301","RC","82570","HCPCS","facility","both","","","","9","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Lysozyme (Muramidase), S/O","20132916","CDM","305","RC","85549","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Testosterone, Free, Bioavailable And Total, Ms, S/O","20132917","CDM","301","RC","84270","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Testosterone, Free, Bioavailable And Total, Ms, S/O","20132918","CDM","301","RC","84403","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphyrins, Total Plasma, S/O","20132919","CDM","301","RC","82542","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Porphobilinogen, Quantitative, Random Urine, S/O","20132920","CDM","301","RC","84110","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Myositis Specific 11 Antibody Panel, S/O","20132921","CDM","301","RC","84182","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Abuse Panel 8, With Confirmation, Serum Or Plasma, S/O","20132922","CDM","301","RC","80307","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamine, Conf, Gc/, S/O","20132923","CDM","301","RC","G0480","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamine, Conf, Gc/, S/O","20132924","CDM","301","RC","G0480","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Benzodiazepine Verif, S/O","20132925","CDM","301","RC","G0480","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Barbiturates, Confir, S/O","20132926","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cocaine Conf Gcms, S, S/O","20132927","CDM","301","RC","G0480","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiate Confirmation, S/O","20132928","CDM","301","RC","G0480","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiate Confirmation, S/O","20132929","CDM","301","RC","G0480","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methadone, Quant. Gc, S/O","20132930","CDM","301","RC","G0480","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Marijuana Conf Gcms, S/O","20132931","CDM","301","RC","G0480","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phencyclidine By Gcms, S/O","20132932","CDM","301","RC","G0480","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Hiv1 Rna, Qualitative Real-Time Pcr, S/O","20132933","CDM","306","RC","87535","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Copeptin, S/O","20132934","CDM","302","RC","86255","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cea, Carcinoembryonic Antigen, Pancreatic Cyst Fluid, S/O","20132935","CDM","301","RC","82378","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Corticosteroid Binding Globulin (Cbg), S/O","20132936","CDM","301","RC","84449","HCPCS","facility","both","","","","100","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86003 Raspberry (Fr343) Ige, S/O","20132937","CDM","302","RC","86003","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Acetylcholinesterase, S/O","20132938","CDM","301","RC","82664","HCPCS","facility","both","","","","42","21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Fetal Hemoglobin, Amnitoic Fluid, S/O","20132939","CDM","301","RC","83033","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Inhibin A, S/O","20132940","CDM","302","RC","86336","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Inhibin B, S/O","20132941","CDM","301","RC","82397","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Pancreatic Polypeptide, Ecl, S/O","20132942","CDM","301","RC","83520","HCPCS","facility","both","","","","80","40","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Creatine, Serum, S/O","20132943","CDM","301","RC","82540","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Intercellular Substance Antibody Titer?, S/O","20132944","CDM","302","RC","86256","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Basement Membrane Zone Antibody Titer, S/O","20132945","CDM","302","RC","86256","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Drug Screen Panel 9, Meconium, S/O","20132946","CDM","301","RC","80307","HCPCS","facility","both","","","","135","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiate, Confirmation, Meconium, S/O","20132947","CDM","301","RC","G0480","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Opiate, Confirmation, Meconium, S/O","20132948","CDM","301","RC","G0480","HCPCS","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Cocaine Confirmation, Meconium, S/O","20132949","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Benzodiazepine, Confirmation By Gcm, S/O","20132950","CDM","301","RC","G0480","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Marijuana, Confirmation, Meconium, S/O","20132951","CDM","301","RC","G0480","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Amphetamines, Confirmation, Meconium, S/O","20132952","CDM","301","RC","G0480","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Barbiturates, Confirmation, Meconium, S/O","20132953","CDM","301","RC","G0480","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Methadone, Confirmation By Gcms, Me, S/O","20132954","CDM","301","RC","G0480","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phencyclidine, Confirmation, Meconium, S/O","20132955","CDM","301","RC","G0480","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Propoxyphene, Confirmation By Gcms, S/O","20132956","CDM","301","RC","G0480","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82088 Aldosterone, 24-Hour Urine With Creatinine, S/O","20132957","CDM","301","RC","82088","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82570 Aldosterone, 24-Hour Urine With Creatinine, S/O","20132958","CDM","301","RC","82570","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82540 Creatine, 24-Hour Urine, S/O","20132959","CDM","301","RC","82540","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84105 Phosphate, Random Urine Without Creatinine, S/O","20132960","CDM","301","RC","84105","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82140 Stonerisk? Diagnostic Profile, S/O","20132961","CDM","301","RC","82140","HCPCS","facility","both","","","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82340 Stonerisk? Diagnostic Profile, S/O","20132962","CDM","301","RC","82340","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82507 Stonerisk? Diagnostic Profile, S/O","20132963","CDM","301","RC","82507","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82570 Stonerisk? Diagnostic Profile, S/O","20132964","CDM","301","RC","82570","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83735 Stonerisk? Diagnostic Profile, S/O","20132965","CDM","301","RC","83735","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83945 Stonerisk? Diagnostic Profile, S/O","20132966","CDM","301","RC","83945","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83986 Stonerisk? Diagnostic Profile, S/O","20132967","CDM","301","RC","83986","HCPCS","facility","both","","","","4","2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84105 Stonerisk? Diagnostic Profile, S/O","20132968","CDM","301","RC","84105","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84133 Stonerisk? Diagnostic Profile, S/O","20132969","CDM","301","RC","84133","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84300 Stonerisk? Diagnostic Profile, S/O","20132970","CDM","301","RC","84300","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84392 Stonerisk? Diagnostic Profile, S/O","20132971","CDM","301","RC","84392","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84560 Stonerisk? Diagnostic Profile, S/O","20132972","CDM","301","RC","84560","HCPCS","facility","both","","","","6","3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80339 Perampanel, Serum/Plasma, S/O","20132973","CDM","301","RC","G0480","HCPCS","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82175 Arsenic, Urine, S/O","20132974","CDM","301","RC","82175","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82570 Arsenic, Urine, S/O","20132975","CDM","301","RC","82570","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82657 Lysosomal Acid Lipase Activity, Blood, S/O","20132976","CDM","301","RC","82657","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87902 Hepatitis C Viral Rna, Lipa, S/O","20132977","CDM","306","RC","87902","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82570 Organic Acids, Comprehensive, Quantitative, Urine, S/O","20132978","CDM","301","RC","82570","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83918 Organic Acids, Comprehensive, Quantitative, Urine, S/O","20132979","CDM","301","RC","83918","HCPCS","facility","both","","","","134","67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86689?Htlv I/Ii, Confirmatory Assay, S/O","20132980","CDM","302","RC","86689","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81479 Jak2, Exon 12 Mutation Analysis, S/O","20132981","CDM","310","RC","81479","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82088 Aldosterone/Cortisol Ratio, Adrenal Vein Sampling 1 Site, S/O","20132982","CDM","301","RC","82088","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82533 Aldosterone/Cortisol Ratio, Adrenal Vein Sampling 1 Site, S/O","20132983","CDM","301","RC","82533","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81517 Enhanced Liver Fibrosis (Elf) Score, S/O","20132984","CDM","310","RC","81517","HCPCS","facility","both","","","","355","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80323 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132985","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80324 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132986","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80335 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132987","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80346 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132988","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80348 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132989","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80353 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132990","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80354 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132991","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80355 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132992","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80356 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132993","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80357 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132994","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80358 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132995","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80359 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132996","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80360 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132997","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80361 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132998","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80362 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20132999","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80365 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133000","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80366 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133001","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80368 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133002","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80369 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133003","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80372 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133004","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80373 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133005","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83992 Drug Monitoring Assess Panel, Extended, Quant, Urine, S/O","20133006","CDM","301","RC","G0480","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80362 Drug Monitoring, Methylphenidate Metabolite Quant, Urine, S/O","20133007","CDM","301","RC","G0480","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81350 Ugt1A1 Gene Polymorphism (Ta Repeat), S/O","20133008","CDM","310","RC","81350","HCPCS","facility","both","","","","56","28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (In) 81406 Invitae Multiple Endocrine Neoplasia Type 2 Test, S/O","20133009","CDM","310","RC","81406","HCPCS","facility","both","","","","1515","757.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 81479 T-Cell Receptor Gene Rearrangement, Pcr, S/O","20133010","CDM","310","RC","81479","HCPCS","facility","both","","","","812","406","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81403 Killer Immunoglobulin-Like Receptors (Kir), S/O","20133012","CDM","310","RC","81403","HCPCS","facility","both","","","","435","217.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ar) 81479 Alport Syndrome Panel, Sequencing And Del/Dupl, S/O","20133013","CDM","310","RC","81479","HCPCS","facility","both","","","","2408","1204","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cmv Pcr Congenital","20133014","CDM","306","RC","87496","HCPCS","facility","both","","","","83","41.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87801 Mycobacterium Tuberculosis Complex And Rifampin Resistance, Pcr, Non-Sputum, S/O","20133015","CDM","302","RC","87801","HCPCS","facility","both","","","","348","174","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86665 Epstein-Barr Virus Viral Capsid Antigen (Vca) Antibody (Igm), S/O","20133016","CDM","302","RC","86665","HCPCS","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81105 Human Platelet Antigen 1 Genotype, S/O","20133017","CDM","310","RC","81105","HCPCS","facility","both","","","","270","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86618 Lyme Antibodies With Reflex, S/O","20133018","CDM","302","RC","86618","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81479 Lynch Syndrome Panel, S/O","20133019","CDM","310","RC","81479","HCPCS","facility","both","","","","1360","680","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 88142 Thinprep Pap, S/O","20133020","CDM","310","RC","88142","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 88175 Thinprep Imaging System Pap, S/O","20133021","CDM","310","RC","G0145","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87491 Chlamydia/Neisseria Gonorrhoeae Rna, Tma, Urogenital, S/O","20133022","CDM","306","RC","87491","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87591 Chlamydia/Neisseria Gonorrhoeae Rna, Tma, Urogenital, S/O","20133023","CDM","306","RC","87591","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87625 Hpv Genotypes 16,18, S/O","20133024","CDM","302","RC","87625","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87624 Thinprep Pap And Hpv Dna With Reflex To Hpv Genotypes 16,18, S/O","20133025","CDM","302","RC","87624","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 88142 Thinprep Pap And Hpv Dna With Reflex To Hpv Genotypes 16,18, S/O","20133026","CDM","310","RC","88142","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87491 Chlamydia Trachomatis Rna, Tma, Urogenital, S/O","20133027","CDM","306","RC","87491","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87661 Trichomonas Vaginalis Rna, Qualitative, Tma, Pap Vial, S/O","20133028","CDM","306","RC","87661","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87491 Chlamydia/N. Gonorrhoeae And T. Vaginalis Rna, Qualitative, Tma, Pap Vial, S/O","20133029","CDM","306","RC","87491","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87591 Chlamydia/N. Gonorrhoeae And T. Vaginalis Rna, Qualitative, Tma, Pap Vial, S/O","20133030","CDM","306","RC","87591","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87661 Chlamydia/N. Gonorrhoeae And T. Vaginalis Rna, Qualitative, Tma, Pap Vial, S/O","20133031","CDM","306","RC","87661","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 88175 Thinprep Imaging Pap And C. Trachomatis, N. Gonorrhoeae, S/O","20133032","CDM","310","RC","88175","HCPCS","facility","both","","","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87491 Thinprep Imaging Pap And C. Trachomatis, N. Gonorrhoeae, S/O","20133033","CDM","306","RC","87491","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87591 Thinprep Imaging Pap And C. Trachomatis, N. Gonorrhoeae, S/O","20133034","CDM","306","RC","87591","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87798 Adenovirus Dna, Qualitative Rt Pcr, S/O","20133035","CDM","306","RC","87798","HCPCS","facility","both","","","","285","142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82103 Alpha-1-Antitrysin, Random Feces, S/O","20133036","CDM","301","RC","82103","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86653 Abovirus Antibodies (Igg, Igm), Ifa Serum, S/O","20133037","CDM","302","RC","86653","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86654 Abovirus Antibodies (Igg, Igm), Ifa Serum, S/O","20133038","CDM","302","RC","86654","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86652 Abovirus Antibodies (Igg, Igm), Ifa Serum, S/O","20133039","CDM","302","RC","86652","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86651 Abovirus Antibodies (Igg, Igm), Ifa Serum, S/O","20133040","CDM","302","RC","86651","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82175 Arsenic, 24-Hour Urine, S/O","20133041","CDM","301","RC","82175","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86790 Chikungunya Igm Titration, S/O","20133042","CDM","302","RC","86790","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 85250 Factor Ix Activity And Human Inhibitor, S/O","20133043","CDM","305","RC","85250","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 85335 Factor Ix Activity And Human Inhibitor, S/O","20133044","CDM","305","RC","85335","HCPCS","facility","both","","","","66","33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80167 Felbamate, S/O","20133045","CDM","301","RC","80167","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 80299 Fondaparinux Sodium (Xa Inhibitor), S/O","20133047","CDM","301","RC","80299","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83519 Pepsinogen Ii, S/O","20133048","CDM","301","RC","83519","HCPCS","facility","both","","","","265","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84220 Pyruvate Kinase Enzyme Activity, Blood , S/O","20133049","CDM","301","RC","84220","HCPCS","facility","both","","","","156","78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86431 ?Rheumatoid Factor, La Titer, S/O","20133050","CDM","302","RC","86431","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83520 Admark Phospho-Tau/Total-Tau/A Beta42, Analysis And Interp, Csf (Symptomatic), S/O","20133051","CDM","301","RC","83520","HCPCS","facility","both","","","","479","239.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83520 Ige Antibody (Anti-Ige Igg), S/O","20133052","CDM","301","RC","83520","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81257 Alpha-Globin Common Mutation Analysis, S/O","20133053","CDM","310","RC","81257","HCPCS","facility","both","","","","464","232","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87635 Sars-Cov-2 Rna (Covid-19), Qualitative Naat, S/O","20133054","CDM","302","RC","87635","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87902 Hcv Rna Genotype 1 Ns5A Drug Resistance, S/O","20133055","CDM","306","RC","87902","HCPCS","facility","both","","","","515","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 83520 Mag-Sgpg Antibody (Igm), Eia, S/O","20133056","CDM","301","RC","83520","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 81479 Cxcr4 Mutation Analysis, Somatic, Lymphoplasmacytic Lymphoma/Waldenstrom Macro, S/O","20133057","CDM","310","RC","81479","HCPCS","facility","both","","","","868","434","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 81305 Myd88, L265P, Somatic Gene Mutation, Dna Allele-Specific Pcr, S/O","20133058","CDM","310","RC","81305","HCPCS","facility","both","","","","773","386.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81479 Myeloproliferative Neoplasms (Mpn) Mini Panel, S/O","20133059","CDM","310","RC","81479","HCPCS","facility","both","","","","1255","627.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81377 Hla-Dq Typing For Narcolepsy, S/O","20133060","CDM","310","RC","81377","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81383 Hla-Dq Typing For Narcolepsy, S/O","20133061","CDM","310","RC","81383","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87624 Hpv Dna, High Risk, S/O","20133062","CDM","302","RC","87624","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81479 Scn9A Full Gene Sequencing & Copy Number Analysis, S/O","20133063","CDM","310","RC","81479","HCPCS","facility","both","","","","837","418.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81479 Scn10A Full Gene Sequencing Analysis, S/O","20133064","CDM","310","RC","81479","HCPCS","facility","both","","","","837","418.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 82784 Celiac Disease Panel, S/O","20133065","CDM","301","RC","82784","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86258 Celiac Disease Panel, S/O","20133066","CDM","302","RC","86258","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86364 Celiac Disease Panel, S/O","20133067","CDM","302","RC","86364","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Uva) 87633 Filmarray Respiratory Panel 2 (Rp2), S/O","20133068","CDM","306","RC","87633","HCPCS","facility","both","","","","516","258","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 88174 Thinprep Imaging System Pap (Imaging Fails), S/O","20133069","CDM","310","RC","88174","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 88141 Physician Interpretation, S/O","20133070","CDM","310","RC","88141","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86364 Tissue Transglutaminase (Ttg) Antibody (Igg), S/O","20133071","CDM","302","RC","86364","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86258 Gliadin (Deamidated) Antibody (Igg), S/O","20133072","CDM","302","RC","86258","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 81479 Platelet Disorders, Comprehensive Gene Panel, Next-Generation Sequencing, Varies, S/","20133074","CDM","310","RC","81479","HCPCS","facility","both","","","","2540","1270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Prom) 81479 Prometheus Ibd Sgi Diagnostic, S/O","20133075","CDM","310","RC","81479","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 87999 Respiratory Panel, Pcr, Varies, S/O","20133076","CDM","306","RC","87999","HCPCS","facility","both","","","","635","317.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87801 Borrelia Species Dna, Qualitative Real-Time Pcr, Miscellaneous, S/O","20133077","CDM","306","RC","87801","HCPCS","facility","both","","","","124","62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87207 Malaria/Babesia/Other Blood Parasites, S/O","20133078","CDM","306","RC","87207","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 87632 Respiratory Virus Pcr Panel Iv, S/O","20133079","CDM","306","RC","87632","HCPCS","facility","both","","","","1718","859","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81479 Jak2 V617F Mutation Analysis, S/O","20133080","CDM","310","RC","81479","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81479 Csf3R Mutation Analysis, S/O","20133081","CDM","310","RC","81479","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81420 Maternit21 Plus Core (Chr21,18,13) No Gender, S/O","20133082","CDM","310","RC","81420","HCPCS","facility","both","","","","810","405","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Gd) 81415 Diagnostic Testing / Xomedx / Whole Exome Sequence Analysis, S/O","20133083","CDM","310","RC","81415","HCPCS","facility","both","","","","5515","2757.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) 81479 Neo Comprehensive - Heme Cancers, S/O","20133084","CDM","310","RC","81479","HCPCS","facility","both","","","","4465","2232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81500 Roma (Risk Of Ovarian Malignancy Algorithm), S/O","20133085","CDM","310","RC","81500","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81479 Jak2V617F Mutation Anls, Quantitative, W Reflex To Calr Mutation And Mdl Mutation An","20133086","CDM","310","RC","81479","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Neo) 81479 Cxcr4 Mutation Analysis, S/O","20133087","CDM","310","RC","81479","HCPCS","facility","both","","","","425","212.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Gd) 81312 Pabpn1 Repeat Analysis, S/O","20133088","CDM","310","RC","81312","HCPCS","facility","both","","","","1215","607.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81340 T-Cell Receptor (Tcr) Beta Gene Rearrangement, Pcr, S/O","20133089","CDM","310","RC","81340","HCPCS","facility","both","","","","390","195","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81342 T-Cell Receptor (Tcr) Gamma Gene Rearrangement, Pcr, S/O","20133090","CDM","310","RC","81342","HCPCS","facility","both","","","","390","195","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81273 Kit D816, Mutation Analysis (Mastocytosis), S/O","20133091","CDM","310","RC","81273","HCPCS","facility","both","","","","398","199","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81271 Huntington Disease Mutation Analysis, S/O","20133092","CDM","310","RC","81271","HCPCS","facility","both","","","","365","182.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86318 Trypanosoma Cruzi Antibody Confirmation, S/O","20133093","CDM","302","RC","86318","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Chkd) 80158 Cyclosporine, S/O","20133094","CDM","301","RC","80158","HCPCS","facility","both","","","","120","60","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Chkd) 80195 Sirolimus, S/O","20133095","CDM","301","RC","80195","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81479 Geneseq(R) Plus, Dmd, S/O","20133096","CDM","310","RC","81479","HCPCS","facility","both","","","","1275","637.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Prom) 81401 Prometheus Crohn's Prognostic, S/O","20133097","CDM","310","RC","81401","HCPCS","facility","both","","","","790","395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81273 Kit (D816V) Digital Pcr, S/O","20133098","CDM","310","RC","81273","HCPCS","facility","both","","","","456","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81401 Admark? Apoe Genotype Analysis & Interpretation (Symptomatic), S/O","20133099","CDM","310","RC","81401","HCPCS","facility","both","","","","565","282.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81405 Familial Hypocalciuric Hypercalcemia (Casr) Dna Sequencing Test, S/O","20133100","CDM","310","RC","81405","HCPCS","facility","both","","","","2035","1017.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81479 Bcr-Abl1 Gene Rearrangement, Quantitative, Pcr, S/O","20133101","CDM","310","RC","81479","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 81401 Apolipoprotein E Genotyping, Blood, S/O","20133102","CDM","310","RC","81401","HCPCS","facility","both","","","","585","292.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Ma) 81271 Huntington Disease, Molecular Analysis, S/O","20133103","CDM","310","RC","81271","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 81596 Liver Fibrosis Fibrotest-Actitest Panel, S/O","20133104","CDM","310","RC","81596","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81401 Apoe Alzheimer's Risk, S/O","20133105","CDM","310","RC","81401","HCPCS","facility","both","","","","340","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Monkeypox, Dna, Pcr","20139999","CDM","300","RC","87593","HCPCS","facility","both","","","","77","38.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201540","CDM","270","RC","","","facility","both","","","","9695.93","4847.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201717","CDM","272","RC","C1766","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201779","CDM","272","RC","C1726","HCPCS","facility","both","","","","981.96","490.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201780","CDM","278","RC","C1726","HCPCS","facility","both","","","","981.96","490.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201790","CDM","278","RC","C1781","HCPCS","facility","both","","","","1817.81","908.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20183","CDM","270","RC","","","facility","both","","","","73.19","36.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","201897","CDM","278","RC","C1776","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20193","CDM","270","RC","","","facility","both","","","","118.34","59.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","202147","CDM","270","RC","","","facility","both","","","","483","241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","202319","CDM","270","RC","","","facility","both","","","","50.27","25.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","202370","CDM","270","RC","","","facility","both","","","","7.89","3.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","202463","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20252","CDM","270","RC","","","facility","both","","","","14.93","7.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20253","CDM","270","RC","","","facility","both","","","","13.58","6.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20254","CDM","270","RC","","","facility","both","","","","13.68","6.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20257","CDM","270","RC","","","facility","both","","","","15.94","7.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20258","CDM","270","RC","","","facility","both","","","","21.3","10.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","202584","CDM","270","RC","","","facility","both","","","","726.8","363.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20297","CDM","270","RC","","","facility","both","","","","43.7","21.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ammonia Stat","20300001","CDM","300","RC","82140","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lactic Acid Bld Stat","20300058","CDM","300","RC","83605","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Basic Metabolic Panel","20300059","CDM","301","RC","80048","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Albumin","20300060","CDM","301","RC","82040","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alkaline Phosphatase","20300061","CDM","301","RC","84075","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alt","20300062","CDM","301","RC","84460","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ast","20300063","CDM","301","RC","84450","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amylase","20300064","CDM","301","RC","82150","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ggt","20300065","CDM","301","RC","82977","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Total Bilirubin","20300066","CDM","301","RC","82247","HCPCS","facility","both","","","","10","5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Total Protein","20300067","CDM","301","RC","84155","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen Urine Stat-6","20300068","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flu+Sars Antigen Fia","20300069","CDM","306","RC","87428","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee Nursing Home","20300100","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lactic Acid Csf Stat","20300153","CDM","300","RC","83605","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucose-Body Fluid Oth T","20300358","CDM","300","RC","82945","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Body Fluid Protein","20300359","CDM","300","RC","84157","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acetaminophen Level Stat","20300506","CDM","300","RC","80143","HCPCS","facility","both","","","","338","169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Salicylate Level","20300508","CDM","300","RC","80179","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lipase","20300509","CDM","300","RC","83690","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lipase Fluid","20300510","CDM","300","RC","83690","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acid Phosphatase","20300512","CDM","300","RC","84060","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphorus Urine","20300513","CDM","300","RC","84105","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bf Crystals","20300530","CDM","300","RC","89060","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ammonia Arterial","20300534","CDM","300","RC","82140","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urinalysis","20300538","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Osmolality Urine","20300539","CDM","300","RC","83935","HCPCS","facility","both","","","","387","193.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bile Urine","20300540","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pregnancy Test Urine Inpt","20300541","CDM","300","RC","81025","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Stool Occult Blood X 3","20300543","CDM","300","RC","82270","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ph Stool","20300545","CDM","300","RC","83986","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urine Specific Gravity","20300549","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ph Urine","20300550","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ketones Urine Stat","20300551","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Osmolality Serum","20300557","CDM","300","RC","83930","HCPCS","facility","both","","","","387","193.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Occult Blood Gastric","20300558","CDM","300","RC","82271","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein Urine Screen","20300566","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Reducing Subst Stool","20300567","CDM","300","RC","84376","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Body Fluid Ph","20300568","CDM","300","RC","83986","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Specific Grav Fluid","20300570","CDM","300","RC","84315","HCPCS","facility","both","","","","118","59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Osmolality Perfusate","20300571","CDM","300","RC","84999","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pregnancy, Serum","20300572","CDM","300","RC","84703","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rpr Stat","20300575","CDM","300","RC","86592","HCPCS","facility","both","","","","144","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Viscosity Serum","20300576","CDM","300","RC","85810","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Draw Fee - Venipuncture Central Testing","20300585","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urinalysis W/Micro","20300586","CDM","300","RC","81001","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcium Ionized","20300589","CDM","300","RC","82330","HCPCS","facility","both","","","","480","240","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Strep Screen Stat","20300594","CDM","300","RC","87880","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amikacin Peak","20300595","CDM","300","RC","80150","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amikacin Trough","20300596","CDM","300","RC","80150","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gentamycin Peak","20300597","CDM","300","RC","80170","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gentamycin 80 Mgs (Garamycin)","20300598","CDM","300","RC","80170","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vancomycin Peak","20300599","CDM","300","RC","80202","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vancomycin Trough","20300600","CDM","300","RC","80202","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ph, Pc02, P02: I-Stat","20300624","CDM","300","RC","82803","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucose I-Stat","20300625","CDM","300","RC","82947","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl I-Stat Abg Venous Ph,Pco2,Po2","20300627","CDM","300","RC","82803","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bun (Urea Nitrogen) I-Stat","20300629","CDM","300","RC","84520","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloride I-Stat","20300630","CDM","300","RC","82435","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium I-Stat","20300631","CDM","300","RC","84132","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium I-Stat","20300632","CDM","300","RC","84295","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pt-Inr Poc","20300634","CDM","300","RC","85610","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta Hydroxybutyrate","20300635","CDM","300","RC","82010","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcium Ionized I-Stat","20300703","CDM","300","RC","82330","HCPCS","facility","both","","","","480","240","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Basic Metabolic Panel","20300706","CDM","300","RC","80047","HCPCS","facility","both","","","","408","204","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bilirubin Fluid","20300900","CDM","300","RC","82247","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fetal Fibronectin","20301370","CDM","300","RC","82731","HCPCS","facility","both","","","","795","397.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Occult Blood Stool - Screen","20301770","CDM","300","RC","82270","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl I-Stat Abg Arterial Cord Bld","20301771","CDM","300","RC","82803","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl I-Stat Abg Venous Cord Bld","20301772","CDM","300","RC","82803","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Co2: I-Stat","20301773","CDM","300","RC","82374","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hct- I-Stat","20302103","CDM","300","RC","85014","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Collection Drug Scr-5","20302105","CDM","300","RC","99001","HCPCS","facility","both","","","","202","101","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl O2 Saturation","20302109","CDM","300","RC","82810","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Carboxy Hgb","20302110","CDM","300","RC","82375","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Met Hgb","20302111","CDM","300","RC","83050","HCPCS","facility","both","","","","321","160.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Act - Atp","20302112","CDM","300","RC","85347","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tobramycin Trough","20302122","CDM","300","RC","80200","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tobramycin Peak","20302123","CDM","300","RC","80200","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine - I-Stat","20302125","CDM","300","RC","82565","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lactate I-Stat","20302128","CDM","300","RC","83605","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyte Poc","20302129","CDM","300","RC","80051","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Tsh","20302159","CDM","300","RC","84443","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lactate Arterial I-Stat","20302175","CDM","300","RC","83605","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ifob","20302180","CDM","300","RC","G0328","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cl Urine Random","20302202","CDM","300","RC","82436","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Reg Entry Draw Fee Ghent Family","20302203","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Req Entry Draw Fee Hoffeimer Hall","20302204","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20304","CDM","270","RC","","","facility","both","","","","286.52","143.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Heelstick","20307999","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Viscosity Fluid","20330002","CDM","300","RC","85810","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Neurol Spec","20330004","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee Veni-Diabetes Inst","20330005","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee St Lukes","20330006","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Ft Norfolk","20330014","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Ndc","20330015","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-First Colonial","20330016","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-New Town","20330017","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Edinburgh","20330018","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Gloucester","20330019","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-Ft Norfolk","20330020","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-Ndc","20330021","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-First Colonial","20330022","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-New Town","20330023","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-Edinburgh","20330024","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-Gloucester","20330025","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta Hcg I-Stat","20330026","CDM","300","RC","84702","HCPCS","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid Rapid Antigen","20330027","CDM","300","RC","87426","HCPCS","facility","both","","","","35.33","17.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-10Th Street","20330028","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heel Stick-10Th Street","20330029","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Specimen Handling Fee-10Th Street","20330030","CDM","300","RC","99000","HCPCS","facility","both","","","","24","12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Iop","20330031","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H. Pylori Test Administration","20330032","CDM","301","RC","83014","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203324","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203330","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203349","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203371","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203372","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203373","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203649","CDM","278","RC","C1713","HCPCS","facility","both","","","","1820","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203675","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203680","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203681","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203704","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","203931","CDM","270","RC","","","facility","both","","","","3625.2","1812.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20394","CDM","270","RC","","","facility","both","","","","87.4","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20397","CDM","270","RC","","","facility","both","","","","297.54","148.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryoglobulin","20400004","CDM","300","RC","82595","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heinz Body Prep","20400034","CDM","300","RC","85441","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyroglobulin Antibody","20400044","CDM","300","RC","86800","HCPCS","facility","both","","","","169","84.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rbc Osmotic Fragility","20400047","CDM","300","RC","85557","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryofibrinogen","20400075","CDM","300","RC","82585","HCPCS","facility","both","","","","202","101","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Insulin Antibodies","20400190","CDM","300","RC","86337","HCPCS","facility","both","","","","222","111","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aso Abs","20400314","CDM","300","RC","86060","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rpr With Reflex","20400317","CDM","300","RC","86592","HCPCS","facility","both","","","","144","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cold Agglutinins","20400318","CDM","300","RC","86157","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heterophile Ab","20400323","CDM","300","RC","86308","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ana Titer","20400325","CDM","300","RC","86039","HCPCS","facility","both","","","","244","122","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Streptozyme","20400326","CDM","300","RC","86403","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Smooth Muscle Antibodies","20400375","CDM","300","RC","86015","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Mitochondrial Antibodies","20400425","CDM","300","RC","86381","HCPCS","facility","both","","","","118","59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blastomycosis Id","20400464","CDM","300","RC","86612","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryptococcal Antigen","20400467","CDM","300","RC","87327","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histoplasmosis Id","20400470","CDM","300","RC","86698","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunoassay By Ria","20400477","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glomerular Base Membrane Ab","20400479","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parietal Cell Antibodies Ifa","20400481","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Reticulin Ab Iga","20400482","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergillus Id","20400483","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Titer Cf","20400487","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Intrinsic Factor Ab","20400526","CDM","300","RC","86340","HCPCS","facility","both","","","","270","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Striated Muscle Ab","20400540","CDM","300","RC","86256","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anti Rnp","20400548","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Eb-Vca Ab Igg","20400576","CDM","300","RC","86665","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fungal Screen Cf","20400578","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Q Fever","20400581","CDM","300","RC","86638","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Adenovirus Titer Cf","20400601","CDM","300","RC","86603","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergillus Cf","20400613","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dnase B Antibody","20400618","CDM","300","RC","86215","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blastomycosis Cf","20400622","CDM","300","RC","86612","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Antibodies","20400628","CDM","300","RC","86628","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coccidiodies Antibody Cf","20400630","CDM","300","RC","86635","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryptococcal Antigen Fluid","20400634","CDM","300","RC","87327","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Arup-Cysticercosis Ab, Igg","20400635","CDM","300","RC","86682","HCPCS","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Echinococcus Titer","20400652","CDM","300","RC","86682","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Filariasis Ab","20400664","CDM","300","RC","86682","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histoplasmosis Cf","20400668","CDM","300","RC","86698","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Antibodies","20400684","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lcm Antibodies","20400686","CDM","300","RC","86727","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Malaria Ab","20400695","CDM","300","RC","86750","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parainfluenza Cf","20400709","CDM","300","RC","86710","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Polio Virus Ab, Cf","20400713","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rabies Titer","20400716","CDM","300","RC","86382","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Resp Syncytial Virus Ab","20400719","CDM","300","RC","86756","HCPCS","facility","both","","","","169","84.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Schistosomiasis","20400726","CDM","300","RC","86682","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Scleroderma Ab","20400727","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sporotrichosis Agglutination","20400729","CDM","300","RC","86671","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Strongylodiasis Ab","20400730","CDM","300","RC","86682","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Teichoic Acid Ab","20400736","CDM","300","RC","86329","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trichinella Antibodies","20400738","CDM","300","RC","86784","HCPCS","facility","both","","","","166","83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Tularemia Agglutination","20400739","CDM","300","RC","86668","HCPCS","facility","both","","","","124","62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 86753 Trypanosoma Cruzi Antibody, Total With Reflex To Confirmation, S/O","20400744","CDM","302","RC","86753","HCPCS","facility","both","","","","106","53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vdrl Csf","20400747","CDM","300","RC","86592","HCPCS","facility","both","","","","144","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herp 6 Igg","20400748","CDM","300","RC","86790","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herp 6 Igm","20400749","CDM","300","RC","86790","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Genotype","20400751","CDM","300","RC","87901","HCPCS","facility","both","","","","1091","545.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Phenotype Add't Drug","20400753","CDM","300","RC","87904","HCPCS","facility","both","","","","270","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Phenotype Add't Drug Gro","20400754","CDM","300","RC","87904","HCPCS","facility","both","","","","270","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cmv-Pcr Nonblood Qnt","20400805","CDM","300","RC","87497","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anti Sm Smith","20400806","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coccidiodies Csf Serum","20400813","CDM","300","RC","86635","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Listeria Antibodies,Cf","20400839","CDM","300","RC","86609","HCPCS","facility","both","","","","121","60.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rmsf Antibodies Igg Eia","20400846","CDM","300","RC","86757","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ra, Quant.","20400906","CDM","300","RC","86431","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rmsf Igm","20400912","CDM","300","RC","86757","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C2 Complement","20400916","CDM","300","RC","86160","HCPCS","facility","both","","","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Epstein Barr Virus","20400922","CDM","300","RC","86665","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Centromere Ab","20400930","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C-1 Est Inh Funct'al","20400932","CDM","300","RC","86161","HCPCS","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Toxocara Ab","20400933","CDM","300","RC","86682","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arboviral Titers","20400937","CDM","300","RC","86651","HCPCS","facility","both","","","","116","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histone Antibodies","20400951","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C1 Esterase Inhibitor Id","20400976","CDM","300","RC","86160","HCPCS","facility","both","","","","245","122.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Subclass 4","20401000","CDM","300","RC","82787","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rubella","20401001","CDM","300","RC","86762","HCPCS","facility","both","","","","222","111","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Subclass 3","20401002","CDM","300","RC","82787","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyme Igm Antibody","20401003","CDM","300","RC","86618","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Epstein Barr Ab-Na","20401012","CDM","300","RC","86664","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Typhus Fever Ab","20401037","CDM","300","RC","86757","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv Ab,Western Blot","20401041","CDM","300","RC","86689","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neuronal Ab,Igg","20401043","CDM","300","RC","83520","HCPCS","facility","both","","","","312","156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ana","20401049","CDM","300","RC","86038","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl E Histolytica Igg","20401050","CDM","300","RC","86753","HCPCS","facility","both","","","","367","183.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Factor Viii Vw Multimetric","20401051","CDM","300","RC","85247","HCPCS","facility","both","","","","422","211","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Dfa","20401053","CDM","300","RC","87270","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hpv Pcr","20401056","CDM","301","RC","87999","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leptospira Abs","20401058","CDM","300","RC","86720","HCPCS","facility","both","","","","499","249.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C1Q Binding Assay","20401061","CDM","300","RC","86332","HCPCS","facility","both","","","","561","280.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Jo-1 Abs,Id","20401066","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Skin Abs","20401067","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dna Ab Single Strand","20401069","CDM","300","RC","86226","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Htlv 1&2 Ab","20401070","CDM","300","RC","86790","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mycoplasma Igg,Eia","20401101","CDM","300","RC","86738","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Squamous Cell Ca Ag","20401103","CDM","300","RC","86316","HCPCS","facility","both","","","","351","175.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Adrenal Ab, Ifa","20401108","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Islet Cell Ab","20401109","CDM","300","RC","86341","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C3A Complement","20401111","CDM","300","RC","86160","HCPCS","facility","both","","","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C5A Complement","20401112","CDM","300","RC","86160","HCPCS","facility","both","","","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parvovirus B19 Igm","20401114","CDM","300","RC","86747","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parvovirus B19 Igg","20401115","CDM","300","RC","86747","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rubeola Abs, Eia, Qn","20401117","CDM","300","RC","86765","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Varicella Zoster Antibod Igm","20401118","CDM","300","RC","86787","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dna Ab","20401125","CDM","300","RC","86225","HCPCS","facility","both","","","","301","150.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyme Igm/Igg Antibodies","20401127","CDM","300","RC","86618","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Toxoplasma Igg,Fluid","20401130","CDM","300","RC","86777","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytomegalovirus, Igg, Qn","20401132","CDM","300","RC","86644","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mumps Virus Igg","20401134","CDM","300","RC","86735","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Raji Cell Assay","20401144","CDM","300","RC","86332","HCPCS","facility","both","","","","561","280.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) 84181 Myelin Associated Glycoprotein (Mag) Antibody, With Reflex To Mag-Sgpg And Mag, Eia,","20401156","CDM","301","RC","84181","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gmi Autoantibody","20401158","CDM","300","RC","83520","HCPCS","facility","both","","","","525","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hu Autoantibody","20401159","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Yo Antibody","20401160","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ri Autoantibody","20401161","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ribosomal P Protein","20401162","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Allergy M5 Candida Igg","20401165","CDM","300","RC","86001","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Helicobacter Pylori Antibody","20401172","CDM","300","RC","86677","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H. Pylori Iga Antibody","20401173","CDM","300","RC","86677","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Diphtheria Antitoxoid","20401174","CDM","300","RC","86317","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Tetanus","20401175","CDM","300","RC","86317","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mycoplasma Pneumonia Igm,Eia","20401177","CDM","300","RC","86738","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sulfatide Antibody","20401183","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sensory Neuropathy Ab","20401184","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Legionella Antigen,Urine","20401187","CDM","300","RC","87449","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gliandin Antibody,Iga","20401188","CDM","300","RC","86258","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gliandin Antibody,Igg","20401189","CDM","300","RC","86258","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bartonella Dna Pcr","20401190","CDM","300","RC","87471","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Varicella Igm Antibody","20401191","CDM","300","RC","86787","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pelvic Cytology (3 Slide)","20401195","CDM","311","RC","P3000","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H Pylori Igm","20401200","CDM","300","RC","86677","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Achr-Blocking Antibodies","20401202","CDM","302","RC","86042","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Achr-Modulating Antibodies","20401203","CDM","302","RC","86043","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blastomyces Ag Urine","20401204","CDM","300","RC","87449","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T-Transglutaminase(Ttg)Igg","20401205","CDM","300","RC","86364","HCPCS","facility","both","","","","122","61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Srp Antibody","20401206","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv Rna Group","20401221","CDM","300","RC","87536","HCPCS","facility","both","","","","658","329","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytomegalovirus Dna Pcr,Qnt","20401231","CDM","300","RC","87497","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Phenotype Result","20401260","CDM","300","RC","87903","HCPCS","facility","both","","","","4943","2471.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Nmo Igg Csf","20401276","CDM","300","RC","86363","HCPCS","facility","both","","","","946","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cysticercus Ab Csf","20401277","CDM","300","RC","86682","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cmv Igg Avidity","20401278","CDM","300","RC","86644","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cmv Igg Avidity Add't","20401279","CDM","300","RC","86644","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Subclass 1","20401300","CDM","300","RC","82787","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Subclass 2","20401301","CDM","300","RC","82787","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Subclasses, Igg Quant","20401302","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B Cpt88305B, Bill Only","20401304","CDM","310","RC","88305","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Myeloperoxidase (Mpo) Ab, Eia","20401308","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histoplasma Antigen","20401309","CDM","300","RC","87385","HCPCS","facility","both","","","","284","142","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pr-3 Antibody,Eia","20401310","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H. Pylori Antigen","20401320","CDM","300","RC","87338","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ehrlic Igg Ab","20401410","CDM","300","RC","86666","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ehrlic Igm Ab","20401411","CDM","300","RC","86666","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mumps Antibody Igm","20401421","CDM","300","RC","86735","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mi-2 Autoantibodies","20401422","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyme Western Blot Igg","20401423","CDM","300","RC","86617","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyme Western Blot Igm","20401424","CDM","300","RC","86617","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia,Ampl Probe Ua","20401425","CDM","300","RC","87491","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gc,Ampl Probe Ua","20401426","CDM","300","RC","87591","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Functional Anti-Fcer","20401430","CDM","300","RC","86352","HCPCS","facility","both","","","","596","298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chikungunya Igg Antibody","20401440","CDM","300","RC","86790","HCPCS","facility","both","","","","256","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chikungunya Igm Antibody","20401441","CDM","300","RC","86790","HCPCS","facility","both","","","","256","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Echo 4 Ab","20401500","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Echo 9 Ab","20401501","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Echo 11 Ab","20401502","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Echo 30 Ab","20401503","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Brucella Abortus Igg Abs","20401504","CDM","300","RC","86622","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Brucella Abortus Igm Abs","20401505","CDM","300","RC","86622","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bk Virus Dna Pcr,Ua","20401620","CDM","300","RC","87799","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta-2 Transferrin","20401800","CDM","300","RC","86334","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Endomysial Iga Ab","20401801","CDM","300","RC","86231","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simplex Igm1","20401900","CDM","300","RC","86695","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simplex Igm2","20401901","CDM","300","RC","86696","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Echo 7 Ab","20402030","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hhv-7,Dna Pcr","20402031","CDM","300","RC","87799","HCPCS","facility","both","","","","1059","529.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Musk Antibody Test","20402032","CDM","300","RC","83519","HCPCS","facility","both","","","","1781","890.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Strep Pneumo Abs,Each","20402053","CDM","300","RC","86317","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Humanherpes Virus-6 Pcr,Qnt","20402218","CDM","300","RC","87533","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Humanherpes Virus-6 Pcr,Qnt No","20402219","CDM","300","RC","87533","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simplex 1&2 Pcr Qual","20402220","CDM","300","RC","87529","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simplex 1&2 Pcr Qnt,","20402221","CDM","300","RC","87530","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Varicella Pcr","20402222","CDM","300","RC","87798","HCPCS","facility","both","","","","1076","538","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Varicella Pcr (Nonbld)","20402223","CDM","300","RC","87799","HCPCS","facility","both","","","","1114","557","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ebv Dna Pcr Qnt,Nonbld","20402224","CDM","300","RC","87799","HCPCS","facility","both","","","","568","284","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sjogren Ssa Antibody","20402225","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sjogren Ssb Antibody","20402226","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Liver-Kidney Microsomal Ab","20402229","CDM","300","RC","86376","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bartonella Henselae Igg,Ifa","20402360","CDM","300","RC","86611","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bartonella Henselae Igm,Ifa","20402361","CDM","300","RC","86611","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bartonella Quintana Igg,Ifa","20402362","CDM","300","RC","86611","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bartonella Quintana Igm,Ifa","20402363","CDM","300","RC","86611","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryptococcal Ag Titer,Fluid","20402364","CDM","300","RC","87327","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryptococcal Ag Titer,Serum","20402365","CDM","300","RC","87327","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyme Dna Pcr","20402366","CDM","300","RC","87801","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Anti-Pm-Scl-75 Ab","20402367","CDM","300","RC","86235","HCPCS","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Immune Complexes","20402368","CDM","300","RC","86628","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tropheryma Whippelii Dna,Pcr","20402373","CDM","300","RC","87798","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sarcolemma Antibodies","20402374","CDM","300","RC","86256","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Salmonella O,Group D Ab.","20402431","CDM","300","RC","86768","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Htlv 1 Ab,Western Blot","20402441","CDM","300","RC","86687","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Htlv 2 Ab,Western Blot","20402442","CDM","300","RC","86688","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hpv High Risk","20402444","CDM","300","RC","87624","HCPCS","facility","both","","","","312","156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Saccharomyces Cerevisiae Igg","20402448","CDM","300","RC","86671","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Saccharomyces Cerevisiae Iga","20402449","CDM","300","RC","86671","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Salmonella H,Group A Abs","20402450","CDM","300","RC","86768","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Salmonella H,Group B Abs","20402451","CDM","300","RC","86768","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Salmonella H,Group D Abs","20402452","CDM","300","RC","86768","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T-Transglutaminase Iga","20402455","CDM","300","RC","86364","HCPCS","facility","both","","","","122","61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie A 2Ab","20402456","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie A 4 Ab","20402457","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie A 7 Ab","20402458","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie A 9 Ab","20402459","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie A 10 Ab","20402460","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie A 16 Ab","20402461","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl West Nile Igg Ab","20402462","CDM","300","RC","86789","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl West Nile Igm Ab","20402463","CDM","300","RC","86788","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta-2 Iga","20402471","CDM","300","RC","86146","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta-2 Igg","20402472","CDM","300","RC","86146","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta-2 Igm","20402473","CDM","300","RC","86146","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylserine Iga Abs","20402474","CDM","300","RC","86148","HCPCS","facility","both","","","","109","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phosphatidylserine/Prothrombin (Ps/Pt) Antibody (Igg), S/O","20402475","CDM","301","RC","83516","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Phosphatidylserine/Prothrombin (Ps/Pt) Antibody (Igg), S/O","20402476","CDM","301","RC","83516","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylinositol Iga Abs","20402477","CDM","300","RC","83520","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylinositol Igg Abs","20402478","CDM","300","RC","83520","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylinositol Igm Abs","20402479","CDM","300","RC","83520","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parvo Pcr","20402480","CDM","300","RC","87798","HCPCS","facility","both","","","","321","160.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Granulocyte Ab","20402481","CDM","300","RC","86021","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gad Ab","20402482","CDM","300","RC","86341","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herp 7 Igg Abs","20402483","CDM","300","RC","86790","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herp 7 Igm Abs","20402484","CDM","300","RC","86790","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidic Acid Iga Abs","20402485","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidic Acid Igg Abs","20402486","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidic Acid Igm Abs","20402487","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylcholine Iga","20402488","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylcholine Igg","20402489","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylcholine Igm","20402490","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylethanolamine Iga","20402491","CDM","300","RC","83520","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylethanolamine Igg","20402492","CDM","300","RC","83520","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphatidylethanolamine Igm","20402493","CDM","300","RC","83520","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Micropoly Faeni Abs","20402494","CDM","300","RC","86609","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thermoactinimyces Candidus","20402495","CDM","300","RC","86602","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Saccharomonospora Viridis Abs","20402496","CDM","300","RC","86602","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thermoa.Vulgaris #1 Abs","20402497","CDM","300","RC","86602","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thermoa. Vulgaris #2 Abs","20402498","CDM","300","RC","86602","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl A. Pullulans Abs","20402499","CDM","300","RC","86671","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Flavus Abs","20402500","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Fumigatis #1 Abs","20402501","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Fumigatus #2 Abs","20402502","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Fumigatus #3 Abs","20402503","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Fumigatus #6 Abs","20402504","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie B1 Ab","20402505","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie B2 Ab","20402506","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie B3 Ab","20402507","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie B4 Ab","20402508","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie B5 Ab","20402509","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coxsackie B6 Ab","20402510","CDM","300","RC","86658","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Influenza A","20402511","CDM","300","RC","86710","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Influenza B","20402512","CDM","300","RC","86710","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parainfluenza 1","20402513","CDM","300","RC","86710","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parainfluenza 2","20402514","CDM","300","RC","86710","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parainfluenza 3","20402515","CDM","300","RC","86710","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simples I/Ii Igm Comb","20402516","CDM","300","RC","86694","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Citrulline Ab","20402517","CDM","300","RC","86200","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Soluble Liver Ag-Ab","20402520","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 86940 Isohemagglutinin Titer, S/O","20402521","CDM","302","RC","86940","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Igm Ab","20402522","CDM","300","RC","86632","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Jc Virus Dna,Pcr","20402523","CDM","300","RC","87799","HCPCS","facility","both","","","","1237","618.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bk Virus Dna Pcr,Bld","20402524","CDM","300","RC","87799","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hhv-8,Dna Pcr","20402525","CDM","300","RC","87798","HCPCS","facility","both","","","","451","225.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl S.Pneumoniae Ag-Urine","20402526","CDM","300","RC","87449","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hep C Virus,Quant","20402530","CDM","300","RC","87522","HCPCS","facility","both","","","","399","199.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Allergen Spec - Ige","20402531","CDM","300","RC","86003","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia,Ampl Probe Other Flu","20402535","CDM","300","RC","87491","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gc,Ampl Probe Other Fluid","20402536","CDM","300","RC","87591","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B. Pertussis Igg","20402539","CDM","300","RC","86615","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B. Pertussis Igm","20402540","CDM","300","RC","86615","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B. Pertussis Dna Pcr","20402541","CDM","300","RC","87798","HCPCS","facility","both","","","","355","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B. Parapertussis Dna Pcr","20402542","CDM","300","RC","87798","HCPCS","facility","both","","","","355","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Toxoplasma Pcr","20402543","CDM","300","RC","87798","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergillus Galactamannan","20402545","CDM","300","RC","87305","HCPCS","facility","both","","","","294","147","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anti Mullerian Hormone","20402557","CDM","300","RC","82397","HCPCS","facility","both","","","","343","171.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunoassay Quan Ria","20402558","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simplex Igg 1","20402571","CDM","300","RC","86695","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Simplex Igg 2","20402572","CDM","300","RC","86696","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hplc,Quantitative","20402579","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Sp.Direct Probe","20402591","CDM","300","RC","87480","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gardnerella Direct Probe","20402592","CDM","300","RC","87510","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trichomonoas Direct Probe","20402593","CDM","300","RC","87660","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 68 Kd Autoantibodies","20402595","CDM","300","RC","84181","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ebv Early Ag,Igg","20402600","CDM","300","RC","86663","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Wa1 Igg Ab","20402610","CDM","300","RC","86753","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Marker,Pnh First","20402611","CDM","300","RC","88184","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Marker,Pnh Add't","20402612","CDM","300","RC","88185","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tb Gold Gamma Interferon","20402613","CDM","300","RC","86480","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Niger Igg","20402676","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Glaucus Igg","20402677","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aspergil. Nidulans Igg","20402678","CDM","300","RC","86606","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Allergen Specific Ige(I)","20402700","CDM","300","RC","86003","HCPCS","facility","both","","","","53","26.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Toxoplasma Igg Quant","20402701","CDM","300","RC","86317","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rubella Igg Quant","20402702","CDM","300","RC","86317","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trich Ampl Probe Ua","20402705","CDM","300","RC","87661","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Donovani Igm Abs","20402710","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Donovani Igg Abs","20402711","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Tropica Igm Abs","20402712","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Tropica Igg Abs","20402713","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Braziliensis Igm Abs","20402714","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Braziliensis Igg Abs","20402715","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Mexicana Igm Abs","20402716","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leishmania Mexicana Igg Abs","20402717","CDM","300","RC","86717","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trichomonas Ampl Probe","20402780","CDM","300","RC","87661","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Antichromatin Ab's","20402960","CDM","300","RC","86235","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tp-Pa","20403000","CDM","300","RC","86780","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Salmonella O,Group V","20403201","CDM","300","RC","86768","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Polio Neutralization","20403300","CDM","300","RC","86382","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Polio Neutralization-Add'l","20403301","CDM","300","RC","86382","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dengue Fever Ab Igg","20403302","CDM","300","RC","86790","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dengue Fever Ab Igm","20403303","CDM","300","RC","86790","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anaplasma Phag Igg","20403304","CDM","300","RC","86666","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anaplasma Phar Igm","20403305","CDM","300","RC","86666","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B.Pertussis Iga","20403306","CDM","300","RC","86615","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fungitell(Beta D)","20403307","CDM","300","RC","84311","HCPCS","facility","both","","","","642","321","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Jc Virus Dna Pcr Csf","20403308","CDM","300","RC","87799","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lyme Dna Pcr Csf","20403309","CDM","300","RC","87801","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Serotonin Rel Assay-High","20403310","CDM","300","RC","86022","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Serotonin Rel Assay-Low","20403311","CDM","300","RC","86022","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hsv,Type I Pcr","20403315","CDM","300","RC","87529","HCPCS","facility","both","","","","535","267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hsv,Type Ii Pcr","20403316","CDM","300","RC","87529","HCPCS","facility","both","","","","535","267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ige Total,Allergy","20403317","CDM","300","RC","82785","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Neutro C-Anca Ab","20403318","CDM","300","RC","86037","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Neutro P-Anca Ab","20403319","CDM","300","RC","86037","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Neutro Atyp-Anca Ab","20403320","CDM","300","RC","86037","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Norovirus Eia (Norwalk)","20403321","CDM","300","RC","87449","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Enterovirus Rna,Pcr Qual","20403323","CDM","300","RC","87498","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenosense Phenotype","20403324","CDM","300","RC","87900","HCPCS","facility","both","","","","588","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenosense Genotype","20403325","CDM","300","RC","87901","HCPCS","facility","both","","","","1091","545.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenosense Na 1-10 Drugs","20403326","CDM","300","RC","87903","HCPCS","facility","both","","","","2176","1088","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenosense Na Add't Drugs","20403327","CDM","300","RC","87904","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dna Ab (Cridthidia)","20403340","CDM","300","RC","86256","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Syphilus Igg","20403341","CDM","300","RC","86780","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Albicans,Naa","20403404","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Glabrata,Naa","20403405","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Babesia Igg","20403406","CDM","300","RC","86753","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Babesia Igm","20403407","CDM","300","RC","86753","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Nmo Igg (Elisa)","20403412","CDM","300","RC","86051","HCPCS","facility","both","","","","761","380.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complement C1Q Quant","20403420","CDM","300","RC","86160","HCPCS","facility","both","","","","382","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 21 Hydroxylase Antibodies","20403421","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chamydia Pharnygeal Swab,Naa","20403450","CDM","300","RC","87491","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gc Pharyngeal Swab,Naa","20403451","CDM","300","RC","87591","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chamydia Rectal Swab,Naa","20403452","CDM","300","RC","87491","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gc Rectal Swab,Naa","20403453","CDM","300","RC","87591","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Conjunctiva Swab,Naa","20403454","CDM","300","RC","87491","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pigeon Serum","20403553","CDM","300","RC","86331","HCPCS","facility","both","","","","135","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thermoactinomyces Sacc","20403554","CDM","300","RC","86602","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trich Vaginalis Naa","20404110","CDM","300","RC","87661","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Trac Naa","20404111","CDM","300","RC","87491","HCPCS","facility","both","","","","337","168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gc Naa","20404112","CDM","300","RC","87591","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hpv 16","20404115","CDM","300","RC","87625","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Coreceptor Tropism","20404122","CDM","300","RC","87999","HCPCS","facility","both","","","","6487","3243.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Integrase","20404127","CDM","300","RC","87906","HCPCS","facility","both","","","","568","284","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hnk1(Cd57)Quant","20404129","CDM","300","RC","86356","HCPCS","facility","both","","","","420","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hnk1(Cd57)Total Count","20404130","CDM","300","RC","86357","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl N-Methyl-D-Asparate Recept Igg","20404134","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immuknow","20404143","CDM","300","RC","86352","HCPCS","facility","both","","","","596","298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Achrb Pae","20404153","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Achrgn Pae","20404154","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nvgkc Pae","20404155","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ntcc Pae","20404156","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl P/Qtcc Pae","20404157","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sm Pae","20404158","CDM","300","RC","83520","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Agn1 Pae","20404159","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amphi Pae","20404160","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ann1 Pae","20404161","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ann2 Pae","20404162","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ann3 Pae","20404163","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Crmp5I Pae","20404164","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pcc1 Pae","20404165","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pcc2 Pae","20404166","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pcct Pae","20404167","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Alpha-Gal Panel Beef Ige","20404171","CDM","300","RC","86003","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Alpha-Gal Panel Lamb Ige","20404172","CDM","300","RC","86003","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Alpha-Gal Panel Pork Ige","20404173","CDM","300","RC","86003","HCPCS","facility","both","","","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Norovirus-Pcr","20404177","CDM","300","RC","87798","HCPCS","facility","both","","","","513","256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Babesia Dna Pcr","20404200","CDM","300","RC","87469","HCPCS","facility","both","","","","852","426","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hu Antobody  Bill Only","20404201","CDM","300","RC","86255","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mag Antibody Bill Only","20404202","CDM","300","RC","84181","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ife Serum    Bill Only","20404203","CDM","300","RC","86334","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gm1 Antibody Bill Only","20404204","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Asialo Gm1 Igg Bill Only","20404205","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Asialo Gm1 Igm Bill Only","20404206","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gd1A Ab Igg    Bill Only","20404207","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gd1A Ab Igm    Bill Only","20404208","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gd1B Ab Igg    Bill Only","20404209","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gd1B Ab Igm    Bill Only","20404210","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gq1B Ab Igg    Bill Only","20404211","CDM","300","RC","83520","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Hiv-1 Qualitative Rna, Diagnostic","20404212","CDM","300","RC","87535","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl - Macroscopic Exam;Arthropod","20406873","CDM","300","RC","87168","HCPCS","facility","both","","","","121","60.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zinc Transporter 8 Autoantibodies","20406874","CDM","300","RC","86341","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Epstein Barr Virus Dna Pcr Csf","20410671","CDM","300","RC","87798","HCPCS","facility","both","","","","659","329.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Epstein Barr Virus Dna Pcr","20410672","CDM","300","RC","87799","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rubeola Igm","20410700","CDM","300","RC","86765","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Borrelia Burgdoferi Igg Antibodies Csf","20420000","CDM","300","RC","86618","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Borrelia Burgdoferi Igm Antibodies Csf?","20420001","CDM","300","RC","86618","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rpr (Sts) Titer","20430013","CDM","300","RC","86593","HCPCS","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Eb-Vca,Iga","20430016","CDM","300","RC","86665","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryptococcal Antibodies","20430021","CDM","300","RC","86641","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Allergen Spec-Igg","20430030","CDM","300","RC","86001","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Pneumoniae Igg","20430031","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Pneumoniae Iga","20430032","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Pneumoniae Igm","20430033","CDM","300","RC","86632","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Trachomatis Igg","20430034","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Trachomatis Iga","20430035","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Trachomatis Igm","20430036","CDM","300","RC","86632","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Psittaci Igg","20430037","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Psittaci Iga","20430038","CDM","300","RC","86631","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Psittaci Igm","20430039","CDM","300","RC","86632","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Albicans,Naa","20430040","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candid Glabrata,Naa","20430041","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Tropicalis,Naa","20430042","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Parapsilosis,Naa","20430043","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candia Lusitaniae,Naa","20430044","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Candida Krusei,Naa","20430045","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Iga Quant","20450025","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ibd Gasca","20450041","CDM","300","RC","86671","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ibd Infectious Agent Ab","20450042","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Ibd Panca","20450043","CDM","300","RC","86036","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Allergen Ige Components","20450056","CDM","300","RC","86008","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Allergen Spec Ige Recomb","20450057","CDM","300","RC","86008","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla B51 Disease Association","20450058","CDM","310","RC","81373","HCPCS","facility","both","","","","374","187","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anticardiolip Ab, Iga/G/M, Qn","20450101","CDM","300","RC","86147","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Toxoplasma Gondii Ab, Igm Qn","20450102","CDM","300","RC","86778","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rubella Antibodies, Igm","20450105","CDM","300","RC","86762","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytomegalovirus (Cmv) Ab, Igm","20450106","CDM","300","RC","86645","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Allergen Mixes","20450107","CDM","300","RC","86005","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quantiferon-Tb Gold Plus","20450108","CDM","300","RC","86480","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Glabrata/C Species Aptima Sw","20450109","CDM","300","RC","87481","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bacterial Vaginosis Aptima Swab","20450110","CDM","300","RC","87801","HCPCS","facility","both","","","","504","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Strep Pneumo And Legionella Pneumo Antigen Urine","20450111","CDM","306","RC","87899","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","204602","CDM","278","RC","C1713","HCPCS","facility","both","","","","1820","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","204603","CDM","278","RC","C1713","HCPCS","facility","both","","","","1820","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","204918","CDM","270","RC","","","facility","both","","","","2528.9","1264.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Wright's Stain","20500002","CDM","300","RC","87205","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Afb Culture","20500003","CDM","300","RC","87116","HCPCS","facility","both","","","","259","129.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fungus Culture","20500005","CDM","300","RC","87102","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cx Throat","20500007","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Pinworm Preparation","20500013","CDM","300","RC","87172","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Orderable Wet Prep","20500014","CDM","300","RC","87210","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anaerobic Culture","20500028","CDM","300","RC","87075","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Culture","20500032","CDM","300","RC","87255","HCPCS","facility","both","","","","350","175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 87252 Viral Culture, General, S/O","20500034","CDM","306","RC","87252","HCPCS","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 87324 Clostridium Difficile Assay","20500041","CDM","306","RC","87324","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 87449 Clostridium Difficile Assay","20500042","CDM","306","RC","87449","HCPCS","facility","both","","","","21","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rotavirus Eia","20500043","CDM","300","RC","87425","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytomegalo Viral Culture","20500044","CDM","300","RC","87254","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Legionella Dfa","20500045","CDM","300","RC","87278","HCPCS","facility","both","","","","116","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Culture","20500046","CDM","300","RC","87110","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Enterovirus Cult","20500047","CDM","300","RC","87252","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Adenovirus Cult","20500048","CDM","300","RC","87252","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Influenza Cult","20500049","CDM","300","RC","87254","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rubella Culture","20500050","CDM","300","RC","87252","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Corynebacteria Culture","20500051","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Abscess Culture","20500107","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Stool Culture","20500109","CDM","300","RC","87045","HCPCS","facility","both","","","","245","122.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cx Urine","20500110","CDM","300","RC","87086","HCPCS","facility","both","","","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Csf Cult","20500111","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blood Culture,Routine","20500118","CDM","300","RC","87040","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Eye Culture","20500512","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ear Culture","20500513","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Genital Culture","20500516","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Environmental Culture","20500517","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fecal Fat Qualitative","20500523","CDM","300","RC","82705","HCPCS","facility","both","","","","119","59.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ova And Parasites - Perm Smear","20500525","CDM","310","RC","87209","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fungal Smear","20500526","CDM","300","RC","87205","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Viral Culture Resp","20500527","CDM","300","RC","87254","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl - Group B Strep Naa","20500529","CDM","300","RC","87150","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Respiratory Culture","20500605","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B.Pertussis Culture","20500612","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl B.Pertussis If Smear","20500613","CDM","300","RC","87265","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sterile Site Culture","20500617","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tissue Culture Routine","20500618","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Umb/Placenta Culture","20500623","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gc Screen","20500624","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Foreign Body Culture","20500627","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Transfusion Reaction Cult","20500628","CDM","300","RC","87040","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blood Culture Fungus","20500629","CDM","300","RC","87103","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blood Culture,Brucella","20500630","CDM","300","RC","87040","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Body Fluid Culture","20500632","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ureoplasma Ureolyticum","20500691","CDM","300","RC","87109","HCPCS","facility","both","","","","144","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sendout For Further Testing","20500705","CDM","300","RC","99001","HCPCS","facility","both","","","","32","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fungus Identification","20500707","CDM","300","RC","87106","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Organism Id-Anaerobic","20500713","CDM","300","RC","87076","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cryptosporidium","20500747","CDM","302","RC","87328","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Legionella Culture","20500748","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytomegalo Blood Cult","20500755","CDM","300","RC","87254","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blood Culture Afb","20500756","CDM","300","RC","87116","HCPCS","facility","both","","","","259","129.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H. Pylori Culture","20500761","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mic(Minimal Inhibitor Conc.)","20500766","CDM","300","RC","87186","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Wound Culture","20500768","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bronchial Culture","20500770","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Organism Id-Nonurine","20500774","CDM","300","RC","87077","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quantitative Bronchial Culture","20500778","CDM","300","RC","87071","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Actinomyces Culture","20500779","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Breakpoint Sensitivity","20500780","CDM","300","RC","87186","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gram Stain","20500783","CDM","300","RC","87205","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl India Ink Prep","20500784","CDM","300","RC","87210","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Koh Prep","20500785","CDM","300","RC","87210","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Afb Smear","20500788","CDM","300","RC","87206","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Blood Culture,Ped","20500790","CDM","300","RC","87040","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mycoplasma Culture","20500792","CDM","300","RC","87109","HCPCS","facility","both","","","","144","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - M. Tb Pcr","20500794","CDM","300","RC","87556","HCPCS","facility","both","","","","293","146.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Herpes Dfa","20500795","CDM","300","RC","87300","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cmv Early Ag-Blood Culture","20500796","CDM","300","RC","87252","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Giardia Eia","20500797","CDM","300","RC","87329","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Resp Sync Viral (Rsv) Ag","20500802","CDM","300","RC","87807","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Microsporidium","20500803","CDM","300","RC","87207","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Afb Smear,Modified","20500804","CDM","300","RC","87206","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mrsa Screen/Culture","20500810","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta Lactamase","20500811","CDM","300","RC","87185","HCPCS","facility","both","","","","162","81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Influenzae Rapid Screen B","20500850","CDM","300","RC","87804","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hcv Rna Naa Qual","20500861","CDM","300","RC","87521","HCPCS","facility","both","","","","282","141","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl O&P-Conc","20501122","CDM","300","RC","87177","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Varicella Zoster Cult","20501133","CDM","300","RC","87254","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vibrio Screen,Bill Only","20501137","CDM","300","RC","87046","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vre Culture/Screen","20501138","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Influenzae Rapid Screen A","20501140","CDM","300","RC","87804","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Shiga-Like Toxin","20501141","CDM","300","RC","87427","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mssa Screen/Culture","20501150","CDM","300","RC","87081","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cystic Fibrosis Resp Cult","20501160","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cyclospora Smear","20501161","CDM","300","RC","87206","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Smear Concentration","20501162","CDM","300","RC","87015","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Legionella Pneumophilia Amp","20507660","CDM","300","RC","87541","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Infectious Agent, Amp","20507661","CDM","300","RC","87798","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Culture Type Immunologic","20507662","CDM","300","RC","87147","HCPCS","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Yersina Media Worksheet","20510012","CDM","300","RC","87046","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Entamoeba Histolytica Ag Eia","20510061","CDM","300","RC","87337","HCPCS","facility","both","","","","213","106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlamydia Psittaci Culture","20510063","CDM","300","RC","87110","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mrsa Surveillance","20520060","CDM","300","RC","87081","HCPCS","facility","both","","","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 87493 C.Diff Toxin Gene, Pcr","20530000","CDM","306","RC","87493","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prosthetic Culture","20530006","CDM","300","RC","87070","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Anaprost","20530008","CDM","300","RC","87075","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Meningitis/Encephalitis By Pcr","20530235","CDM","300","RC","87483","HCPCS","facility","both","","","","927","463.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Influenza A&B By Pcr","20530236","CDM","300","RC","87502","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Campylobacter Antigen","20530300","CDM","300","RC","87899","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Lab","20530301","CDM","300","RC","U0004","HCPCS","facility","both","","","","100","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid, Influ A&B, Rsv Amp Prb","20530302","CDM","300","RC","87637","HCPCS","facility","both","","","","300","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid, Influ A&B Amp Prb","20530303","CDM","300","RC","87636","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cepheid Covid, Influ A&B, Rsv","20530304","CDM","300","RC","0241U","HCPCS","facility","both","","","","300","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cepheid Covid, Influ A&B","20530305","CDM","300","RC","0240U","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl M. Tuberculosis Rifampin Resistance Pcr","20530306","CDM","300","RC","87798","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl M. Tuberculosis Pcr","20530307","CDM","300","RC","87556","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Genmark Eplex Bcid Gram-Positive, 4 Genes","20530308","CDM","300","RC","0141U","HCPCS","facility","both","","","","397","198.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Genmark Eplex Bcid Gram-Negative, 6 Genes","20530309","CDM","300","RC","0142U","HCPCS","facility","both","","","","594","297","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mold Identification","20530310","CDM","306","RC","87107","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205653","CDM","278","RC","C1713","HCPCS","facility","both","","","","1456","728","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205654","CDM","278","RC","C1713","HCPCS","facility","both","","","","2256.3","1128.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205655","CDM","278","RC","C1713","HCPCS","facility","both","","","","2445.3","1222.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205656","CDM","278","RC","C1713","HCPCS","facility","both","","","","3240.45","1620.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205673","CDM","278","RC","C2617","HCPCS","facility","both","","","","778.09","389.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205711","CDM","270","RC","","","facility","both","","","","1302.91","651.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205721","CDM","278","RC","Q4100","HCPCS","facility","both","","","","5229.87","2614.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205726","CDM","270","RC","","","facility","both","","","","97.18","48.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205727","CDM","270","RC","","","facility","both","","","","88.94","44.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205735","CDM","278","RC","C1874","HCPCS","facility","both","","","","17057.25","8528.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205758","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205801","CDM","270","RC","","","facility","both","","","","1308.43","654.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205830","CDM","270","RC","","","facility","both","","","","1642.39","821.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205835","CDM","270","RC","","","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205839","CDM","270","RC","","","facility","both","","","","1062.6","531.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205840","CDM","270","RC","","","facility","both","","","","1062.6","531.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205843","CDM","270","RC","","","facility","both","","","","574.41","287.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205844","CDM","270","RC","","","facility","both","","","","806.35","403.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205845","CDM","270","RC","","","facility","both","","","","47.31","23.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205853","CDM","270","RC","","","facility","both","","","","1547","773.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205859","CDM","278","RC","C1750","HCPCS","facility","both","","","","2185","1092.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","205862","CDM","270","RC","","","facility","both","","","","575","287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eluate","20600002","CDM","300","RC","86860","HCPCS","facility","both","","","","382","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Antiglobulin Poly","20600006","CDM","300","RC","86880","HCPCS","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antibody Screen (Iat)","20600007","CDM","300","RC","86850","HCPCS","facility","both","","","","246","123","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indirect Coombs Titer","20600008","CDM","300","RC","86886","HCPCS","facility","both","","","","271","135.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immediate Spin Crossmatch","20600057","CDM","300","RC","86920","HCPCS","facility","both","","","","426","213","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therapeutic Apheresis Plasma","20600075","CDM","940","RC","36514","HCPCS","facility","both","","","","5581","2790.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Irradiation","20600080","CDM","300","RC","86945","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Autologous Bld Processing/Storage","20600098","CDM","390","RC","86890","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ag Type Unit","20600125","CDM","300","RC","86902","HCPCS","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Screen Test","20600128","CDM","300","RC","85461","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antibody Ident Charge","20600132","CDM","300","RC","86870","HCPCS","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phenotype","20600149","CDM","300","RC","86906","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pro/Adm Fee Pool Comp","20600151","CDM","300","RC","86965","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pro/Adm Split Products","20600152","CDM","300","RC","86985","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cryoprecipitate","20600186","CDM","390","RC","P9012","HCPCS","facility","both","","","","328","164","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deglycerolized Rbc","20600187","CDM","390","RC","P9039","HCPCS","facility","both","","","","1527","763.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thawed Plasma","20600188","CDM","390","RC","P9059","HCPCS","facility","both","","","","540","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leukoreduced Rbc","20600190","CDM","390","RC","P9016","HCPCS","facility","both","","","","1389","694.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lvds Non-Irradiated Platelet Pheresis","20600194","CDM","390","RC","P9035","HCPCS","facility","both","","","","3794","1897","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prbc Autologous","20600195","CDM","390","RC","P9021","HCPCS","facility","both","","","","1389","694.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washed Rbc","20600197","CDM","390","RC","P9022","HCPCS","facility","both","","","","1092","546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Whole Blood","20600198","CDM","390","RC","P9010","HCPCS","facility","both","","","","1666","833","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abo","20600205","CDM","300","RC","86900","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rh","20600207","CDM","300","RC","86901","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"37C Crossmatch","20600210","CDM","300","RC","86921","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ahg Crossmatch","20600211","CDM","300","RC","86922","HCPCS","facility","both","","","","347","173.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Directed Donor","20600213","CDM","390","RC","P9021","HCPCS","facility","both","","","","706","353","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Abo","20600303","CDM","300","RC","86900","HCPCS","facility","both","","","","108","54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Rh","20600304","CDM","300","RC","86901","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Antibody Screen (Iat)","20600305","CDM","300","RC","86850","HCPCS","facility","both","","","","188","94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Elution","20600306","CDM","300","RC","86860","HCPCS","facility","both","","","","291","145.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Antibody Identification","20600307","CDM","300","RC","86870","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Dat Each Antisera","20600308","CDM","300","RC","86880","HCPCS","facility","both","","","","128","64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Coombs Titer","20600309","CDM","300","RC","86886","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Antigen Typing Each Pt","20600310","CDM","300","RC","86905","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Rh Phenotype","20600311","CDM","300","RC","86906","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Rbc Pretreatment","20600312","CDM","300","RC","86970","HCPCS","facility","both","","","","177","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Retic Separation","20600313","CDM","300","RC","86972","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Incubate With Drugs","20600314","CDM","300","RC","86975","HCPCS","facility","both","","","","169","84.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Serum Dilution","20600315","CDM","300","RC","86976","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Abs Of Serum","20600317","CDM","300","RC","86978","HCPCS","facility","both","","","","277","138.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Ahg Crossmatch","20600319","CDM","300","RC","86922","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Cold Agglutinin Screen","20600320","CDM","300","RC","86156","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Antiglobulin Igg","20600321","CDM","300","RC","86880","HCPCS","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Antiglobulin Complement","20600322","CDM","300","RC","86880","HCPCS","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Enzyme Pretreat","20600325","CDM","300","RC","86971","HCPCS","facility","both","","","","169","84.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rbc Antigen Typing Pt Each","20600326","CDM","300","RC","86905","HCPCS","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Washed Platelets Lr Irradiated","20600331","CDM","390","RC","P9037","HCPCS","facility","both","","","","2223","1111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Washed Platelets Leukoreduced","20600332","CDM","390","RC","P9035","HCPCS","facility","both","","","","2044","1022","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Apheresis Platelet, Bacterial Monitoring 36H,Lvds","20600336","CDM","390","RC","","","facility","both","","","","1420","710","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pathogen Test For Platelets","20600337","CDM","300","RC","P9100","HCPCS","facility","both","","","","87","43.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Auto Transf Comp Ser Set Up","20600991","CDM","360","RC","","","facility","both","","","","2248","1124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Auto Transf Collection - Stand","20600992","CDM","360","RC","","","facility","both","","","","711","355.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Auto Transf Per 15 Min","20600993","CDM","360","RC","","","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leukoreduced Rbc Irradiated","20601251","CDM","390","RC","P9040","HCPCS","facility","both","","","","1666","833","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leukoreduced Rbc Divided","20601252","CDM","390","RC","P9011","HCPCS","facility","both","","","","600","300","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lvds Irradiated Platelet Pheresis","20601258","CDM","390","RC","P9037","HCPCS","facility","both","","","","5013","2506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therapeutic Apheresis For Wbc","20601261","CDM","940","RC","36511","HCPCS","facility","both","","","","5581","2790.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therapeutic Apheresis For Rbc","20601262","CDM","940","RC","36512","HCPCS","facility","both","","","","5581","2790.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therapeutic Apheresis Platelets","20601263","CDM","940","RC","36513","HCPCS","facility","both","","","","7431","3715.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Platelet Crossmatch","20601860","CDM","300","RC","86022","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Octaplas-200 Ml","20601990","CDM","390","RC","P9023","HCPCS","facility","both","","","","540","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abo Neo","20602070","CDM","300","RC","86900","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rh Neo","20602071","CDM","300","RC","86901","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Abid Each Cell","20602080","CDM","300","RC","86885","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Ag Typing Per Unit","20602081","CDM","300","RC","86902","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Ag Screen Pt Serum","20602082","CDM","300","RC","86904","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Pretreatment Per Cell","20602083","CDM","300","RC","86970","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reference Lab Hypotonic Separation","20602085","CDM","300","RC","86972","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"A1 Antigen Type Donor","20604025","CDM","300","RC","86900","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electronic Crossmatch","20604026","CDM","300","RC","86923","HCPCS","facility","both","","","","405","202.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Apheresis Platelet Pas","20604039","CDM","390","RC","P9073","HCPCS","facility","both","","","","2008","1004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Liquid Plasma","20604078","CDM","390","RC","P9044","HCPCS","facility","both","","","","657","328.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Whole Bld Leuco Reduced Irrad","20604088","CDM","390","RC","P9056","HCPCS","facility","both","","","","1130","565","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Declot Vascular Access","20604089","CDM","940","RC","36593","HCPCS","facility","both","","","","1454","727","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206268","CDM","272","RC","C1884","HCPCS","facility","both","","","","6260.5","3130.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206276","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206277","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206279","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206280","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206282","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206283","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206286","CDM","278","RC","C1876","HCPCS","facility","both","","","","4655","2327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206339","CDM","278","RC","C1713","HCPCS","facility","both","","","","446.2","223.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206340","CDM","278","RC","C1713","HCPCS","facility","both","","","","446.2","223.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206341","CDM","278","RC","C1713","HCPCS","facility","both","","","","792.3","396.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206342","CDM","278","RC","C1713","HCPCS","facility","both","","","","446.2","223.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206367","CDM","278","RC","C1713","HCPCS","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206369","CDM","278","RC","C1713","HCPCS","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206376","CDM","278","RC","C1713","HCPCS","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206383","CDM","278","RC","C1713","HCPCS","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206385","CDM","278","RC","C1713","HCPCS","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206394","CDM","278","RC","C1713","HCPCS","facility","both","","","","404.8","202.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206413","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206414","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206420","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206431","CDM","278","RC","C1713","HCPCS","facility","both","","","","404.8","202.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206432","CDM","278","RC","C1713","HCPCS","facility","both","","","","404.8","202.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206433","CDM","278","RC","C1713","HCPCS","facility","both","","","","404.8","202.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206434","CDM","278","RC","C1713","HCPCS","facility","both","","","","404.8","202.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206435","CDM","278","RC","C1713","HCPCS","facility","both","","","","404.8","202.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206447","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206448","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206449","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206454","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206459","CDM","278","RC","C1713","HCPCS","facility","both","","","","234.6","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206461","CDM","270","RC","","","facility","both","","","","43.28","21.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206544","CDM","270","RC","","","facility","both","","","","782","391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206552","CDM","278","RC","C1713","HCPCS","facility","both","","","","4465","2232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206590","CDM","278","RC","C1713","HCPCS","facility","both","","","","119.6","59.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206591","CDM","278","RC","C1713","HCPCS","facility","both","","","","119.6","59.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206593","CDM","278","RC","C1713","HCPCS","facility","both","","","","119.6","59.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206612","CDM","278","RC","C1713","HCPCS","facility","both","","","","170.43","85.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206717","CDM","278","RC","C1776","HCPCS","facility","both","","","","5001.75","2500.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206937","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206950","CDM","278","RC","C1713","HCPCS","facility","both","","","","3800","1900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206951","CDM","278","RC","C1713","HCPCS","facility","both","","","","3800","1900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206953","CDM","278","RC","C1713","HCPCS","facility","both","","","","3800","1900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206960","CDM","278","RC","C1713","HCPCS","facility","both","","","","1461.08","730.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206971","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206974","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206975","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206976","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","206977","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207","CDM","270","RC","","","facility","both","","","","42.21","21.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Decal Procedure","20700100","CDM","312","RC","88311","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level I","20700106","CDM","310","RC","88300","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level Ii","20700107","CDM","310","RC","88302","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level Iii","20700108","CDM","310","RC","88304","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level Iv","20700109","CDM","310","RC","88305","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level V","20700110","CDM","310","RC","88307","HCPCS","facility","both","","","","726","363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level Vi","20700111","CDM","310","RC","88309","HCPCS","facility","both","","","","1095","547.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Spec Stain Group I","20700113","CDM","310","RC","88312","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Spec Stain Group Ii","20700114","CDM","310","RC","88313","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Frozen Add'l","20700117","CDM","310","RC","88332","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Biopsy-Quan-Iron-Mayo","20700123","CDM","300","RC","83540","HCPCS","facility","both","","","","524","262","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Consult During Surgery","20700125","CDM","310","RC","88329","HCPCS","facility","both","","","","169","84.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Electron Micro-Diag","20700129","CDM","310","RC","88348","HCPCS","facility","both","","","","1293","646.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Slide Prepar/Block","20700135","CDM","310","RC","88323","HCPCS","facility","both","","","","314","157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histochem - Enzyme","20700140","CDM","310","RC","88319","HCPCS","facility","both","","","","789","394.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Consult Refer-Slide Prep","20700141","CDM","310","RC","88323","HCPCS","facility","both","","","","314","157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl In Situ Hybrid,Interp And Rpt","20700148","CDM","310","RC","88365","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bone Marrow Asp Clot","20700150","CDM","310","RC","88305","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bone Marrow Bx Interpret","20700156","CDM","310","RC","88305","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Receptor Assay: Estrogen","20700161","CDM","310","RC","88360","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Receptor Assay: Progesterone","20700162","CDM","310","RC","88360","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Or Consult W/Rapid Micro (1/2)","20700178","CDM","310","RC","88331","HCPCS","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Touch Prep","20700184","CDM","310","RC","88160","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Special Stain Group Ii (9 Or M","20700185","CDM","310","RC","88313","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunohistochem - Sp","20700187","CDM","300","RC","88342","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunohistochem - Additional","20700189","CDM","300","RC","88341","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Morphometric Analysis:Ihc","20700190","CDM","300","RC","88361","HCPCS","facility","both","","","","421","210.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Biopsy Quan Copper Tissue","20700196","CDM","300","RC","82525","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Touch Prep","20700200","CDM","300","RC","88333","HCPCS","facility","both","","","","789","394.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fish Hem Manual (Sp)","20700243","CDM","300","RC","88368","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup Microdissection","20700248","CDM","300","RC","88381","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Braf Mutation Thyroid","20700261","CDM","310","RC","81210","HCPCS","facility","both","","","","1350","675","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  Ihc Multiplex Stain","20700275","CDM","300","RC","88344","HCPCS","facility","both","","","","330","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prostate Biopsies>4","20700590","CDM","310","RC","G0416","HCPCS","facility","both","","","","1111","555.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest Mollecular Thyroid Panel","20701101","CDM","310","RC","81479","HCPCS","facility","both","","","","5867","2933.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207016","CDM","270","RC","","","facility","both","","","","3515","1757.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207018","CDM","270","RC","","","facility","both","","","","385.71","192.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ihc Count","20701800","CDM","300","RC","88342","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207019","CDM","270","RC","","","facility","both","","","","204.93","102.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Mgmt Methylation By Pcr","20701960","CDM","310","RC","81287","HCPCS","facility","both","","","","600","300","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207020","CDM","270","RC","","","facility","both","","","","205.72","102.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Touch Prep-Additional","20702001","CDM","300","RC","88334","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path Level 2 - Tech Only","20702075","CDM","310","RC","88302","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Surg Path  Level 3 - Tech Only","20702076","CDM","310","RC","88304","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Morphometric Analysis:Manual,E","20702336","CDM","310","RC","88360","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207049","CDM","270","RC","","","facility","both","","","","58.7","29.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lifenet Heart","20705005","CDM","300","RC","88399","HCPCS","facility","both","","","","572","286","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  1P/19Q Deletion","20706861","CDM","300","RC","88367","HCPCS","facility","both","","","","742","371","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amyloid Protein","20706863","CDM","300","RC","83789","HCPCS","facility","both","","","","546","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ab Stain Addt'l (Ihc)","20706865","CDM","310","RC","88350","HCPCS","facility","both","","","","245","122.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lifenet Vascular","20707000","CDM","300","RC","88399","HCPCS","facility","both","","","","319","159.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunohistochem-Sp-Mc","20708000","CDM","300","RC","88342","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  Immunohistochem-Add't-Mc","20708001","CDM","300","RC","88341","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Insitu Ea Add Probe, Per Spec","20709650","CDM","300","RC","88364","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Knight-Myd88","20709651","CDM","310","RC","81305","HCPCS","facility","both","","","","513","256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Myd88 L265 Mutation, Pcr","20709660","CDM","310","RC","81305","HCPCS","facility","both","","","","704","352","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mlh1 Promoter Methylation, Paraffin","20709661","CDM","310","RC","81288","HCPCS","facility","both","","","","681","340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mlh1 Promoter Methylation, Paraffin","20709662","CDM","310","RC","88381","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Biother-Cancer Type Id","20709663","CDM","310","RC","81540","HCPCS","facility","both","","","","7856","3928","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Huntington Disease","20709665","CDM","310","RC","81271","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Qu) Alpha-1-Antitrypsin (Aat) Mutation Analysis, S/O","20709667","CDM","310","RC","81332","HCPCS","facility","both","","","","102","51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Tymp Dna Sequencing","20709668","CDM","310","RC","81405","HCPCS","facility","both","","","","1520","760","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Pai-1 4G/5G Polymorphism","20709669","CDM","310","RC","81400","HCPCS","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Ugt1A1 Genotyping","20709670","CDM","310","RC","81350","HCPCS","facility","both","","","","634","317","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quest-Lhon Mtdna Evaluation","20709671","CDM","310","RC","81479","HCPCS","facility","both","","","","2302","1151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Canavan Disease Mutation","20709673","CDM","310","RC","81200","HCPCS","facility","both","","","","285","142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Idh1 Mutation Exon 4","20709674","CDM","310","RC","81479","HCPCS","facility","both","","","","614","307","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Jak2 Exons 12-15","20709676","CDM","310","RC","81279","HCPCS","facility","both","","","","366","183","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Calr & Mpl Mutation Analysi","20709681","CDM","310","RC","81479","HCPCS","facility","both","","","","1822","911","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Periodic Fever Syndromes","20709686","CDM","310","RC","81479","HCPCS","facility","both","","","","4935","2467.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Gastrointestinal Prof Stool","20709688","CDM","300","RC","87507","HCPCS","facility","both","","","","700","350","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla-A29 Uvetis Birshot Chor","20709695","CDM","310","RC","81381","HCPCS","facility","both","","","","634","317","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mayo-Hemophilia A F8 Gene","20709698","CDM","310","RC","81403","HCPCS","facility","both","","","","1267","633.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Legionella Pneumophila Igg","20709699","CDM","300","RC","86713","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Complement C4A Level","20709700","CDM","300","RC","86160","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Mitotane, S/O","20709701","CDM","300","RC","G0480","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Prostaglandin D2 Urine","20709702","CDM","300","RC","84150","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Haemophilus Influenza B Igg","20709703","CDM","300","RC","86684","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Legionella Pneumophila Igm","20709704","CDM","300","RC","86713","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Calr+Jak2 12-15+Mpl Mutatio","20709705","CDM","310","RC","81479","HCPCS","facility","both","","","","1280","640","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Tp53 Mutation Analysis","20709708","CDM","310","RC","81352","HCPCS","facility","both","","","","1646","823","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla Drb1 Intermediate Resol","20709709","CDM","310","RC","81376","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hla A,B,C,Dr1,3,4,5 Dq","20709710","CDM","310","RC","81370","HCPCS","facility","both","","","","1932","966","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) 81420 Maternit21 Plus, S/O","20709711","CDM","310","RC","81420","HCPCS","facility","both","","","","810","405","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Afb Ident By Dna Probe","20709712","CDM","300","RC","87149","HCPCS","facility","both","","","","135","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Afb Ident Gene Sequence","20709713","CDM","300","RC","87153","HCPCS","facility","both","","","","340","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Tgfbr1 Fgs","20709714","CDM","310","RC","81405","HCPCS","facility","both","","","","1038","519","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Potassium Fluid, S/O","20709715","CDM","301","RC","84999","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Apoe Alzheimer's Risk","20709719","CDM","310","RC","81401","HCPCS","facility","both","","","","591","295.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-B-Cell Rearrangment Profile","20709720","CDM","310","RC","81479","HCPCS","facility","both","","","","685","342.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Tcrb & Tcrg Gene Profile","20709722","CDM","310","RC","81479","HCPCS","facility","both","","","","765","382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bcw-Serotonin Release Assay","20709724","CDM","300","RC","86022","HCPCS","facility","both","","","","678","339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trans Growth Factor Beta 1","20709725","CDM","300","RC","83520","HCPCS","facility","both","","","","148","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lysosomal Acid Lipase","20709726","CDM","300","RC","82657","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Clobazam, Serum Or Plasma, S/O","20709784","CDM","300","RC","G0480","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sngh Surg Path Misc Sendout","20709788","CDM","310","RC","88399","HCPCS","facility","both","","","","89.22","44.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207170","CDM","272","RC","C1725","HCPCS","facility","both","","","","1471.6","735.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207196","CDM","270","RC","C1769","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207198","CDM","270","RC","","","facility","both","","","","312.8","156.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207287","CDM","270","RC","","","facility","both","","","","1364.48","682.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207290","CDM","270","RC","C1713","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207291","CDM","270","RC","C1713","HCPCS","facility","both","","","","1012","506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207296","CDM","270","RC","","","facility","both","","","","187.58","93.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207460","CDM","270","RC","","","facility","both","","","","1911","955.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207501","CDM","270","RC","C1713","HCPCS","facility","both","","","","1959.6","979.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207514","CDM","272","RC","C1821","HCPCS","facility","both","","","","9025","4512.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207516","CDM","272","RC","C1821","HCPCS","facility","both","","","","9025","4512.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207526","CDM","270","RC","","","facility","both","","","","84.33","42.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207657","CDM","270","RC","","","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207659","CDM","270","RC","","","facility","both","","","","2117.52","1058.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207693","CDM","270","RC","","","facility","both","","","","499.43","249.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207695","CDM","270","RC","","","facility","both","","","","138.54","69.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207811","CDM","270","RC","","","facility","both","","","","239.46","119.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20785","CDM","270","RC","","","facility","both","","","","32.2","16.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207860","CDM","270","RC","","","facility","both","","","","204.93","102.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207865","CDM","270","RC","","","facility","both","","","","6840","3420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","207915","CDM","278","RC","C1776","HCPCS","facility","both","","","","2208","1104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Serum Protein Electrophoresis","20800001","CDM","300","RC","84165","HCPCS","facility","both","","","","341","170.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Haptoglobin","20800006","CDM","300","RC","83010","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Complement Ag, Each","20800007","CDM","300","RC","86160","HCPCS","facility","both","","","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T3 Uptake","20800009","CDM","300","RC","84479","HCPCS","facility","both","","","","299","149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyroxine","20800010","CDM","300","RC","84436","HCPCS","facility","both","","","","256","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hemoglobin Electrophoresis","20800012","CDM","300","RC","83020","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ldh Isoenzymes","20800014","CDM","300","RC","83625","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hgh Growth Hormone (Somat), Ria","20800019","CDM","300","RC","83003","HCPCS","facility","both","","","","359","179.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cortisol Total","20800020","CDM","300","RC","82533","HCPCS","facility","both","","","","296","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Renin Peripheral","20800021","CDM","300","RC","84244","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 17 Oh Corticosteroids","20800024","CDM","300","RC","83491","HCPCS","facility","both","","","","361","180.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 17 Ketosteroids","20800025","CDM","300","RC","83586","HCPCS","facility","both","","","","146","73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vma 24 Hr Urine","20800026","CDM","300","RC","84585","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aldosterone Serum","20800029","CDM","300","RC","82088","HCPCS","facility","both","","","","465","232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 5-Hiaa Urine","20800030","CDM","300","RC","83497","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Myoglobin Urine Quan","20800031","CDM","300","RC","83874","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Heavy Metal Screen","20800035","CDM","300","RC","83015","HCPCS","facility","both","","","","233","116.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein Elec Urine","20800036","CDM","300","RC","84166","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lead Urine","20800039","CDM","300","RC","83655","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lh","20800055","CDM","300","RC","83002","HCPCS","facility","both","","","","316","158","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Testosterone ,Total","20800056","CDM","300","RC","84403","HCPCS","facility","both","","","","256","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aminolevulinic Acid","20800059","CDM","300","RC","82135","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phospholipids","20800061","CDM","300","RC","84311","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Csf","20800065","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Iga","20800066","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg","20800067","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igm","20800068","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igd","20800069","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hemoglobin A2 Col","20800073","CDM","300","RC","83021","HCPCS","facility","both","","","","254","127","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acid Mucopolysacc","20800079","CDM","300","RC","83864","HCPCS","facility","both","","","","292","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Am Acid Quan Plasma","20800082","CDM","300","RC","82139","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lead Blood","20800084","CDM","300","RC","83655","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glutethimide","20800086","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Propoxyphene Quant","20800088","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenytoin","20800089","CDM","300","RC","80185","HCPCS","facility","both","","","","313","156.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Diazepam","20800090","CDM","300","RC","G0480","HCPCS","facility","both","","","","375","187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlordiazepoxide","20800091","CDM","300","RC","G0480","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenothiazine Screen","20800094","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Methadone Quantitative","20800097","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arsenic Blood","20800098","CDM","300","RC","82175","HCPCS","facility","both","","","","226","113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Copper Serum","20800100","CDM","300","RC","82525","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fsh","20800114","CDM","300","RC","83001","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estrogen,Total Urine","20800116","CDM","300","RC","82672","HCPCS","facility","both","","","","343","171.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Insulin, Total","20800117","CDM","300","RC","83525","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Digoxin","20800119","CDM","300","RC","80162","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Digitoxin","20800120","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Free T4","20800130","CDM","300","RC","84439","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Hep B Surface Antigen","20800131","CDM","300","RC","87340","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Antimony","20800132","CDM","300","RC","83018","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cea","20800138","CDM","300","RC","82378","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histamine","20800140","CDM","300","RC","83088","HCPCS","facility","both","","","","119","59.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cortisol Urine Free","20800143","CDM","300","RC","82533","HCPCS","facility","both","","","","296","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ck Isoenzymes","20800151","CDM","300","RC","82552","HCPCS","facility","both","","","","361","180.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta Hcg Serum","20800154","CDM","300","RC","84702","HCPCS","facility","both","","","","403","201.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cholinesterase, Rbc","20800156","CDM","300","RC","82482","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alcohol Methyl Glc","20800157","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenobarbital","20800159","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein Elec Csf","20800161","CDM","300","RC","84166","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Theophylline","20800163","CDM","300","RC","80198","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Procainamide, S/O","20800164","CDM","300","RC","80192","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T3 Total","20800165","CDM","300","RC","84480","HCPCS","facility","both","","","","374","187","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gentamycin","20800166","CDM","300","RC","80170","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tobramycin","20800167","CDM","300","RC","80200","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gastrin Serum","20800168","CDM","300","RC","82941","HCPCS","facility","both","","","","443","221.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quinidine","20800169","CDM","300","RC","80194","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ethosuximide","20800170","CDM","300","RC","80168","HCPCS","facility","both","","","","407","203.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha Fetoprotein","20800171","CDM","300","RC","82105","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ascorbic Acid Serum","20800172","CDM","300","RC","82180","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ceruloplasmin","20800174","CDM","300","RC","82390","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chlorpromazine","20800175","CDM","300","RC","80299","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acth","20800177","CDM","300","RC","82024","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Primidone, S/O","20800178","CDM","300","RC","80188","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nucleotidase","20800179","CDM","300","RC","83915","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Morphine","20800183","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prolactin","20800185","CDM","300","RC","84146","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Progesterone","20800186","CDM","300","RC","84144","HCPCS","facility","both","","","","362","181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Muramidase Serum","20800188","CDM","300","RC","85549","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amikacin","20800191","CDM","300","RC","80150","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Manganese Plasma","20800198","CDM","300","RC","83785","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oxalate","20800199","CDM","300","RC","83945","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zinc Blood","20800200","CDM","300","RC","84630","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Ferritin","20800207","CDM","300","RC","82728","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C4 Complement","20800210","CDM","300","RC","86160","HCPCS","facility","both","","","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amylase Serum","20800214","CDM","300","RC","82150","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein, Total","20800216","CDM","300","RC","84155","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Albumin","20800217","CDM","300","RC","82040","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Globulin Serum","20800218","CDM","300","RC","84155","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cholesterol","20800219","CDM","300","RC","82465","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine Serum","20800221","CDM","300","RC","82565","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Uric Acid Serum","20800222","CDM","300","RC","84550","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bilirubin Total","20800223","CDM","300","RC","82247","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcium","20800225","CDM","300","RC","82310","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphorous","20800226","CDM","300","RC","84100","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cpk","20800227","CDM","300","RC","82550","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ldh","20800228","CDM","300","RC","83615","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ast (Sgot)","20800229","CDM","300","RC","84450","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alt (Sgpt)","20800230","CDM","300","RC","84460","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alkaline Phosphatase","20800232","CDM","300","RC","84075","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Iron","20800233","CDM","300","RC","83540","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bromide Serum","20800235","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloride","20800238","CDM","300","RC","82435","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C02","20800239","CDM","300","RC","82374","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium","20800240","CDM","300","RC","84132","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium","20800241","CDM","300","RC","84295","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bun","20800242","CDM","300","RC","84520","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium Urine","20800249","CDM","300","RC","84300","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium Urine","20800250","CDM","300","RC","84133","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloride Urine","20800251","CDM","300","RC","82436","HCPCS","facility","both","","","","66","33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urea Nitrogen, Urine","20800252","CDM","300","RC","84540","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucose Urine Quan","20800253","CDM","300","RC","82945","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcium Urine","20800254","CDM","300","RC","82340","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Uric Acid Urine","20800256","CDM","300","RC","84560","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine Urine","20800257","CDM","300","RC","82570","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amylase Urine","20800258","CDM","300","RC","82150","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Porphobilinogen Quantitative","20800260","CDM","300","RC","84110","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Porphyrins Quantitative","20800261","CDM","300","RC","84120","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein,Total Urine","20800262","CDM","300","RC","84156","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acetone Serum","20800264","CDM","300","RC","82009","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pyruvic Acid","20800265","CDM","300","RC","84210","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hdl Cholesterol","20800266","CDM","300","RC","83718","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aldolase","20800268","CDM","300","RC","82085","HCPCS","facility","both","","","","287","143.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cholinesterase,Serum","20800271","CDM","300","RC","82480","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lithium","20800281","CDM","300","RC","80178","HCPCS","facility","both","","","","234","117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sulfa Serum Level","20800282","CDM","300","RC","84311","HCPCS","facility","both","","","","757","378.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Magnesium Serum","20800285","CDM","300","RC","83735","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hemoglobin Free","20800300","CDM","300","RC","83051","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Triglyceride Serum","20800301","CDM","300","RC","84478","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ggt Serum","20800302","CDM","300","RC","82977","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose,Quan.Blood","20800328","CDM","300","RC","82947","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bilirubin Direct","20800329","CDM","300","RC","82248","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nortriptyline","20800341","CDM","300","RC","G0480","HCPCS","facility","both","","","","198","99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amitriptyline Serum","20800342","CDM","300","RC","G0480","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Desipramine","20800347","CDM","300","RC","G0480","HCPCS","facility","both","","","","235","117.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Imipramine","20800348","CDM","300","RC","G0480","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Doxepin","20800351","CDM","300","RC","G0480","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protriptyline","20800352","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alcohol Isopropyl Gc","20800453","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Valproic Acid","20800456","CDM","300","RC","80164","HCPCS","facility","both","","","","374","187","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Carbamazepine;Tot","20800462","CDM","300","RC","80156","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Myelin Basic Protein","20800472","CDM","300","RC","83873","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oligoclonal Bands","20800473","CDM","300","RC","83916","HCPCS","facility","both","","","","377","188.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amoxapine","20800474","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Lidocaine","20800475","CDM","300","RC","80176","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Disopyramide","20800476","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anti Diuretic Hormone","20800478","CDM","300","RC","84588","HCPCS","facility","both","","","","422","211","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Catecholamines:Fractionated","20800486","CDM","300","RC","82384","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Homovanillic Acid","20800490","CDM","300","RC","83150","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Orosomucoid","20800496","CDM","300","RC","83864","HCPCS","facility","both","","","","292","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatine Urine","20800497","CDM","300","RC","82540","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cyanide Blood","20800498","CDM","300","RC","82600","HCPCS","facility","both","","","","360","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cyclic Amp Plasma","20800499","CDM","300","RC","82030","HCPCS","facility","both","","","","379","189.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis B Surface Ab","20800500","CDM","300","RC","86706","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hepatitis B Core Ab","20800501","CDM","300","RC","86704","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis A Ab Igm","20800502","CDM","300","RC","86709","HCPCS","facility","both","","","","114","57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis Be Antibody","20800505","CDM","300","RC","86707","HCPCS","facility","both","","","","116","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cyclic Amp Urine","20800506","CDM","300","RC","82030","HCPCS","facility","both","","","","379","189.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cystine Urine Qnt","20800507","CDM","300","RC","82131","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dhea Sulf Serum","20800509","CDM","300","RC","82627","HCPCS","facility","both","","","","313","156.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dyphylline","20800510","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Erythropoietin","20800511","CDM","300","RC","82668","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estradiol","20800512","CDM","300","RC","82670","HCPCS","facility","both","","","","351","175.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fatty Acids","20800513","CDM","300","RC","82725","HCPCS","facility","both","","","","330","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fecal Fats Quant","20800514","CDM","300","RC","82710","HCPCS","facility","both","","","","234","117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Folic Acid Rbc","20800515","CDM","300","RC","82747","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fsh Urine","20800516","CDM","300","RC","83001","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Galactose-1-Phos Uridyl","20800517","CDM","300","RC","82775","HCPCS","facility","both","","","","309","154.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gallstone Infrared","20800518","CDM","300","RC","82365","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 17 Oh Progesterone","20800523","CDM","300","RC","83498","HCPCS","facility","both","","","","489","244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Propranolol Serum","20800525","CDM","300","RC","80299","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mercury","20800528","CDM","300","RC","83825","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Somatomedin C","20800532","CDM","300","RC","84305","HCPCS","facility","both","","","","267","133.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vip","20800536","CDM","300","RC","84586","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl-Lc-Nms-5 Fluorocytosine","20800537","CDM","300","RC","G0480","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arsenic Quantitative","20800541","CDM","300","RC","82175","HCPCS","facility","both","","","","226","113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bile Acids:Total","20800543","CDM","300","RC","82239","HCPCS","facility","both","","","","216","108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Methsuximide","20800547","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Citric Acid Serum","20800549","CDM","300","RC","82507","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Clonazepam","20800550","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C Peptide Reactivity","20800552","CDM","300","RC","84681","HCPCS","facility","both","","","","259","129.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pepsinogen","20800554","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pyruvate Kinase Rbc","20800556","CDM","300","RC","84220","HCPCS","facility","both","","","","299","149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T3 Free","20800558","CDM","300","RC","84481","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Transferrin","20800560","CDM","300","RC","84466","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thiamine, Whole Blood","20800564","CDM","300","RC","84425","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin B2","20800565","CDM","300","RC","84252","HCPCS","facility","both","","","","256","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin B6","20800566","CDM","300","RC","84207","HCPCS","facility","both","","","","352","176","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vit B12 Unsat Bind","20800567","CDM","300","RC","82608","HCPCS","facility","both","","","","351","175.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin D 25 Oh","20800569","CDM","300","RC","82306","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Temazepam","20800572","CDM","300","RC","G0480","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Copper Urine","20800582","CDM","300","RC","82525","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amylase Isoenzymes","20800605","CDM","300","RC","82150","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Albumin Fluid","20800606","CDM","300","RC","82042","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aldosterone Urine","20800608","CDM","300","RC","82088","HCPCS","facility","both","","","","465","232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amylase Fluid","20800609","CDM","300","RC","82150","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis Be Antigen","20800610","CDM","300","RC","87350","HCPCS","facility","both","","","","300","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amobarbital","20800611","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arsenic Urine","20800612","CDM","300","RC","82175","HCPCS","facility","both","","","","226","113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Am Acid Quan Urine","20800615","CDM","300","RC","82139","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Butalbital","20800624","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Butabarbital","20800625","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Benzene Urine","20800626","CDM","300","RC","84600","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Berylium Urine","20800627","CDM","300","RC","83018","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cadmium Urine","20800637","CDM","300","RC","82300","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chkd-Caffeine","20800638","CDM","300","RC","80155","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloral Hydrate Serum","20800640","CDM","300","RC","82441","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloride Fluid","20800641","CDM","300","RC","82438","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Creatine Serum","20800642","CDM","300","RC","82540","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 11 Deoxycortisol","20800644","CDM","300","RC","82634","HCPCS","facility","both","","","","448","224","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Diphenhydramine","20800646","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl D Xylose Blood","20800648","CDM","300","RC","84620","HCPCS","facility","both","","","","268","134","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl D Xylose Urine","20800649","CDM","300","RC","84620","HCPCS","facility","both","","","","268","134","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estriol Urine","20800650","CDM","300","RC","82677","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ethylene Glycol","20800660","CDM","300","RC","82693","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ethchlorvynol","20800661","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flurazepam Qnt","20800662","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hexachlorobenzene","20800667","CDM","300","RC","82441","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hexosaminadase Ab","20800669","CDM","300","RC","83080","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Isoniazid","20800673","CDM","300","RC","80299","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 17 Ketosteroid Frac,24 Hr","20800679","CDM","300","RC","83593","HCPCS","facility","both","","","","383","191.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lactose Tolerance","20800682","CDM","300","RC","82951","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ldh Fluid","20800687","CDM","300","RC","83615","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Maprotiline","20800689","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Meperidine Serum","20800690","CDM","300","RC","G0480","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mephobarbital","20800691","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Meprobamate","20800692","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mephenytoin","20800693","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Magnesium Urine","20800696","CDM","300","RC","83735","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Myoglobin Serum","20800699","CDM","300","RC","83874","HCPCS","facility","both","","","","332","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium Fluid","20800704","CDM","300","RC","84132","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenol Quan","20800710","CDM","300","RC","84600","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pentobarbital","20800714","CDM","300","RC","G0480","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Secobarbital","20800723","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium Fluid","20800732","CDM","300","RC","84302","HCPCS","facility","both","","","","66","33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thiocyanate","20800733","CDM","300","RC","84430","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thioridazine","20800734","CDM","300","RC","G0480","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thallium Urine","20800741","CDM","300","RC","83018","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trazadone","20800742","CDM","300","RC","80299","HCPCS","facility","both","","","","132","66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urea Clearance","20800745","CDM","300","RC","84545","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vancomycin","20800751","CDM","300","RC","80202","HCPCS","facility","both","","","","302","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Warfarin Serum","20800752","CDM","300","RC","80299","HCPCS","facility","both","","","","342","171","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zinc Urine","20800754","CDM","300","RC","84630","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bun (Urea Nitrogen) - Post Dia","20800755","CDM","300","RC","84520","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aprobarbital","20800801","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloramphenicol","20800802","CDM","300","RC","82415","HCPCS","facility","both","","","","192","96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Citric Acid Urine","20800807","CDM","300","RC","82507","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Methamphetamine","20800825","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alcohol Glc","20800841","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha Fetoprotein Fluid","20800842","CDM","300","RC","82106","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phencyclidine Quant","20800844","CDM","300","RC","G0480","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acetone Glc","20800849","CDM","300","RC","82010","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Albumin Csf","20800862","CDM","300","RC","82042","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alcohol Ethyl","20800863","CDM","300","RC","82077","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amphet Quan Urine","20800865","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Androsterone Serum","20800866","CDM","300","RC","82160","HCPCS","facility","both","","","","771","385.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Barbituate Quan","20800868","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Benzodiaz Quan Serum","20800870","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Electrolytes Panel","20800873","CDM","300","RC","80051","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Codeine","20800875","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine Clearance","20800876","CDM","300","RC","82575","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ife Serum","20800884","CDM","300","RC","86334","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ife Urine","20800885","CDM","302","RC","86335","HCPCS","facility","both","","","","301","150.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenacetin","20800892","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphorus Urine","20800898","CDM","300","RC","84105","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Catechol Frac Urine","20800909","CDM","300","RC","82384","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cea Fluid","20800911","CDM","300","RC","82378","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pcb","20800917","CDM","300","RC","82441","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nitrogen Urine","20800918","CDM","300","RC","84540","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Streptomycin","20800920","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Basic Metabolic Panel","20800938","CDM","300","RC","80048","HCPCS","facility","both","","","","400","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zinc Protoporphyrin","20800944","CDM","300","RC","84202","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thiopental","20800954","CDM","300","RC","G0480","HCPCS","facility","both","","","","128","64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Aluminum Serum","20800962","CDM","300","RC","82108","HCPCS","facility","both","","","","313","156.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dhea Serum","20800963","CDM","300","RC","82626","HCPCS","facility","both","","","","422","211","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin B12","20800964","CDM","300","RC","82607","HCPCS","facility","both","","","","387","193.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prostatic Acid Phos","20800965","CDM","300","RC","84066","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Folic Acid Serum","20800966","CDM","300","RC","82746","HCPCS","facility","both","","","","359","179.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Carotene","20800967","CDM","300","RC","82380","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leucine Amino Pep","20800968","CDM","300","RC","83670","HCPCS","facility","both","","","","502","251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin A","20800970","CDM","300","RC","84590","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alkaline Phos Isoenzymes","20800972","CDM","300","RC","84080","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Androstenedione Serum","20800975","CDM","300","RC","82157","HCPCS","facility","both","","","","362","181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcitonin","20800977","CDM","300","RC","82308","HCPCS","facility","both","","","","465","232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chga-Hemoglobin A1C","20800978","CDM","300","RC","83036","HCPCS","facility","both","","","","219","109.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chkd-Methotrexate Level","20800979","CDM","300","RC","80204","HCPCS","facility","both","","","","525","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Paraldehyde","20800980","CDM","300","RC","80299","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Angiotensin Conv Enzyme","20800986","CDM","300","RC","82164","HCPCS","facility","both","","","","309","154.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cocaine Screen","20800989","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyrobinding Globulin","20800995","CDM","300","RC","84442","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prealbumin","20800998","CDM","300","RC","84134","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Manganese Whole Blood","20801004","CDM","300","RC","83785","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Crp","20801007","CDM","300","RC","86140","HCPCS","facility","both","","","","248","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Beta-2-Microglobulin","20801013","CDM","300","RC","82232","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alcohol Urine","20801014","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ca-125 Tumor Ag","20801033","CDM","300","RC","86304","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucola 1 Hour","20801036","CDM","300","RC","82950","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cannabinoids Screen","20801038","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis A Virus Ab Total","20801047","CDM","300","RC","86708","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gastric Acid,Free & Total","20801050","CDM","300","RC","82930","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oligo Bands-Ms Profile","20801054","CDM","300","RC","83916","HCPCS","facility","both","","","","295","147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tumor Necrosis Factor","20801060","CDM","300","RC","83520","HCPCS","facility","both","","","","1004","502","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine Random Cf","20801061","CDM","300","RC","82570","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Catecholamines Random","20801062","CDM","300","RC","82384","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Human Epididymis Prot","20801063","CDM","300","RC","86305","HCPCS","facility","both","","","","705","352.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ghrelin,Total","20801064","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Adalimumab Conc","20801065","CDM","300","RC","80145","HCPCS","facility","both","","","","419","209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Anti-Adalimumab","20801066","CDM","300","RC","82397","HCPCS","facility","both","","","","482","241","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium,Fecal","20801083","CDM","300","RC","84999","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pain Management Drug 13","20801084","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Class B Drug Elisa/Non-Tlc","20801085","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Renal Function Panel","20801110","CDM","300","RC","80069","HCPCS","facility","both","","","","464","232","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Comprehensive Metabolic Panel","20801120","CDM","300","RC","80053","HCPCS","facility","both","","","","493","246.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatic Function Panel","20801121","CDM","300","RC","80076","HCPCS","facility","both","","","","310","155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pth Intraoperative Baseline","20801130","CDM","300","RC","83970","HCPCS","facility","both","","","","507","253.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pth Intraoperative Additional","20801131","CDM","300","RC","83970","HCPCS","facility","both","","","","507","253.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Infliximab Conc","20801160","CDM","300","RC","80230","HCPCS","facility","both","","","","397","198.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Infliximab Ab","20801161","CDM","300","RC","82397","HCPCS","facility","both","","","","457","228.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv1/O/2-4Th Gen","20801162","CDM","300","RC","G0475","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-1 Ab Diff","20801163","CDM","300","RC","86701","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv-2 Ab Diff","20801164","CDM","300","RC","86702","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Propoxyphene Confirmation,Ur","20801261","CDM","300","RC","G0480","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen 11","20801300","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chkd-Cmv Pcr Congenital","20801350","CDM","306","RC","87496","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estrone,Serum","20801371","CDM","300","RC","82679","HCPCS","facility","both","","","","522","261","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Basic Drug Screen-2","20801438","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen Urine, Complete-11","20801439","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Barbiturate Screen","20801441","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Benzo Screen","20801442","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Methadone Screen","20801443","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Propoxyphene Screen","20801445","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cannabinoids Quant","20801446","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cocaine Quant","20801447","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Opiate Screen","20801448","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Amphetamine Screen","20801449","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prostatic Spec Ag","20801450","CDM","300","RC","84153","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Apolipoprotein A1","20801452","CDM","300","RC","82172","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Apolipoprotein B100","20801453","CDM","300","RC","82172","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha-1-Antitrypsin","20801454","CDM","300","RC","82103","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ibuprofen","20801455","CDM","300","RC","80299","HCPCS","facility","both","","","","342","171","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis B Core Igm Antibody","20801456","CDM","300","RC","86705","HCPCS","facility","both","","","","213","106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tocainide","20801457","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ca 15 3","20801458","CDM","300","RC","86300","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Buspar (Buspiron)","20801459","CDM","300","RC","80299","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc- Flecainide","20801460","CDM","300","RC","80181","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Complement Total Ch50","20801461","CDM","300","RC","86162","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cyclosporine Mono","20801462","CDM","300","RC","80158","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Amiodarone","20801467","CDM","300","RC","80151","HCPCS","facility","both","","","","312","156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ca 19-9 Tumor Ag","20801468","CDM","300","RC","86301","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lasa-P Tumor Ag","20801469","CDM","300","RC","84275","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin D 1,25 Dioh","20801471","CDM","300","RC","82652","HCPCS","facility","both","","","","443","221.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Renin Ivc","20801472","CDM","300","RC","84244","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Renin Rr","20801473","CDM","300","RC","84244","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Renin Lr","20801474","CDM","300","RC","84244","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine Fluid","20801475","CDM","300","RC","82570","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis C Ab","20801476","CDM","300","RC","86803","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ck Mb","20801484","CDM","300","RC","82553","HCPCS","facility","both","","","","540","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen U-5","20801485","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Parathormone Intact","20801488","CDM","300","RC","83970","HCPCS","facility","both","","","","507","253.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Testosterone Free","20801489","CDM","300","RC","84402","HCPCS","facility","both","","","","533","266.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thy Stim Glob (Tsi)","20801491","CDM","300","RC","84445","HCPCS","facility","both","","","","660","330","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fluoxetine","20801492","CDM","300","RC","80299","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Dihydrotestosterone","20801493","CDM","300","RC","82642","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Osteocalcin","20801494","CDM","300","RC","83937","HCPCS","facility","both","","","","531","265.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bhcg Triple Screen","20801497","CDM","300","RC","84702","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estriol Triple Screen","20801498","CDM","300","RC","82677","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Afp Triple Screen","20801499","CDM","300","RC","82105","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis Panel Acute Viral","20801500","CDM","300","RC","80074","HCPCS","facility","both","","","","546","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Iron Binding Capacity (P)","20801520","CDM","300","RC","83550","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T4 (P)","20801522","CDM","300","RC","84436","HCPCS","facility","both","","","","243","121.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zinc Protoporphyrin(P)","20801525","CDM","300","RC","84202","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lead Blood (P)","20801526","CDM","300","RC","83655","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lipoprotein (A)","20801528","CDM","300","RC","83695","HCPCS","facility","both","","","","361","180.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyroid Cascade","20801530","CDM","300","RC","84443","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyroid Replacement","20801531","CDM","300","RC","84443","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T4 Free (Cascade)","20801532","CDM","300","RC","84439","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T4 Free (Replacement)","20801535","CDM","300","RC","84439","HCPCS","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis B Surf Ab Quan","20801536","CDM","300","RC","86317","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lipid Panel Complete","20801556","CDM","300","RC","80061","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prostatic Spec Ag, Screening","20801640","CDM","300","RC","G0103","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen Complete,Reflex-9","20801647","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Inhibin B","20801696","CDM","300","RC","83520","HCPCS","facility","both","","","","864","432","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Homocystein, Serum","20801701","CDM","300","RC","83090","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Methylmalonic Acid Plasma","20801702","CDM","300","RC","83921","HCPCS","facility","both","","","","541","270.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neurontin (Gabapentin)","20801703","CDM","300","RC","80171","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fructosamine","20801704","CDM","300","RC","82985","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pancreatic Polypeptide","20801706","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chromium Plasma","20801708","CDM","300","RC","82495","HCPCS","facility","both","","","","257","128.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Clozaril","20801709","CDM","300","RC","80159","HCPCS","facility","both","","","","339","169.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pth Related Peptide","20801711","CDM","300","RC","82397","HCPCS","facility","both","","","","343","171.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Proinsulin","20801712","CDM","300","RC","84206","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Somatostatin","20801714","CDM","300","RC","84307","HCPCS","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Psa Total - %Free Psa","20801716","CDM","300","RC","84154","HCPCS","facility","both","","","","321","160.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Insulin Free","20801717","CDM","300","RC","83527","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fk506 (Tacrolimus Level)","20801721","CDM","300","RC","80197","HCPCS","facility","both","","","","268","134","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hgb F Quant","20801722","CDM","300","RC","83021","HCPCS","facility","both","","","","254","127","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lamictal","20801723","CDM","300","RC","80175","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dilantin Free","20801724","CDM","300","RC","80186","HCPCS","facility","both","","","","219","109.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rf Quant","20801727","CDM","300","RC","86431","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ca 27 29","20801728","CDM","300","RC","86300","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ldl Cholesterol Direct","20801730","CDM","300","RC","83721","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Serotonin Serum","20801735","CDM","300","RC","84260","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gtt,3 Spec And Glucola","20801736","CDM","300","RC","82951","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Wellbutrin (Bupropion)","20801739","CDM","300","RC","80299","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Methadone Serum","20801740","CDM","300","RC","G0480","HCPCS","facility","both","","","","160","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nicotine Screen Urine","20801741","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pregnenolone,Serum","20801742","CDM","300","RC","84140","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl T3,Reverse","20801743","CDM","300","RC","84482","HCPCS","facility","both","","","","280","140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Olanzapine Serum","20801744","CDM","300","RC","80299","HCPCS","facility","both","","","","259","129.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mdma Confirmation","20801747","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lipid Panel Hdl Ratio","20801752","CDM","300","RC","80061","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl H Pylori Urea Breath Test","20801802","CDM","300","RC","83013","HCPCS","facility","both","","","","969","484.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estrogen Total,Serum","20801820","CDM","300","RC","82672","HCPCS","facility","both","","","","343","171.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucagon,Plasma","20801821","CDM","300","RC","82943","HCPCS","facility","both","","","","268","134","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucose,Post Glucose Dose(W/Gl","20801840","CDM","300","RC","82950","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dimeric Inhibin A","20801841","CDM","300","RC","86336","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cortisol,Total-Add'l Test","20801842","CDM","300","RC","82533","HCPCS","facility","both","","","","296","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nmr Lipoprofile","20801843","CDM","300","RC","83704","HCPCS","facility","both","","","","219","109.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Crp High Sensitivity","20801844","CDM","300","RC","86141","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cell Cept (Mycophenolic Acid)","20801845","CDM","300","RC","80180","HCPCS","facility","both","","","","522","261","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hepatitis C Genotype","20801847","CDM","300","RC","87902","HCPCS","facility","both","","","","698","349","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Selenium Blood","20801848","CDM","300","RC","84255","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oxcarbazepine","20801849","CDM","300","RC","80183","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sex Hormone Binding Globulin","20801851","CDM","300","RC","84270","HCPCS","facility","both","","","","330","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oxycodone Quant","20801854","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oxycodone Screen","20801855","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha Subunit,Free","20801860","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neuron-Specific Enolase(Nse)","20801861","CDM","300","RC","86316","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin K","20801862","CDM","300","RC","84597","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Porphyrins,Serum","20801863","CDM","300","RC","84311","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coenzyme Q10","20801864","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Vgcc Antibody","20801865","CDM","300","RC","86596","HCPCS","facility","both","","","","849","424.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bicarbonate Urine","20801866","CDM","300","RC","82374","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neurokinin A","20801867","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igfbp-3","20801869","CDM","300","RC","83520","HCPCS","facility","both","","","","321","160.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alk Phos,Bone Specific","20801870","CDM","300","RC","84080","HCPCS","facility","both","","","","355","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chromogranin A","20801900","CDM","300","RC","86316","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl N-Telopeptide Urine","20801901","CDM","300","RC","82523","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Creatinine Urine","20801902","CDM","300","RC","82570","HCPCS","facility","both","","","","42","21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Keppra","20801903","CDM","300","RC","80177","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucagon-Like Peptide(Glp1)","20801920","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Afp W/Afp-L3% Serum","20801921","CDM","300","RC","82107","HCPCS","facility","both","","","","614","307","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Carb-Def Transferrin(Cdt)","20801923","CDM","300","RC","82373","HCPCS","facility","both","","","","585","292.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Iodine, Random Urine","20801925","CDM","300","RC","83789","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunoglobulin A 1","20801928","CDM","300","RC","83883","HCPCS","facility","both","","","","163","81.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunoglobulin A 2","20801929","CDM","300","RC","83883","HCPCS","facility","both","","","","163","81.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunoglobulin A Total","20801930","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Leflunomide Serum","20801932","CDM","300","RC","80193","HCPCS","facility","both","","","","530","265","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lanreotide","20801933","CDM","300","RC","80299","HCPCS","facility","both","","","","964","482","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nicotine Quant,Serum","20801938","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha-1-Antitrypsin,Total","20802034","CDM","300","RC","82103","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha-1-Antitrypsin,Phenotype","20802035","CDM","300","RC","82104","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bhcg-First Trimester","20802036","CDM","300","RC","84702","HCPCS","facility","both","","","","328","164","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Papp-A-First Trimester","20802037","CDM","300","RC","84163","HCPCS","facility","both","","","","223","111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pancreastatin","20802039","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ocetreotide","20802040","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl D-Lactate","20802051","CDM","300","RC","83605","HCPCS","facility","both","","","","195","97.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glutathione","20802052","CDM","300","RC","82978","HCPCS","facility","both","","","","444","222","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Quetiapine","20802053","CDM","300","RC","80299","HCPCS","facility","both","","","","431","215.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lorazepam","20802054","CDM","300","RC","G0480","HCPCS","facility","both","","","","285","142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cystatin C","20802055","CDM","300","RC","82610","HCPCS","facility","both","","","","692","346","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl General Chemistry Misc","20802089","CDM","300","RC","84999","HCPCS","facility","both","","","","191.54","95.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Posaconazole","20802100","CDM","300","RC","80187","HCPCS","facility","both","","","","283","141.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatine Kinase: Total (Lc)","20802106","CDM","300","RC","82550","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cholesterol Fluid","20802227","CDM","300","RC","82465","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Triglyceride Fluid","20802228","CDM","300","RC","84478","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen Urine - 3","20802229","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gtt,Additional Specimen","20802230","CDM","300","RC","82952","HCPCS","facility","both","","","","66","33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Carbon Monoxide,Blood","20802231","CDM","300","RC","82375","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rapamycin (Sirolimus)","20802232","CDM","300","RC","80195","HCPCS","facility","both","","","","808","404","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucose Postprandial","20802233","CDM","300","RC","82947","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Angiotensin Conv Enzyme,Csf","20802234","CDM","300","RC","82164","HCPCS","facility","both","","","","309","154.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Topiramate","20802300","CDM","300","RC","80201","HCPCS","facility","both","","","","468","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tryptase","20802301","CDM","300","RC","83520","HCPCS","facility","both","","","","585","292.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trypsin Serum","20802302","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Soluble Transferrin Recp Ab","20802303","CDM","300","RC","84238","HCPCS","facility","both","","","","452","226","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Histamine,Urine","20802304","CDM","300","RC","83088","HCPCS","facility","both","","","","119","59.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Substance P","20802305","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lactoferrin","20802306","CDM","300","RC","83631","HCPCS","facility","both","","","","481","240.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl N-Telopeptide,Serum","20802307","CDM","300","RC","82523","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Free Kappa Light Chain, Urine","20802309","CDM","300","RC","83521","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Free Lambda Light Chain, Urine","20802310","CDM","300","RC","83521","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Free Kappa Light Chain, Serum","20802311","CDM","300","RC","83521","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Free Lambda Light Chain, Serum","20802312","CDM","300","RC","83521","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Voriconzaole","20802313","CDM","300","RC","80285","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cortisol Binding Globulin","20802314","CDM","300","RC","84449","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cortisol, Total Serum","20802315","CDM","300","RC","82533","HCPCS","facility","both","","","","296","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 5 Hiaa,Random","20802400","CDM","300","RC","83497","HCPCS","facility","both","","","","152","76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Carnitine Free/Total","20802402","CDM","300","RC","82379","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Adioponectin","20802403","CDM","300","RC","83520","HCPCS","facility","both","","","","716","358","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Everolimus","20802404","CDM","300","RC","80169","HCPCS","facility","both","","","","970","485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Lacosamide","20802405","CDM","300","RC","80235","HCPCS","facility","both","","","","457","228.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Interleukin-6","20802546","CDM","300","RC","83529","HCPCS","facility","both","","","","456","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Therapuetic Drug Screen(P)","20802550","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha Feto Screen(P)","20802553","CDM","300","RC","82105","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Estriol Screen(P)","20802554","CDM","300","RC","82677","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Papp-A Screen","20802555","CDM","300","RC","84163","HCPCS","facility","both","","","","223","111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bhcg Seq Screen(P)","20802556","CDM","300","RC","84702","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dimeric Inhibin A Screen(P)","20802557","CDM","300","RC","86336","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl P1Np","20802606","CDM","300","RC","82523","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin B3 (Nicotinic Acid)","20803100","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcium,Urine (Ks Panel)","20803101","CDM","300","RC","82340","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oxalate,Urine (Ks Panel)","20803102","CDM","300","RC","83945","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chloride,Urine (Ks Panel)","20803103","CDM","300","RC","82436","HCPCS","facility","both","","","","66","33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ammonia,Urine (Ks Panel)","20803104","CDM","300","RC","82140","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine,Urine (Ks Panel)","20803105","CDM","300","RC","82570","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Magnesium,Urine (Ks Panel)","20803106","CDM","300","RC","83735","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phosphorus,Urine (Ks Panel)","20803107","CDM","300","RC","84105","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium,Urine (Ks Panel)","20803108","CDM","300","RC","84133","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium,Urine (Ks Panel)","20803109","CDM","300","RC","84300","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Uric Acid,Urine (Ks Panel)","20803110","CDM","300","RC","84560","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Citrate,Urine (Ks Panel)","20803111","CDM","300","RC","82507","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sulfate,Urine (Ks Panel)","20803112","CDM","300","RC","84392","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cystine,Urine (Ks Panel)","20803113","CDM","300","RC","82131","HCPCS","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urea Nitrogen,Urine (Ks Panel)","20803114","CDM","300","RC","84540","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Antithyroid Peroxidase Ab","20803120","CDM","300","RC","86376","HCPCS","facility","both","","","","153","76.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Metanephrines,Plasma","20803121","CDM","300","RC","83835","HCPCS","facility","both","","","","514","257","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ganciclover","20803123","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Adenosine Deaminase Fluid","20803124","CDM","300","RC","84311","HCPCS","facility","both","","","","436","218","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lp-Pla2","20803128","CDM","300","RC","83698","HCPCS","facility","both","","","","885","442.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium;Other Source","20803129","CDM","300","RC","84302","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zonisamide (Zonegran)","20803156","CDM","300","RC","80203","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Troponin T Quant","20803200","CDM","300","RC","84484","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nt-Pro-B-Type Natriuretic Pept","20803201","CDM","301","RC","83880","HCPCS","facility","both","","","","529","264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl C-Telopeptide","20803205","CDM","300","RC","82523","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Tpmt By Gc/Ms,Quant","20803210","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Acylcarnitine Profile","20803211","CDM","300","RC","82017","HCPCS","facility","both","","","","864","432","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc- Itraconazole","20803220","CDM","300","RC","80189","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyrotropin Receptor Ab","20803225","CDM","300","RC","83520","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Platelet Neutralization","20803226","CDM","300","RC","85597","HCPCS","facility","both","","","","417","208.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cortisol,Salivary","20803227","CDM","300","RC","82533","HCPCS","facility","both","","","","296","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-N-Methylhistamine Urine","20803250","CDM","300","RC","82542","HCPCS","facility","both","","","","405","202.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dibucaine Number","20803300","CDM","300","RC","82638","HCPCS","facility","both","","","","192","96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calprotectin","20803301","CDM","300","RC","83993","HCPCS","facility","both","","","","655","327.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Procalcitonin","20803302","CDM","300","RC","84145","HCPCS","facility","both","","","","925","462.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Inhibin A,Ultrasensitive","20803303","CDM","300","RC","86336","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium,Rbc","20803304","CDM","300","RC","84132","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Zinc,Rbc","20803305","CDM","300","RC","84630","HCPCS","facility","both","","","","465","232.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Magnesium,Rbc","20803306","CDM","300","RC","83735","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Valproic Acid,Free","20803307","CDM","300","RC","80165","HCPCS","facility","both","","","","677","338.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Selenium,Rbc","20803308","CDM","300","RC","84255","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Porphyrins,Random Urine","20803309","CDM","300","RC","84120","HCPCS","facility","both","","","","284","142","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Calcium Urine,Random","20803310","CDM","300","RC","82340","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-14-3-3 Protein Tau","20803311","CDM","300","RC","86317","HCPCS","facility","both","","","","166","83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-14-3-3 Protein","20803312","CDM","300","RC","84182","HCPCS","facility","both","","","","114","57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha-1-Antitrypsin,Stool","20803320","CDM","300","RC","82103","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 18-Hydroxycorticosterone","20803321","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen 7","20803353","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Panel Blood 6","20803354","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Panel Blood 8","20803355","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Meconium Drug Panel 5","20803356","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Creatinine Urine-Random","20803400","CDM","300","RC","82570","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vma Urine-Random","20803401","CDM","300","RC","84585","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Metanephrines,Urine","20803402","CDM","300","RC","83835","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cobalt,Plasma","20803403","CDM","300","RC","83018","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Nickel,Plasma","20803404","CDM","300","RC","83885","HCPCS","facility","both","","","","555","277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chromium Urine Random","20803405","CDM","300","RC","82495","HCPCS","facility","both","","","","257","128.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc - Pancreatic Elastase Fecal","20803406","CDM","300","RC","82653","HCPCS","facility","both","","","","872","436","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Organic Acids;Qual","20803408","CDM","300","RC","83919","HCPCS","facility","both","","","","1562","781","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Felbamate","20803409","CDM","300","RC","80167","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gabitril (Tiagabine)","20803410","CDM","300","RC","80199","HCPCS","facility","both","","","","366","183","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prot Elec Serum W/Reflx","20803420","CDM","300","RC","84165","HCPCS","facility","both","","","","341","170.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prot Elec Urine W/Reflx","20803421","CDM","300","RC","84166","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Alpha 2-Macroglobin (Nash)","20803425","CDM","300","RC","83883","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Bilirubin Total (Nash)","20803426","CDM","300","RC","82247","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cholesterol,Total (Nash)","20803427","CDM","300","RC","82465","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Glucose,Serum (Nash)","20803428","CDM","300","RC","82947","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ggt (Nash)","20803429","CDM","300","RC","82977","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Haptoglobin (Nash)","20803430","CDM","300","RC","83010","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Apolipoprotein A1 (Nash)","20803431","CDM","300","RC","82172","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sgot(Ast)(Nash)","20803432","CDM","300","RC","84450","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sgpt(Alt)(Nash)","20803433","CDM","300","RC","84460","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Triglycerides (Nash)","20803434","CDM","300","RC","84478","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Estradiol, Free-Serum","20803440","CDM","300","RC","82670","HCPCS","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Embryotoxicity Assay","20803441","CDM","300","RC","83655","HCPCS","facility","both","","","","1224","612","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cadium,Blood","20803442","CDM","300","RC","82300","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dexamethasone,Serum","20803443","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Testosterone,Free(P)","20803444","CDM","300","RC","84402","HCPCS","facility","both","","","","533","266.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Testosterone,Total(P)","20803445","CDM","300","RC","84403","HCPCS","facility","both","","","","256","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Fabry Enzyme Analysis","20803461","CDM","300","RC","82657","HCPCS","facility","both","","","","285","142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin B7 (Biotin)","20803462","CDM","300","RC","84591","HCPCS","facility","both","","","","812","406","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin B5 (Pantothenic Acid)","20803463","CDM","300","RC","84591","HCPCS","facility","both","","","","937","468.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pregabalin (Lyrica)","20803464","CDM","300","RC","80299","HCPCS","facility","both","","","","213","106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Risperidone (Risperdal)","20803470","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Gamma Hydroxybutyric Acid Bl","20803480","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Voltage Gated Potassium Ch Ab","20803501","CDM","300","RC","83519","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Prostaglandin D2 Plasma","20803502","CDM","300","RC","84150","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Buprenorphine, Urine","20803505","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl 17 Hydroxypregnenolone","20803508","CDM","300","RC","84143","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Metylmalonic Acid, Ur.","20803509","CDM","300","RC","83921","HCPCS","facility","both","","","","917","458.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sulfonylurea Screen, Serum","20803510","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Buprenorphine Conf Ua","20803512","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sodium Urine Random","20803525","CDM","300","RC","84300","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Potassium Urine Random","20803526","CDM","300","RC","84133","HCPCS","facility","both","","","","94","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cl Ur Rndm","20803527","CDM","300","RC","82436","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Total Protien Random Urine","20803528","CDM","300","RC","84156","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hiv 1/2 Antibody/Antigen Combo,Stat","20803529","CDM","300","RC","87806","HCPCS","facility","both","","","","79","39.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Rivaroxaban","20803543","CDM","300","RC","80299","HCPCS","facility","both","","","","314","157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Rufinamide","20803544","CDM","300","RC","80210","HCPCS","facility","both","","","","146","73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Molybdenum,Serum","20803550","CDM","300","RC","83018","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Phosphatidylethanol (Peth)","20803610","CDM","300","RC","G0480","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flunitrazepam","20803651","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Lc Apixaban","20803656","CDM","300","RC","80299","HCPCS","facility","both","","","","284","142","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","208040","CDM","278","RC","C1713","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fluconazole","20809801","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Leptin","20810000","CDM","300","RC","83520","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Anti-Ige","20810001","CDM","300","RC","83516","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Abuse 8 Serum","20810006","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Compliance Drug Screen","20810007","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lipid Cascade","20810022","CDM","300","RC","80061","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","208246","CDM","278","RC","C1713","HCPCS","facility","both","","","","1030.4","515.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Trypsin","20830004","CDM","300","RC","84488","HCPCS","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Coproporphyrins","20830016","CDM","300","RC","84120","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Metanephrines,Fractionated","20830020","CDM","300","RC","83835","HCPCS","facility","both","","","","514","257","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hep Delta Antibody","20830032","CDM","300","RC","86692","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Mexiletine (Mexitil)","20830043","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Haldol","20830045","CDM","300","RC","80173","HCPCS","facility","both","","","","224","112","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Thyroglobulin","20830047","CDM","300","RC","84432","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Clomipramine","20830048","CDM","300","RC","80299","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vitamin E","20830049","CDM","300","RC","84446","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Albumin Serum(Ms Profile)","20830058","CDM","300","RC","82040","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Igg Serum","20830059","CDM","300","RC","82784","HCPCS","facility","both","","","","111","55.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Albumin Csf(Ms Profile)","20830060","CDM","300","RC","82042","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Microalbumin Qnt Random U","20830061","CDM","300","RC","82043","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Barbituate Quant Urine","20830065","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Benzodiazepine Gcms","20830066","CDM","300","RC","G0480","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fna Parathyroid (Pth)","20830067","CDM","300","RC","83970","HCPCS","facility","both","","","","507","253.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fna Thyroglobulin","20830068","CDM","300","RC","84432","HCPCS","facility","both","","","","566","283","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lead Blood Adult","20830069","CDM","300","RC","83655","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vit D2 D3 Fractionated","20830118","CDM","300","RC","82306","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Leukotriene E4","20830120","CDM","300","RC","82542","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Oxalate","20830124","CDM","300","RC","83945","HCPCS","facility","both","","","","516","258","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Vascular Endothelial Growth Factor","20830125","CDM","300","RC","83520","HCPCS","facility","both","","","","481","240.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc Toxassure 13","20830129","CDM","300","RC","80307","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Athena-Admark Phospho-Tau Ab42","20830130","CDM","300","RC","83520","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Iodine, Total (Serum)","20830132","CDM","300","RC","83789","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Athena-Optic Atrophy (Opa1)","20830133","CDM","310","RC","81407","HCPCS","facility","both","","","","3419","1709.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Zika Virus, Mac-Elisa, Igm","20830134","CDM","302","RC","86794","HCPCS","facility","both","","","","193","96.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Porphobilinogen, Quanturine","20830135","CDM","301","RC","84110","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hcv Ns5A Drug Resistance","20830136","CDM","306","RC","87900","HCPCS","facility","both","","","","480","240","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hcv Ns5A Drug Resistance","20830137","CDM","306","RC","87902","HCPCS","facility","both","","","","826","413","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Igf-1 With Z Score","20830138","CDM","301","RC","84305","HCPCS","facility","both","","","","106","53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Early Sjogren's Syndrome","20830139","CDM","301","RC","83520","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Opiate Confirmation, Urine, S/O","20830140","CDM","300","RC","G0480","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Maternit Genome","20830141","CDM","310","RC","81420","HCPCS","facility","both","","","","4216","2108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Jo-1 Ab","20830144","CDM","300","RC","86235","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Pl-7 Ab","20830145","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Pl-12 Ab","20830146","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Ej Ab","20830147","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Oj Ab","20830148","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Srp Ab","20830149","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Mi-2 Ab","20830150","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Tif-1 Gamma Ab","20830151","CDM","300","RC","86235","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Mda-5 Ab (Cadm-140)","20830152","CDM","300","RC","83520","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Nxp-2 (P140) Ab","20830153","CDM","300","RC","86235","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Pm/Scl-100 Ab","20830154","CDM","300","RC","86235","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-U2 Rnp (Fibrillarin)","20830155","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-U2 Rnp Ab","20830156","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-U1-Rnp Ab","20830157","CDM","300","RC","86235","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Ku Ab","20830158","CDM","300","RC","83516","HCPCS","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Myomarker 3 & 3 Plus Anti-Ss-A 52Kd Ab, Igg","20830159","CDM","300","RC","86235","HCPCS","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Aspergillus Ab Did Flavus","20830160","CDM","300","RC","86606","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Aspergillusab Did Fumigatus","20830161","CDM","300","RC","86606","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Aspergillus Ab Did Niger","20830162","CDM","300","RC","86606","HCPCS","facility","both","","","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Rdl-Anti-Hmgcr Ab Igg","20830163","CDM","300","RC","83516","HCPCS","facility","both","","","","358","179","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Viracor Thyroid Peroxidase","20830164","CDM","300","RC","86376","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Viracor Thyroglobulin Ab","20830165","CDM","300","RC","86800","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Viracor Tsh","20830166","CDM","300","RC","84443","HCPCS","facility","both","","","","61","30.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Viracor Cu Index","20830167","CDM","300","RC","86352","HCPCS","facility","both","","","","462","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Caredx Allomap Processing","20830184","CDM","300","RC","","","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Phenobarbital, Serum","20830185","CDM","300","RC","80184","HCPCS","facility","both","","","","64","32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Arup Fatty Acid Profile Ess","20830186","CDM","300","RC","82542","HCPCS","facility","both","","","","928","464","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Paliperidone Serum Orplasma","20830187","CDM","300","RC","G0480","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Lc) Fluphenazine Serum Or Plasma, S/O","20830188","CDM","300","RC","G0480","HCPCS","facility","both","","","","97","48.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Dabigatran","20830189","CDM","300","RC","G0480","HCPCS","facility","both","","","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Vedolizumab/Antivedolizumab","20830190","CDM","300","RC","80280","HCPCS","facility","both","","","","314","157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Vedolizumab/Antivedolizumab","20830191","CDM","300","RC","82397","HCPCS","facility","both","","","","361","180.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hiv Hcv Hbv Donor Nat","20830192","CDM","300","RC","87801","HCPCS","facility","both","","","","245","122.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Hepatitis C Virus Fibrosure","20830193","CDM","310","RC","81596","HCPCS","facility","both","","","","274","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl (Arup) Perampanel Quantitative, S/O","20830194","CDM","300","RC","G0480","HCPCS","facility","both","","","","378","189","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Arup-Pml-Rara Translocation","20830195","CDM","310","RC","81315","HCPCS","facility","both","","","","812","406","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Ntrk Ngs Fusion Profile","20830197","CDM","310","RC","81194","HCPCS","facility","both","","","","1344","672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Cardio Familial Arrhythmia","20830198","CDM","310","RC","81413","HCPCS","facility","both","","","","5090","2545","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Mumps Viral Culture","20830199","CDM","300","RC","87254","HCPCS","facility","both","","","","145","72.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Rheumassure-Ra Factor","20830201","CDM","300","RC","86431","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Rheumassure-Ccp Antibodies","20830202","CDM","300","RC","86200","HCPCS","facility","both","","","","93","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Rheumassure-14 3 3 Eta Ra","20830203","CDM","300","RC","83520","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-F2 Isoprostane-Creatinine","20830204","CDM","300","RC","82542","HCPCS","facility","both","","","","106","53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-F2 Isoprostane-Creatinine","20830205","CDM","300","RC","82570","HCPCS","facility","both","","","","26","13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-14 3 3 Eta Rheum Arthritis","20830206","CDM","300","RC","83520","HCPCS","facility","both","","","","224","112","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Billing Correction Clinical-Svbgh","20830212","CDM","300","RC","","","facility","both","","","","285.2","142.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Billing Correction Clinical-Swrmc","20830213","CDM","300","RC","","","facility","both","","","","305.9","152.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Billing Correction Clinical-Sngh","20830215","CDM","300","RC","","","facility","both","","","","156.98","78.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Neogen-Mds Cmml Profile","20830307","CDM","310","RC","81450","HCPCS","facility","both","","","","3981","1990.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc-Drug Profile 12 Urine","20831207","CDM","300","RC","80307","HCPCS","facility","both","","","","270","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chkd-Hsv 1&2 Pcr","20831209","CDM","300","RC","87529","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Chkd-Hsv 1&2 Pcr","20831210","CDM","300","RC","87529","HCPCS","facility","both","","","","84","42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Caredx Heartcare Processing","20831211","CDM","300","RC","","","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid Antibody - Chemistry","20831212","CDM","300","RC","86769","HCPCS","facility","both","","","","42.13","21.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid-19","20831213","CDM","300","RC","87635","HCPCS","facility","both","","","","51.31","25.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen Urine 9","20831214","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Covid Antibody Quantitative","20831215","CDM","300","RC","86769","HCPCS","facility","both","","","","42.13","21.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Protein S Free","20831216","CDM","300","RC","85306","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Drug Screen 10","20831217","CDM","300","RC","80307","HCPCS","facility","both","","","","401","200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20834","CDM","270","RC","","","facility","both","","","","210.38","105.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","208350","CDM","278","RC","C1713","HCPCS","facility","both","","","","1030.4","515.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","208352","CDM","278","RC","C1713","HCPCS","facility","both","","","","1030.4","515.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20847","CDM","270","RC","","","facility","both","","","","239.38","119.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20883","CDM","270","RC","","","facility","both","","","","717.14","358.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Donor Typing Opo Dnr","20900032","CDM","300","RC","86813","HCPCS","facility","both","","","","2300","1150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Type Abc","20900039","CDM","300","RC","81372","HCPCS","facility","both","","","","2556","1278","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd3 Pan T-Cell Marker","20900091","CDM","310","RC","86359","HCPCS","facility","both","","","","271","135.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd19 B Lymph Ag-P","20900101","CDM","310","RC","86355","HCPCS","facility","both","","","","482","241","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd4 Cd8 Absolute With Ratio","20900108","CDM","300","RC","86360","HCPCS","facility","both","","","","255","127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd4 Helper T Lymph","20900109","CDM","300","RC","86361","HCPCS","facility","both","","","","235","117.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd16 T,Plasma Nk Cell","20900115","CDM","300","RC","86357","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Donor Organ Heart","20900146","CDM","300","RC","81372","HCPCS","facility","both","","","","2556","1278","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd3 Leu4 Pan Tcell-P","20900155","CDM","310","RC","86359","HCPCS","facility","both","","","","271","135.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd4 Cd8 Absolute With Ratio","20900169","CDM","300","RC","86360","HCPCS","facility","both","","","","255","127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Immunofluor Direct","20900195","CDM","310","RC","88346","HCPCS","facility","both","","","","330","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cd34 Stem Cell Marker","20900205","CDM","311","RC","86367","HCPCS","facility","both","","","","213","106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Serum Sep Storage","20900250","CDM","300","RC","","","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Urovysion Probe Ea - Manual","20900253","CDM","310","RC","88120","HCPCS","facility","both","","","","914","457","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Dr/Dq Diagnostic","20900258","CDM","300","RC","81375","HCPCS","facility","both","","","","2556","1278","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Cytometry,Cell Surface;Fi","20900277","CDM","311","RC","88184","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Cytometry,Cell Surface;Se","20900278","CDM","311","RC","88185","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Cytometry,Cell Surface;Ad","20900279","CDM","311","RC","88185","HCPCS","facility","both","","","","250","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Xm Renal","20900285","CDM","300","RC","86825","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Xm Living Donor","20900286","CDM","300","RC","86825","HCPCS","facility","both","","","","925","462.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Xm Heart","20900287","CDM","300","RC","86825","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Xm Pancreas","20900298","CDM","300","RC","86825","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Id1 Renal","20900301","CDM","300","RC","86832","HCPCS","facility","both","","","","1264","632","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Id2 Renal","20900302","CDM","300","RC","86833","HCPCS","facility","both","","","","1126","563","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Id1 Heart","20900304","CDM","300","RC","86832","HCPCS","facility","both","","","","1264","632","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Id2 Heart","20900305","CDM","300","RC","86833","HCPCS","facility","both","","","","1126","563","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Id1 Pancreas","20900307","CDM","300","RC","86832","HCPCS","facility","both","","","","1264","632","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Id2 Pancreas","20900308","CDM","300","RC","86833","HCPCS","facility","both","","","","1126","563","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow Cyto Smear","20900312","CDM","300","RC","88160","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow I & Ii Ab Screen Renal","20900405","CDM","300","RC","86828","HCPCS","facility","both","","","","2303","1151.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow I & Ii Ab Screen Heart","20900406","CDM","300","RC","86828","HCPCS","facility","both","","","","2303","1151.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow I & Ii Ab Screen Lung","20900407","CDM","300","RC","86828","HCPCS","facility","both","","","","2303","1151.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow I & Ii Ab Screen Pancreas","20900408","CDM","300","RC","86828","HCPCS","facility","both","","","","2303","1151.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Abc/Drdq  Pancreas","20900409","CDM","300","RC","81370","HCPCS","facility","both","","","","4146","2073","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Abc/Drdq Heart","20900410","CDM","300","RC","81370","HCPCS","facility","both","","","","4146","2073","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Abc/Drdq Lr Donor","20900411","CDM","300","RC","81370","HCPCS","facility","both","","","","4146","2073","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Abc/Drdq Renal","20900412","CDM","300","RC","81370","HCPCS","facility","both","","","","4146","2073","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Abc/Drdq Dd Shared","20900413","CDM","300","RC","81370","HCPCS","facility","both","","","","4146","2073","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20902","CDM","272","RC","C1729","HCPCS","facility","both","","","","12.88","6.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Lc Ovarian Malignancy Panel","20902003","CDM","310","RC","81500","HCPCS","facility","both","","","","442","221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Dpa Renal","20902004","CDM","300","RC","81376","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Dpb Renal","20902005","CDM","300","RC","81376","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Dpa Heart","20902006","CDM","300","RC","81376","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Dpb Heart","20902007","CDM","300","RC","81376","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Dpa Pancreas","20902008","CDM","300","RC","81376","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hla Dpb Pancreas","20902009","CDM","300","RC","81376","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anti A1 Titer","20902010","CDM","300","RC","86886","HCPCS","facility","both","","","","271","135.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sars-Cov-2 Covid-19 Antibody","20902011","CDM","300","RC","86769","HCPCS","facility","both","","","","42.13","21.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sars-Cov-2 Covid-19 Antibody (No Modifier)","20902012","CDM","300","RC","86769","HCPCS","facility","both","","","","42.13","21.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Sars-Cov-2 Covid-19 Antibody (Modifier Cs)","20902013","CDM","300","RC","86769","HCPCS","facility","both","","","","42.13","21.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Ld Molecular Processing Fee","20902014","CDM","300","RC","86849","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20903","CDM","272","RC","C1729","HCPCS","facility","both","","","","25.88","12.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Flow I & Ii Ab Screen Post","20907681","CDM","300","RC","86828","HCPCS","facility","both","","","","2303","1151.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Dsa2 Renal","20907682","CDM","300","RC","86833","HCPCS","facility","both","","","","1126","563","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Luminex Dsa1 Renal","20907687","CDM","300","RC","86832","HCPCS","facility","both","","","","1264","632","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20937","CDM","270","RC","","","facility","both","","","","979.52","489.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","20940","CDM","270","RC","","","facility","both","","","","258.56","129.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209417","CDM","278","RC","C1713","HCPCS","facility","both","","","","2840.5","1420.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209431","CDM","270","RC","","","facility","both","","","","680.8","340.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209432","CDM","270","RC","","","facility","both","","","","680.8","340.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209442","CDM","270","RC","","","facility","both","","","","680.8","340.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209454","CDM","278","RC","C1713","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209455","CDM","278","RC","C1713","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209457","CDM","278","RC","C1713","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209467","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209475","CDM","270","RC","","","facility","both","","","","363.4","181.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","209477","CDM","270","RC","","","facility","both","","","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pelvic Cytology Screening","21000001","CDM","311","RC","P3000","HCPCS","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  Needle Asp/Fna Interp","21000060","CDM","310","RC","88173","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Fna Adequacy By Tech","21000078","CDM","310","RC","88172","HCPCS","facility","both","","","","388","194","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytology Cell Block","21000081","CDM","310","RC","88305","HCPCS","facility","both","","","","438","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytology Smear","21000090","CDM","310","RC","88104","HCPCS","facility","both","","","","515","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytology Fluid Conc","21000091","CDM","310","RC","88108","HCPCS","facility","both","","","","288","144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytology Scrape/Discharge","21000092","CDM","310","RC","88160","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Liquid Based Nongyn Prep","21000094","CDM","310","RC","88112","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  Fna Adeq Add't","21000099","CDM","300","RC","88177","HCPCS","facility","both","","","","213","106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Imaged Pap","21000105","CDM","300","RC","G0145","HCPCS","facility","both","","","","159","79.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl  Liquid Based Nongyn Prp - Add'l","21000109","CDM","300","RC","88112","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Touch Prep Cyto","21000250","CDM","300","RC","88333","HCPCS","facility","both","","","","789","394.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Touch Prep Cyto Add'l","21000251","CDM","300","RC","88334","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pap- Thin Layer Screen","21000890","CDM","311","RC","G0123","HCPCS","facility","both","","","","164","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Pap Thin Layer Diagnostic","21000891","CDM","311","RC","88142","HCPCS","facility","both","","","","258","129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytology Level 5","21003125","CDM","310","RC","88307","HCPCS","facility","both","","","","726","363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytology Decal","21003126","CDM","310","RC","88311","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Cytosmear Prep/Screen/Interp","21003127","CDM","310","RC","88161","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210187","CDM","270","RC","","","facility","both","","","","319.93","159.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210212","CDM","270","RC","","","facility","both","","","","204.93","102.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210267","CDM","270","RC","","","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210269","CDM","278","RC","C1874","HCPCS","facility","both","","","","17057.25","8528.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210331","CDM","278","RC","C1789","HCPCS","facility","both","","","","2457","1228.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","21039","CDM","272","RC","C1769","HCPCS","facility","both","","","","81.19","40.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210391","CDM","270","RC","","","facility","both","","","","19311.6","9655.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210402","CDM","270","RC","","","facility","both","","","","828","414","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210423","CDM","270","RC","","","facility","both","","","","1569.75","784.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210427","CDM","270","RC","","","facility","both","","","","599.43","299.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210428","CDM","278","RC","C1713","HCPCS","facility","both","","","","2664.5","1332.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210433","CDM","278","RC","C1713","HCPCS","facility","both","","","","3767.45","1883.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210436","CDM","278","RC","C1713","HCPCS","facility","both","","","","3767.45","1883.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210437","CDM","278","RC","C1713","HCPCS","facility","both","","","","3767.45","1883.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210438","CDM","278","RC","C1713","HCPCS","facility","both","","","","3767.45","1883.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210443","CDM","278","RC","C1713","HCPCS","facility","both","","","","2602.09","1301.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210448","CDM","278","RC","C1713","HCPCS","facility","both","","","","3767.45","1883.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210453","CDM","278","RC","C1713","HCPCS","facility","both","","","","3767.45","1883.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210458","CDM","278","RC","C1713","HCPCS","facility","both","","","","2753.22","1376.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210474","CDM","278","RC","C1874","HCPCS","facility","both","","","","17057.25","8528.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210475","CDM","278","RC","C1874","HCPCS","facility","both","","","","17057.25","8528.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210670","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210671","CDM","270","RC","","","facility","both","","","","89.7","44.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210679","CDM","270","RC","","","facility","both","","","","249.17","124.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","210702","CDM","270","RC","","","facility","both","","","","2131.96","1065.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211143","CDM","270","RC","","","facility","both","","","","253","126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211191","CDM","270","RC","","","facility","both","","","","3.35","1.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211192","CDM","270","RC","","","facility","both","","","","1254.1","627.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211227","CDM","270","RC","","","facility","both","","","","1214.49","607.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211259","CDM","270","RC","","","facility","both","","","","838.5","419.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211338","CDM","270","RC","","","facility","both","","","","108.08","54.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211407","CDM","270","RC","","","facility","both","","","","88.64","44.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211485","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211489","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211491","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211493","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211494","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211496","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211499","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211502","CDM","270","RC","","","facility","both","","","","2036.8","1018.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211504","CDM","270","RC","","","facility","both","","","","2036.8","1018.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211507","CDM","270","RC","","","facility","both","","","","2036.8","1018.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211508","CDM","270","RC","","","facility","both","","","","2036.8","1018.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211520","CDM","270","RC","","","facility","both","","","","2698","1349","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211524","CDM","270","RC","","","facility","both","","","","2698","1349","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211525","CDM","270","RC","","","facility","both","","","","2698","1349","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211540","CDM","270","RC","","","facility","both","","","","2698","1349","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211614","CDM","270","RC","","","facility","both","","","","4750","2375","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211822","CDM","278","RC","C1776","HCPCS","facility","both","","","","4782.45","2391.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211976","CDM","270","RC","","","facility","both","","","","1937.8","968.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211980","CDM","270","RC","","","facility","both","","","","1857.25","928.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211981","CDM","270","RC","","","facility","both","","","","72.88","36.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211984","CDM","270","RC","","","facility","both","","","","2049.3","1024.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","211986","CDM","270","RC","","","facility","both","","","","786.6","393.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","212037","CDM","278","RC","C1713","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","212096","CDM","278","RC","C1713","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","212129","CDM","270","RC","","","facility","both","","","","114.67","57.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","212161","CDM","270","RC","","","facility","both","","","","101.43","50.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","212225","CDM","278","RC","C1763","HCPCS","facility","both","","","","3066.6","1533.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","21235","CDM","272","RC","C1729","HCPCS","facility","both","","","","13.26","6.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213392","CDM","270","RC","","","facility","both","","","","1867.6","933.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213395","CDM","270","RC","","","facility","both","","","","198.77","99.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213396","CDM","270","RC","","","facility","both","","","","120.31","60.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213491","CDM","270","RC","","","facility","both","","","","409.2","204.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213653","CDM","278","RC","C1713","HCPCS","facility","both","","","","2480.4","1240.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213946","CDM","278","RC","C1781","HCPCS","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213948","CDM","278","RC","C1781","HCPCS","facility","both","","","","5082.5","2541.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213952","CDM","278","RC","C1781","HCPCS","facility","both","","","","14763","7381.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","213966","CDM","278","RC","C1762","HCPCS","facility","both","","","","12958","6479","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214475","CDM","270","RC","","","facility","both","","","","1007.4","503.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214659","CDM","270","RC","","","facility","both","","","","35.65","17.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214662","CDM","278","RC","C1713","HCPCS","facility","both","","","","1411.8","705.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214752","CDM","270","RC","","","facility","both","","","","524.4","262.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214769","CDM","270","RC","","","facility","both","","","","2208","1104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214816","CDM","272","RC","C1894","HCPCS","facility","both","","","","48.9","24.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214820","CDM","278","RC","C1768","HCPCS","facility","both","","","","2838.75","1419.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214821","CDM","278","RC","C1713","HCPCS","facility","both","","","","1885","942.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214887","CDM","276","RC","V2632","HCPCS","facility","both","","","","199","99.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214927","CDM","270","RC","","","facility","both","","","","94.06","47.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","214929","CDM","270","RC","","","facility","both","","","","86.56","43.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215186","CDM","278","RC","A4648","HCPCS","facility","both","","","","398.67","199.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215190","CDM","270","RC","","","facility","both","","","","2042.18","1021.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215354","CDM","278","RC","C1874","HCPCS","facility","both","","","","7594.3","3797.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215374","CDM","272","RC","C1729","HCPCS","facility","both","","","","295.92","147.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215378","CDM","272","RC","C1729","HCPCS","facility","both","","","","295.92","147.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215381","CDM","270","RC","","","facility","both","","","","1534","767","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215387","CDM","272","RC","C1769","HCPCS","facility","both","","","","1702.27","851.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215403","CDM","272","RC","C1769","HCPCS","facility","both","","","","174.8","87.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215443","CDM","270","RC","","","facility","both","","","","915.4","457.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215513","CDM","278","RC","C1781","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215520","CDM","270","RC","","","facility","both","","","","1156.74","578.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215523","CDM","278","RC","C1713","HCPCS","facility","both","","","","772.8","386.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215525","CDM","270","RC","","","facility","both","","","","665.67","332.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215526","CDM","270","RC","","","facility","both","","","","2090.74","1045.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215527","CDM","270","RC","","","facility","both","","","","1305.14","652.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215528","CDM","270","RC","","","facility","both","","","","1369.19","684.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215529","CDM","270","RC","","","facility","both","","","","1638.8","819.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215763","CDM","272","RC","C1887","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215817","CDM","270","RC","","","facility","both","","","","1824.67","912.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215818","CDM","270","RC","","","facility","both","","","","1300.69","650.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215937","CDM","270","RC","","","facility","both","","","","81.97","40.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","215939","CDM","270","RC","","","facility","both","","","","81.97","40.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216216","CDM","270","RC","C1758","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216217","CDM","270","RC","","","facility","both","","","","565.8","282.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216231","CDM","270","RC","","","facility","both","","","","2528.9","1264.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216278","CDM","270","RC","","","facility","both","","","","2070.54","1035.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216279","CDM","270","RC","","","facility","both","","","","1670.97","835.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216299","CDM","270","RC","","","facility","both","","","","602.07","301.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216398","CDM","278","RC","C1876","HCPCS","facility","both","","","","4275","2137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216401","CDM","278","RC","C1874","HCPCS","facility","both","","","","3910.2","1955.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216411","CDM","272","RC","C1769","HCPCS","facility","both","","","","786.74","393.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","216444","CDM","278","RC","C1789","HCPCS","facility","both","","","","2840.5","1420.25","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","216525","CDM","270","RC","","","facility","both","","","","105.8","52.9","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","216930","CDM","270","RC","","","facility","both","","","","64.4","32.2","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","217126","CDM","270","RC","","","facility","both","","","","2103.17","1051.58","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","217162","CDM","270","RC","","","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217196","CDM","278","RC","C1776","HCPCS","facility","both","","","","2277.15","1138.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217200","CDM","278","RC","C1776","HCPCS","facility","both","","","","4913.64","2456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217308","CDM","270","RC","","","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217325","CDM","270","RC","","","facility","both","","","","565.8","282.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217329","CDM","270","RC","","","facility","both","","","","2413","1206.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217364","CDM","270","RC","","","facility","both","","","","128.8","64.4","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","217368","CDM","278","RC","C1755","HCPCS","facility","both","","","","1998.79","999.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","217370","CDM","270","RC","","","facility","both","","","","142.74","71.37","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","217817","CDM","278","RC","C1874","HCPCS","facility","both","","","","8360","4180","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","2179","CDM","270","RC","","","facility","both","","","","88.57","44.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","218116","CDM","270","RC","","","facility","both","","","","2277","1138.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","21812","CDM","270","RC","","","facility","both","","","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","218572","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","21862","CDM","270","RC","","","facility","both","","","","20.99","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","21863","CDM","270","RC","","","facility","both","","","","21.3","10.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220087","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220089","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220102","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220114","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220518","CDM","278","RC","Q4128","HCPCS","facility","both","","","","47.7","23.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220520","CDM","270","RC","","","facility","both","","","","17.86","8.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220524","CDM","278","RC","C1713","HCPCS","facility","both","","","","2340","1170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220538","CDM","278","RC","Q4121","HCPCS","facility","both","","","","405.29","202.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220729","CDM","278","RC","C1713","HCPCS","facility","both","","","","1690","845","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","220740","CDM","270","RC","","","facility","both","","","","98.53","49.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Travel Allowance - Mileage","22100108","CDM","300","RC","P9603","HCPCS","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Draw Fee-Lab Req Entry","22100110","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Prenatal Panel","22100300","CDM","300","RC","80055","HCPCS","facility","both","","","","440","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22112","CDM","270","RC","","","facility","both","","","","16.04","8.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22138","CDM","270","RC","","","facility","both","","","","417.5","208.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","221623","CDM","270","RC","","","facility","both","","","","851","425.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","221624","CDM","270","RC","","","facility","both","","","","851","425.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","222203","CDM","278","RC","C1713","HCPCS","facility","both","","","","2470","1235","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","222212","CDM","278","RC","C1713","HCPCS","facility","both","","","","2470","1235","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","222241","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22269","CDM","270","RC","","","facility","both","","","","1073.93","536.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22270","CDM","270","RC","","","facility","both","","","","1073.92","536.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22271","CDM","270","RC","","","facility","both","","","","1073.93","536.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223031","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223070","CDM","278","RC","C1713","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223219","CDM","278","RC","C1713","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223823","CDM","270","RC","","","facility","both","","","","101.43","50.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223881","CDM","278","RC","C1713","HCPCS","facility","both","","","","5225","2612.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223882","CDM","278","RC","C1762","HCPCS","facility","both","","","","2132","1066","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223883","CDM","278","RC","C1713","HCPCS","facility","both","","","","2992.5","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223884","CDM","278","RC","C1713","HCPCS","facility","both","","","","5225","2612.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223885","CDM","278","RC","C1713","HCPCS","facility","both","","","","2132","1066","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223886","CDM","278","RC","C1713","HCPCS","facility","both","","","","2992.5","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223887","CDM","278","RC","C1713","HCPCS","facility","both","","","","5225","2612.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223910","CDM","270","RC","","","facility","both","","","","146.05","73.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","223983","CDM","278","RC","C9356","HCPCS","facility","both","","","","46.7","23.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","224165","CDM","278","RC","C1713","HCPCS","facility","both","","","","264.96","132.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","224174","CDM","270","RC","","","facility","both","","","","1191.4","595.7","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","224488","CDM","270","RC","","","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","224495","CDM","270","RC","","","facility","both","","","","1937.15","968.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","224501","CDM","270","RC","","","facility","both","","","","511","255.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","224503","CDM","270","RC","","","facility","both","","","","39.47","19.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22518","CDM","270","RC","","","facility","both","","","","46.4","23.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22519","CDM","270","RC","","","facility","both","","","","36.11","18.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225418","CDM","270","RC","","","facility","both","","","","1863","931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225419","CDM","270","RC","","","facility","both","","","","1863","931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225463","CDM","270","RC","C1781","HCPCS","facility","both","","","","2527.2","1263.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22550","CDM","270","RC","","","facility","both","","","","8.92","4.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22554","CDM","270","RC","","","facility","both","","","","10.15","5.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225562","CDM","278","RC","C1713","HCPCS","facility","both","","","","215.05","107.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225563","CDM","278","RC","C1713","HCPCS","facility","both","","","","911.03","455.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22558","CDM","270","RC","","","facility","both","","","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22564","CDM","270","RC","","","facility","both","","","","8.12","4.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225708","CDM","272","RC","C1725","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","225990","CDM","278","RC","C1776","HCPCS","facility","both","","","","1768","884","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22601","CDM","270","RC","","","facility","both","","","","7.14","3.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22603","CDM","270","RC","","","facility","both","","","","6.99","3.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22604","CDM","270","RC","","","facility","both","","","","7.14","3.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226064","CDM","270","RC","","","facility","both","","","","109.41","54.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226066","CDM","270","RC","","","facility","both","","","","19.56","9.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22610","CDM","270","RC","","","facility","both","","","","5.71","2.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22613","CDM","270","RC","","","facility","both","","","","14.66","7.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226131","CDM","270","RC","","","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226166","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226171","CDM","270","RC","","","facility","both","","","","70.15","35.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226200","CDM","270","RC","","","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226201","CDM","270","RC","","","facility","both","","","","74.79","37.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226202","CDM","270","RC","","","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226203","CDM","270","RC","","","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226224","CDM","270","RC","","","facility","both","","","","531.3","265.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226280","CDM","278","RC","Q4121","HCPCS","facility","both","","","","55.35","27.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226289","CDM","270","RC","","","facility","both","","","","680.8","340.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226290","CDM","272","RC","C1782","HCPCS","facility","both","","","","1988.03","994.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226293","CDM","272","RC","C1894","HCPCS","facility","both","","","","4170.5","2085.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226298","CDM","270","RC","","","facility","both","","","","1034.23","517.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226310","CDM","278","RC","Q4196","HCPCS","facility","both","","","","180.5","90.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22637","CDM","270","RC","","","facility","both","","","","11.98","5.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22638","CDM","270","RC","","","facility","both","","","","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22642","CDM","270","RC","","","facility","both","","","","5.39","2.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22643","CDM","270","RC","","","facility","both","","","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","22644","CDM","270","RC","","","facility","both","","","","5.18","2.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226516","CDM","278","RC","C1874","HCPCS","facility","both","","","","5521.4","2760.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","226544","CDM","278","RC","C1874","HCPCS","facility","both","","","","6165.5","3082.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","227225","CDM","278","RC","C1767","HCPCS","facility","both","","","","49092.2","24546.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","227228","CDM","272","RC","C1758","HCPCS","facility","both","","","","174.02","87.01","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","227348","CDM","270","RC","","","facility","both","","","","805.92","402.96","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","227500","CDM","278","RC","C1713","HCPCS","facility","both","","","","4112.46","2056.23","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","227587","CDM","278","RC","C1713","HCPCS","facility","both","","","","201.48","100.74","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","229971","CDM","270","RC","","","facility","both","","","","5791.02","2895.51","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","230967","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","231185","CDM","270","RC","","","facility","both","","","","29.9","14.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232073","CDM","272","RC","C1887","HCPCS","facility","both","","","","970.6","485.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232091","CDM","272","RC","C1894","HCPCS","facility","both","","","","4170.5","2085.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232102","CDM","272","RC","C1773","HCPCS","facility","both","","","","3220.5","1610.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232128","CDM","270","RC","","","facility","both","","","","663.87","331.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232129","CDM","270","RC","","","facility","both","","","","663.87","331.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232134","CDM","270","RC","","","facility","both","","","","1339.71","669.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232229","CDM","270","RC","","","facility","both","","","","1352","676","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232230","CDM","270","RC","","","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232238","CDM","272","RC","C1894","HCPCS","facility","both","","","","73.91","36.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232239","CDM","272","RC","C1894","HCPCS","facility","both","","","","73.6","36.8","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","232640","CDM","270","RC","","","facility","both","","","","1587","793.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","232893","CDM","270","RC","","","facility","both","","","","342.65","171.32","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","233032","CDM","278","RC","C1713","HCPCS","facility","both","","","","2065.4","1032.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233033","CDM","278","RC","C1713","HCPCS","facility","both","","","","3834.2","1917.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233034","CDM","278","RC","C1713","HCPCS","facility","both","","","","6403","3201.5","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","233180","CDM","270","RC","","","facility","both","","","","162.7","81.35","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","233320","CDM","270","RC","","","facility","both","","","","106.54","53.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233321","CDM","278","RC","C1713","HCPCS","facility","both","","","","1499.69","749.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233322","CDM","278","RC","C1713","HCPCS","facility","both","","","","1787.01","893.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233323","CDM","270","RC","C1713","HCPCS","facility","both","","","","671.37","335.68","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","233329","CDM","270","RC","","","facility","both","","","","10639.51","5319.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233363","CDM","278","RC","Q4133","HCPCS","facility","both","","","","397.29","198.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233364","CDM","278","RC","Q4133","HCPCS","facility","both","","","","274.61","137.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","233404","CDM","270","RC","","","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","234633","CDM","270","RC","","","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","236277","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","236279","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","236295","CDM","278","RC","C1713","HCPCS","facility","both","","","","768.2","384.1","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","236335","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","2366","CDM","272","RC","C1729","HCPCS","facility","both","","","","42.63","21.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","2392","CDM","272","RC","C1729","HCPCS","facility","both","","","","51.06","25.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","24311","CDM","270","RC","","","facility","both","","","","5.82","2.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","244683","CDM","278","RC","C1713","HCPCS","facility","both","","","","1610","805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","244773","CDM","278","RC","C1713","HCPCS","facility","both","","","","1461.08","730.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","244774","CDM","278","RC","C1713","HCPCS","facility","both","","","","1461.08","730.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","245394","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","245395","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","245665","CDM","278","RC","C1713","HCPCS","facility","both","","","","6222.5","3111.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","245666","CDM","278","RC","C1713","HCPCS","facility","both","","","","6222.5","3111.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","24614","CDM","270","RC","","","facility","both","","","","9.23","4.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","24898","CDM","270","RC","","","facility","both","","","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","24908","CDM","270","RC","","","facility","both","","","","19.25","9.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","24909","CDM","270","RC","","","facility","both","","","","90.3","45.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","24911","CDM","270","RC","","","facility","both","","","","20.47","10.24","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","281598","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Observation Hours","30010062","CDM","762","RC","G0378","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","301637","CDM","270","RC","","","facility","both","","","","174.8","87.4","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","306301","CDM","272","RC","C1769","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","306317","CDM","270","RC","","","facility","both","","","","1491.75","745.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","306334","CDM","270","RC","","","facility","both","","","","49.54","24.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","306433","CDM","270","RC","","","facility","both","","","","78.89","39.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307222","CDM","278","RC","C1776","HCPCS","facility","both","","","","4725.49","2362.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307225","CDM","278","RC","C1776","HCPCS","facility","both","","","","2418.47","1209.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307239","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307253","CDM","278","RC","C1713","HCPCS","facility","both","","","","3610","1805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307295","CDM","270","RC","","","facility","both","","","","650.39","325.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307299","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307312","CDM","278","RC","C2625","HCPCS","facility","both","","","","1035","517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307325","CDM","270","RC","","","facility","both","","","","886.64","443.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307329","CDM","270","RC","","","facility","both","","","","735.26","367.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307333","CDM","270","RC","","","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307334","CDM","270","RC","","","facility","both","","","","58.6","29.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307335","CDM","270","RC","","","facility","both","","","","58.6","29.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307339","CDM","270","RC","","","facility","both","","","","269.55","134.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307342","CDM","278","RC","C1768","HCPCS","facility","both","","","","15460.09","7730.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307361","CDM","272","RC","C1886","HCPCS","facility","both","","","","3629","1814.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30782","CDM","270","RC","","","facility","both","","","","34.67","17.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307822","CDM","278","RC","L8612","HCPCS","facility","both","","","","4088.8","2044.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307875","CDM","270","RC","","","facility","both","","","","2537.76","1268.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30793","CDM","270","RC","","","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","307981","CDM","270","RC","","","facility","both","","","","99.18","49.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308004","CDM","278","RC","C1713","HCPCS","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30809","CDM","270","RC","","","facility","both","","","","5.78","2.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308135","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308136","CDM","278","RC","C1713","HCPCS","facility","both","","","","1725","862.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308137","CDM","278","RC","C1713","HCPCS","facility","both","","","","1625","812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30816","CDM","270","RC","","","facility","both","","","","16.33","8.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308317","CDM","278","RC","C1713","HCPCS","facility","both","","","","473.8","236.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308329","CDM","278","RC","C1713","HCPCS","facility","both","","","","2257.45","1128.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308404","CDM","278","RC","Q4100","HCPCS","facility","both","","","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30847","CDM","270","RC","","","facility","both","","","","5.8","2.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308573","CDM","270","RC","","","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308580","CDM","270","RC","","","facility","both","","","","1679","839.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30865","CDM","270","RC","","","facility","both","","","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30867","CDM","270","RC","","","facility","both","","","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30873","CDM","270","RC","","","facility","both","","","","21.23","10.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30874","CDM","270","RC","","","facility","both","","","","5.73","2.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308782","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30888","CDM","270","RC","","","facility","both","","","","177.33","88.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308912","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308916","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308928","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","308951","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30902","CDM","270","RC","","","facility","both","","","","176.54","88.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309062","CDM","278","RC","C1713","HCPCS","facility","both","","","","409.4","204.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309063","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309108","CDM","278","RC","C1763","HCPCS","facility","both","","","","4618.43","2309.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309109","CDM","278","RC","C1713","HCPCS","facility","both","","","","1450.2","725.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309110","CDM","278","RC","C1713","HCPCS","facility","both","","","","1612.73","806.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30914","CDM","270","RC","","","facility","both","","","","179.29","89.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30924","CDM","270","RC","","","facility","both","","","","5.72","2.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309729","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30973","CDM","272","RC","C1729","HCPCS","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","309760","CDM","278","RC","C1713","HCPCS","facility","both","","","","2840.5","1420.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30987","CDM","278","RC","C1713","HCPCS","facility","both","","","","940.74","470.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30992","CDM","270","RC","","","facility","both","","","","5.82","2.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30997","CDM","270","RC","","","facility","both","","","","8.45","4.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","30999","CDM","270","RC","","","facility","both","","","","19.97","9.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","31009","CDM","270","RC","","","facility","both","","","","19.64","9.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310135","CDM","278","RC","C1713","HCPCS","facility","both","","","","2560.73","1280.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310147","CDM","278","RC","C1713","HCPCS","facility","both","","","","486.45","243.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310164","CDM","278","RC","C1713","HCPCS","facility","both","","","","2218.73","1109.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","31022","CDM","270","RC","","","facility","both","","","","5.46","2.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310474","CDM","278","RC","C1713","HCPCS","facility","both","","","","2337","1168.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310475","CDM","278","RC","C1713","HCPCS","facility","both","","","","4664.5","2332.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310476","CDM","278","RC","C1713","HCPCS","facility","both","","","","8379","4189.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310539","CDM","270","RC","","","facility","both","","","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310612","CDM","270","RC","","","facility","both","","","","1796.6","898.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310613","CDM","272","RC","C1729","HCPCS","facility","both","","","","1471.57","735.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310614","CDM","270","RC","","","facility","both","","","","1318.2","659.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310893","CDM","278","RC","C1713","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","310963","CDM","278","RC","C1713","HCPCS","facility","both","","","","6175","3087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","31131","CDM","270","RC","","","facility","both","","","","8.99","4.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312126","CDM","278","RC","C1876","HCPCS","facility","both","","","","15770.3","7885.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312128","CDM","278","RC","C1876","HCPCS","facility","both","","","","15770.3","7885.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312148","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312313","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312612","CDM","278","RC","C1789","HCPCS","facility","both","","","","2945","1472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312758","CDM","272","RC","C1769","HCPCS","facility","both","","","","130.93","65.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","31276","CDM","270","RC","","","facility","both","","","","20.19","10.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312778","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312780","CDM","278","RC","C1713","HCPCS","facility","both","","","","1616.11","808.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312781","CDM","278","RC","C1713","HCPCS","facility","both","","","","1826.06","913.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312824","CDM","270","RC","","","facility","both","","","","1414.4","707.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312858","CDM","278","RC","C1713","HCPCS","facility","both","","","","3426.21","1713.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312861","CDM","270","RC","","","facility","both","","","","421.87","210.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312879","CDM","270","RC","","","facility","both","","","","9665.27","4832.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","312896","CDM","270","RC","","","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313350","CDM","270","RC","","","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313373","CDM","270","RC","","","facility","both","","","","94.3","47.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313375","CDM","270","RC","","","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313377","CDM","270","RC","","","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313387","CDM","278","RC","C1713","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313403","CDM","278","RC","C1713","HCPCS","facility","both","","","","839.5","419.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313424","CDM","272","RC","C1725","HCPCS","facility","both","","","","874","437","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313430","CDM","270","RC","","","facility","both","","","","269.28","134.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313433","CDM","270","RC","","","facility","both","","","","82.07","41.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313759","CDM","270","RC","","","facility","both","","","","1440","720","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313760","CDM","270","RC","","","facility","both","","","","1110.9","555.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313761","CDM","270","RC","","","facility","both","","","","1098.93","549.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313762","CDM","270","RC","","","facility","both","","","","1107.55","553.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313763","CDM","270","RC","","","facility","both","","","","1110.9","555.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313770","CDM","278","RC","Q4100","HCPCS","facility","both","","","","5282","2641","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","313969","CDM","272","RC","C1894","HCPCS","facility","both","","","","73.6","36.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314010","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314025","CDM","278","RC","C1713","HCPCS","facility","both","","","","1535.56","767.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314026","CDM","278","RC","C1713","HCPCS","facility","both","","","","1636.04","818.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314027","CDM","278","RC","C1713","HCPCS","facility","both","","","","1535.56","767.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314032","CDM","278","RC","C1713","HCPCS","facility","both","","","","1535.56","767.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314033","CDM","278","RC","C1713","HCPCS","facility","both","","","","1736.51","868.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314034","CDM","278","RC","C1713","HCPCS","facility","both","","","","1636.04","818.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314041","CDM","270","RC","","","facility","both","","","","650.39","325.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314043","CDM","270","RC","","","facility","both","","","","650.39","325.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314047","CDM","270","RC","","","facility","both","","","","1334","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314055","CDM","270","RC","","","facility","both","","","","382.19","191.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314067","CDM","278","RC","C1713","HCPCS","facility","both","","","","1395.86","697.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314070","CDM","278","RC","C1771","HCPCS","facility","both","","","","13990.84","6995.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314085","CDM","278","RC","C1713","HCPCS","facility","both","","","","1468.84","734.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314086","CDM","278","RC","C1713","HCPCS","facility","both","","","","1660.83","830.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314088","CDM","278","RC","C1713","HCPCS","facility","both","","","","1468.84","734.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314092","CDM","278","RC","C1713","HCPCS","facility","both","","","","1468.84","734.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314093","CDM","278","RC","C1713","HCPCS","facility","both","","","","1660.83","830.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314094","CDM","278","RC","C1713","HCPCS","facility","both","","","","1517.99","759","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314095","CDM","278","RC","C1713","HCPCS","facility","both","","","","1468.84","734.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314097","CDM","278","RC","C1713","HCPCS","facility","both","","","","1395.86","697.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314107","CDM","278","RC","C1713","HCPCS","facility","both","","","","1395.86","697.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314169","CDM","278","RC","C1783","HCPCS","facility","both","","","","3372.5","1686.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314204","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314205","CDM","278","RC","C1713","HCPCS","facility","both","","","","3021.48","1510.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","314206","CDM","278","RC","C1713","HCPCS","facility","both","","","","5700","2850","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","320762","CDM","270","RC","","","facility","both","","","","63.91","31.96","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","320974","CDM","278","RC","A2006","HCPCS","facility","both","","","","21.28","10.64","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","323914","CDM","278","RC","C1713","HCPCS","facility","both","","","","1690","845","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","324382","CDM","272","RC","C1769","HCPCS","facility","both","","","","108.74","54.37","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","326636","CDM","272","RC","C1887","HCPCS","facility","both","","","","524.4","262.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","326770","CDM","278","RC","Q4100","HCPCS","facility","both","","","","1385.8","692.9","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","326799","CDM","270","RC","","","facility","both","","","","137.89","68.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","326800","CDM","270","RC","","","facility","both","","","","133.29","66.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","326801","CDM","270","RC","","","facility","both","","","","60.7","30.35","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","326845","CDM","270","RC","","","facility","both","","","","12682.5","6341.25","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","326984","CDM","278","RC","C1713","HCPCS","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","326994","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","326996","CDM","270","RC","C1713","HCPCS","facility","both","","","","2035.45","1017.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","326999","CDM","270","RC","","","facility","both","","","","1055.7","527.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327000","CDM","270","RC","","","facility","both","","","","1055.7","527.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327005","CDM","270","RC","","","facility","both","","","","1456.16","728.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327056","CDM","278","RC","C1713","HCPCS","facility","both","","","","1959.45","979.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32734","CDM","272","RC","C1773","HCPCS","facility","both","","","","1412.32","706.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327493","CDM","278","RC","C1789","HCPCS","facility","both","","","","3372.5","1686.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327561","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327563","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327565","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327583","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327601","CDM","278","RC","C1713","HCPCS","facility","both","","","","1037.49","518.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327609","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327613","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32764","CDM","270","RC","","","facility","both","","","","11.07","5.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32765","CDM","270","RC","","","facility","both","","","","26.08","13.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327727","CDM","278","RC","C1713","HCPCS","facility","both","","","","904.18","452.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327817","CDM","278","RC","C1713","HCPCS","facility","both","","","","3562.73","1781.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","327847","CDM","278","RC","C1713","HCPCS","facility","both","","","","3562.73","1781.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32789","CDM","272","RC","C1769","HCPCS","facility","both","","","","200.77","100.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328016","CDM","272","RC","C1757","HCPCS","facility","both","","","","10659","5329.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328018","CDM","272","RC","C1757","HCPCS","facility","both","","","","3192","1596","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328071","CDM","270","RC","","","facility","both","","","","1656","828","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328084","CDM","278","RC","C1713","HCPCS","facility","both","","","","2470","1235","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328087","CDM","270","RC","","","facility","both","","","","2705.6","1352.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328088","CDM","278","RC","C1713","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328090","CDM","278","RC","C1713","HCPCS","facility","both","","","","6365","3182.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328136","CDM","278","RC","C1713","HCPCS","facility","both","","","","4005.2","2002.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328142","CDM","272","RC","C1769","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328144","CDM","270","RC","","","facility","both","","","","8415.1","4207.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328158","CDM","270","RC","","","facility","both","","","","1380","690","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328171","CDM","270","RC","","","facility","both","","","","2080.88","1040.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328186","CDM","278","RC","C1713","HCPCS","facility","both","","","","547.4","273.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328205","CDM","270","RC","","","facility","both","","","","1847.82","923.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328214","CDM","270","RC","","","facility","both","","","","593.54","296.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328265","CDM","272","RC","C1713","HCPCS","facility","both","","","","2028","1014","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32830","CDM","270","RC","","","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328454","CDM","270","RC","","","facility","both","","","","208.84","104.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328455","CDM","270","RC","","","facility","both","","","","208.84","104.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328456","CDM","270","RC","","","facility","both","","","","208.84","104.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328458","CDM","270","RC","","","facility","both","","","","226.5","113.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328464","CDM","270","RC","","","facility","both","","","","192.97","96.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328671","CDM","270","RC","","","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328685","CDM","278","RC","C1713","HCPCS","facility","both","","","","1887.6","943.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328690","CDM","278","RC","C1713","HCPCS","facility","both","","","","1887.6","943.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328693","CDM","278","RC","C1713","HCPCS","facility","both","","","","1887.6","943.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328695","CDM","278","RC","C1713","HCPCS","facility","both","","","","2087.25","1043.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328704","CDM","278","RC","C1713","HCPCS","facility","both","","","","1461.1","730.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328713","CDM","270","RC","","","facility","both","","","","2500.16","1250.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32873","CDM","270","RC","","","facility","both","","","","17.63","8.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328850","CDM","270","RC","","","facility","both","","","","1679","839.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328851","CDM","270","RC","","","facility","both","","","","2565","1282.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328916","CDM","278","RC","C1713","HCPCS","facility","both","","","","2280","1140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32895","CDM","270","RC","","","facility","both","","","","436.39","218.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328954","CDM","278","RC","C1874","HCPCS","facility","both","","","","4560","2280","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328960","CDM","270","RC","","","facility","both","","","","1309.97","654.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328961","CDM","270","RC","","","facility","both","","","","1309.97","654.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328963","CDM","270","RC","","","facility","both","","","","1304","652","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328979","CDM","270","RC","","","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328981","CDM","270","RC","","","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328985","CDM","270","RC","","","facility","both","","","","1266.93","633.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","328987","CDM","270","RC","","","facility","both","","","","1345.5","672.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32904","CDM","270","RC","","","facility","both","","","","168.48","84.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32910","CDM","270","RC","","","facility","both","","","","32.38","16.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329129","CDM","270","RC","","","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329132","CDM","278","RC","C1713","HCPCS","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329134","CDM","278","RC","C1713","HCPCS","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329143","CDM","278","RC","C1713","HCPCS","facility","both","","","","3103.65","1551.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329146","CDM","278","RC","C1713","HCPCS","facility","both","","","","1887.6","943.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329151","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329154","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32917","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.52","21.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329187","CDM","270","RC","","","facility","both","","","","1545.6","772.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329239","CDM","270","RC","","","facility","both","","","","2263.73","1131.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329240","CDM","270","RC","","","facility","both","","","","628.67","314.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329330","CDM","278","RC","C1713","HCPCS","facility","both","","","","1573","786.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329348","CDM","270","RC","","","facility","both","","","","1656","828","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329559","CDM","278","RC","L8699","HCPCS","facility","both","","","","2535","1267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329560","CDM","278","RC","L8699","HCPCS","facility","both","","","","2535","1267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32969","CDM","272","RC","C2627","HCPCS","facility","both","","","","295.23","147.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32972","CDM","278","RC","C1781","HCPCS","facility","both","","","","590.64","295.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329804","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","329806","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","32984","CDM","272","RC","C1757","HCPCS","facility","both","","","","968.39","484.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330064","CDM","270","RC","","","facility","both","","","","146.05","73.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33019","CDM","270","RC","","","facility","both","","","","852.2","426.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33020","CDM","270","RC","","","facility","both","","","","1815.68","907.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33023","CDM","278","RC","C1762","HCPCS","facility","both","","","","1398.4","699.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33027","CDM","270","RC","","","facility","both","","","","336.77","168.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33028","CDM","270","RC","","","facility","both","","","","613.85","306.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33029","CDM","270","RC","","","facility","both","","","","62.7","31.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330362","CDM","270","RC","","","facility","both","","","","2441.5","1220.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330385","CDM","270","RC","","","facility","both","","","","2070","1035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330391","CDM","270","RC","","","facility","both","","","","25.35","12.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330393","CDM","270","RC","","","facility","both","","","","25.35","12.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330394","CDM","270","RC","","","facility","both","","","","20.29","10.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330430","CDM","272","RC","C1894","HCPCS","facility","both","","","","253","126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330431","CDM","272","RC","C1894","HCPCS","facility","both","","","","253","126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33045","CDM","270","RC","","","facility","both","","","","33.72","16.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330507","CDM","270","RC","","","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33052","CDM","270","RC","C1713","HCPCS","facility","both","","","","4.72","2.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33053","CDM","270","RC","C1713","HCPCS","facility","both","","","","7.54","3.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330535","CDM","278","RC","C1713","HCPCS","facility","both","","","","1887.6","943.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330536","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33054","CDM","270","RC","","","facility","both","","","","8.69","4.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330556","CDM","278","RC","C1713","HCPCS","facility","both","","","","1690","845","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330559","CDM","278","RC","C1713","HCPCS","facility","both","","","","373.75","186.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330572","CDM","278","RC","Q4158","HCPCS","facility","both","","","","172.77","86.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330586","CDM","278","RC","Q4158","HCPCS","facility","both","","","","84.57","42.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33059","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330594","CDM","278","RC","Q4158","HCPCS","facility","both","","","","91","45.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330599","CDM","270","RC","","","facility","both","","","","529","264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33060","CDM","270","RC","","","facility","both","","","","28.75","14.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330606","CDM","278","RC","C1713","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330608","CDM","278","RC","C1713","HCPCS","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330609","CDM","278","RC","C1713","HCPCS","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330621","CDM","278","RC","C1713","HCPCS","facility","both","","","","621","310.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33066","CDM","270","RC","","","facility","both","","","","152.58","76.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33071","CDM","270","RC","","","facility","both","","","","88.18","44.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330843","CDM","278","RC","C1713","HCPCS","facility","both","","","","1357","678.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330844","CDM","278","RC","C1713","HCPCS","facility","both","","","","1357","678.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3309","CDM","272","RC","C1729","HCPCS","facility","both","","","","17.51","8.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330925","CDM","270","RC","","","facility","both","","","","529","264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330949","CDM","278","RC","C1713","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330964","CDM","278","RC","C1713","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330973","CDM","278","RC","C1713","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","330990","CDM","272","RC","C1713","HCPCS","facility","both","","","","7600","3800","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331161","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331177","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331290","CDM","270","RC","","","facility","both","","","","1368.5","684.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331291","CDM","270","RC","","","facility","both","","","","1368.5","684.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331292","CDM","270","RC","","","facility","both","","","","1368.5","684.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331407","CDM","278","RC","C1713","HCPCS","facility","both","","","","2080","1040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33141","CDM","270","RC","","","facility","both","","","","981.08","490.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331473","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331474","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331504","CDM","270","RC","","","facility","both","","","","2757.89","1378.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331506","CDM","278","RC","C1762","HCPCS","facility","both","","","","3003.9","1501.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331533","CDM","278","RC","C1713","HCPCS","facility","both","","","","906.75","453.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331556","CDM","278","RC","C1713","HCPCS","facility","both","","","","3305.54","1652.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331567","CDM","278","RC","C1713","HCPCS","facility","both","","","","3578.08","1789.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331576","CDM","278","RC","C1713","HCPCS","facility","both","","","","218.27","109.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33159","CDM","270","RC","","","facility","both","","","","250.52","125.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331593","CDM","270","RC","","","facility","both","","","","1196","598","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331604","CDM","278","RC","C1713","HCPCS","facility","both","","","","1325.61","662.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331608","CDM","278","RC","C1713","HCPCS","facility","both","","","","1581.3","790.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33161","CDM","270","RC","","","facility","both","","","","250.52","125.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","33162","CDM","278","RC","C1765","HCPCS","facility","both","","","","1501.34","750.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331664","CDM","278","RC","C1713","HCPCS","facility","both","","","","1883.7","941.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331671","CDM","278","RC","C1713","HCPCS","facility","both","","","","1466.22","733.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331735","CDM","270","RC","","","facility","both","","","","57000","28500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331737","CDM","270","RC","C1894","HCPCS","facility","both","","","","4009","2004.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331738","CDM","270","RC","C1894","HCPCS","facility","both","","","","4009","2004.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331739","CDM","270","RC","C1894","HCPCS","facility","both","","","","1794","897","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331740","CDM","270","RC","C1894","HCPCS","facility","both","","","","1794","897","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331897","CDM","270","RC","","","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331903","CDM","270","RC","","","facility","both","","","","12.04","6.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331904","CDM","270","RC","","","facility","both","","","","26.96","13.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331905","CDM","270","RC","","","facility","both","","","","360.64","180.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331923","CDM","270","RC","","","facility","both","","","","2033.01","1016.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331991","CDM","270","RC","","","facility","both","","","","2327","1163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331992","CDM","270","RC","","","facility","both","","","","557.19","278.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","331996","CDM","270","RC","L8000","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3335","CDM","272","RC","C1729","HCPCS","facility","both","","","","19.32","9.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","334","CDM","278","RC","C2625","HCPCS","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3340","CDM","272","RC","C1729","HCPCS","facility","both","","","","20.19","10.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3352","CDM","272","RC","C1729","HCPCS","facility","both","","","","16.43","8.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3355","CDM","272","RC","C1729","HCPCS","facility","both","","","","15.96","7.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3362","CDM","272","RC","C1729","HCPCS","facility","both","","","","17.97","8.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","343","CDM","272","RC","C1729","HCPCS","facility","both","","","","13.06","6.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35210","CDM","272","RC","C1887","HCPCS","facility","both","","","","58.19","29.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35340","CDM","270","RC","","","facility","both","","","","50.76","25.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35343","CDM","270","RC","","","facility","both","","","","2245.89","1122.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35378","CDM","270","RC","","","facility","both","","","","133.22","66.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35395","CDM","278","RC","C1781","HCPCS","facility","both","","","","695.98","347.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35396","CDM","270","RC","","","facility","both","","","","66.7","33.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35504","CDM","272","RC","C1757","HCPCS","facility","both","","","","358.8","179.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35505","CDM","272","RC","C1757","HCPCS","facility","both","","","","383.92","191.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35533","CDM","278","RC","C1713","HCPCS","facility","both","","","","437","218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35640","CDM","270","RC","","","facility","both","","","","67.54","33.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35642","CDM","270","RC","","","facility","both","","","","141.8","70.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35658","CDM","270","RC","","","facility","both","","","","13.57","6.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35830","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35831","CDM","278","RC","C1713","HCPCS","facility","both","","","","133.13","66.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35832","CDM","278","RC","C1713","HCPCS","facility","both","","","","114.79","57.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35833","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35834","CDM","278","RC","C1713","HCPCS","facility","both","","","","91.94","45.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35835","CDM","278","RC","C1713","HCPCS","facility","both","","","","97.48","48.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35836","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35837","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35838","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35839","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35840","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35841","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35842","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35843","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35844","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35845","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35847","CDM","278","RC","C1713","HCPCS","facility","both","","","","67.3","33.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35851","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35857","CDM","278","RC","C1713","HCPCS","facility","both","","","","958.79","479.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35858","CDM","278","RC","C1713","HCPCS","facility","both","","","","932.65","466.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35859","CDM","278","RC","C1713","HCPCS","facility","both","","","","1011.08","505.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35860","CDM","278","RC","C1713","HCPCS","facility","both","","","","932.65","466.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35863","CDM","278","RC","C1713","HCPCS","facility","both","","","","932.65","466.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35932","CDM","272","RC","C1769","HCPCS","facility","both","","","","111.46","55.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35933","CDM","272","RC","C1769","HCPCS","facility","both","","","","175.89","87.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35936","CDM","278","RC","C1713","HCPCS","facility","both","","","","362.79","181.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35939","CDM","270","RC","","","facility","both","","","","1638.02","819.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35940","CDM","270","RC","","","facility","both","","","","1647.22","823.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359644","CDM","278","RC","C1713","HCPCS","facility","both","","","","3040","1520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359645","CDM","278","RC","C1713","HCPCS","facility","both","","","","3040","1520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359690","CDM","272","RC","C1894","HCPCS","facility","both","","","","73.6","36.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359691","CDM","272","RC","C1894","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359693","CDM","272","RC","C1894","HCPCS","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359696","CDM","278","RC","C1713","HCPCS","facility","both","","","","2991.15","1495.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359700","CDM","278","RC","C1713","HCPCS","facility","both","","","","3271.02","1635.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359704","CDM","270","RC","","","facility","both","","","","105.8","52.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359707","CDM","270","RC","","","facility","both","","","","1404","702","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359708","CDM","270","RC","","","facility","both","","","","1137.12","568.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359711","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359712","CDM","278","RC","C1713","HCPCS","facility","both","","","","1483.94","741.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359714","CDM","270","RC","","","facility","both","","","","575","287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359715","CDM","270","RC","","","facility","both","","","","1341.67","670.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359717","CDM","270","RC","","","facility","both","","","","1403","701.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359752","CDM","278","RC","C1713","HCPCS","facility","both","","","","1736.51","868.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359753","CDM","278","RC","C1713","HCPCS","facility","both","","","","6175","3087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359756","CDM","278","RC","C1713","HCPCS","facility","both","","","","6175","3087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35976","CDM","270","RC","","","facility","both","","","","1019.13","509.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35977","CDM","270","RC","","","facility","both","","","","996.7","498.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359806","CDM","270","RC","","","facility","both","","","","680.8","340.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359813","CDM","270","RC","","","facility","both","","","","1866.15","933.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359847","CDM","270","RC","","","facility","both","","","","1131.81","565.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359853","CDM","270","RC","","","facility","both","","","","1054.22","527.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","359857","CDM","278","RC","C1713","HCPCS","facility","both","","","","2650.5","1325.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","35996","CDM","278","RC","C1713","HCPCS","facility","both","","","","101.48","50.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36214","CDM","270","RC","","","facility","both","","","","310.26","155.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3648","CDM","270","RC","","","facility","both","","","","118.37","59.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36577","CDM","270","RC","C1887","HCPCS","facility","both","","","","58.19","29.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36592","CDM","278","RC","C2617","HCPCS","facility","both","","","","473.8","236.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36646","CDM","272","RC","A6258","HCPCS","facility","both","","","","2.89","1.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36647","CDM","270","RC","","","facility","both","","","","22.87","11.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36675","CDM","270","RC","","","facility","both","","","","9.49","4.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36714","CDM","270","RC","","","facility","both","","","","42.68","21.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36840","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36880","CDM","270","RC","","","facility","both","","","","397.16","198.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36881","CDM","270","RC","","","facility","both","","","","163.88","81.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36882","CDM","270","RC","","","facility","both","","","","271.96","135.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36883","CDM","270","RC","","","facility","both","","","","228.93","114.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36884","CDM","270","RC","","","facility","both","","","","1489.39","744.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36885","CDM","270","RC","","","facility","both","","","","77.79","38.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36886","CDM","270","RC","","","facility","both","","","","875.72","437.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36887","CDM","270","RC","","","facility","both","","","","334.51","167.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36888","CDM","270","RC","","","facility","both","","","","288.87","144.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36890","CDM","270","RC","","","facility","both","","","","178.67","89.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36891","CDM","270","RC","","","facility","both","","","","135.92","67.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36892","CDM","270","RC","","","facility","both","","","","334.24","167.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36893","CDM","270","RC","","","facility","both","","","","149.67","74.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36895","CDM","270","RC","","","facility","both","","","","390.51","195.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36896","CDM","270","RC","","","facility","both","","","","818.05","409.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36897","CDM","270","RC","","","facility","both","","","","271","135.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36898","CDM","270","RC","","","facility","both","","","","267.41","133.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36902","CDM","270","RC","","","facility","both","","","","839.57","419.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36903","CDM","270","RC","","","facility","both","","","","220.15","110.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36904","CDM","270","RC","","","facility","both","","","","180.25","90.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36906","CDM","270","RC","","","facility","both","","","","239.53","119.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36907","CDM","270","RC","","","facility","both","","","","260.53","130.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","36916","CDM","270","RC","","","facility","both","","","","7.36","3.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37056","CDM","270","RC","","","facility","both","","","","45.69","22.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37110","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.52","21.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37112","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.52","21.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37113","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.52","21.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37115","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.52","21.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37207","CDM","270","RC","L3908","HCPCS","facility","both","","","","38.69","19.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37430","CDM","278","RC","C1713","HCPCS","facility","both","","","","715.02","357.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37561","CDM","278","RC","C1713","HCPCS","facility","both","","","","41.19","20.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3764","CDM","270","RC","","","facility","both","","","","15.9","7.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37708","CDM","278","RC","C1713","HCPCS","facility","both","","","","358.2","179.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37709","CDM","278","RC","C1713","HCPCS","facility","both","","","","606.92","303.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37715","CDM","278","RC","C1713","HCPCS","facility","both","","","","606.92","303.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37719","CDM","278","RC","C1713","HCPCS","facility","both","","","","703.03","351.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37721","CDM","278","RC","C1713","HCPCS","facility","both","","","","700.82","350.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37734","CDM","270","RC","","","facility","both","","","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37735","CDM","270","RC","","","facility","both","","","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37742","CDM","270","RC","","","facility","both","","","","324","162","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37763","CDM","270","RC","","","facility","both","","","","496.71","248.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3786","CDM","270","RC","","","facility","both","","","","16.2","8.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37983","CDM","270","RC","","","facility","both","","","","21.91","10.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","37984","CDM","270","RC","","","facility","both","","","","18.61","9.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38229","CDM","270","RC","","","facility","both","","","","70.72","35.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38231","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38246","CDM","270","RC","","","facility","both","","","","297.07","148.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38314","CDM","270","RC","","","facility","both","","","","18.98","9.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38510","CDM","270","RC","C1713","HCPCS","facility","both","","","","833.8","416.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38545","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38547","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38548","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38550","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38551","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38558","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38560","CDM","278","RC","C1713","HCPCS","facility","both","","","","766.36","383.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38624","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38806","CDM","270","RC","","","facility","both","","","","36.39","18.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38807","CDM","270","RC","","","facility","both","","","","71.64","35.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38808","CDM","270","RC","","","facility","both","","","","55.48","27.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38809","CDM","270","RC","","","facility","both","","","","165.39","82.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38843","CDM","270","RC","","","facility","both","","","","139.55","69.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38845","CDM","272","RC","C1726","HCPCS","facility","both","","","","861.76","430.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38846","CDM","272","RC","C1726","HCPCS","facility","both","","","","861.76","430.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38847","CDM","272","RC","C1726","HCPCS","facility","both","","","","861.76","430.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38848","CDM","272","RC","C1726","HCPCS","facility","both","","","","861.76","430.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38850","CDM","272","RC","C1726","HCPCS","facility","both","","","","861.76","430.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","38871","CDM","270","RC","L0174","HCPCS","facility","both","","","","217.12","108.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39001","CDM","278","RC","C1713","HCPCS","facility","both","","","","397.99","199","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39027","CDM","270","RC","","","facility","both","","","","690.51","345.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39112","CDM","270","RC","","","facility","both","","","","1000.16","500.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39113","CDM","270","RC","","","facility","both","","","","1034.77","517.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39123","CDM","270","RC","","","facility","both","","","","1700.64","850.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39125","CDM","270","RC","","","facility","both","","","","589.03","294.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39466","CDM","270","RC","","","facility","both","","","","1262.39","631.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39497","CDM","270","RC","","","facility","both","","","","54.02","27.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3950","CDM","270","RC","","","facility","both","","","","963.47","481.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39562","CDM","278","RC","C1713","HCPCS","facility","both","","","","711.85","355.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3964","CDM","270","RC","","","facility","both","","","","80.04","40.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39649","CDM","278","RC","C1713","HCPCS","facility","both","","","","932.65","466.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39688","CDM","270","RC","L1830","HCPCS","facility","both","","","","74.89","37.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3982","CDM","270","RC","","","facility","both","","","","80.04","40.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","3986","CDM","270","RC","","","facility","both","","","","80.06","40.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39885","CDM","270","RC","C1713","HCPCS","facility","both","","","","190.67","95.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39931","CDM","270","RC","","","facility","both","","","","132.52","66.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","39942","CDM","270","RC","","","facility","both","","","","58.19","29.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pace Va Medicaid Dual Rate","40000000","CDM","3103","RC","","","facility","both","","","","6154.63","3077.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40003","CDM","270","RC","","","facility","both","","","","21.33","10.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40006","CDM","270","RC","","","facility","both","","","","251.38","125.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40048","CDM","278","RC","C1750","HCPCS","facility","both","","","","499.53","249.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40062","CDM","270","RC","","","facility","both","","","","250.52","125.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40069","CDM","270","RC","","","facility","both","","","","316.71","158.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40070","CDM","270","RC","","","facility","both","","","","301.66","150.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40074","CDM","270","RC","","","facility","both","","","","238.59","119.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40079","CDM","270","RC","","","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40081","CDM","270","RC","","","facility","both","","","","79.76","39.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40134","CDM","272","RC","C1769","HCPCS","facility","both","","","","252.85","126.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40346","CDM","270","RC","","","facility","both","","","","73.01","36.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40515","CDM","270","RC","","","facility","both","","","","15.9","7.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40516","CDM","270","RC","","","facility","both","","","","15.01","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40593","CDM","270","RC","","","facility","both","","","","12.26","6.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40601","CDM","270","RC","","","facility","both","","","","48.13","24.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40745","CDM","270","RC","","","facility","both","","","","28.21","14.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40748","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40811","CDM","270","RC","","","facility","both","","","","285.55","142.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40812","CDM","270","RC","","","facility","both","","","","171.9","85.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40813","CDM","270","RC","","","facility","both","","","","284.15","142.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40815","CDM","270","RC","","","facility","both","","","","435.8","217.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40816","CDM","270","RC","","","facility","both","","","","497.83","248.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40817","CDM","270","RC","","","facility","both","","","","188.73","94.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40818","CDM","270","RC","","","facility","both","","","","176.67","88.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40821","CDM","270","RC","","","facility","both","","","","418.57","209.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40823","CDM","270","RC","","","facility","both","","","","342.51","171.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40824","CDM","270","RC","","","facility","both","","","","375.65","187.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40825","CDM","270","RC","","","facility","both","","","","293.49","146.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40826","CDM","270","RC","","","facility","both","","","","308.47","154.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40827","CDM","270","RC","","","facility","both","","","","231.3","115.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40828","CDM","270","RC","","","facility","both","","","","547.46","273.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40829","CDM","270","RC","","","facility","both","","","","530.54","265.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40830","CDM","270","RC","","","facility","both","","","","340.01","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40831","CDM","270","RC","","","facility","both","","","","546.31","273.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","40849","CDM","270","RC","C1726","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4096","CDM","270","RC","","","facility","both","","","","258.25","129.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41017","CDM","270","RC","","","facility","both","","","","58.03","29.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41064","CDM","270","RC","L1830","HCPCS","facility","both","","","","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41065","CDM","270","RC","","","facility","both","","","","71.06","35.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41066","CDM","270","RC","L1830","HCPCS","facility","both","","","","50.19","25.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41109","CDM","270","RC","","","facility","both","","","","57.59","28.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41151","CDM","270","RC","","","facility","both","","","","36.96","18.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41229","CDM","272","RC","C1758","HCPCS","facility","both","","","","3.47","1.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41237","CDM","270","RC","","","facility","both","","","","181.64","90.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4138","CDM","272","RC","A6254","HCPCS","facility","both","","","","2.19","1.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41714","CDM","270","RC","","","facility","both","","","","8.83","4.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41727","CDM","270","RC","","","facility","both","","","","68.21","34.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41733","CDM","270","RC","","","facility","both","","","","525.95","262.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41739","CDM","270","RC","","","facility","both","","","","53.29","26.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41742","CDM","270","RC","","","facility","both","","","","9.11","4.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41744","CDM","270","RC","","","facility","both","","","","49.38","24.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41754","CDM","270","RC","","","facility","both","","","","12.06","6.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41755","CDM","270","RC","","","facility","both","","","","20.99","10.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41767","CDM","270","RC","","","facility","both","","","","39.03","19.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41769","CDM","270","RC","","","facility","both","","","","39.19","19.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41770","CDM","270","RC","","","facility","both","","","","39.17","19.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41777","CDM","270","RC","","","facility","both","","","","53.57","26.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41791","CDM","270","RC","","","facility","both","","","","4.43","2.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41793","CDM","270","RC","","","facility","both","","","","8.87","4.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41795","CDM","270","RC","","","facility","both","","","","19.31","9.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41797","CDM","270","RC","","","facility","both","","","","12.24","6.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41799","CDM","270","RC","","","facility","both","","","","12.33","6.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41802","CDM","270","RC","","","facility","both","","","","10.78","5.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41809","CDM","270","RC","","","facility","both","","","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41810","CDM","270","RC","","","facility","both","","","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41814","CDM","270","RC","","","facility","both","","","","8.26","4.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41815","CDM","270","RC","","","facility","both","","","","7.9","3.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41816","CDM","270","RC","","","facility","both","","","","15.17","7.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41826","CDM","270","RC","","","facility","both","","","","7.3","3.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41829","CDM","270","RC","","","facility","both","","","","8.45","4.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41830","CDM","270","RC","","","facility","both","","","","8.45","4.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41834","CDM","270","RC","","","facility","both","","","","8.14","4.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41835","CDM","270","RC","","","facility","both","","","","9.12","4.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","41836","CDM","270","RC","","","facility","both","","","","12.47","6.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42117","CDM","272","RC","C2628","HCPCS","facility","both","","","","1048.11","524.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42198","CDM","278","RC","C2617","HCPCS","facility","both","","","","463.07","231.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42199","CDM","278","RC","C2617","HCPCS","facility","both","","","","473.8","236.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42229","CDM","272","RC","C1769","HCPCS","facility","both","","","","100.79","50.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42244","CDM","272","RC","C1769","HCPCS","facility","both","","","","80.65","40.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42770","CDM","272","RC","C1769","HCPCS","facility","both","","","","437","218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42920","CDM","272","RC","C1894","HCPCS","facility","both","","","","317.49","158.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42944","CDM","272","RC","C1769","HCPCS","facility","both","","","","76.54","38.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42964","CDM","272","RC","C1892","HCPCS","facility","both","","","","211.32","105.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42970","CDM","272","RC","C1892","HCPCS","facility","both","","","","211.32","105.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","42980","CDM","272","RC","C1769","HCPCS","facility","both","","","","219.58","109.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4303","CDM","270","RC","","","facility","both","","","","27.45","13.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43032","CDM","272","RC","C1729","HCPCS","facility","both","","","","70.37","35.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43053","CDM","270","RC","","","facility","both","","","","156.81","78.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4307","CDM","270","RC","","","facility","both","","","","12.33","6.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43195","CDM","270","RC","","","facility","both","","","","57.45","28.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43196","CDM","270","RC","","","facility","both","","","","57.45","28.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43197","CDM","270","RC","","","facility","both","","","","57.45","28.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43198","CDM","270","RC","","","facility","both","","","","57.45","28.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43203","CDM","270","RC","","","facility","both","","","","66.24","33.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43216","CDM","270","RC","","","facility","both","","","","28.75","14.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43300","CDM","270","RC","","","facility","both","","","","161.77","80.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43301","CDM","270","RC","","","facility","both","","","","131.23","65.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43310","CDM","270","RC","","","facility","both","","","","235.04","117.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43320","CDM","270","RC","","","facility","both","","","","71.24","35.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43334","CDM","270","RC","","","facility","both","","","","43.7","21.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43343","CDM","270","RC","","","facility","both","","","","196.65","98.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43364","CDM","270","RC","","","facility","both","","","","23.63","11.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43366","CDM","270","RC","","","facility","both","","","","20.68","10.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43367","CDM","270","RC","","","facility","both","","","","20.68","10.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43369","CDM","270","RC","","","facility","both","","","","23.63","11.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43445","CDM","278","RC","C1713","HCPCS","facility","both","","","","1936.6","968.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43459","CDM","278","RC","C1762","HCPCS","facility","both","","","","1662.7","831.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43509","CDM","278","RC","C1755","HCPCS","facility","both","","","","640.55","320.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43635","CDM","278","RC","C1781","HCPCS","facility","both","","","","667.92","333.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43636","CDM","278","RC","C1781","HCPCS","facility","both","","","","743.94","371.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43637","CDM","278","RC","C1781","HCPCS","facility","both","","","","726.34","363.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43777","CDM","272","RC","C2629","HCPCS","facility","both","","","","5690.5","2845.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43967","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","43987","CDM","270","RC","","","facility","both","","","","193.2","96.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44008","CDM","270","RC","C1758","HCPCS","facility","both","","","","524.4","262.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44009","CDM","270","RC","C1758","HCPCS","facility","both","","","","867.91","433.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44011","CDM","270","RC","","","facility","both","","","","138.83","69.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44014","CDM","272","RC","C1758","HCPCS","facility","both","","","","158.06","79.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4402","CDM","270","RC","","","facility","both","","","","740.6","370.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44161","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44285","CDM","270","RC","","","facility","both","","","","18.08","9.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44289","CDM","270","RC","","","facility","both","","","","52.03","26.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44293","CDM","270","RC","","","facility","both","","","","1323.83","661.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44315","CDM","270","RC","","","facility","both","","","","80.5","40.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44448","CDM","278","RC","C1713","HCPCS","facility","both","","","","1612","806","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44817","CDM","270","RC","","","facility","both","","","","15.89","7.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44942","CDM","270","RC","","","facility","both","","","","179.4","89.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44950","CDM","270","RC","","","facility","both","","","","787.2","393.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","44952","CDM","270","RC","","","facility","both","","","","62.28","31.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45012","CDM","270","RC","","","facility","both","","","","34.21","17.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45019","CDM","270","RC","","","facility","both","","","","18.31","9.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45020","CDM","270","RC","","","facility","both","","","","20.51","10.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45021","CDM","270","RC","","","facility","both","","","","21.31","10.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4510","CDM","278","RC","C1768","HCPCS","facility","both","","","","543.81","271.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45254","CDM","272","RC","C1769","HCPCS","facility","both","","","","45.03","22.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45256","CDM","272","RC","C1769","HCPCS","facility","both","","","","1468.9","734.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45314","CDM","270","RC","","","facility","both","","","","1633","816.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45357","CDM","270","RC","","","facility","both","","","","434.61","217.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45369","CDM","270","RC","","","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45372","CDM","270","RC","","","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45381","CDM","272","RC","C1769","HCPCS","facility","both","","","","447.17","223.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45384","CDM","270","RC","C1726","HCPCS","facility","both","","","","981.96","490.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45385","CDM","272","RC","C1726","HCPCS","facility","both","","","","981.96","490.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45386","CDM","272","RC","C1726","HCPCS","facility","both","","","","981.96","490.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45387","CDM","272","RC","C1726","HCPCS","facility","both","","","","981.96","490.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45395","CDM","270","RC","","","facility","both","","","","286.9","143.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45413","CDM","270","RC","","","facility","both","","","","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45417","CDM","270","RC","","","facility","both","","","","230.44","115.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4543","CDM","270","RC","","","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45452","CDM","278","RC","C1713","HCPCS","facility","both","","","","12.45","6.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45453","CDM","278","RC","C1713","HCPCS","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45495","CDM","270","RC","","","facility","both","","","","33.39","16.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45579","CDM","270","RC","","","facility","both","","","","102.72","51.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45601","CDM","270","RC","","","facility","both","","","","792.31","396.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45603","CDM","270","RC","","","facility","both","","","","39.41","19.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45607","CDM","270","RC","","","facility","both","","","","8.8","4.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45608","CDM","270","RC","","","facility","both","","","","9.37","4.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45610","CDM","270","RC","","","facility","both","","","","45.65","22.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45611","CDM","270","RC","","","facility","both","","","","22.46","11.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45622","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45626","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45641","CDM","270","RC","","","facility","both","","","","91.23","45.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45682","CDM","270","RC","","","facility","both","","","","75.17","37.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","457","CDM","270","RC","","","facility","both","","","","36.3","18.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45729","CDM","270","RC","","","facility","both","","","","45.26","22.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45736","CDM","270","RC","","","facility","both","","","","543.3","271.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45748","CDM","270","RC","","","facility","both","","","","708.08","354.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45751","CDM","270","RC","","","facility","both","","","","91.77","45.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45752","CDM","270","RC","","","facility","both","","","","542.62","271.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","458","CDM","270","RC","","","facility","both","","","","20.4","10.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45844","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45855","CDM","270","RC","","","facility","both","","","","10.45","5.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45875","CDM","270","RC","","","facility","both","","","","66.88","33.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45878","CDM","270","RC","","","facility","both","","","","123.16","61.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45880","CDM","270","RC","","","facility","both","","","","135.7","67.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45882","CDM","270","RC","","","facility","both","","","","139.87","69.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45887","CDM","270","RC","","","facility","both","","","","377.04","188.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","45888","CDM","270","RC","","","facility","both","","","","411.59","205.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46055","CDM","270","RC","L4360","HCPCS","facility","both","","","","158.65","79.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46196","CDM","278","RC","C2625","HCPCS","facility","both","","","","394.73","197.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46197","CDM","278","RC","C2625","HCPCS","facility","both","","","","394.73","197.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46202","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46203","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46204","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46205","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46208","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46209","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-Fb-Removal Subcuta Tissue","46300401","CDM","361","RC","10120","HCPCS","facility","both","","","","1381","690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sp-Arthrocentes-Int Jnt W/O Us","46300407","CDM","761","RC","20605","HCPCS","facility","both","","","","846","423","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-Arthrocent-Maj Jnt W/O Us","46300408","CDM","761","RC","20610","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Sp-Arthrocentesi-Sm Jnt W/O Us","46300409","CDM","761","RC","20600","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision & Drainage Abscess Simple/Single","46300465","CDM","761","RC","10060","HCPCS","facility","both","","","","1305","652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-I+D Abscess Complex Or Mu","46300466","CDM","361","RC","10061","HCPCS","facility","both","","","","1501","750.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-Endometrial Sample/Biopsy","46300471","CDM","361","RC","58100","HCPCS","facility","both","","","","974","487","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-Aerosol Nebulization","46300472","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-Iv Inf Therapy Up To 1Hr","46300477","CDM","260","RC","96360","HCPCS","facility","both","","","","672","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj-Administration Fee","46300485","CDM","940","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","46300496","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lab-Glucose Stick/Accucheck","46300497","CDM","300","RC","82948","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy","46300550","CDM","361","RC","57452","HCPCS","facility","both","","","","2719","1359.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy With Biospy","46300551","CDM","361","RC","57454","HCPCS","facility","both","","","","1119","559.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Influenza Vaccine","46301121","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Pneumococcal Vac","46301122","CDM","771","RC","G0009","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Spec-Arthrocent-Maj Jnt W/ Us","46301132","CDM","761","RC","20611","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystoscopy","46301133","CDM","490","RC","52000","HCPCS","facility","both","","","","2864","1432","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Iud","46301135","CDM","761","RC","58300","HCPCS","facility","both","","","","442","221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Test Tb Intradermal (Sngh)","46301136","CDM","300","RC","86580","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addtl-Hepatitis","46301137","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addl-Other (Sngh)","46301138","CDM","771","RC","90472","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Debride 6 Or >Any Method (Sngh)","46301140","CDM","761","RC","11721","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervic Colp W Cervix Bx","46301142","CDM","510","RC","57455","HCPCS","facility","both","","","","4062","2031","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Drug Implant","46301143","CDM","510","RC","11982","HCPCS","facility","both","","","","1350","675","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Iud","46301144","CDM","510","RC","58301","HCPCS","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Impacted Ear Wax","46301145","CDM","510","RC","69209","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystoscopy And Treatment","46301146","CDM","361","RC","52310","HCPCS","facility","both","","","","4294","2147","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Cervix","46301147","CDM","761","RC","57500","HCPCS","facility","both","","","","3830","1915","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hysteroscopy Biopsy","46301148","CDM","490","RC","58558","HCPCS","facility","both","","","","8987","4493.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Pneumococcal Vacc Ea Add","46301151","CDM","771","RC","G0009","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Influenza Vacc Ea Addtl","46301152","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Hepatitis B Vacc","46301153","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath","46301154","CDM","360","RC","51702","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Contraceptive Device","46301155","CDM","360","RC","11976","HCPCS","facility","both","","","","2370","1185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine/Immun Inj-Other","46301156","CDM","771","RC","90471","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"App Short Leg Splint 29515","46301157","CDM","510","RC","29515","HCPCS","facility","both","","","","886","443","","","","","","","","","","","","","Gross Charge Type: Standard"
"Methotrexate Im","46301159","CDM","331","RC","96401","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punct Aspiration Skin Les","46301161","CDM","360","RC","10160","HCPCS","facility","both","","","","630","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Inj Sq_Im(Horm Anti)","46301162","CDM","331","RC","96402","HCPCS","facility","both","","","","451","225.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Fold Wedge Excision","46301163","CDM","510","RC","11765","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Drug Implant","46301167","CDM","510","RC","11981","HCPCS","facility","both","","","","2114","1057","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove/Insert Drug Implant","46301168","CDM","510","RC","11983","HCPCS","facility","both","","","","1554","777","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vulva/Perineum 1 Lesion","46301169","CDM","510","RC","56605","HCPCS","facility","both","","","","2370","1185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Vulva/Perineum Addtl Lesion","46301170","CDM","510","RC","56606","HCPCS","facility","both","","","","2467","1233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Anal Lesion Smpl,Chem","46301171","CDM","761","RC","46900","HCPCS","facility","both","","","","1290","645","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct B9 Lesion 1-14","46301172","CDM","510","RC","17110","HCPCS","facility","both","","","","274","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct Premalg Lesion","46301173","CDM","510","RC","17000","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspiration/Inj Ganglion Cyst","46301174","CDM","510","RC","20612","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Muscle Percutaneous","46301175","CDM","510","RC","20206","HCPCS","facility","both","","","","1863","931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystourethro,Cal/Dil,M/F","46301176","CDM","510","RC","52281","HCPCS","facility","both","","","","6031","3015.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","46301177","CDM","369","RC","11104","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proced Skin Mm","46301178","CDM","369","RC","17999","HCPCS","facility","both","","","","1360","680","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Init=<1Hr","46301180","CDM","260","RC","96365","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Ea Sep/Addl","46301181","CDM","369","RC","11103","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Ea Addl Lesion","46301182","CDM","369","RC","11105","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incisional Bx Single Lesion","46301183","CDM","369","RC","11106","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incisional Bx Ea Addl Lesion","46301184","CDM","369","RC","11107","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Laryngoscopy","46301185","CDM","369","RC","31575","HCPCS","facility","both","","","","785","392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare Benign Les; Sgl","46301186","CDM","369","RC","11055","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Skin Lesions 2 To 4","46301187","CDM","369","RC","11056","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Benign Hyperkerat>4","46301188","CDM","369","RC","11057","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Single Les","46301189","CDM","761","RC","11102","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg</=0.5Cm","46301190","CDM","761","RC","11420","HCPCS","facility","both","","","","3306","1653","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridmnt Selec-1St 20Sqcm/<","46301191","CDM","510","RC","97597","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Sf Mdm 15 Minutes","46301192","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fundus Photography","46301197","CDM","920","RC","92250","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Trigger Point 1/2 Muscl","46301198","CDM","761","RC","20552","HCPCS","facility","both","","","","1244","622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tixagev And Cilgav Inj","46301202","CDM","771","RC","M0220","HCPCS","facility","both","","","","150.5","75.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Les Sc < 3 Cm","46301204","CDM","761","RC","21930","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tixagev And Cilgav Inj Hm","46301205","CDM","771","RC","M0221","HCPCS","facility","both","","","","250.5","125.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystoscopy And Treatment","46301206","CDM","490","RC","52315","HCPCS","facility","both","","","","6407","3203.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avul Nail Plate Simp-1","46301207","CDM","761","RC","11730","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Nail Plate Add-On","46301208","CDM","761","RC","11732","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Hematoma Seroma/Fluid Collection","46301209","CDM","490","RC","10140","HCPCS","facility","both","","","","4270","2135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46346","CDM","270","RC","","","facility","both","","","","1514.39","757.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46379","CDM","278","RC","C1713","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","46396","CDM","270","RC","","","facility","both","","","","879.57","439.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","467","CDM","270","RC","","","facility","both","","","","20.68","10.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4706","CDM","270","RC","","","facility","both","","","","25.94","12.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","47098","CDM","270","RC","","","facility","both","","","","150.53","75.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","47168","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","47170","CDM","270","RC","","","facility","both","","","","374.99","187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","47767","CDM","270","RC","","","facility","both","","","","62.28","31.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","47821","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48014","CDM","270","RC","","","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","4824","CDM","270","RC","","","facility","both","","","","782","391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48240","CDM","270","RC","","","facility","both","","","","136.41","68.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48304","CDM","278","RC","C1768","HCPCS","facility","both","","","","1921.74","960.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48321","CDM","270","RC","","","facility","both","","","","122.12","61.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48323","CDM","272","RC","C1769","HCPCS","facility","both","","","","46.61","23.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48324","CDM","272","RC","C1769","HCPCS","facility","both","","","","59.8","29.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","48391","CDM","272","RC","C1894","HCPCS","facility","both","","","","133.54","66.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","485","CDM","278","RC","C1813","HCPCS","facility","both","","","","16686.67","8343.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49078","CDM","272","RC","C1773","HCPCS","facility","both","","","","1242","621","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49081","CDM","278","RC","C2629","HCPCS","facility","both","","","","5690.5","2845.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49082","CDM","278","RC","C2629","HCPCS","facility","both","","","","5690.5","2845.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49233","CDM","270","RC","","","facility","both","","","","21.77","10.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49989","CDM","270","RC","","","facility","both","","","","418.65","209.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49991","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","49993","CDM","270","RC","","","facility","both","","","","320.3","160.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50002","CDM","270","RC","","","facility","both","","","","784.48","392.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50004","CDM","270","RC","","","facility","both","","","","784.48","392.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50009","CDM","270","RC","","","facility","both","","","","881.77","440.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50027","CDM","270","RC","C1727","HCPCS","facility","both","","","","1232.2","616.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50269","CDM","270","RC","","","facility","both","","","","72.82","36.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50318","CDM","278","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50319","CDM","272","RC","C1894","HCPCS","facility","both","","","","86.25","43.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50320","CDM","272","RC","C1894","HCPCS","facility","both","","","","86.25","43.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50321","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50323","CDM","272","RC","C1894","HCPCS","facility","both","","","","86.25","43.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50324","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50328","CDM","272","RC","C1894","HCPCS","facility","both","","","","93.69","46.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50329","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50337","CDM","272","RC","C1894","HCPCS","facility","both","","","","30.36","15.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50345","CDM","272","RC","C1894","HCPCS","facility","both","","","","30.36","15.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50346","CDM","270","RC","","","facility","both","","","","50.6","25.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50355","CDM","272","RC","C1894","HCPCS","facility","both","","","","30.36","15.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50474","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50475","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50476","CDM","270","RC","","","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50477","CDM","270","RC","","","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50478","CDM","270","RC","","","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50486","CDM","270","RC","","","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50489","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50491","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50499","CDM","272","RC","C1769","HCPCS","facility","both","","","","48.3","24.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50503","CDM","272","RC","C1769","HCPCS","facility","both","","","","117.3","58.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50529","CDM","270","RC","C1887","HCPCS","facility","both","","","","248.4","124.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50530","CDM","270","RC","","","facility","both","","","","248.4","124.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50650","CDM","270","RC","","","facility","both","","","","42.07","21.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50653","CDM","272","RC","C1725","HCPCS","facility","both","","","","416.35","208.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50667","CDM","270","RC","","","facility","both","","","","96.6","48.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50672","CDM","270","RC","","","facility","both","","","","129.08","64.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50708","CDM","272","RC","C1769","HCPCS","facility","both","","","","239.33","119.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50909","CDM","278","RC","C1751","HCPCS","facility","both","","","","73.6","36.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","5093","CDM","270","RC","","","facility","both","","","","1011.86","505.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50962","CDM","270","RC","","","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50979","CDM","270","RC","","","facility","both","","","","29.25","14.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50980","CDM","270","RC","","","facility","both","","","","2228.2","1114.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","50986","CDM","270","RC","","","facility","both","","","","207.92","103.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51024","CDM","270","RC","","","facility","both","","","","212.87","106.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51026","CDM","270","RC","","","facility","both","","","","208.18","104.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51032","CDM","278","RC","C1768","HCPCS","facility","both","","","","4252.94","2126.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51055","CDM","278","RC","C1768","HCPCS","facility","both","","","","2163.84","1081.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51056","CDM","278","RC","C1768","HCPCS","facility","both","","","","1308.66","654.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51058","CDM","270","RC","","","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51076","CDM","272","RC","C1769","HCPCS","facility","both","","","","48.3","24.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51092","CDM","270","RC","","","facility","both","","","","76.82","38.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51145","CDM","270","RC","","","facility","both","","","","642.85","321.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51243","CDM","278","RC","C1768","HCPCS","facility","both","","","","1468.87","734.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51422","CDM","270","RC","","","facility","both","","","","1406.06","703.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51423","CDM","270","RC","","","facility","both","","","","178.48","89.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51429","CDM","278","RC","C1713","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51433","CDM","270","RC","","","facility","both","","","","146.49","73.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51436","CDM","270","RC","","","facility","both","","","","1768.2","884.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51437","CDM","270","RC","","","facility","both","","","","2041.71","1020.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51442","CDM","270","RC","","","facility","both","","","","282.21","141.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51443","CDM","270","RC","","","facility","both","","","","488.11","244.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51519","CDM","272","RC","C1884","HCPCS","facility","both","","","","1084.27","542.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51540","CDM","278","RC","C1887","HCPCS","facility","both","","","","2101.7","1050.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51576","CDM","278","RC","C1713","HCPCS","facility","both","","","","1840","920","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51625","CDM","270","RC","","","facility","both","","","","147.2","73.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51627","CDM","270","RC","","","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51630","CDM","270","RC","","","facility","both","","","","146.83","73.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51646","CDM","270","RC","","","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51767","CDM","270","RC","","","facility","both","","","","19.96","9.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51768","CDM","270","RC","","","facility","both","","","","1726.33","863.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51773","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51774","CDM","270","RC","","","facility","both","","","","294.17","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51804","CDM","270","RC","","","facility","both","","","","87.4","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51809","CDM","270","RC","","","facility","both","","","","10.07","5.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51815","CDM","270","RC","","","facility","both","","","","48.35","24.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51824","CDM","270","RC","","","facility","both","","","","193.04","96.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51827","CDM","270","RC","","","facility","both","","","","5.4","2.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51837","CDM","270","RC","","","facility","both","","","","39.43","19.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51849","CDM","270","RC","","","facility","both","","","","448.64","224.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51850","CDM","270","RC","","","facility","both","","","","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51851","CDM","270","RC","","","facility","both","","","","13.91","6.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51854","CDM","270","RC","","","facility","both","","","","8.81","4.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51860","CDM","270","RC","","","facility","both","","","","11.13","5.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51980","CDM","272","RC","C1894","HCPCS","facility","both","","","","1288","644","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","51982","CDM","270","RC","","","facility","both","","","","476.33","238.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52002","CDM","270","RC","","","facility","both","","","","166.55","83.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52003","CDM","270","RC","","","facility","both","","","","142.26","71.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52004","CDM","270","RC","","","facility","both","","","","118.86","59.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52006","CDM","270","RC","","","facility","both","","","","84.79","42.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52007","CDM","270","RC","","","facility","both","","","","131.39","65.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52030","CDM","278","RC","C1751","HCPCS","facility","both","","","","6.9","3.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52032","CDM","272","RC","C1751","HCPCS","facility","both","","","","21.05","10.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52034","CDM","272","RC","C1751","HCPCS","facility","both","","","","6.9","3.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52213","CDM","272","RC","C1894","HCPCS","facility","both","","","","86.26","43.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52224","CDM","272","RC","C1725","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52265","CDM","272","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52268","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52427","CDM","270","RC","","","facility","both","","","","109.33","54.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52430","CDM","270","RC","","","facility","both","","","","191.11","95.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52431","CDM","270","RC","","","facility","both","","","","256.94","128.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52432","CDM","270","RC","","","facility","both","","","","192.19","96.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52440","CDM","270","RC","","","facility","both","","","","382.57","191.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52490","CDM","270","RC","","","facility","both","","","","186.21","93.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52542","CDM","272","RC","C1725","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52546","CDM","272","RC","C1725","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52557","CDM","272","RC","C1729","HCPCS","facility","both","","","","17.53","8.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52581","CDM","270","RC","","","facility","both","","","","102.65","51.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52585","CDM","270","RC","","","facility","both","","","","141.77","70.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52599","CDM","270","RC","","","facility","both","","","","283.1","141.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","527","CDM","270","RC","","","facility","both","","","","18.98","9.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52728","CDM","272","RC","C1729","HCPCS","facility","both","","","","93.47","46.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52730","CDM","272","RC","C1729","HCPCS","facility","both","","","","33.59","16.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52732","CDM","272","RC","C1729","HCPCS","facility","both","","","","33.63","16.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52733","CDM","272","RC","C1729","HCPCS","facility","both","","","","32.99","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52734","CDM","272","RC","C1729","HCPCS","facility","both","","","","33.01","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52735","CDM","272","RC","C1729","HCPCS","facility","both","","","","55.84","27.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52736","CDM","272","RC","C1729","HCPCS","facility","both","","","","33.18","16.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52737","CDM","272","RC","C1729","HCPCS","facility","both","","","","33.95","16.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52740","CDM","272","RC","C1729","HCPCS","facility","both","","","","34.55","17.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52741","CDM","272","RC","C1729","HCPCS","facility","both","","","","34.8","17.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52742","CDM","272","RC","C1729","HCPCS","facility","both","","","","34.55","17.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52746","CDM","272","RC","C1729","HCPCS","facility","both","","","","54.51","27.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52748","CDM","272","RC","C1729","HCPCS","facility","both","","","","56.79","28.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52749","CDM","272","RC","C1729","HCPCS","facility","both","","","","56.79","28.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52750","CDM","270","RC","","","facility","both","","","","15.71","7.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52767","CDM","270","RC","","","facility","both","","","","130.82","65.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52776","CDM","270","RC","","","facility","both","","","","7780.5","3890.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52782","CDM","270","RC","","","facility","both","","","","7780.5","3890.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52789","CDM","270","RC","","","facility","both","","","","178.94","89.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52794","CDM","270","RC","","","facility","both","","","","289.8","144.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52795","CDM","270","RC","","","facility","both","","","","289.8","144.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52817","CDM","272","RC","C1729","HCPCS","facility","both","","","","71.23","35.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52830","CDM","270","RC","","","facility","both","","","","241.32","120.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52850","CDM","270","RC","","","facility","both","","","","46.32","23.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52858","CDM","270","RC","","","facility","both","","","","300.63","150.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52861","CDM","272","RC","C1753","HCPCS","facility","both","","","","1625","812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52863","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52881","CDM","272","RC","C1894","HCPCS","facility","both","","","","31.74","15.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52986","CDM","270","RC","","","facility","both","","","","123.14","61.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","52998","CDM","272","RC","C1757","HCPCS","facility","both","","","","383.92","191.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53084","CDM","272","RC","C1769","HCPCS","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53085","CDM","272","RC","C1769","HCPCS","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53091","CDM","270","RC","","","facility","both","","","","133.26","66.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53095","CDM","270","RC","","","facility","both","","","","143.61","71.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53119","CDM","270","RC","","","facility","both","","","","135.02","67.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53153","CDM","270","RC","","","facility","both","","","","255.77","127.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53178","CDM","270","RC","L3670","HCPCS","facility","both","","","","300.98","150.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53198","CDM","272","RC","C1729","HCPCS","facility","both","","","","54.9","27.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53209","CDM","272","RC","C1729","HCPCS","facility","both","","","","54.95","27.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53219","CDM","272","RC","C1729","HCPCS","facility","both","","","","32.84","16.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53304","CDM","272","RC","C1729","HCPCS","facility","both","","","","55.84","27.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53305","CDM","272","RC","C1729","HCPCS","facility","both","","","","670.13","335.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53312","CDM","272","RC","C1729","HCPCS","facility","both","","","","33.95","16.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53319","CDM","270","RC","","","facility","both","","","","1559.75","779.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53321","CDM","270","RC","","","facility","both","","","","1551.01","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53383","CDM","270","RC","","","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53393","CDM","272","RC","C1769","HCPCS","facility","both","","","","447.17","223.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53400","CDM","270","RC","","","facility","both","","","","88.18","44.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","5342","CDM","270","RC","","","facility","both","","","","101.77","50.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53455","CDM","272","RC","C1894","HCPCS","facility","both","","","","607.57","303.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53466","CDM","272","RC","C1894","HCPCS","facility","both","","","","382.72","191.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53539","CDM","270","RC","","","facility","both","","","","465.29","232.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53559","CDM","270","RC","","","facility","both","","","","425.5","212.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","536","CDM","270","RC","","","facility","both","","","","2115.77","1057.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53691","CDM","272","RC","C1729","HCPCS","facility","both","","","","775.1","387.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53708","CDM","270","RC","","","facility","both","","","","613.09","306.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53711","CDM","270","RC","","","facility","both","","","","595.98","297.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53720","CDM","270","RC","","","facility","both","","","","593.54","296.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53722","CDM","270","RC","","","facility","both","","","","488.38","244.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53739","CDM","270","RC","","","facility","both","","","","441.83","220.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53744","CDM","270","RC","","","facility","both","","","","585.72","292.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53745","CDM","270","RC","","","facility","both","","","","585.72","292.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53746","CDM","270","RC","","","facility","both","","","","613.09","306.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53795","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53796","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53798","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","53873","CDM","270","RC","","","facility","both","","","","70.43","35.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54283","CDM","272","RC","C1769","HCPCS","facility","both","","","","563.56","281.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54321","CDM","270","RC","","","facility","both","","","","46.37","23.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54322","CDM","270","RC","","","facility","both","","","","2.4","1.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54323","CDM","270","RC","","","facility","both","","","","4.02","2.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54324","CDM","270","RC","","","facility","both","","","","31.28","15.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54326","CDM","270","RC","","","facility","both","","","","20.15","10.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","54329","CDM","270","RC","","","facility","both","","","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","54339","CDM","272","RC","C1725","HCPCS","facility","both","","","","1101.33","550.66","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","54881","CDM","270","RC","","","facility","both","","","","47.65","23.82","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","55016","CDM","270","RC","","","facility","both","","","","318.46","159.23","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","55127","CDM","272","RC","C1769","HCPCS","facility","both","","","","94.9","47.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","55151","CDM","278","RC","C1713","HCPCS","facility","both","","","","2460.5","1230.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","55177","CDM","278","RC","C1713","HCPCS","facility","both","","","","437","218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","56350","CDM","270","RC","","","facility","both","","","","250.52","125.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","5663","CDM","270","RC","L3670","HCPCS","facility","both","","","","39.37","19.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","56643","CDM","270","RC","","","facility","both","","","","373.76","186.88","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","57075","CDM","270","RC","","","facility","both","","","","15.65","7.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","57288","CDM","270","RC","","","facility","both","","","","372.84","186.42","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","57822","CDM","272","RC","C1894","HCPCS","facility","both","","","","50.6","25.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","57874","CDM","270","RC","","","facility","both","","","","178.93","89.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","57964","CDM","278","RC","C1894","HCPCS","facility","both","","","","211.32","105.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58080","CDM","278","RC","C1713","HCPCS","facility","both","","","","11435.42","5717.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58091","CDM","278","RC","C1713","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58434","CDM","270","RC","","","facility","both","","","","1149.82","574.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58465","CDM","270","RC","C1729","HCPCS","facility","both","","","","82.57","41.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","5856","CDM","272","RC","C1894","HCPCS","facility","both","","","","326.51","163.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58562","CDM","270","RC","","","facility","both","","","","24.52","12.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58823","CDM","270","RC","","","facility","both","","","","372.71","186.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","58914","CDM","272","RC","C1887","HCPCS","facility","both","","","","63.48","31.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","5895","CDM","272","RC","C1892","HCPCS","facility","both","","","","1255.8","627.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59031","CDM","270","RC","","","facility","both","","","","52.28","26.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59032","CDM","270","RC","","","facility","both","","","","50.51","25.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59175","CDM","270","RC","","","facility","both","","","","212.36","106.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59179","CDM","270","RC","","","facility","both","","","","38.93","19.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59257","CDM","278","RC","C1713","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59582","CDM","270","RC","","","facility","both","","","","14.44","7.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59860","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","59909","CDM","272","RC","C1769","HCPCS","facility","both","","","","62.31","31.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60038","CDM","270","RC","","","facility","both","","","","415.38","207.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60044","CDM","270","RC","","","facility","both","","","","193.2","96.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60045","CDM","270","RC","","","facility","both","","","","98.21","49.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60051","CDM","270","RC","","","facility","both","","","","448.64","224.32","","","","","","","","","","","","","Gross Charge Type: Standard"
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"Noncdm Charge Record Medical Supplies","60196","CDM","270","RC","","","facility","both","","","","14.37","7.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60197","CDM","270","RC","","","facility","both","","","","10.91","5.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60198","CDM","270","RC","","","facility","both","","","","38.92","19.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60213","CDM","270","RC","","","facility","both","","","","11.06","5.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60219","CDM","270","RC","","","facility","both","","","","42.58","21.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60220","CDM","270","RC","","","facility","both","","","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60225","CDM","270","RC","","","facility","both","","","","8.22","4.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60240","CDM","272","RC","C1729","HCPCS","facility","both","","","","56.53","28.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60243","CDM","272","RC","C1729","HCPCS","facility","both","","","","73.2","36.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60244","CDM","272","RC","C1729","HCPCS","facility","both","","","","56.63","28.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60248","CDM","272","RC","C1729","HCPCS","facility","both","","","","72.08","36.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60255","CDM","270","RC","","","facility","both","","","","7.27","3.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60281","CDM","270","RC","","","facility","both","","","","1612.96","806.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60697","CDM","270","RC","","","facility","both","","","","171.87","85.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60699","CDM","270","RC","","","facility","both","","","","264.51","132.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60701","CDM","270","RC","","","facility","both","","","","248.44","124.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60702","CDM","270","RC","","","facility","both","","","","193.67","96.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","60788","CDM","270","RC","","","facility","both","","","","58.65","29.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","610","CDM","270","RC","","","facility","both","","","","319.24","159.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61232","CDM","270","RC","","","facility","both","","","","112.23","56.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61233","CDM","270","RC","","","facility","both","","","","1102.76","551.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61234","CDM","270","RC","","","facility","both","","","","1152.84","576.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61344","CDM","272","RC","C1726","HCPCS","facility","both","","","","1919","959.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61369","CDM","270","RC","","","facility","both","","","","90.69","45.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61414","CDM","270","RC","","","facility","both","","","","15.79","7.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61426","CDM","272","RC","C1751","HCPCS","facility","both","","","","6.9","3.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61521","CDM","270","RC","","","facility","both","","","","1849.39","924.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61530","CDM","270","RC","","","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61556","CDM","278","RC","C1762","HCPCS","facility","both","","","","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61650","CDM","272","RC","C1894","HCPCS","facility","both","","","","86.26","43.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61653","CDM","270","RC","C1894","HCPCS","facility","both","","","","30.36","15.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","61916","CDM","270","RC","","","facility","both","","","","27.93","13.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","6199","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","6203","CDM","270","RC","","","facility","both","","","","12.9","6.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62039","CDM","270","RC","","","facility","both","","","","5.59","2.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62079","CDM","278","RC","C1768","HCPCS","facility","both","","","","1468.87","734.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62224","CDM","270","RC","","","facility","both","","","","500.71","250.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62229","CDM","270","RC","","","facility","both","","","","403.65","201.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62392","CDM","272","RC","C1769","HCPCS","facility","both","","","","40.23","20.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62497","CDM","272","RC","C1769","HCPCS","facility","both","","","","55.18","27.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","62779","CDM","270","RC","B4087","HCPCS","facility","both","","","","102.43","51.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63029","CDM","278","RC","C1713","HCPCS","facility","both","","","","501.4","250.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63074","CDM","270","RC","","","facility","both","","","","67.85","33.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63075","CDM","270","RC","","","facility","both","","","","62.42","31.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63076","CDM","270","RC","","","facility","both","","","","62.42","31.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","631","CDM","270","RC","","","facility","both","","","","20.32","10.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63186","CDM","272","RC","C1758","HCPCS","facility","both","","","","41.69","20.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63187","CDM","270","RC","L0120","HCPCS","facility","both","","","","30.04","15.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63202","CDM","272","RC","C1769","HCPCS","facility","both","","","","573.16","286.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63214","CDM","270","RC","L3670","HCPCS","facility","both","","","","190.85","95.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63216","CDM","270","RC","","","facility","both","","","","470.3","235.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63250","CDM","270","RC","","","facility","both","","","","524.62","262.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63266","CDM","270","RC","","","facility","both","","","","577.53","288.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63267","CDM","270","RC","","","facility","both","","","","513.23","256.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63278","CDM","270","RC","","","facility","both","","","","24.2","12.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63292","CDM","270","RC","","","facility","both","","","","3.42","1.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63294","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63296","CDM","270","RC","","","facility","both","","","","297.07","148.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63332","CDM","270","RC","","","facility","both","","","","3.64","1.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63485","CDM","270","RC","","","facility","both","","","","506","253","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63516","CDM","278","RC","C1713","HCPCS","facility","both","","","","588.8","294.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63535","CDM","270","RC","","","facility","both","","","","1738.8","869.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63615","CDM","270","RC","","","facility","both","","","","167.39","83.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63716","CDM","270","RC","","","facility","both","","","","156.4","78.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63727","CDM","270","RC","","","facility","both","","","","381.8","190.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63734","CDM","270","RC","","","facility","both","","","","266.57","133.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63799","CDM","270","RC","","","facility","both","","","","88.16","44.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63814","CDM","270","RC","","","facility","both","","","","250.52","125.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63906","CDM","278","RC","C1713","HCPCS","facility","both","","","","2049.21","1024.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","63936","CDM","278","RC","C1713","HCPCS","facility","both","","","","2139","1069.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64015","CDM","278","RC","C1713","HCPCS","facility","both","","","","364.32","182.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64022","CDM","278","RC","C1713","HCPCS","facility","both","","","","207.64","103.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64023","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64024","CDM","278","RC","C1713","HCPCS","facility","both","","","","83.17","41.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64031","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.72","227.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64032","CDM","278","RC","C1713","HCPCS","facility","both","","","","518.89","259.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64033","CDM","278","RC","C1713","HCPCS","facility","both","","","","484.99","242.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64034","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.72","227.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64035","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.72","227.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64036","CDM","278","RC","C1713","HCPCS","facility","both","","","","512.84","256.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64039","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.72","227.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64040","CDM","278","RC","C1713","HCPCS","facility","both","","","","571.87","285.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64042","CDM","278","RC","C1713","HCPCS","facility","both","","","","571.87","285.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64043","CDM","278","RC","C1713","HCPCS","facility","both","","","","571.87","285.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64044","CDM","278","RC","C1713","HCPCS","facility","both","","","","571.87","285.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64045","CDM","278","RC","C1713","HCPCS","facility","both","","","","571.87","285.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64046","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.72","227.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64049","CDM","278","RC","C1713","HCPCS","facility","both","","","","455.72","227.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64063","CDM","270","RC","","","facility","both","","","","71.81","35.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64249","CDM","270","RC","","","facility","both","","","","661.2","330.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64359","CDM","278","RC","C1713","HCPCS","facility","both","","","","1172.08","586.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64360","CDM","278","RC","C1713","HCPCS","facility","both","","","","1337.38","668.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64532","CDM","278","RC","C1763","HCPCS","facility","both","","","","2139","1069.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64683","CDM","270","RC","","","facility","both","","","","644.24","322.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64684","CDM","270","RC","","","facility","both","","","","725.44","362.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64887","CDM","270","RC","","","facility","both","","","","118.21","59.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","64888","CDM","270","RC","","","facility","both","","","","135.7","67.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65034","CDM","278","RC","C1713","HCPCS","facility","both","","","","1262.88","631.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65059","CDM","270","RC","","","facility","both","","","","71.35","35.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65174","CDM","270","RC","","","facility","both","","","","1282.7","641.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65229","CDM","270","RC","","","facility","both","","","","312.8","156.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65261","CDM","278","RC","C1713","HCPCS","facility","both","","","","12710.07","6355.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65360","CDM","278","RC","C1713","HCPCS","facility","both","","","","610.93","305.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65362","CDM","278","RC","C1713","HCPCS","facility","both","","","","620.86","310.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65381","CDM","278","RC","C1713","HCPCS","facility","both","","","","658.67","329.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65427","CDM","278","RC","C1713","HCPCS","facility","both","","","","1827.95","913.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65444","CDM","278","RC","C1713","HCPCS","facility","both","","","","61.49","30.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65463","CDM","270","RC","","","facility","both","","","","350.8","175.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65499","CDM","270","RC","","","facility","both","","","","1548.79","774.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65707","CDM","270","RC","","","facility","both","","","","598.53","299.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65708","CDM","270","RC","","","facility","both","","","","661.2","330.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65709","CDM","270","RC","","","facility","both","","","","605.59","302.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","65805","CDM","272","RC","C1769","HCPCS","facility","both","","","","87.4","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","6586","CDM","270","RC","","","facility","both","","","","14.31","7.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66017","CDM","270","RC","L3670","HCPCS","facility","both","","","","27.28","13.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66140","CDM","272","RC","C1769","HCPCS","facility","both","","","","94.9","47.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66164","CDM","270","RC","","","facility","both","","","","297.07","148.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66167","CDM","278","RC","Q4116","HCPCS","facility","both","","","","202.48","101.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66680","CDM","270","RC","","","facility","both","","","","8.79","4.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66681","CDM","270","RC","","","facility","both","","","","64.17","32.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","6669","CDM","270","RC","","","facility","both","","","","23.35","11.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66731","CDM","270","RC","","","facility","both","","","","38.87","19.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66735","CDM","270","RC","","","facility","both","","","","65.91","32.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66741","CDM","270","RC","","","facility","both","","","","14.14","7.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66746","CDM","270","RC","","","facility","both","","","","10.12","5.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66748","CDM","270","RC","","","facility","both","","","","9.26","4.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66758","CDM","270","RC","","","facility","both","","","","777.4","388.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66879","CDM","278","RC","C1713","HCPCS","facility","both","","","","1796.94","898.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66969","CDM","272","RC","C1729","HCPCS","facility","both","","","","39.93","19.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","66985","CDM","270","RC","","","facility","both","","","","1251.84","625.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67020","CDM","270","RC","","","facility","both","","","","849.09","424.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67103","CDM","270","RC","","","facility","both","","","","36.12","18.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67105","CDM","270","RC","","","facility","both","","","","19.89","9.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67177","CDM","270","RC","","","facility","both","","","","119.6","59.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67200","CDM","270","RC","","","facility","both","","","","1330.5","665.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","673","CDM","270","RC","","","facility","both","","","","34.74","17.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67346","CDM","278","RC","C1725","HCPCS","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67603","CDM","272","RC","C1773","HCPCS","facility","both","","","","1242","621","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67632","CDM","270","RC","C1713","HCPCS","facility","both","","","","322","161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67648","CDM","278","RC","C1713","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67649","CDM","270","RC","","","facility","both","","","","538.2","269.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67650","CDM","278","RC","C1713","HCPCS","facility","both","","","","506","253","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67652","CDM","270","RC","","","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","67703","CDM","270","RC","","","facility","both","","","","1277.63","638.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68125","CDM","270","RC","","","facility","both","","","","130.6","65.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68464","CDM","272","RC","C1769","HCPCS","facility","both","","","","271.4","135.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68573","CDM","272","RC","C1769","HCPCS","facility","both","","","","107.23","53.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68594","CDM","272","RC","C1769","HCPCS","facility","both","","","","46.76","23.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68677","CDM","270","RC","","","facility","both","","","","70.98","35.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68782","CDM","272","RC","C1769","HCPCS","facility","both","","","","213.61","106.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","68872","CDM","278","RC","C1760","HCPCS","facility","both","","","","1361.04","680.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","691","CDM","270","RC","","","facility","both","","","","22.36","11.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","692","CDM","270","RC","","","facility","both","","","","286.53","143.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69384","CDM","270","RC","","","facility","both","","","","353.97","176.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69466","CDM","278","RC","C1772","HCPCS","facility","both","","","","21707.66","10853.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69480","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69481","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69495","CDM","272","RC","C1894","HCPCS","facility","both","","","","86.25","43.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69548","CDM","270","RC","","","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69550","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69606","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69610","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69611","CDM","270","RC","C1887","HCPCS","facility","both","","","","39.1","19.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","6963","CDM","278","RC","C1781","HCPCS","facility","both","","","","161.54","80.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","697","CDM","270","RC","","","facility","both","","","","278.85","139.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69799","CDM","272","RC","C1887","HCPCS","facility","both","","","","58.19","29.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69805","CDM","272","RC","C1769","HCPCS","facility","both","","","","784.23","392.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69808","CDM","270","RC","","","facility","both","","","","609.41","304.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69817","CDM","272","RC","C1769","HCPCS","facility","both","","","","686.5","343.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","69866","CDM","270","RC","","","facility","both","","","","35.54","17.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70055","CDM","272","RC","A6257","HCPCS","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70057","CDM","272","RC","A6258","HCPCS","facility","both","","","","4.13","2.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70059","CDM","272","RC","A6257","HCPCS","facility","both","","","","4.37","2.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oxygen/Day","70100001","CDM","270","RC","","","facility","both","","","","238","119","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resuscitation Per Event","70100002","CDM","480","RC","92950","HCPCS","facility","both","","","","1883","941.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70100003","CDM","460","RC","94799","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70100004","CDM","460","RC","94799","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpap Treatment","70100006","CDM","410","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulse Oximetry Cont","70100007","CDM","460","RC","94762","HCPCS","facility","both","","","","688","344","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulse Oximetry Spot Check","70100008","CDM","460","RC","94760","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpap Sleep Apnea/Day","70100010","CDM","410","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ippb Initial","70100011","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ippb Subsequent","70100012","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vent Adult-Subsequent Day","70100014","CDM","410","RC","94003","HCPCS","facility","both","","","","2900","1450","","","","","","","","","","","","","Gross Charge Type: Standard"
"Respiratory Critical Care Rec","70100015","CDM","410","RC","","","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chest Pt Subsequent","70100016","CDM","410","RC","94668","HCPCS","facility","both","","","","198","99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diffusion Studies","70100019","CDM","460","RC","94729","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer Hh Tx Initial","70100027","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer Hh Tx Subsequent","70100028","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer Treatment Vent Initi","70100029","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer Inline Tx Subseq","70100030","CDM","410","RC","94640","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70100055","CDM","410","RC","94799","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sputum Induction","70100061","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70100067","CDM","410","RC","","","facility","both","","","","257","128.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70100085","CDM","410","RC","94799","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mid Inline T.X.","70100095","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Delivery Assist Per Half Hour","70100110","CDM","410","RC","99464","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infant Resp Assist Whoc","70100112","CDM","410","RC","99465","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chest Physiotherapy Initial","70100116","CDM","410","RC","94667","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aerosol/Day","70100158","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipap/Cpap","70100191","CDM","410","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nitric Oxide Ther Per Hr","70100200","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hyperbaric/Ventilator Appl","70100204","CDM","410","RC","94002","HCPCS","facility","both","","","","2593","1296.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70100368","CDM","460","RC","94799","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surfactant Administration","70100370","CDM","410","RC","94610","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Metered Dose Inhaler Treatment","70100383","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulized Pentamidine Tx","70100385","CDM","410","RC","94642","HCPCS","facility","both","","","","420","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acapella Initial","70100400","CDM","410","RC","94667","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acapella Subseqent","70100401","CDM","410","RC","94668","HCPCS","facility","both","","","","198","99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aerosol Prostacyclin Daly","70100520","CDM","460","RC","94799","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Continuous Inhal Tn Tx-1St Hr","70100700","CDM","410","RC","94644","HCPCS","facility","both","","","","486","243","","","","","","","","","","","","","Gross Charge Type: Standard"
"Continuous Inhatn Tx-Addtl Hr","70100701","CDM","410","RC","94645","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Highflow Nas Cann 1St Day","70100800","CDM","270","RC","","","facility","both","","","","525.7","262.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Highflow Nas Cann Sb Day","70100801","CDM","270","RC","","","facility","both","","","","506.08","253.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpap Neonatal-Sub Day","70100900","CDM","410","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oxyhood Neonatal Per Day","70100903","CDM","270","RC","","","facility","both","","","","333.27","166.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpap Neonatal 1St Day","70100950","CDM","410","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Misc Respiratory Procedure","70100998","CDM","410","RC","94799","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vent Adult 1St Day","70101002","CDM","410","RC","94002","HCPCS","facility","both","","","","3300","1650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spontaneous Heliox 1St Day","70101100","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spontaneous Subseq Days","70101101","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vent Initial Heox 1St Day","70101112","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vent Heox-Subsequent Day","70101113","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Metered Dose Inhaler Tx Initial","70101383","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ventilator Neonate-1St Day","70101385","CDM","410","RC","94002","HCPCS","facility","both","","","","2593","1296.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vent Neonate- Subseq Day","70101386","CDM","410","RC","94003","HCPCS","facility","both","","","","2215","1107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrapulmonary Secretion Clearance","70101390","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrapulmonary Secretion Clearance","70101391","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrapulmonary Secretion Clearance","70101392","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrapulmonary Secretion Clearance","70101393","CDM","410","RC","94640","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry W/Bronchodil","70200001","CDM","460","RC","94060","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry W/O Broncho","70200002","CDM","460","RC","94010","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Npt","70200006","CDM","920","RC","54250","HCPCS","facility","both","","","","913","456.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pfs Complete W/O Bronc","70200013","CDM","460","RC","94010","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin Atp","70200020","CDM","300","RC","85018","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pfs Complete W/Bronchodilator","70200025","CDM","460","RC","94060","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hast","70200027","CDM","460","RC","94452","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Hast W/ Oxygen","70200028","CDM","460","RC","94453","HCPCS","facility","both","","","","696","348","","","","","","","","","","","","","Gross Charge Type: Standard"
"A-Line Insertion","70200033","CDM","361","RC","36620","HCPCS","facility","both","","","","1994","997","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry Bedside","70200038","CDM","460","RC","94010","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Airway Provocation Test","70200044","CDM","460","RC","94070","HCPCS","facility","both","","","","1531","765.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Raw/Vtg/Cl/Ct","70200045","CDM","460","RC","94726","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Calorimetry Indirect","70200050","CDM","460","RC","94681","HCPCS","facility","both","","","","819","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fick Cardiac Output","70200060","CDM","460","RC","94690","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulm Stress Test Incomplete","70200068","CDM","460","RC","94799","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bal Mini Non-Fiberoptic","70200075","CDM","460","RC","94799","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Raw/Vtg W Bronch","70200080","CDM","921","RC","94726","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg/Bbtg/R","70200089","CDM","730","RC","93005","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulse Oximetry Multiple Determ","70200090","CDM","460","RC","94761","HCPCS","facility","both","","","","688","344","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipap/Capa","70200091","CDM","460","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","70200096","CDM","460","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mip/Mep Determination","70200097","CDM","460","RC","94010","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Mslt","70200200","CDM","740","RC","95805","HCPCS","facility","both","","","","2936","1468","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Apnea/Narco","70200201","CDM","920","RC","95810","HCPCS","facility","both","","","","4376","2188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Cpap/Bipap","70200205","CDM","740","RC","95811","HCPCS","facility","both","","","","5908","2954","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep  Study Apnea&Eeg","70200210","CDM","920","RC","95810","HCPCS","facility","both","","","","4376","2188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Cpap Titration-Red Svc","70200215","CDM","920","RC","95811","HCPCS","facility","both","","","","2049","1024.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study-Reduce Svc","70200217","CDM","920","RC","95810","HCPCS","facility","both","","","","4376","2188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maintenance Wakefulness Test","70200219","CDM","740","RC","95805","HCPCS","facility","both","","","","2936","1468","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phys Contr Type Iii Hst","70200225","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Markers","70200226","CDM","490","RC","31626","HCPCS","facility","both","","","","15455","7727.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Pulse Oxim","70200335","CDM","460","RC","94762","HCPCS","facility","both","","","","688","344","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","70200365","CDM","460","RC","94799","HCPCS","facility","both","","","","491","245.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bronchoscopy, Diagnostic","70200376","CDM","361","RC","","","facility","both","","","","1007","503.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frc By Nitrogen Washout","70200377","CDM","460","RC","94727","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulm Stress Test Complex","70200401","CDM","460","RC","94621","HCPCS","facility","both","","","","3068","1534","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc Pleural Drain-Endo Suite","70200450","CDM","360","RC","","","facility","both","","","","6765","3382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy-Endo Suite","70200451","CDM","360","RC","","","facility","both","","","","5362","2681","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Wash","70200452","CDM","490","RC","31622","HCPCS","facility","both","","","","4065","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch/Brush-Bedside","70200453","CDM","490","RC","31623","HCPCS","facility","both","","","","4065","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch/Alveolar Lavage-Bedside","70200454","CDM","490","RC","31624","HCPCS","facility","both","","","","4065","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch/Bronch Bx(S)-Bedside","70200455","CDM","490","RC","31625","HCPCS","facility","both","","","","4065","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch/Needle Aspir Bxs Bedside","70200457","CDM","490","RC","31629","HCPCS","facility","both","","","","8342","4171","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Cessation Vt>10 Mi","70200501","CDM","942","RC","99407","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Unatt&Resp Efft","70200600","CDM","920","RC","95806","HCPCS","facility","both","","","","1014","507","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slp Stdy Unatnd W/Hrt Rate/O2 Sat/Resp/Slp Time","70200700","CDM","920","RC","95800","HCPCS","facility","both","","","","966","483","","","","","","","","","","","","","Gross Charge Type: Standard"
"Misc Pulmonary Procer","70200999","CDM","460","RC","94799","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neo Airway Box","70202024","CDM","270","RC","","","facility","both","","","","428","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulmonary Stress Testing","70202025","CDM","460","RC","94618","HCPCS","facility","both","","","","696","348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Tst Brncspsm","70202026","CDM","460","RC","94617","HCPCS","facility","both","","","","696","348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study; Attended","70202027","CDM","920","RC","95807","HCPCS","facility","both","","","","2338","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","703","CDM","270","RC","","","facility","both","","","","300.09","150.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Awake","70300001","CDM","740","RC","95816","HCPCS","facility","both","","","","1074","537","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Asleep Or Coma","70300002","CDM","740","RC","95822","HCPCS","facility","both","","","","2239","1119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Awake And Asleep","70300003","CDM","740","RC","95819","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg-Ver","70300013","CDM","922","RC","95930","HCPCS","facility","both","","","","754","377","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg-Nonintracranial Monit.","70300015","CDM","740","RC","95955","HCPCS","facility","both","","","","1498","749","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Cerebral Death Eval","70300021","CDM","740","RC","95824","HCPCS","facility","both","","","","804","402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hearing Aid Fitting & Orient","70300034","CDM","470","RC","92591","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Modify Voice Prosthesis","70300047","CDM","440","RC","92597","HCPCS","facility","both","","","","339","169.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eval Voice Prosthe Use/Fit","70300048","CDM","440","RC","92597","HCPCS","facility","both","","","","908","454","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imped New: Acoustic Reflex","70300065","CDM","471","RC","92568","HCPCS","facility","both","","","","291","145.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oae-Simple","70300067","CDM","471","RC","92587","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oae-Complex","70300068","CDM","471","RC","92588","HCPCS","facility","both","","","","575","287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aep Thrshld Est Mlt Freq I&R","70300076","CDM","471","RC","92652","HCPCS","facility","both","","","","1833","916.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aep Neurodiagnostic I&R","70300077","CDM","471","RC","92653","HCPCS","facility","both","","","","1833","916.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-1 Extremity","70300120","CDM","922","RC","95860","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-2 Extremities","70300121","CDM","922","RC","95861","HCPCS","facility","both","","","","493","246.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-3 Extremities","70300122","CDM","922","RC","95863","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-4 Extremities","70300123","CDM","922","RC","95864","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-Cranial Nerve Unilat","70300124","CDM","922","RC","95867","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg - Cranial Bilateral","70300125","CDM","922","RC","95868","HCPCS","facility","both","","","","897","448.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Limitied Study","70300126","CDM","922","RC","95869","HCPCS","facility","both","","","","294","147","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrocorticogram In O.R.","70300133","CDM","740","RC","95829","HCPCS","facility","both","","","","1687","843.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg-Sser Upper","70300157","CDM","922","RC","95925","HCPCS","facility","both","","","","1432","716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg-Sser Lower","70300158","CDM","922","RC","95926","HCPCS","facility","both","","","","1432","716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Auditory Func Eval.Initl 60Min","70300170","CDM","471","RC","92620","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Auditory Function Ea.Add 15Min","70300171","CDM","471","RC","92621","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eval Aud. Status Rehab Ea. 15Min","70300173","CDM","470","RC","92627","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aud Rehab Pre-Ling Hear Loss","70300174","CDM","470","RC","92630","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Function Cortical Mapp To 1 Hr","70300180","CDM","740","RC","95961","HCPCS","facility","both","","","","1343","671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Funct Cort Ea Addtl Hr","70300182","CDM","740","RC","95962","HCPCS","facility","both","","","","1343","671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg Limited Study 1 Ext","70300183","CDM","922","RC","95870","HCPCS","facility","both","","","","369","184.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Extend Monito 41-60 Mins","70300185","CDM","740","RC","95812","HCPCS","facility","both","","","","573","286.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Digital Anal Eeg Spike","70300186","CDM","740","RC","95957","HCPCS","facility","both","","","","926","463","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Extend Greater Than 1Hr","70300187","CDM","740","RC","95813","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wada Activation","70300198","CDM","740","RC","95958","HCPCS","facility","both","","","","1143","571.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction Studies 1-2 Studies","70300210","CDM","922","RC","95907","HCPCS","facility","both","","","","584","292","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction,5-6 Studies","70300212","CDM","922","RC","95909","HCPCS","facility","both","","","","838","419","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction,7-8 Studies","70300213","CDM","922","RC","95910","HCPCS","facility","both","","","","952","476","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction,9-10 Studies","70300214","CDM","922","RC","95911","HCPCS","facility","both","","","","1205","602.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction Studies 13/> Studies","70300216","CDM","922","RC","95913","HCPCS","facility","both","","","","1731","865.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Op Assist Or 15 Min","70300217","CDM","740","RC","95940","HCPCS","facility","both","","","","220","110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Op Tech,Non Or Per Hour","70300218","CDM","740","RC","95941","HCPCS","facility","both","","","","840","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg Anal Sphincter","70300250","CDM","761","RC","51785","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Optokineic Nystagamus Test","70300260","CDM","471","RC","92544","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Posturagraphy Comptrzd Dynamic","70300261","CDM","470","RC","92548","HCPCS","facility","both","","","","503","251.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spontaneous Nystagamus Test","70300262","CDM","471","RC","92541","HCPCS","facility","both","","","","503","251.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Somatosensory Test -Up&Low Limb","70300270","CDM","740","RC","95938","HCPCS","facility","both","","","","2859","1429.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcemep Upper & Lower Extremities","70300271","CDM","740","RC","95939","HCPCS","facility","both","","","","2859","1429.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg-Extrmty W/Ncs Limit","70300500","CDM","922","RC","95885","HCPCS","facility","both","","","","346","173","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg Ea Extremty W/Paraspinl Area Complete","70300501","CDM","922","RC","95886","HCPCS","facility","both","","","","492","246","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg-Nonextrmty Wncs","70300502","CDM","922","RC","95887","HCPCS","facility","both","","","","346","173","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Tcemep Lower Extrm","70301000","CDM","740","RC","95928","HCPCS","facility","both","","","","1719","859.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Tcemep Upper Extrem","70301001","CDM","740","RC","95929","HCPCS","facility","both","","","","1719","859.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Cont Rec W/Vid Eeg Tech","70301100","CDM","740","RC","95700","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg W/O Vid 2-12 Hr Unmntr","70301101","CDM","740","RC","95705","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Wo Vid 2-12Hr Intmt Mntr","70301102","CDM","740","RC","95706","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg W/O Vid 2-12Hr Cont Mntr","70301103","CDM","740","RC","95707","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Wo Vid Ea 12-26Hr Unmntr","70301104","CDM","740","RC","95708","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg W/O Vid Ea 12-26Hr Intmt","70301105","CDM","740","RC","95709","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg W/O Vid Ea 12-26Hr Cont","70301106","CDM","740","RC","95710","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Veeg 2-12 Hr Unmonitored","70301107","CDM","740","RC","95711","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Veeg 2-12 Hr Intmt Mntr","70301108","CDM","740","RC","95712","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Veeg 2-12 Hr Cont Mntr","70301109","CDM","740","RC","95713","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Veeg Ea 12-26 Hr Unmntr","70301110","CDM","740","RC","95714","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Veeg Ea 12-26Hr Intmt Mntr","70301111","CDM","740","RC","95715","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Veeg Ea 12-26Hr Cont Mntr","70301112","CDM","740","RC","95716","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phys/Qhp 2-12 Hr W/O Vid","70301113","CDM","740","RC","95717","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phys/Qhp 2-12 Hr W/Veeg","70301114","CDM","740","RC","95718","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phys/Qhp Ea Incr W/O Vid","70301115","CDM","740","RC","95719","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp Ea Incr W/Veeg","70301116","CDM","740","RC","95720","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp>36<60 Hr W/O Vid","70301117","CDM","740","RC","95721","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp>36<60 Hr W/Veeg","70301118","CDM","740","RC","95722","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp>60<84 Hr W/O Vid","70301119","CDM","740","RC","95723","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp>60<84 Hr W/Veeg","70301120","CDM","740","RC","95724","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp>84 Hr W/O Vid","70301121","CDM","740","RC","95725","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg Phy/Qhp>84 Hr W/Veeg","70301122","CDM","740","RC","95726","HCPCS","facility","both","","","","5184","2592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Strep A Assay W/Optic","70400150","CDM","300","RC","87880","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcutaneous Bilirbin Scrn","70400450","CDM","300","RC","88720","HCPCS","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Blood Atp","70400558","CDM","300","RC","82962","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Act Atp","70400559","CDM","300","RC","85347","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hematocrit","70400560","CDM","300","RC","85013","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastric Occult Blood","70400561","CDM","300","RC","82271","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastric Ph","70400562","CDM","300","RC","83986","HCPCS","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dipstick Urine","70400563","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occult Blood Stool Atp","70400564","CDM","300","RC","82272","HCPCS","facility","both","","","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venipuncture Draw Fee","70400565","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Newborn Metabolic Screen","70400567","CDM","300","RC","84030","HCPCS","facility","both","","","","610","305","","","","","","","","","","","","","Gross Charge Type: Standard"
"Umbilical Cath-Exc Trans","70400568","CDM","360","RC","36450","HCPCS","facility","both","","","","1443","721.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cranial Access Kit Seps","70400572","CDM","920","RC","","","facility","both","","","","5244","2622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Puncture-Neonate","70400578","CDM","490","RC","62270","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Camino Insertion","70400579","CDM","920","RC","","","facility","both","","","","4066","2033","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peritoneal Dialysis Per Hour","70400580","CDM","802","RC","","","facility","both","","","","1428","714","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ats Abd Wound Vac Dressing","70400593","CDM","420","RC","97605","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Licox Insertion","70400594","CDM","920","RC","","","facility","both","","","","5164","2582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venipuncture Draw Fee","70400680","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urine Preg Poc Clinitek","70400900","CDM","300","RC","84703","HCPCS","facility","both","","","","211","105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urine Preg Poc","70400901","CDM","300","RC","81025","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Direct Referral","70402000","CDM","762","RC","G0379","HCPCS","facility","both","","","","930","465","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70404","CDM","270","RC","","","facility","both","","","","559.98","279.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Hemoglobin A1C (Poc)","70406813","CDM","300","RC","83036","HCPCS","facility","both","","","","219","109.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70418","CDM","270","RC","","","facility","both","","","","495.85","247.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70444","CDM","270","RC","","","facility","both","","","","131.73","65.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70447","CDM","270","RC","","","facility","both","","","","193.02","96.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Group","70600017","CDM","420","RC","97150","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Swallow Eval/Barium Assist","70600023","CDM","440","RC","92611","HCPCS","facility","both","","","","606","303","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Unna Boot Application","70600024","CDM","420","RC","29580","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Electric Stim Other","70600026","CDM","420","RC","G0282","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"St-Larngsc Exam Wo Stroboscopy","70600030","CDM","440","RC","31575","HCPCS","facility","both","","","","785","392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"St-Diag Larngsc Flex/Rig","70600031","CDM","440","RC","31579","HCPCS","facility","both","","","","1445","722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngeal Function Study","70600190","CDM","440","RC","92520","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Low Mdm 30 Minutes","70600202","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hyperbaric Chamber Treat","70600203","CDM","413","RC","G0277","HCPCS","facility","both","","","","1127","563.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adl Training - Ot 15 Minutes","70600206","CDM","430","RC","97535","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hyperbaric Ekg Tracing","70600207","CDM","730","RC","93041","HCPCS","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adl Training - Pt 15 Minutes","70600208","CDM","420","RC","97535","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Canalith Repositioning Proced  Cpt 95992","70600300","CDM","420","RC","95992","HCPCS","facility","both","","","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manual Ther Tech Ot","70600781","CDM","430","RC","97140","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manual Therapy Technique","70600782","CDM","420","RC","97140","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anodyne Infrared Treat","70600800","CDM","420","RC","97026","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Contrast Bath","70600900","CDM","420","RC","97034","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrical Stimulation","70600901","CDM","420","RC","97032","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrical Stimulat Unattnd-Pt","70600912","CDM","420","RC","G0283","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Performance Test","70600915","CDM","420","RC","97750","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Exercise - Isokinetic","70600916","CDM","420","RC","97110","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New High Mdm 60 Minutes","70601003","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Speech Treatment","70601112","CDM","440","RC","92507","HCPCS","facility","both","","","","521","260.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Swallowing Evaluation","70601113","CDM","440","RC","92610","HCPCS","facility","both","","","","599","299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Swallowing Treatment","70601114","CDM","440","RC","92526","HCPCS","facility","both","","","","519","259.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech/Swallow Therapy Group","70601116","CDM","443","RC","92508","HCPCS","facility","both","","","","277","138.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eval Performance Test Ot 15Mi","70601120","CDM","430","RC","97750","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Central Nervous Eval","70601740","CDM","440","RC","96125","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cognitive Linguistic Evaluation","70601742","CDM","440","RC","96125","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Therapeutic -15 Min","70601802","CDM","420","RC","97110","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Whirlpool/Fluido","70601815","CDM","420","RC","97022","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Function Activity","70601817","CDM","420","RC","97530","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gait Train-Up To 15Min","70601820","CDM","420","RC","97116","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iontophoresis","70601827","CDM","420","RC","97033","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paraffin Bath","70601836","CDM","420","RC","97018","HCPCS","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prosth Train","70601840","CDM","420","RC","97761","HCPCS","facility","both","","","","273","136.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Community/Work Integration 15M Ot","70601844","CDM","430","RC","97537","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mechanical Traction","70601846","CDM","420","RC","97012","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound","70601848","CDM","420","RC","97035","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasopneumatic","70601851","CDM","420","RC","97016","HCPCS","facility","both","","","","142","71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diathermy","70601852","CDM","420","RC","97024","HCPCS","facility","both","","","","118","59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Community/Work Integration 15M Pt","70601855","CDM","420","RC","97537","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aquatic Therapy 15","70603001","CDM","420","RC","97113","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing  Small","70603003","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing  Medium","70603004","CDM","270","RC","","","facility","both","","","","125.24","62.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing  Large","70603005","CDM","270","RC","","","facility","both","","","","152.15","76.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Elec Stim-Ot","70603018","CDM","430","RC","97032","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise - Therapeutic-Ot 15Mn","70603020","CDM","430","RC","97110","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluidotherapy-Ot","70603021","CDM","430","RC","97022","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Functional Activity - 15 Min","70603022","CDM","430","RC","97530","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paraffin Bath-Ot","70603025","CDM","430","RC","97018","HCPCS","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wheelchair Trn","70603028","CDM","420","RC","97542","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound-Ot","70603029","CDM","430","RC","97035","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Aphasia Assessment","70603039","CDM","440","RC","96105","HCPCS","facility","both","","","","304","152","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wound Irrigation","70603042","CDM","420","RC","97799","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orthotic Fitt/Train","70603043","CDM","420","RC","97760","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orth Fit/Train Ot 15 M","70603044","CDM","430","RC","97760","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Work Hardening Addl 1Hr Pt","70603049","CDM","420","RC","97546","HCPCS","facility","both","","","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuromuscular Reed","70603125","CDM","420","RC","97112","HCPCS","facility","both","","","","218","109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disch Environ/Home Asses-Ot-15","70603127","CDM","430","RC","97535","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Contrast Bath-Ot","70603202","CDM","430","RC","97034","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electric Stimulation Unatnd-Ot","70603203","CDM","430","RC","G0283","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exer Sup Grp Ot 1X Day Only","70603204","CDM","430","RC","97150","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iontophoresis Each 15 Min-Ot","70603206","CDM","430","RC","97033","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuromuscular Reed","70603207","CDM","430","RC","97112","HCPCS","facility","both","","","","218","109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prosth Train-Ot 15 M","70603208","CDM","430","RC","97761","HCPCS","facility","both","","","","273","136.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasopneum Tx-Ot 20 M","70603210","CDM","430","RC","97016","HCPCS","facility","both","","","","142","71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wheelchr Train-Ot 15","70603211","CDM","430","RC","97542","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Work Hardening-Ot Initial 2Hr","70603212","CDM","430","RC","97545","HCPCS","facility","both","","","","507","253.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Day Rehab Nursing Proc-10Min","70603213","CDM","550","RC","G0128","HCPCS","facility","both","","","","86","43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sens Integ Ot 15 Min","70603218","CDM","430","RC","97533","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sens Integr","70603219","CDM","420","RC","97533","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","70603220","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","70603221","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","70603222","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiberoptic Endo Eval Of Swall","70603223","CDM","440","RC","92612","HCPCS","facility","both","","","","697","348.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech Generat Dev Eval 60","70603224","CDM","440","RC","92607","HCPCS","facility","both","","","","885","442.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech Generat Dev Eval Add 30","70603225","CDM","440","RC","92608","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech Generat Dev Trmnt","70603226","CDM","440","RC","92609","HCPCS","facility","both","","","","662","331","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryangeal & Swallow Eval Fibe","70603227","CDM","440","RC","92616","HCPCS","facility","both","","","","942","471","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryangeal Eval Fiberoptic","70603228","CDM","440","RC","92614","HCPCS","facility","both","","","","767","383.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrical Stimulation-St","70603234","CDM","440","RC","97032","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","70603236","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hypbrc Trmt-Wound Asmnt V-Est","70603237","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Comp Wrap Below Knee","70603239","CDM","420","RC","29581","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applic Comp Wrap Ue/Hand","70603242","CDM","420","RC","29584","HCPCS","facility","both","","","","550","275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Work Hardening-Pt Initial 2Hr","70603243","CDM","420","RC","97545","HCPCS","facility","both","","","","585","292.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applic Comp Wrap Below Knee","70603244","CDM","430","RC","29581","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applic Comp Wrap Ue/Hand (Go)","70603247","CDM","430","RC","29584","HCPCS","facility","both","","","","550","275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Op Shoe W Rocker Bottom","70604003","CDM","274","RC","L3260","HCPCS","facility","both","","","","94.19","47.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evaluation Of Speech Fluency","70604200","CDM","440","RC","92521","HCPCS","facility","both","","","","657","328.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evaluate Speech Production","70604201","CDM","440","RC","92522","HCPCS","facility","both","","","","657","328.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech Sound Lang Comprehen","70604202","CDM","440","RC","92523","HCPCS","facility","both","","","","657","328.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behavral Qualit Analys Voice","70604203","CDM","440","RC","92524","HCPCS","facility","both","","","","657","328.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Eval Low Complex 20 Mins","70604523","CDM","424","RC","97161","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Eval Mod Complex 30 Mins","70604524","CDM","424","RC","97162","HCPCS","facility","both","","","","527","263.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Eval High Complex 45 Mins","70604525","CDM","424","RC","97163","HCPCS","facility","both","","","","579","289.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Re-Eval Est Plan Care","70604526","CDM","424","RC","97164","HCPCS","facility","both","","","","247","123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Eval Low Complex 30 Min","70604527","CDM","434","RC","97165","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Eval Mod Complex 45 Mins","70604528","CDM","434","RC","97166","HCPCS","facility","both","","","","527","263.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Eval High Complex 60 Mins","70604529","CDM","434","RC","97167","HCPCS","facility","both","","","","579","289.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Re-Eval Est Plan Care","70604530","CDM","434","RC","97168","HCPCS","facility","both","","","","273","136.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Orthc/Prostc Mgmt Sbsq Enc","70605020","CDM","420","RC","97763","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot-Orthc/Prostc Mgmt Sbsq Enc","70605021","CDM","430","RC","97763","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Devel Tst Phys/Qhp 1St Hr","70605025","CDM","440","RC","96112","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Devel Tst Phys/Qhp Ea Addl","70605026","CDM","440","RC","96113","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Devel Tst Phys/Qhp 1St Hr","70605027","CDM","430","RC","96112","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Devel Tst Phys/Qhp Ea Addl","70605028","CDM","430","RC","96113","HCPCS","facility","both","","","","239","119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Telehealth Self-Pay One Visit","70605032","CDM","999","RC","","","facility","both","","","","49.99","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"St-Ther Ivntj Cog Func 1St 15","70605040","CDM","440","RC","97129","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot-Ther Ivntj Cog Func 1St 15","70605041","CDM","430","RC","97129","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Ther Ivntj Cog Func 1St 15","70605042","CDM","420","RC","97129","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"St-Ther Ivntj Cog Func Addl 15","70605043","CDM","440","RC","97130","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot-Ther Ivntj Cog Func Addl 15","70605044","CDM","430","RC","97130","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Ther Ivntj Cog Func Addl 15","70605045","CDM","420","RC","97130","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Bfb Training 1St 15 Min","70605046","CDM","420","RC","90912","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot-Bfb Training 1St 15 Min","70605047","CDM","430","RC","90912","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Bfb Training Ea Addl 15 Min","70605049","CDM","420","RC","90913","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adult Self-Pay Rehab Rate","70605052","CDM","999","RC","","","facility","both","","","","100","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peds Self-Pay Rehab Rate","70605053","CDM","999","RC","","","facility","both","","","","83","41.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dry Needling Self-Pay Ot","70605054","CDM","999","RC","","","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dry Needling Self-Pay Pt","70605055","CDM","999","RC","","","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aep Scr Auditory Potential","70605056","CDM","471","RC","92650","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chiro Manipulation 1-2 Regions","70605057","CDM","940","RC","98940","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chiro Manipulation 3-4 Regions","70605058","CDM","940","RC","98941","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chiro Manipulation 5 Regions","70605059","CDM","940","RC","98942","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Sf Mdm 15 Minutes","70605060","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupunct W/O Stimul 15 Min","70605061","CDM","940","RC","97810","HCPCS","facility","both","","","","183","91.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupunct W/Stimul 15 Min","70605062","CDM","940","RC","97813","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupuncture 1/> Ndls W/O Elec Stimj Ea 15 Min","70605063","CDM","940","RC","97811","HCPCS","facility","both","","","","183","91.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aquatic Therapy - Ot 15 Minute","70605065","CDM","430","RC","97113","HCPCS","facility","both","","","","161","80.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Post Rehab Rate","70605066","CDM","999","RC","","","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Crutch Training Without Crutches","70605067","CDM","999","RC","","","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Crutch Training With Crutches Included","70605068","CDM","999","RC","","","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage - 2 Hours","70605069","CDM","999","RC","","","facility","both","","","","100","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Nutrition Consult","70605072","CDM","999","RC","","","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Nutrition Follow-Up","70605073","CDM","999","RC","","","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage - 1/2 Hours","70605074","CDM","999","RC","","","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Driving Evaluation","70605075","CDM","999","RC","","","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt Subs Tx For Change Dx","70605076","CDM","942","RC","G0270","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Group Mnt 2 Or More 30 Mins","70605077","CDM","942","RC","G0271","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage - 1 Hour","70605079","CDM","999","RC","","","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Ugen Device Purchase","70605080","CDM","999","RC","","","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Ugen Home Monthly Fee","70605081","CDM","999","RC","","","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Ugen In-Clinic Fee","70605082","CDM","999","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Telehealth Self-Pay Two Visit","70605083","CDM","999","RC","","","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Virtual Hep Self-Pay","70605084","CDM","999","RC","","","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Rem Ther Mntr Ea Addl 20 Min","70605085","CDM","420","RC","98981","HCPCS","facility","both","","","","214","107","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Rem Ther Mntr Ea Addl 20 Min","70605086","CDM","430","RC","98981","HCPCS","facility","both","","","","214","107","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Rem Ther Mntr 1St 20 Min","70605087","CDM","420","RC","98980","HCPCS","facility","both","","","","263","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Rem Ther Mntr 1St 20 Min","70605088","CDM","430","RC","98980","HCPCS","facility","both","","","","263","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Rem Ther Mntr Dv Sply","70605089","CDM","420","RC","98977","HCPCS","facility","both","","","","292","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Rem Ther Mntr Dv Sply","70605090","CDM","430","RC","98977","HCPCS","facility","both","","","","292","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Rem Ther Mntr 1St Setup&Edu","70605091","CDM","420","RC","98975","HCPCS","facility","both","","","","162","81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ot Rem Ther Mntr 1St Setup&Edu","70605092","CDM","430","RC","98975","HCPCS","facility","both","","","","162","81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Eval Low Complex 15 Mins","70605093","CDM","951","RC","97169","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Eval Mod Complex 30 Mins","70605094","CDM","951","RC","97170","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Eval High Complex 45 Mins","70605095","CDM","951","RC","97171","HCPCS","facility","both","","","","578","289","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Re-Eval Est Plan Care 20 Mins","70605096","CDM","951","RC","97172","HCPCS","facility","both","","","","246","123","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acup 1/> Ndls W/Elec Stimj Ea 15 Min W/Re-Insj","70605097","CDM","940","RC","97814","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Adl Training 15 Min","70605098","CDM","951","RC","97535","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Manual Therapy Tqs","70605099","CDM","951","RC","97140","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Contrast Bath 15 Min","70605100","CDM","951","RC","97034","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Electrical Stimulation","70605101","CDM","951","RC","97032","HCPCS","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Electrical Stimulat Unattnd","70605102","CDM","951","RC","G0283","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Performance Test","70605103","CDM","951","RC","97750","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Therapeutic Exercises","70605104","CDM","951","RC","97110","HCPCS","facility","both","","","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Whirlpool Therapy","70605105","CDM","951","RC","97022","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Function Activity","70605106","CDM","951","RC","97530","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Gait Train Up To 15Min","70605107","CDM","951","RC","97116","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Iontophoresis","70605108","CDM","951","RC","97033","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Paraffin Bath","70605109","CDM","951","RC","97018","HCPCS","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Mechanical Traction","70605110","CDM","951","RC","97012","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Ultrasound Therapy","70605111","CDM","951","RC","97035","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Vasopneumatic","70605112","CDM","951","RC","97016","HCPCS","facility","both","","","","142","71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Orthotic Fitt/Train","70605113","CDM","951","RC","97760","HCPCS","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Neuromuscular Reed","70605114","CDM","951","RC","97112","HCPCS","facility","both","","","","218","109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Orthc/Prostc Mgmt Sbsq Enc","70605115","CDM","951","RC","97763","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Rehab Rate Mechanical Traction","70605116","CDM","999","RC","","","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Rehab Rate Vasopnematic Treatment","70605117","CDM","999","RC","","","facility","both","","","","12","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay No Show Fee Pt, Ot, Slp, Chiro, Massage","70605118","CDM","999","RC","","","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Acupuncture Caregiver - New Client","70605119","CDM","999","RC","","","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Acupuncture Caregiver - Established Client","70605120","CDM","999","RC","","","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Cancer Acupuncture Initial","70605121","CDM","999","RC","","","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Cancer Acupuncture Subsequent","70605122","CDM","999","RC","","","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Us Diagnostic Complete Extremity/Joint Study","70605123","CDM","999","RC","","","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Diagnostic Limited Extremity/Joint Study","70605124","CDM","999","RC","","","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage Package; 30 Minutes X 3","70605125","CDM","999","RC","","","facility","both","","","","135","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage Package; 30 Minutes X 5","70605126","CDM","999","RC","","","facility","both","","","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage Package; 60 Minutes X 3","70605127","CDM","999","RC","","","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Massage Package; 60 Minutes X 5","70605128","CDM","999","RC","","","facility","both","","","","330","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Qnhp Ol Digital Assmt&Mgmt Est Pt <7 D 5-10 Min","70605129","CDM","420","RC","98970","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Qnhp Ol Digital Assmt&Mgmt Est Pt <7 D 11-20 Min","70605130","CDM","420","RC","98971","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Qnhp Ol Digital Assmt&Mgmt Est Pt <7 D 21+ Min","70605131","CDM","420","RC","98972","HCPCS","facility","both","","","","100","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70687","CDM","270","RC","","","facility","both","","","","385.71","192.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70695","CDM","270","RC","","","facility","both","","","","304.98","152.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flight Fee - Loaded Mile","70700211","CDM","540","RC","A0436","HCPCS","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transport - Base Rate - Single","70700212","CDM","545","RC","A0431","HCPCS","facility","both","","","","15220","7610","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70899","CDM","278","RC","Q4100","HCPCS","facility","both","","","","2045.2","1022.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70900","CDM","278","RC","C1763","HCPCS","facility","both","","","","2600.12","1300.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Band Adjustment","70900504","CDM","761","RC","43999","HCPCS","facility","both","","","","2626","1313","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Mano Esophageal","70901004","CDM","920","RC","91010","HCPCS","facility","both","","","","1107","553.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agile Patency Procedure","70901011","CDM","750","RC","91299","HCPCS","facility","both","","","","779","389.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hi Res Esophageal Motility St","70901012","CDM","750","RC","91299","HCPCS","facility","both","","","","779","389.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","70909","CDM","270","RC","C1814","HCPCS","facility","both","","","","2007.07","1003.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo M2A Cap Endo","70945386","CDM","750","RC","91110","HCPCS","facility","both","","","","4962","2481","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","70945387","CDM","370","RC","99152","HCPCS","facility","both","","","","646","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","70945388","CDM","370","RC","99153","HCPCS","facility","both","","","","646","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Initial 15 Mins <5 Yrs","70945389","CDM","370","RC","99155","HCPCS","facility","both","","","","646","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Initial 15 Mins 5/> Yrs","70945390","CDM","370","RC","99156","HCPCS","facility","both","","","","646","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Each Addl 15 Mins","70945391","CDM","370","RC","99157","HCPCS","facility","both","","","","646","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscopy Case- First 30 Minutes","70945392","CDM","750","RC","","","facility","both","","","","3382.21","1691.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscopy Case- Additional 15 Minutes","70945393","CDM","750","RC","","","facility","both","","","","1522.17","761.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71002","CDM","270","RC","","","facility","both","","","","152.95","76.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71019","CDM","270","RC","","","facility","both","","","","87.4","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71107","CDM","278","RC","C2617","HCPCS","facility","both","","","","372.42","186.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71119","CDM","270","RC","","","facility","both","","","","10.83","5.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71145","CDM","278","RC","C1776","HCPCS","facility","both","","","","2509.71","1254.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Critical Care Op 1:1","71200002","CDM","820","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Capd Inpatient","71200005","CDM","803","RC","90945","HCPCS","facility","both","","","","1028","514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cvvh Critical Care Setup","71200010","CDM","800","RC","90999","HCPCS","facility","both","","","","886","443","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrafiltration Daily","71200013","CDM","881","RC","","","facility","both","","","","2331","1165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrafiltration Circuit","71200016","CDM","881","RC","","","facility","both","","","","2959","1479.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Administration","71200017","CDM","391","RC","36430","HCPCS","facility","both","","","","1611","805.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Dialysis Ip 1:1","71200018","CDM","801","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Dialysis Ip 2:1","71200019","CDM","801","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Dialysis Ip 3:1","71200020","CDM","801","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Dialysis Op 1:1","71200021","CDM","820","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Dialysis Op 2:1","71200022","CDM","820","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Dialysis Op 3:1","71200023","CDM","820","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cvvhd Critical Care Support","71200060","CDM","800","RC","90999","HCPCS","facility","both","","","","886","443","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemo Critical Care Ip 1:1","71200096","CDM","801","RC","G0257","HCPCS","facility","both","","","","2130","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Cannula Declot","71200201","CDM","320","RC","36860","HCPCS","facility","both","","","","2701","1350.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71321","CDM","270","RC","","","facility","both","","","","84.55","42.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71404","CDM","270","RC","","","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71405","CDM","270","RC","","","facility","both","","","","90.53","45.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","715","CDM","270","RC","","","facility","both","","","","275.08","137.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71513","CDM","278","RC","C1776","HCPCS","facility","both","","","","1855.31","927.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71607","CDM","278","RC","C1776","HCPCS","facility","both","","","","1755","877.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71635","CDM","270","RC","","","facility","both","","","","8.16","4.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71650","CDM","278","RC","C1776","HCPCS","facility","both","","","","2277","1138.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","71737","CDM","278","RC","C1713","HCPCS","facility","both","","","","528.26","264.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","72047","CDM","272","RC","C1757","HCPCS","facility","both","","","","383.92","191.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","72435","CDM","278","RC","C1713","HCPCS","facility","both","","","","537.65","268.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Davinci Set Up And Use","72602045","CDM","272","RC","","","facility","both","","","","9500","4750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Change Not For Burns","72602049","CDM","361","RC","15852","HCPCS","facility","both","","","","4224","2112","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Ankle Arm Index","72700050","CDM","921","RC","93922","HCPCS","facility","both","","","","720","360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Ue","72700071","CDM","921","RC","93923","HCPCS","facility","both","","","","1500","750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Le With Exercise","72700081","CDM","921","RC","93924","HCPCS","facility","both","","","","1858","929","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Allen Test","72700100","CDM","921","RC","93922","HCPCS","facility","both","","","","720","360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Carotid Artery","72700170","CDM","921","RC","93880","HCPCS","facility","both","","","","1707","853.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Digital Pressures","72700181","CDM","921","RC","93922","HCPCS","facility","both","","","","720","360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Penile Duplex","72700184","CDM","921","RC","93980","HCPCS","facility","both","","","","2070","1035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Graft Duplex","72700191","CDM","921","RC","93931","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Duplex","72700193","CDM","921","RC","93930","HCPCS","facility","both","","","","2209","1104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manual Occlusion Of Pseudoaneu","72700195","CDM","402","RC","76936","HCPCS","facility","both","","","","874","437","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Epigastric Artery","72700201","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Trauma Scan Le","72700207","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Mesenteric Duplex","72700300","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Renal Artery Unilat","72700302","CDM","921","RC","93976","HCPCS","facility","both","","","","1807","903.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Abd Renal","72700304","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Abdominal Aorta Duplex","72700306","CDM","921","RC","93978","HCPCS","facility","both","","","","1399","699.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Venous Exam Le","72700308","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Venous Duplex Le","72700310","CDM","921","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Duplex  Unilat","72700312","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Duplex Bilat","72700314","CDM","921","RC","93925","HCPCS","facility","both","","","","2213","1106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Vein Map Unilat","72700316","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Vein Map Bilat","72700318","CDM","921","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Aortic Graft Le Unilat","72700320","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Renal Transplant","72700326","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Intraop Carotid Duplex","72700328","CDM","921","RC","93882","HCPCS","facility","both","","","","1070","535","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Groin Duplex Unilat","72700334","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Groin Duplex Bilat","72700336","CDM","921","RC","93925","HCPCS","facility","both","","","","2213","1106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Venous Exam Ue Unilat","72700338","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Venous Duplex Ue Bilat","72700339","CDM","921","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Vein Map Ue Unilat","72700340","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Vein Map Ue Bilat","72700341","CDM","921","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Duplex Ue Unilat","72700342","CDM","921","RC","93931","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Le Without Exercise","72700344","CDM","920","RC","93923","HCPCS","facility","both","","","","1500","750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Trauma Vein Duplex Le Unilat","72700346","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Avf Steal Study","72700348","CDM","921","RC","93923","HCPCS","facility","both","","","","1500","750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Trauma Duplex Le Bilat","72700349","CDM","921","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Intraop Visceral Duplex","72700350","CDM","921","RC","93976","HCPCS","facility","both","","","","1807","903.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Intraop Graft Duplex Le","72700351","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Portal Hepatic Duplex","72700354","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Graft Duplex Le Bilateral","72700355","CDM","921","RC","93925","HCPCS","facility","both","","","","2213","1106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Ivc Duplex","72700356","CDM","921","RC","93978","HCPCS","facility","both","","","","1399","699.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Abdominal Aorta Limited","72700359","CDM","921","RC","93979","HCPCS","facility","both","","","","928","464","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Carotid Artery Unilat","72700362","CDM","921","RC","93882","HCPCS","facility","both","","","","1070","535","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Transcranial Doppler","72700363","CDM","921","RC","93886","HCPCS","facility","both","","","","1801","900.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Trauma Vein Duplex Ue Unilat","72700364","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Intraop Le Art Duplex Unilat","72700366","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Le With Cold Immersion","72700368","CDM","921","RC","93923","HCPCS","facility","both","","","","1500","750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Arterial Ue With Cold Immersion","72700369","CDM","921","RC","93923","HCPCS","facility","both","","","","1500","750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Dialysis Acces Duplex Ue Unilat","72700370","CDM","921","RC","93990","HCPCS","facility","both","","","","841","420.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Dialysis Acces Duplex Le Unilat","72700371","CDM","921","RC","93990","HCPCS","facility","both","","","","841","420.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Us Guidance For Needle","72700377","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Transcranial Doppler Ltd","72700378","CDM","921","RC","93888","HCPCS","facility","both","","","","956","478","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Penile Duplex W/O Injection","72700379","CDM","921","RC","93981","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Portal-Hepatic Tips","72700380","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Pancreatic Transplant","72700402","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Liver Transplant","72700403","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Duplex Scan Extracranial Art Compl Bi Study","72701016","CDM","921","RC","93880","HCPCS","facility","both","","","","1707","853.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Duplex Scan Extracranial Art Uni/Lmtd Study","72701017","CDM","921","RC","93882","HCPCS","facility","both","","","","1070","535","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pv Trauma Scan Le Bilat","72702008","CDM","921","RC","93925","HCPCS","facility","both","","","","2213","1106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ni Self-Pay Screening Carotid","72702020","CDM","999","RC","","","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ni Self-Pay Screening Aaa","72702021","CDM","999","RC","","","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ni Self-Pay Screening Abi","72702022","CDM","999","RC","","","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ni Sp Screen Carotid,Aaa,Abi","72702023","CDM","999","RC","","","facility","both","","","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ehe Vascular Screening","72702101","CDM","270","RC","","","facility","both","","","","222.53","111.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penile Injection","72702102","CDM","369","RC","54235","HCPCS","facility","both","","","","1157","578.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ect Treatment","72800001","CDM","901","RC","90870","HCPCS","facility","both","","","","1589","794.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Family Therapy W/ Patient","72800025","CDM","916","RC","90847","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcranial Mag Stim Tx Plan","72800174","CDM","900","RC","90867","HCPCS","facility","both","","","","989","494.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcranial Magn Stim Tx Deli","72800175","CDM","900","RC","90868","HCPCS","facility","both","","","","989","494.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcran Mag Stm Redet Motr","72800176","CDM","761","RC","90869","HCPCS","facility","both","","","","938","469","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Psych Assessment","72800200","CDM","900","RC","90791","HCPCS","facility","both","","","","624","312","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indiv Therapy (30 Min)","72800202","CDM","914","RC","90832","HCPCS","facility","both","","","","301","150.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indiv Therapy (45 Min)","72800203","CDM","914","RC","90834","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","72830","CDM","278","RC","C1776","HCPCS","facility","both","","","","2579.16","1289.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Erg In Addition To Cath","72900009","CDM","730","RC","93024","HCPCS","facility","both","","","","552","276","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Iabp Procedure Only","72900014","CDM","481","RC","33967","HCPCS","facility","both","","","","11979","5989.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temporary Pacing Wire Procedur","72900018","CDM","481","RC","33210","HCPCS","facility","both","","","","10197","5098.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temporary Pacing Wire Procedur","72900019","CDM","481","RC","33210","HCPCS","facility","both","","","","10197","5098.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aicd Trnsvn Check Invasive Lab","72900027","CDM","480","RC","93642","HCPCS","facility","both","","","","1933","966.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Ven 1St Ord(Renal, Jugular)","72900028","CDM","480","RC","93640","HCPCS","facility","both","","","","3327","1663.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep Comprehensive Study","72900032","CDM","480","RC","93620","HCPCS","facility","both","","","","15568","7784","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stress Test - Cardiovascula","72900045","CDM","482","RC","93017","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Stress Echo W/O Contrast","72900048","CDM","480","RC","93350","HCPCS","facility","both","","","","2559","1279.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiopulmonary Resuscitation","72900065","CDM","481","RC","92950","HCPCS","facility","both","","","","1883","941.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep Ventricular Study","72900080","CDM","480","RC","93622","HCPCS","facility","both","","","","9816","4908","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep Atrial/His Study","72900081","CDM","480","RC","93621","HCPCS","facility","both","","","","9816","4908","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Myocardial Biopsy With Cath","72900092","CDM","481","RC","93505","HCPCS","facility","both","","","","4346","2173","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ic Ablation Av Node","72900095","CDM","481","RC","93650","HCPCS","facility","both","","","","9263","4631.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Supraventricular Mapping","72900115","CDM","480","RC","93609","HCPCS","facility","both","","","","7390","3695","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echocardiogram","72900120","CDM","480","RC","93307","HCPCS","facility","both","","","","1730","865","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mapping","72900121","CDM","480","RC","93609","HCPCS","facility","both","","","","7390","3695","","","","","","","","","","","","","Gross Charge Type: Standard"
"Color Flow Velocity Mapping","72900122","CDM","480","RC","93325","HCPCS","facility","both","","","","823","411.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo Limited Study","72900124","CDM","480","RC","93308","HCPCS","facility","both","","","","1191","595.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doppler Echo","72900126","CDM","480","RC","93320","HCPCS","facility","both","","","","1013","506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cn Tee W / O Contrast","72900129","CDM","480","RC","93312","HCPCS","facility","both","","","","3699","1849.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pharmacologic Stress Echo","72900131","CDM","480","RC","93350","HCPCS","facility","both","","","","2559","1279.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Myocardial Biopsy Only","72900146","CDM","481","RC","93505","HCPCS","facility","both","","","","4346","2173","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Monitoring Swan Procedure","72900194","CDM","481","RC","93503","HCPCS","facility","both","","","","3238","1619","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Cardioverison","72900199","CDM","480","RC","92960","HCPCS","facility","both","","","","2400","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker Temporary/Day","72900206","CDM","480","RC","92953","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Defibrillator","72900207","CDM","480","RC","92960","HCPCS","facility","both","","","","2400","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Aortic Balloon Fee","72900226","CDM","480","RC","","","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo,3D","72900264","CDM","320","RC","76376","HCPCS","facility","both","","","","1402","701","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Valvuloplasty Ao","72900403","CDM","480","RC","92986","HCPCS","facility","both","","","","12037","6018.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Valvuloplasty Mitral","72900404","CDM","480","RC","92987","HCPCS","facility","both","","","","13863","6931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Artery Abdm Pel Ext 1St","72900527","CDM","481","RC","36245","HCPCS","facility","both","","","","5396","2698","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Ep Follow Up W / Pacing And Reco","72900552","CDM","480","RC","93624","HCPCS","facility","both","","","","6840","3420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Icd & Leads Check Same Day","72900553","CDM","480","RC","93641","HCPCS","facility","both","","","","2845","1422.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tilt Table Test","72900616","CDM","480","RC","93660","HCPCS","facility","both","","","","1509","754.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tilt Table/Medication Challenge","72900617","CDM","480","RC","93660","HCPCS","facility","both","","","","1509","754.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angiojetonly","72900619","CDM","481","RC","92973","HCPCS","facility","both","","","","10211","5105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Asd Closure, Only","72900620","CDM","481","RC","93580","HCPCS","facility","both","","","","27590","13795","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Vsd Closure, Only","72900621","CDM","481","RC","93581","HCPCS","facility","both","","","","27590","13795","","","","","","","","","","","","","Gross Charge Type: Standard"
"Event Recording & Hookup","72900626","CDM","480","RC","93270","HCPCS","facility","both","","","","361","180.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo Limited Study W Contrast","72900801","CDM","480","RC","C8924","HCPCS","facility","both","","","","2381","1190.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transesoph Echo W Contrast","72900802","CDM","480","RC","C8925","HCPCS","facility","both","","","","4086","2043","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Stress Echo Wcontrast","72900803","CDM","480","RC","C8928","HCPCS","facility","both","","","","3832","1916","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cn Pharmacologic Stress W / Contrast","72900804","CDM","480","RC","C8928","HCPCS","facility","both","","","","3832","1916","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echocardiogram Complete W/O Contrast","72900902","CDM","483","RC","93306","HCPCS","facility","both","","","","3452","1726","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cn Echocardiogram Comp W / Contrast","72900903","CDM","480","RC","C8929","HCPCS","facility","both","","","","3688","1844","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pharmacologic Stress Test","72901200","CDM","482","RC","93017","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Angio Renal,1St Order,Uni","72902200","CDM","481","RC","36251","HCPCS","facility","both","","","","14030","7015","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Renal,High Order,Uni","72902201","CDM","481","RC","36253","HCPCS","facility","both","","","","12217","6108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Renal,1St Order,Bilat","72902202","CDM","481","RC","36252","HCPCS","facility","both","","","","15986","7993","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Renal,High Order,Bilat","72902203","CDM","481","RC","36254","HCPCS","facility","both","","","","12217","6108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrombectomy Mechanical Arterial","72903001","CDM","480","RC","37184","HCPCS","facility","both","","","","14793","7396.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromb,Mech Arterial,Addtl Ves","72903002","CDM","480","RC","37185","HCPCS","facility","both","","","","11938","5969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromb,Mech Arterial,In Add","72903003","CDM","480","RC","37186","HCPCS","facility","both","","","","12870","6435","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dental Surgery Procedure","72903200","CDM","761","RC","41899","HCPCS","facility","both","","","","3951","1975.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nips Procedure","72904005","CDM","480","RC","93724","HCPCS","facility","both","","","","1287","643.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bundle Of His Recording Only","72905212","CDM","480","RC","93600","HCPCS","facility","both","","","","7180","3590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra Atrial Recording Only","72905213","CDM","480","RC","93602","HCPCS","facility","both","","","","7180","3590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Right Ventricular Recording On","72905214","CDM","480","RC","93603","HCPCS","facility","both","","","","4723","2361.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Atrial Pacing","72905215","CDM","480","RC","93610","HCPCS","facility","both","","","","7180","3590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intracardiac 3D Mapping","72905217","CDM","480","RC","93613","HCPCS","facility","both","","","","4728","2364","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aarhyhymia Induction By Pacing","72905218","CDM","480","RC","93618","HCPCS","facility","both","","","","4502","2251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep Study W/O Induction Of Arrh","72905219","CDM","480","RC","93619","HCPCS","facility","both","","","","9342","4671","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pharmacologic Stimulation","72905220","CDM","480","RC","93623","HCPCS","facility","both","","","","7450","3725","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cn Spectral Analysis Follow Up Or Limit","72905222","CDM","480","RC","93321","HCPCS","facility","both","","","","861","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Intercardiac Ultrasound","72905228","CDM","480","RC","93662","HCPCS","facility","both","","","","6706","3353","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Pressure Wire Procedure","72905229","CDM","480","RC","93571","HCPCS","facility","both","","","","3559","1779.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Pressure Wire Place, Add Vessel","72905230","CDM","480","RC","93572","HCPCS","facility","both","","","","1152","576","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Pocket Evacuation","72905245","CDM","481","RC","10140","HCPCS","facility","both","","","","4270","2135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Program/Eval Sgl Pacer","72905254","CDM","480","RC","93279","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Program/Eval Dual Pacer","72905255","CDM","480","RC","93280","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Program/Eval Bi-V Pacer","72905256","CDM","480","RC","93281","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Program/Eval Sgl Trnsvn Defb","72905257","CDM","480","RC","93282","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Program/Eval Dual Trnsvn Defb","72905258","CDM","480","RC","93283","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Program/Eval Bi-V Transvn Defb","72905259","CDM","480","RC","93284","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inprs Prgrm Dev Eval Rhythm Mn","72905260","CDM","480","RC","93285","HCPCS","facility","both","","","","448","224","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peri-Procedure Pacer","72905261","CDM","480","RC","93286","HCPCS","facility","both","","","","278","139","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peri-Procedure Icd","72905262","CDM","480","RC","93287","HCPCS","facility","both","","","","555","277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interroga Pacer","72905263","CDM","480","RC","93288","HCPCS","facility","both","","","","244","122","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interrogation Transven Defib","72905264","CDM","480","RC","93289","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interrogation Loop Recorder","72905266","CDM","480","RC","93291","HCPCS","facility","both","","","","632","316","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remote Interrogation Pacer","72905267","CDM","480","RC","93296","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remote Interrogation Icd","72905268","CDM","480","RC","93296","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecg Transesophageal Cong","72905523","CDM","480","RC","93315","HCPCS","facility","both","","","","2208","1104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vad Per Minute","72905550","CDM","480","RC","","","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Aortogram Thor Serial","72906001","CDM","320","RC","75605","HCPCS","facility","both","","","","6102","3051","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Aortogram Abdomen Serial","72906002","CDM","320","RC","75625","HCPCS","facility","both","","","","5878","2939","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Aortogram Abdomen W / Runoff","72906003","CDM","320","RC","75630","HCPCS","facility","both","","","","5878","2939","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Extr Bilat","72906014","CDM","320","RC","75716","HCPCS","facility","both","","","","5811","2905.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Visc Sel W / Or W / O F","72906017","CDM","320","RC","75726","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Pelvic, Sel Or Supras","72906018","CDM","320","RC","75736","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Pulmonary Unilat","72906019","CDM","320","RC","75741","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Select Addl","72906021","CDM","320","RC","75774","HCPCS","facility","both","","","","3250","1625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Ivc","72906022","CDM","320","RC","75825","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Venous Renal Unilateral","72906023","CDM","320","RC","75831","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Venous Renal Bilateral","72906024","CDM","320","RC","75833","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Sinus Or Jugular","72906025","CDM","320","RC","75860","HCPCS","facility","both","","","","3565","1782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Thromboly, Angio Fol Up Exis Ca","72906027","CDM","320","RC","75898","HCPCS","facility","both","","","","3239","1619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Extr Unilateral","72906042","CDM","320","RC","75710","HCPCS","facility","both","","","","4651","2325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coagulation Time-Teg Poc","72906046","CDM","300","RC","85347","HCPCS","facility","both","","","","139","69.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibrinogen-Teg Proc","72906047","CDM","300","RC","85384","HCPCS","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Plate Aggregtn-Teg Poc","72906048","CDM","300","RC","85576","HCPCS","facility","both","","","","295","147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibrinolysisn Screen Teg Poc","72906049","CDM","300","RC","85390","HCPCS","facility","both","","","","104","52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Platelet Aggregation Each","72906050","CDM","300","RC","85576","HCPCS","facility","both","","","","405","202.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tee Probe Insertion Only","72906601","CDM","480","RC","93313","HCPCS","facility","both","","","","3323","1661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tee Probe Insertion Only Cong","72906602","CDM","480","RC","93316","HCPCS","facility","both","","","","3323","1661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracentesis W/ Img Guide","72906604","CDM","481","RC","32555","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Nonsel Thor Aort+Arch Image","72906605","CDM","320","RC","36221","HCPCS","facility","both","","","","14991","7495.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromb,Angi Fol-Up Exchan Cat","72906606","CDM","320","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Sel Cth Cca/Inom+Cerbl Imag","72906607","CDM","320","RC","36223","HCPCS","facility","both","","","","23788","11894","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Sel Cth Ica/Inom+Cerbl Imag","72906608","CDM","481","RC","36224","HCPCS","facility","both","","","","23857","11928.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Sel Cth Inom/Subc+Vert Imag","72906609","CDM","320","RC","36225","HCPCS","facility","both","","","","31690","15845","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Sel Cth Vertbrl+Vert Image","72906610","CDM","481","RC","36226","HCPCS","facility","both","","","","31087","15543.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Sel Cth Eca+Eca Image","72906613","CDM","481","RC","36227","HCPCS","facility","both","","","","9138","4569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Angioplasty Addl Vsl","72906614","CDM","481","RC","92921","HCPCS","facility","both","","","","12037","6018.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Athrect/Angioplasty 1 Vsl","72906615","CDM","481","RC","92924","HCPCS","facility","both","","","","17473","8736.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Athrect/Angioplasty Addl","72906616","CDM","481","RC","92925","HCPCS","facility","both","","","","17473","8736.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep&Ablatn Supravent Arrhytm","72906617","CDM","480","RC","93653","HCPCS","facility","both","","","","33791","16895.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep&Ablatn Ventric Tachy+3D Map","72906618","CDM","480","RC","93654","HCPCS","facility","both","","","","38979","19489.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablate Discrete Arrhytm Add-On","72906619","CDM","480","RC","93655","HCPCS","facility","both","","","","13538","6769","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep&Ablatn Afib Pulm Vein Isol","72906620","CDM","480","RC","93656","HCPCS","facility","both","","","","33791","16895.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablatn Afib Aftr Pul Vein Isol","72906621","CDM","480","RC","93657","HCPCS","facility","both","","","","13538","6769","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd-Sel Cth Cca/Inom+Cervl Imag","72906626","CDM","320","RC","36222","HCPCS","facility","both","","","","18711","9355.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Stent W/Angio 1 Vsl","72907050","CDM","481","RC","92928","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Stent W/Angio Addl","72907051","CDM","481","RC","92929","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Stent/Ath/Angio","72907052","CDM","481","RC","92933","HCPCS","facility","both","","","","24434","12217","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Stent/Ath/Angio Addl","72907053","CDM","481","RC","92934","HCPCS","facility","both","","","","19709","9854.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Revasc Byp Graft 1 Vsl","72907054","CDM","481","RC","92937","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Revasc Byp Graft Addl","72907055","CDM","481","RC","92938","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Revasc Mi 1 Vsl","72907056","CDM","481","RC","92941","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Revasc Chronic 1Vsl","72907057","CDM","481","RC","92943","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Card Revasc Chronic Addl","72907058","CDM","481","RC","92944","HCPCS","facility","both","","","","15849","7924.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci De Stent W/Angiopl 1 Vsl","72907059","CDM","481","RC","C9600","HCPCS","facility","both","","","","33132","16566","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci De Stent W/Angiopl Addl","72907060","CDM","481","RC","C9601","HCPCS","facility","both","","","","22088","11044","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci De Stent/Ath/Angio 1 Vsl","72907061","CDM","481","RC","C9602","HCPCS","facility","both","","","","28833","14416.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci De Stent/Ath/Angio Addtl","72907062","CDM","481","RC","C9603","HCPCS","facility","both","","","","25438","12719","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Pyp Graft 1 Vsl-Des/At/Ag","72907063","CDM","481","RC","C9604","HCPCS","facility","both","","","","22088","11044","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Byp Graft Addl-Des/At/Ag","72907064","CDM","481","RC","C9605","HCPCS","facility","both","","","","22088","11044","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Mi 1 Vsl-Des/Ath/Angiopl","72907065","CDM","481","RC","C9606","HCPCS","facility","both","","","","33132","16566","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Chronic 1Vsl-Des/Ath/Angi","72907066","CDM","481","RC","C9607","HCPCS","facility","both","","","","22088","11044","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Chronic Addl-Des/Ath/Angi","72907067","CDM","481","RC","C9608","HCPCS","facility","both","","","","22088","11044","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cd-Sel Cth Ica/Vertrbl+Image","72907080","CDM","320","RC","36228","HCPCS","facility","both","","","","9138","4569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cath Pleura W/Image","72907085","CDM","369","RC","32557","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pda Closure","72907086","CDM","481","RC","93582","HCPCS","facility","both","","","","27590","13795","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vad Different Session","72907097","CDM","481","RC","33992","HCPCS","facility","both","","","","4448","2224","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carotid Stent Common Or Innomi","72907098","CDM","481","RC","37218","HCPCS","facility","both","","","","35078","17539","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrophysiology Evaluation","72908001","CDM","480","RC","93644","HCPCS","facility","both","","","","2845","1422.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thrombolytic Art Therapy","72908002","CDM","320","RC","37211","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Thrombolytic Venous Therapy","72908003","CDM","320","RC","37212","HCPCS","facility","both","","","","9692","4846","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Thromblytic Art/Ven Therapy","72908004","CDM","320","RC","37213","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cessj Therapy Cath Removal","72908005","CDM","320","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Cardiovascular Service/Procedure","72908007","CDM","480","RC","93799","HCPCS","facility","both","","","","386","193","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ambulatory Bp Analysis 24+Hrs","72908025","CDM","480","RC","93788","HCPCS","facility","both","","","","1144","572","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myocrd Strain Img Spckl Trck","72908100","CDM","761","RC","93356","HCPCS","facility","both","","","","851","425.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Heartmate Php","72910510","CDM","270","RC","","","facility","both","","","","48751.61","24375.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","72910512","CDM","761","RC","11042","HCPCS","facility","both","","","","1736","868","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tee,2D Continuous Assessment","72910515","CDM","483","RC","93318","HCPCS","facility","both","","","","3585","1792.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echocardiography Tee","72910522","CDM","483","RC","93355","HCPCS","facility","both","","","","3642","1821","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcath Mitral Valve Repair","72910524","CDM","369","RC","33418","HCPCS","facility","both","","","","51144","25572","","","","","","","","","","","","","Gross Charge Type: Standard"
"Addl Transcath Mitral Valve","72910525","CDM","369","RC","33419","HCPCS","facility","both","","","","25845","12922.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"R&L Hrt Cath Chd Nml Nt Cnj","72910528","CDM","481","RC","93596","HCPCS","facility","both","","","","25024","12512","","","","","","","","","","","","","Gross Charge Type: Standard"
"R&L Hrt Cath Chd Abnl Nt Cnj","72910529","CDM","481","RC","93597","HCPCS","facility","both","","","","25024","12512","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Outp Meas Drg Cath Chd","72910530","CDM","481","RC","93598","HCPCS","facility","both","","","","1569","784.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interrogate Subq Defib","72910531","CDM","480","RC","93261","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prgrmg Dev Eval Scrms Remote","72910532","CDM","480","RC","0650T","HCPCS","facility","both","","","","142","71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Transcath Septal Reduxn","72910533","CDM","481","RC","93583","HCPCS","facility","both","","","","30673","15336.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prgrmg Dev Eval Impltbl Sys","72910534","CDM","480","RC","93260","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phleb Veins-Extrem 20+","72910535","CDM","369","RC","37766","HCPCS","facility","both","","","","11963","5981.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Pvi First 30 Mins","72910536","CDM","710","RC","","","facility","both","","","","1247.49","623.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Phase I Pvi Each Addl 15 Mins","72910537","CDM","710","RC","","","facility","both","","","","657.5","328.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Phase Ii Pvi Each Addl 15 Mins","72910538","CDM","710","RC","","","facility","both","","","","564.86","282.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep-Cath Lab First 30 Mins","72910539","CDM","481","RC","","","facility","both","","","","16215","8107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ep-Cath Lab Each Addl 15 Mins","72910540","CDM","481","RC","","","facility","both","","","","5980","2990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Interrog Icpms <30 D Phys/Qhp","72910541","CDM","480","RC","93297","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Interrog Scrms <30 D Phys/Qhp","72910542","CDM","480","RC","93298","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","72929","CDM","278","RC","C1713","HCPCS","facility","both","","","","740.6","370.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","72935","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7295","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7296","CDM","270","RC","","","facility","both","","","","11.86","5.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cadaver Heart","73000001","CDM","812","RC","","","facility","both","","","","162570","81285","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kidney Acquisition Charge- Cad","73000501","CDM","812","RC","","","facility","both","","","","141949","70974.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiac Assist Dressing Lvad","73000511","CDM","270","RC","","","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiac Assist Dressing Bivad","73000512","CDM","270","RC","","","facility","both","","","","270.14","135.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Sf Mdm 15 Minutes","73000522","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Low Mdm 30 Minutes","73000523","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Moderate Mdm 45 Minutes","73000524","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New High Mdm 60 Minutes","73000525","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kidney Aquistion Chrg-Ld","73000601","CDM","811","RC","","","facility","both","","","","141949","70974.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pancreas Acquisition Charge","73000602","CDM","810","RC","","","facility","both","","","","76258","38129","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73000621","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","73000622","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73000623","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","73000624","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Follow Up Visit Level 5","73000625","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Of Op Sf 10-19 Min Lv2 -25","73000626","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Of Op Low 20-29 Min L3 -25","73000627","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Of O/P Min Prob Lev 1 -25","73000628","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Of Op Mod 30-39 Min L4 -25","73000629","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Follow Up Visit Lvl 5 W/Mod 25","73000630","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73000631","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73000632","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Swan Ganz Introducer Arrow","73100007","CDM","270","RC","","","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set V8631 Additive Adult Prim","73100010","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Spring Stainless Steel","73100011","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Fee","73100012","CDM","940","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph Iv Inf Init=<1Hr","73100025","CDM","260","RC","96365","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Addon","73100026","CDM","260","RC","96366","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iv Cath Cv Double Iumen","73100851","CDM","270","RC","","","facility","both","","","","367.43","183.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hemodialysis (Each)","73101986","CDM","270","RC","","","facility","both","","","","421.25","210.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infusion Controller Set","73103108","CDM","270","RC","","","facility","both","","","","172.85","86.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iv Tubing For Taxol Admin Ea","73109165","CDM","270","RC","","","facility","both","","","","80.73","40.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ed Level Iv - Er Dept Visit","73200018","CDM","450","RC","99284","HCPCS","facility","both","","","","1819","909.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ed Level V - Er Dept Visit","73200019","CDM","450","RC","99285","HCPCS","facility","both","","","","2867","1433.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ed Critical Care 30-74 Minutes","73200020","CDM","450","RC","99291","HCPCS","facility","both","","","","5322","2661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bravo Trauma Activation","73200022","CDM","681","RC","G0390","HCPCS","facility","both","","","","7197","3598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alpha Trauma Activation","73200023","CDM","681","RC","G0390","HCPCS","facility","both","","","","7197","3598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Add'l 30 Mins","73200024","CDM","450","RC","99292","HCPCS","facility","both","","","","1053","526.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level I - Er Dept Visit","73200026","CDM","450","RC","99281","HCPCS","facility","both","","","","260","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level Ii - Er Dept Visit","73200027","CDM","450","RC","99282","HCPCS","facility","both","","","","497","248.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level Iii - Er Dept Visit","73200028","CDM","450","RC","99283","HCPCS","facility","both","","","","982","491","","","","","","","","","","","","","Gross Charge Type: Standard"
"96360 Hydration Infusion","73200030","CDM","450","RC","96360","HCPCS","facility","both","","","","672","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"96361 Hydration Inf Ea Addl Hr","73200031","CDM","450","RC","96361","HCPCS","facility","both","","","","323","161.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"96365 Drug Infusion 1St Hr","73200032","CDM","450","RC","96365","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"96366 Drug Inf Ea Addl Hr","73200033","CDM","450","RC","96366","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"10060 Incision & Drainage Abscess Simple/Single","73200500","CDM","450","RC","10060","HCPCS","facility","both","","","","1305","652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10061 I&D Skin Abscess-Complic","73200501","CDM","450","RC","10061","HCPCS","facility","both","","","","1501","750.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10080 Pilonidal Cyst-Simple","73200502","CDM","450","RC","10080","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"10120 I&Fb Removal Subq-Simple","73200503","CDM","450","RC","10120","HCPCS","facility","both","","","","1381","690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10121 I&Fb Removal Subq-Comp","73200504","CDM","450","RC","10121","HCPCS","facility","both","","","","6803","3401.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10140 I&D Hematoma/Fluid","73200505","CDM","450","RC","10140","HCPCS","facility","both","","","","4270","2135","","","","","","","","","","","","","Gross Charge Type: Standard"
"10160 Punct Aspirat'n Skin Les","73200506","CDM","450","RC","10160","HCPCS","facility","both","","","","630","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"11000 Debrd Inf Skin-10% Body","73200507","CDM","450","RC","11000","HCPCS","facility","both","","","","680","340","","","","","","","","","","","","","Gross Charge Type: Standard"
"11042 Debrd Skin&Subq 20Sqcm/<","73200509","CDM","450","RC","11042","HCPCS","facility","both","","","","1736","868","","","","","","","","","","","","","Gross Charge Type: Standard"
"11200 Remov Mult Skin Tag 1-15","73200510","CDM","450","RC","11200","HCPCS","facility","both","","","","643","321.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11730 Avul Nail Plate Simp-1","73200511","CDM","450","RC","11730","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11732 Avul Nail Plate Ea Add","73200512","CDM","450","RC","11732","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"11740 Evac Subungual Hematoma","73200513","CDM","450","RC","11740","HCPCS","facility","both","","","","378","189","","","","","","","","","","","","","Gross Charge Type: Standard"
"11750 Exc Nail&Matrx-Perm Rml","73200514","CDM","450","RC","11750","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"11760 Repair Of Nailbed","73200516","CDM","450","RC","11760","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"11765 Nail Fold Wedge Excision","73200517","CDM","450","RC","11765","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12001 Simple Rep Trunk=<2.5Cm","73200518","CDM","450","RC","12001","HCPCS","facility","both","","","","923","461.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12002 Simp Rep Trunk 2.6-7.5Cm","73200519","CDM","450","RC","12002","HCPCS","facility","both","","","","1551","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12004 Simp Rep Trnk 7.6-12.5Cm","73200520","CDM","450","RC","12004","HCPCS","facility","both","","","","1708","854","","","","","","","","","","","","","Gross Charge Type: Standard"
"12005 Simp Rep Trunk 12.6-20Cm","73200521","CDM","450","RC","12005","HCPCS","facility","both","","","","1877","938.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12006 Simp Rep Trunk 20.1-30Cm","73200522","CDM","450","RC","12006","HCPCS","facility","both","","","","2067","1033.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12007 Simple Rep Trunk>30Cm","73200523","CDM","450","RC","12007","HCPCS","facility","both","","","","2272","1136","","","","","","","","","","","","","Gross Charge Type: Standard"
"12011 Simple Rep Face=<2.5Cm","73200524","CDM","450","RC","12011","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12013 Simple Repair F/E/E/N/L/M 2.6Cm-5.0 Cm","73200525","CDM","450","RC","12013","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"12014 Simp Rep Face 5.1-7.5Cm","73200526","CDM","450","RC","12014","HCPCS","facility","both","","","","1403","701.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12015 Simp Rep Face 7.6-12.5Cm","73200527","CDM","450","RC","12015","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"12016 Simp Rep Face 12.6-20Cm","73200528","CDM","450","RC","12016","HCPCS","facility","both","","","","1773","886.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12018 Simp Rep Face >30Cm","73200529","CDM","450","RC","12018","HCPCS","facility","both","","","","2344","1172","","","","","","","","","","","","","Gross Charge Type: Standard"
"12020 Rx Supfcl Wd Dehis-Simp","73200530","CDM","450","RC","12020","HCPCS","facility","both","","","","2150","1075","","","","","","","","","","","","","Gross Charge Type: Standard"
"12021 Rx Supfcl Wd Deshi-Pack","73200531","CDM","450","RC","12021","HCPCS","facility","both","","","","1475","737.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12031 Repair Intermediate S/A/T/E 2.5 Cm/<","73200532","CDM","450","RC","12031","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"12032 Repair Intermediate S/A/T/E 2.6-7.5 Cm","73200533","CDM","450","RC","12032","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"12034 Repair Intermediate S/A/T/E 7.6-12.5 Cm","73200534","CDM","450","RC","12034","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"12035 Repair Intermediate S/A/T/E 12.6-20.0Cm","73200535","CDM","450","RC","12035","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"12036 Repair Intermediate S/A/T/E 20.1-30.0 Cm","73200536","CDM","450","RC","12036","HCPCS","facility","both","","","","1894","947","","","","","","","","","","","","","Gross Charge Type: Standard"
"12037 Repair Intermediate S/A/T/E >30.0 Cm","73200538","CDM","450","RC","12037","HCPCS","facility","both","","","","6196","3098","","","","","","","","","","","","","Gross Charge Type: Standard"
"12041  Lay Clos Hnd/Ft=<2.5Cm","73200539","CDM","450","RC","12041","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12042 Lay Cls Hnd/Ft 2.6-7.5Cm","73200540","CDM","450","RC","12042","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12044 Lay Cls Hnd/F 7.6-12.5Cm","73200541","CDM","450","RC","12044","HCPCS","facility","both","","","","811","405.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12045 Lay Cls Hnd/Ft 12.6-20Cm","73200542","CDM","450","RC","12045","HCPCS","facility","both","","","","811","405.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12051 Layr Closr Face=<2.5Cm","73200543","CDM","450","RC","12051","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12052 Layr Closr Face 2.6-5Cm","73200544","CDM","450","RC","12052","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12053 Layr Clos Face 5.1-7.5Cm","73200545","CDM","450","RC","12053","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12054 Lay Clos Face 7.6-12.5Cm","73200546","CDM","450","RC","12054","HCPCS","facility","both","","","","523","261.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"12055 Lay Clos Face 12.6-20Cm","73200547","CDM","450","RC","12055","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"12056 Layr Clos Face 20.1-30Cm","73200548","CDM","450","RC","12056","HCPCS","facility","both","","","","840","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"12057 Layr Closr Face >30Cm","73200549","CDM","450","RC","12057","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13100 Comp Rep Trunk 1.1-2.5Cm","73200550","CDM","450","RC","13100","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13101 Comp Rep Trunk 2.6-7.5Cm","73200551","CDM","450","RC","13101","HCPCS","facility","both","","","","2079","1039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13102 Comp Rep Trnk Ea Add 5Cm","73200552","CDM","450","RC","13102","HCPCS","facility","both","","","","1074","537","","","","","","","","","","","","","Gross Charge Type: Standard"
"13120 Comp Rep Ext/1.1-2.5Cm","73200553","CDM","450","RC","13120","HCPCS","facility","both","","","","1288","644","","","","","","","","","","","","","Gross Charge Type: Standard"
"13121 Comp Rep Ext/2.6-75.Cm","73200554","CDM","450","RC","13121","HCPCS","facility","both","","","","1478","739","","","","","","","","","","","","","Gross Charge Type: Standard"
"13122 Comp Rep Ext/Ea Add 5Cm","73200555","CDM","450","RC","13122","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13131 Comp Rep Face/1.1-2.5Cm","73200556","CDM","450","RC","13131","HCPCS","facility","both","","","","1321","660.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13132 Comp Rep Face/2.6-7.5Cm","73200557","CDM","450","RC","13132","HCPCS","facility","both","","","","1523","761.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13133 Comp Rep Fac/Ea Add 5Cm","73200558","CDM","450","RC","13133","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"13151 Comp Rep Eyeld/1.1-2.5Cm","73200560","CDM","450","RC","13151","HCPCS","facility","both","","","","2029","1014.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13152 Comp Rep Eyeld/2.6-7.5Cm","73200561","CDM","450","RC","13152","HCPCS","facility","both","","","","2331","1165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13153 Cmp Rep Eyeld/Ea Add 5Cm","73200562","CDM","450","RC","13153","HCPCS","facility","both","","","","2680","1340","","","","","","","","","","","","","Gross Charge Type: Standard"
"16000 1St Degree Burn-Init Rx","73200563","CDM","450","RC","16000","HCPCS","facility","both","","","","486","243","","","","","","","","","","","","","Gross Charge Type: Standard"
"16030 Burn Dsrg/Debr W Anes-Lg","73200565","CDM","450","RC","16030","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"16020 Dress/Debrd P-Thick Burn","73200566","CDM","450","RC","16020","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"16025 Burn Dsg/Dbrid S Anes-Md","73200567","CDM","450","RC","16025","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"19000 Breast Cyst Punc Aspirat","73200569","CDM","450","RC","19000","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"20100 Penetr Wound Explor-Neck","73200571","CDM","450","RC","20100","HCPCS","facility","both","","","","1782","891","","","","","","","","","","","","","Gross Charge Type: Standard"
"20101 Penetr Wound Expl-Chest","73200572","CDM","450","RC","20101","HCPCS","facility","both","","","","5583","2791.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20102 Pen Wnd Expl-Abd/Flnk/Bk","73200573","CDM","450","RC","20102","HCPCS","facility","both","","","","5583","2791.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20103 Penetr Wnd Expl-Extrem","73200574","CDM","450","RC","20103","HCPCS","facility","both","","","","2947","1473.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20520 Rem Mscle/Tndn Fb Simpl","73200575","CDM","450","RC","20520","HCPCS","facility","both","","","","1753","876.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20600 Arthrcents-Sm Jnt W/O Us","73200576","CDM","450","RC","20600","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20605 Arthrcent-Int Jnt W/O Us","73200577","CDM","450","RC","20605","HCPCS","facility","both","","","","846","423","","","","","","","","","","","","","Gross Charge Type: Standard"
"20610 Arthrcents-Mj Jnt W/O Us","73200578","CDM","450","RC","20610","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"20650 Insert Wire/Pin Sk Trac","73200579","CDM","450","RC","20650","HCPCS","facility","both","","","","5137","2568.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"21315 Closed Tx Nose Fx W/O Stablj","73200585","CDM","450","RC","21315","HCPCS","facility","both","","","","4532","2266","","","","","","","","","","","","","Gross Charge Type: Standard"
"21320 Closed Tx Nose Fx W/ Stablj","73200586","CDM","450","RC","21320","HCPCS","facility","both","","","","7213","3606.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"21453 Cl Rx Mand Fx-Dental Fix","73200590","CDM","450","RC","21453","HCPCS","facility","both","","","","10715","5357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"21480 Clsd Rx Tmj Dislocation","73200591","CDM","450","RC","21480","HCPCS","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23330 Removal Subq Fb Shoulder","73200597","CDM","450","RC","23330","HCPCS","facility","both","","","","3102","1551","","","","","","","","","","","","","Gross Charge Type: Standard"
"23505 Clsd Rx Clav Fx W Manip","73200599","CDM","450","RC","23505","HCPCS","facility","both","","","","4299","2149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23545 Clsd Rx Ac Disl W Manip","73200601","CDM","450","RC","23545","HCPCS","facility","both","","","","2241","1120.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23600 Cl Rx Humer Fx No Manip","73200603","CDM","450","RC","23600","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23605 Clsd Rx Humer Fx W Manip","73200604","CDM","450","RC","23605","HCPCS","facility","both","","","","2867","1433.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23650 Cl Rx Sh Dsl-Man-No Anes","73200606","CDM","450","RC","23650","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"24200 Rem Subq Fb Up Arm/Elbow","73200609","CDM","450","RC","24200","HCPCS","facility","both","","","","1753","876.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24500 Cl Rx Hum Shft Fx No Man","73200610","CDM","450","RC","24500","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24535 Cl Rx Condylr Fx W Mnip","73200613","CDM","450","RC","24535","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24565 Cl Rx Condylar Fx W Mnip","73200615","CDM","450","RC","24565","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24577 Cl Rx Condylr Fx W Man","73200617","CDM","450","RC","24577","HCPCS","facility","both","","","","5028","2514","","","","","","","","","","","","","Gross Charge Type: Standard"
"24600 Rx Cl Elb Dslctn No Anes","73200618","CDM","450","RC","24600","HCPCS","facility","both","","","","758","379","","","","","","","","","","","","","Gross Charge Type: Standard"
"24640 Rx Nursmd El W Mani-Chld","73200620","CDM","450","RC","24640","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"24655 Clsd Rx Radial Fx W Mnip","73200622","CDM","450","RC","24655","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24670 Cl Rx Prox Uln Fx No Man","73200623","CDM","450","RC","24670","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"24675 Cl Rx Prox Uln Fx W Manp","73200624","CDM","450","RC","24675","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"25505 Cl Rx Radial Fx W Manip","73200626","CDM","450","RC","25505","HCPCS","facility","both","","","","3102","1551","","","","","","","","","","","","","Gross Charge Type: Standard"
"25535 Clsd Rx Ulnar Fx W Manip","73200629","CDM","450","RC","25535","HCPCS","facility","both","","","","2901","1450.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"25560 Cl Tx Rad&Ul Fx No Manip","73200630","CDM","450","RC","25560","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"25565 Clsd Rx Rad&Ul Fx W Mnip","73200631","CDM","450","RC","25565","HCPCS","facility","both","","","","5028","2514","","","","","","","","","","","","","Gross Charge Type: Standard"
"25600 Cl Rx Epiph Spen No Mnip","73200632","CDM","450","RC","25600","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"25605 Cl Rx Epiph Sepn W Manip","73200633","CDM","450","RC","25605","HCPCS","facility","both","","","","2208","1104","","","","","","","","","","","","","Gross Charge Type: Standard"
"25622 Cl Rx Scaphod Fx-No Mnip","73200634","CDM","450","RC","25622","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"25624 Cl Tx Carpl Scaphoid Fx","73200635","CDM","450","RC","25624","HCPCS","facility","both","","","","2705","1352.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"25635 Cl Rx Carp Fx W Mnip Ea","73200637","CDM","450","RC","25635","HCPCS","facility","both","","","","1725","862.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"25650 Clsd Rx Ulnar Styloid Fx","73200638","CDM","450","RC","25650","HCPCS","facility","both","","","","720","360","","","","","","","","","","","","","Gross Charge Type: Standard"
"25675 Cl Rx Radoulnr Dslo-Mnip","73200640","CDM","450","RC","25675","HCPCS","facility","both","","","","575","287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"25690 Cl Rx Lunat Disl W Manip","73200641","CDM","450","RC","25690","HCPCS","facility","both","","","","4874","2437","","","","","","","","","","","","","Gross Charge Type: Standard"
"26010 Smpl Drain Fngr Abscess","73200642","CDM","450","RC","26010","HCPCS","facility","both","","","","359","179.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26011 Compl Drain Fing Abscess","73200643","CDM","450","RC","26011","HCPCS","facility","both","","","","2462","1231","","","","","","","","","","","","","Gross Charge Type: Standard"
"26600 Cl Rx Metacarp Fx No Man","73200644","CDM","450","RC","26600","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"26605 Cl Rx Metcrpl Fx W Manip","73200645","CDM","450","RC","26605","HCPCS","facility","both","","","","1198","599","","","","","","","","","","","","","Gross Charge Type: Standard"
"26641 Rx Car/Metcarp Dslo-Mnip","73200646","CDM","450","RC","26641","HCPCS","facility","both","","","","316","158","","","","","","","","","","","","","Gross Charge Type: Standard"
"26645 Cl Rx Bennett Fx W Manip","73200647","CDM","450","RC","26645","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26670 Cl Rx Carpmetcarp Disloc","73200648","CDM","450","RC","26670","HCPCS","facility","both","","","","540","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"26700 Cl Rx M-P Dslo Sngl-Mnip","73200649","CDM","450","RC","26700","HCPCS","facility","both","","","","754","377","","","","","","","","","","","","","Gross Charge Type: Standard"
"26705 Cl Rx M-P Dslo W Anes","73200650","CDM","450","RC","26705","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26720 Cl Rx Fngr Fx-No Mnip Ea","73200651","CDM","450","RC","26720","HCPCS","facility","both","","","","561","280.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26725 Cl Rx Finger Fx W Man Ea","73200652","CDM","450","RC","26725","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"26740 Cl Rx M-P/I-P Fx No Mnip","73200653","CDM","450","RC","26740","HCPCS","facility","both","","","","739","369.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26742 Cl Rx Mcp/Ip Fx W Manip","73200654","CDM","450","RC","26742","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26750 Closed Rx Dstl Finger Fx","73200655","CDM","450","RC","26750","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"26755 Cl Rx Dstl Fngr Fx W Man","73200656","CDM","450","RC","26755","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"26770 Cl Rx Ip Dslo Hand W Man","73200657","CDM","450","RC","26770","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"26775 Cl Rx Ip Dslo-Man & Anes","73200658","CDM","450","RC","26775","HCPCS","facility","both","","","","4759","2379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27086 Rmvl Subq Fb Pelvis/Hip","73200659","CDM","450","RC","27086","HCPCS","facility","both","","","","3019","1509.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Hip Socket Fracture","73200663","CDM","450","RC","27222","HCPCS","facility","both","","","","3983","1991.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27250 Cl Rx Hip Dslo-No Anes","73200669","CDM","450","RC","27250","HCPCS","facility","both","","","","422","211","","","","","","","","","","","","","Gross Charge Type: Standard"
"27265 Cl Rx Post Hip Arthr Dis","73200670","CDM","450","RC","27265","HCPCS","facility","both","","","","651","325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27502 Cl Rx Fem Shaft Fx W Man","73200673","CDM","450","RC","27502","HCPCS","facility","both","","","","5142","2571","","","","","","","","","","","","","Gross Charge Type: Standard"
"27503 Cl Tx Sc/Tc Femur Fx Man","73200674","CDM","450","RC","27503","HCPCS","facility","both","","","","4606","2303","","","","","","","","","","","","","Gross Charge Type: Standard"
"27510 Cl Tx Femur Fx Or Epiphy","73200676","CDM","450","RC","27510","HCPCS","facility","both","","","","2250","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"27532 Cl Tx Prox Tibial Fx","73200681","CDM","450","RC","27532","HCPCS","facility","both","","","","3478","1739","","","","","","","","","","","","","Gross Charge Type: Standard"
"27550 Cl Rx Knee Dslo-No Anes","73200683","CDM","450","RC","27550","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"27560 Cl Rx Patla Dslo-No Anes","73200684","CDM","450","RC","27560","HCPCS","facility","both","","","","430","215","","","","","","","","","","","","","Gross Charge Type: Standard"
"27752 Cl Rx Tibial Fx W Manip","73200686","CDM","450","RC","27752","HCPCS","facility","both","","","","8533","4266.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27762 Cl Rx Dstl Tib Fx W Mnip","73200688","CDM","450","RC","27762","HCPCS","facility","both","","","","4640","2320","","","","","","","","","","","","","Gross Charge Type: Standard"
"27781 Cl Rx Fibula Fx W Manip","73200690","CDM","450","RC","27781","HCPCS","facility","both","","","","5727","2863.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27786 Cl Rx Dstl Fib Fx-No Man","73200691","CDM","450","RC","27786","HCPCS","facility","both","","","","406","203","","","","","","","","","","","","","Gross Charge Type: Standard"
"27788 Cl Rx Dstl Fib Fx W Mnip","73200692","CDM","450","RC","27788","HCPCS","facility","both","","","","478","239","","","","","","","","","","","","","Gross Charge Type: Standard"
"27808 Cl Rx Bimaleor Fx-No Man","73200693","CDM","450","RC","27808","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"27810 Cl Rx Bimaleor Fx W Mnip","73200694","CDM","450","RC","27810","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27816 Cl Rx Trimaler Fx No Man","73200695","CDM","450","RC","27816","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"27818 Cl Rx Trimaleor Fx-Manip","73200696","CDM","450","RC","27818","HCPCS","facility","both","","","","2505","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27824 Cl Rx Dstl Tib Fx-No Man","73200697","CDM","450","RC","27824","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"27840 Cl Rx Ankl Dslo-No Anes","73200698","CDM","450","RC","27840","HCPCS","facility","both","","","","1464","732","","","","","","","","","","","","","Gross Charge Type: Standard"
"28190 Removal Subq Fb-Foot","73200699","CDM","450","RC","28190","HCPCS","facility","both","","","","2523","1261.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28405 Cl Rx Calcaneal Fx; W Ma","73200701","CDM","450","RC","28405","HCPCS","facility","both","","","","1132","566","","","","","","","","","","","","","Gross Charge Type: Standard"
"28435 Cl Rx Talus Fx W Manip","73200703","CDM","450","RC","28435","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28455 Tx Tarsal Bone Fx;W Mani","73200705","CDM","450","RC","28455","HCPCS","facility","both","","","","3649","1824.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28470 Cl Rx Metarsal Fx-No Mnp","73200706","CDM","450","RC","28470","HCPCS","facility","both","","","","581","290.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28475 Cl Rx Metarsal Fx-Manip","73200707","CDM","450","RC","28475","HCPCS","facility","both","","","","1267","633.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28495 Cl Rx Grt Tow Fx W Manip","73200709","CDM","450","RC","28495","HCPCS","facility","both","","","","1155","577.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28510 Cl Rx Phalanx Fx-No Mnip","73200710","CDM","450","RC","28510","HCPCS","facility","both","","","","642","321","","","","","","","","","","","","","Gross Charge Type: Standard"
"28515 Cl Rx Phalanx Fx W Manip","73200711","CDM","450","RC","28515","HCPCS","facility","both","","","","758","379","","","","","","","","","","","","","Gross Charge Type: Standard"
"28630 Cl Rx Metphl Dsl-No Anes","73200715","CDM","450","RC","28630","HCPCS","facility","both","","","","597","298.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28660 Cl Rx Ip Dislocatn-Toe","73200716","CDM","450","RC","28660","HCPCS","facility","both","","","","443","221.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28665 Cl Rx Ip Disloc-Toe-Anes","73200717","CDM","450","RC","28665","HCPCS","facility","both","","","","1527","763.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29075 Apply Short Arm Cast","73200719","CDM","450","RC","29075","HCPCS","facility","both","","","","599","299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29105 Apply Long Arm Splint","73200720","CDM","450","RC","29105","HCPCS","facility","both","","","","978","489","","","","","","","","","","","","","Gross Charge Type: Standard"
"29125 Apply Short Arm Splint","73200721","CDM","450","RC","29125","HCPCS","facility","both","","","","844","422","","","","","","","","","","","","","Gross Charge Type: Standard"
"29130 Apply Fngr Splint-Static","73200722","CDM","450","RC","29130","HCPCS","facility","both","","","","890","445","","","","","","","","","","","","","Gross Charge Type: Standard"
"29240 Strapping-Shoulder","73200723","CDM","450","RC","29240","HCPCS","facility","both","","","","973","486.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29405 Short Leg Cast","73200725","CDM","450","RC","29405","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29505 App Long Leg Splint","73200726","CDM","450","RC","29505","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29515 App Short Leg Splint","73200727","CDM","450","RC","29515","HCPCS","facility","both","","","","886","443","","","","","","","","","","","","","Gross Charge Type: Standard"
"29530 Strapping-Knee","73200728","CDM","450","RC","29530","HCPCS","facility","both","","","","770","385","","","","","","","","","","","","","Gross Charge Type: Standard"
"29540 Strapping-Ankle","73200729","CDM","450","RC","29540","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29550 Strapping-Toes","73200730","CDM","450","RC","29550","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"30300 Remove Nose Fb-Office Px","73200731","CDM","450","RC","30300","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"30901 Control Nose Bleed-Smpl","73200732","CDM","450","RC","30901","HCPCS","facility","both","","","","938","469","","","","","","","","","","","","","Gross Charge Type: Standard"
"30905 Nose Bl-Post Pack-Initl","73200734","CDM","450","RC","30905","HCPCS","facility","both","","","","546","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"30906 Nose Bl-Post Pack-Sbsqnt","73200735","CDM","450","RC","30906","HCPCS","facility","both","","","","546","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"31500 Endotrachl Intubatn-Emer","73200736","CDM","450","RC","31500","HCPCS","facility","both","","","","2264","1132","","","","","","","","","","","","","Gross Charge Type: Standard"
"31502 Tracheotomy Tube Change","73200737","CDM","450","RC","31502","HCPCS","facility","both","","","","590","295","","","","","","","","","","","","","Gross Charge Type: Standard"
"31505 Indirct Dxtic Laryngscpy","73200738","CDM","450","RC","31505","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"31575 Dxtic Fibreopt Laryngosc","73200739","CDM","450","RC","31575","HCPCS","facility","both","","","","785","392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"31603 Emerg Trnstrach Tracheos","73200740","CDM","450","RC","31603","HCPCS","facility","both","","","","2099","1049.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"32551 Tube Thoracostomy","73200743","CDM","450","RC","32551","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"32160 Mj Thorctomy W Cardc Mas","73200744","CDM","450","RC","32160","HCPCS","facility","both","","","","1014","507","","","","","","","","","","","","","Gross Charge Type: Standard"
"36000 Needle/Intracath In Vein","73200746","CDM","450","RC","36000","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"36405 Bl Draw <3Rs Scalp Vein","73200749","CDM","450","RC","36405","HCPCS","facility","both","","","","1044","522","","","","","","","","","","","","","Gross Charge Type: Standard"
"36415 Routine Venipunct/Stick","73200750","CDM","450","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36430 Bld Cmpnts Indirct Trnsf","73200751","CDM","450","RC","36430","HCPCS","facility","both","","","","1611","805.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36600 Arterial Puncture","73200753","CDM","450","RC","36600","HCPCS","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"40650 Lip Rp Ful Thick-Vermil","73200755","CDM","450","RC","40650","HCPCS","facility","both","","","","1782","891","","","","","","","","","","","","","Gross Charge Type: Standard"
"40654 Lip Rp Ful->1/2 Vert Ht","73200756","CDM","450","RC","40654","HCPCS","facility","both","","","","3563","1781.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"40800 I&D Cyt Vestbl Mouth-Smp","73200757","CDM","450","RC","40800","HCPCS","facility","both","","","","996","498","","","","","","","","","","","","","Gross Charge Type: Standard"
"40830 Sut Lac Mouth To 2.5Cm","73200758","CDM","450","RC","40830","HCPCS","facility","both","","","","996","498","","","","","","","","","","","","","Gross Charge Type: Standard"
"41000 I&D Les Intraoral Lingul","73200760","CDM","450","RC","41000","HCPCS","facility","both","","","","4014","2007","","","","","","","","","","","","","Gross Charge Type: Standard"
"41250 Rp Lac Ant 2/3 Tong-2Cm","73200761","CDM","450","RC","41250","HCPCS","facility","both","","","","546","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"41252 Rp Lac Tongue Over 2Cm","73200762","CDM","450","RC","41252","HCPCS","facility","both","","","","3200","1600","","","","","","","","","","","","","Gross Charge Type: Standard"
"41800 I&D Lesion Dentoalveolar","73200763","CDM","450","RC","41800","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"42000 I&D Palate/Uvula Lesion","73200764","CDM","450","RC","42000","HCPCS","facility","both","","","","803","401.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"42310 I&D Absc-Submax/Lingual","73200765","CDM","450","RC","42310","HCPCS","facility","both","","","","1640","820","","","","","","","","","","","","","Gross Charge Type: Standard"
"42700 I&D Absc-Peritonsillar","73200766","CDM","450","RC","42700","HCPCS","facility","both","","","","1350","675","","","","","","","","","","","","","Gross Charge Type: Standard"
"42809 Pharyngeal Fb Removal","73200767","CDM","450","RC","42809","HCPCS","facility","both","","","","1194","597","","","","","","","","","","","","","Gross Charge Type: Standard"
"42960 Contrl Orophar Bleed-Smp","73200768","CDM","450","RC","42960","HCPCS","facility","both","","","","1902","951","","","","","","","","","","","","","Gross Charge Type: Standard"
"43761 Repos Gtube Thru Duoden","73200770","CDM","450","RC","43761","HCPCS","facility","both","","","","2047","1023.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"45005 I&D Submuc Absc-Rectum","73200771","CDM","450","RC","45005","HCPCS","facility","both","","","","3297","1648.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"46040 I&D Ischo/Perirectl Absc","73200772","CDM","450","RC","46040","HCPCS","facility","both","","","","5597","2798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"46050 I&D Supficl Perianl Absc","73200773","CDM","450","RC","46050","HCPCS","facility","both","","","","3297","1648.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"46083 Ext Incis-Thrombosd Pile","73200774","CDM","450","RC","46083","HCPCS","facility","both","","","","794","397","","","","","","","","","","","","","Gross Charge Type: Standard"
"46608 Anoscopy With Removal Fb","73200775","CDM","450","RC","46608","HCPCS","facility","both","","","","3039","1519.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"51700 Bladder Irrigation","73200777","CDM","450","RC","51700","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"56405 I&D Vulva/Perineal Absc","73200781","CDM","450","RC","56405","HCPCS","facility","both","","","","981","490.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"56420 I&D Barth Bland Abscess","73200782","CDM","450","RC","56420","HCPCS","facility","both","","","","2107","1053.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"57200 Colporrhaphy (Nonobstet)","73200783","CDM","450","RC","57200","HCPCS","facility","both","","","","3432","1716","","","","","","","","","","","","","Gross Charge Type: Standard"
"57415 Rem Vaginal Foreign Body","73200784","CDM","450","RC","57415","HCPCS","facility","both","","","","7694","3847","","","","","","","","","","","","","Gross Charge Type: Standard"
"58120 Nonobstetrical D&C","73200785","CDM","450","RC","58120","HCPCS","facility","both","","","","4678","2339","","","","","","","","","","","","","Gross Charge Type: Standard"
"58301 Remove Iud","73200786","CDM","450","RC","58301","HCPCS","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"59409 Vaginal Delivery Only","73200787","CDM","450","RC","59409","HCPCS","facility","both","","","","4202","2101","","","","","","","","","","","","","Gross Charge Type: Standard"
"59414 Deliver Placenta","73200788","CDM","450","RC","59414","HCPCS","facility","both","","","","3756","1878","","","","","","","","","","","","","Gross Charge Type: Standard"
"59514 Caesarean Delivery Only","73200789","CDM","450","RC","59514","HCPCS","facility","both","","","","3908","1954","","","","","","","","","","","","","Gross Charge Type: Standard"
"62270 Lumbar Sp Puncture-Dx","73200790","CDM","450","RC","62270","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"62272  Theraputic Sp Punc-Drai","73200791","CDM","450","RC","62272","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"62273  Epidur Inj Bl/Clot Patc","73200792","CDM","450","RC","62273","HCPCS","facility","both","","","","2067","1033.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65205 Rmv Superficl Fb Conjun","73200793","CDM","450","RC","65205","HCPCS","facility","both","","","","797","398.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65210 Rmv Embedded Fb Conjunct","73200794","CDM","450","RC","65210","HCPCS","facility","both","","","","821","410.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65220 Removal Corneal Fb","73200795","CDM","450","RC","65220","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65222 Rmv Fb Cornea,Slit Lamp","73200796","CDM","450","RC","65222","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"69000 I&D Ear Absc/Hematm Simp","73200797","CDM","450","RC","69000","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"69200 Ext Audit Canal Fb Remov","73200798","CDM","450","RC","69200","HCPCS","facility","both","","","","585","292.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"69210 Impact Cerumen Rem Unila","73200799","CDM","450","RC","69210","HCPCS","facility","both","","","","373","186.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"96372 Injection (Sc) (Im)","73200804","CDM","450","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"96374 Intravenous Injection","73200805","CDM","450","RC","96374","HCPCS","facility","both","","","","542","271","","","","","","","","","","","","","Gross Charge Type: Standard"
"92950 Cardiopulm Resuscitation","73200808","CDM","450","RC","92950","HCPCS","facility","both","","","","1883","941.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"92953 Temp Trancutan Pacing","73200809","CDM","450","RC","92953","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"92960 Extern Elect Cardioversn","73200810","CDM","450","RC","92960","HCPCS","facility","both","","","","2400","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"12017 Smple Rep Face 20.1-30Cm","73200817","CDM","450","RC","12017","HCPCS","facility","both","","","","2038","1019","","","","","","","","","","","","","Gross Charge Type: Standard"
"12047 Lay Clos Hnd/Ft>30Cm","73200823","CDM","450","RC","12047","HCPCS","facility","both","","","","2594","1297","","","","","","","","","","","","","Gross Charge Type: Standard"
"13160 2Nd Clos Of Surg Wound","73200829","CDM","450","RC","13160","HCPCS","facility","both","","","","6172","3086","","","","","","","","","","","","","Gross Charge Type: Standard"
"29000 Appl Of Halo Body Cast","73200830","CDM","450","RC","29000","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"29010 Appl Risser Jacket,Body","73200831","CDM","450","RC","29010","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29015 Appl Risser Jac Inc Head","73200832","CDM","450","RC","29015","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29035 Appl Bdy Cast,Sh To Hips","73200835","CDM","450","RC","29035","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29040 Body Cast,Sh,Hips,Head","73200836","CDM","450","RC","29040","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"29044 Bdy Cast,Sh,Hips,Thigh","73200837","CDM","450","RC","29044","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29046 Bdy Cast,Sh,Hips,2Thighs","73200838","CDM","450","RC","29046","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29049 Appl Figure Eight","73200839","CDM","450","RC","29049","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"29055 Appl Shoulder Spica","73200840","CDM","450","RC","29055","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29058 Appl Plaster Velpeau","73200841","CDM","450","RC","29058","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"29085 Appl Cast Hand,Low Arm","73200842","CDM","450","RC","29085","HCPCS","facility","both","","","","382","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"29126 Appl Forearm Splint","73200844","CDM","450","RC","29126","HCPCS","facility","both","","","","338","169","","","","","","","","","","","","","Gross Charge Type: Standard"
"29131 Appl Finger Splint","73200845","CDM","450","RC","29131","HCPCS","facility","both","","","","500","250","","","","","","","","","","","","","Gross Charge Type: Standard"
"29280 Strapping Hand Or Finger","73200848","CDM","450","RC","29280","HCPCS","facility","both","","","","951","475.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29305 App Hip Spica Cast,1 Lg","73200849","CDM","450","RC","29305","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29325 Hip Cast 1+Hlf Spica 2Lg","73200850","CDM","450","RC","29325","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29345 Appl Long Leg Cast","73200851","CDM","450","RC","29345","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29358 App Long Leg Cast Brace","73200853","CDM","450","RC","29358","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29425 App Sh Leg Cast,Walker","73200855","CDM","450","RC","29425","HCPCS","facility","both","","","","555","277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29435 App Patellar (Ptb) Cast","73200856","CDM","450","RC","29435","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"29440 Add Walker To Appl Cast","73200857","CDM","450","RC","29440","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29450 App Clubft Cast,Molding","73200859","CDM","450","RC","29450","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29520 Strapping Of Hip","73200860","CDM","450","RC","29520","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"51701 Non-Indwel Bladder Cath","73200872","CDM","450","RC","51701","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"51702 Insert Temp Bladder Cath","73200874","CDM","450","RC","51702","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"51703 Insert Bladder Cath,Comp","73200875","CDM","450","RC","51703","HCPCS","facility","both","","","","468","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"90471 Immunization Admin,1 Vac","73200876","CDM","771","RC","90471","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"93005 Ecg 12-Lead - Ed Tracing","73200879","CDM","450","RC","93005","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"94150 Spec-Peak Flow Rate","73200881","CDM","450","RC","94150","HCPCS","facility","both","","","","356","178","","","","","","","","","","","","","Gross Charge Type: Standard"
"94640 Hand-Held/Aerosl Nebuliz","73200882","CDM","450","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"94760 Pulse Oximetry Spot Chec","73200883","CDM","460","RC","94760","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"94761 Pulse Oximetry Mult Dete","73200884","CDM","460","RC","94761","HCPCS","facility","both","","","","688","344","","","","","","","","","","","","","Gross Charge Type: Standard"
"20552 Trigger Point Injection","73200886","CDM","450","RC","20552","HCPCS","facility","both","","","","1244","622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uds Collection Only","73200887","CDM","450","RC","","","facility","both","","","","100","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Collection Screening","73200890","CDM","450","RC","","","facility","both","","","","174","87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urine Screen Sap 10 Colle","73200892","CDM","450","RC","","","facility","both","","","","199","99.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uds Collection-Lab Corp","73200894","CDM","450","RC","","","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11012 Debridement Of Open Fx/D","73200895","CDM","450","RC","11012","HCPCS","facility","both","","","","3844","1922","","","","","","","","","","","","","Gross Charge Type: Standard"
"16035 Escharotomy","73200896","CDM","450","RC","16035","HCPCS","facility","both","","","","727","363.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20550 Inject Tend Sheath Lig T","73200897","CDM","450","RC","20550","HCPCS","facility","both","","","","735","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"21337 Clo Trt Nasal Septal Fx","73200949","CDM","450","RC","21337","HCPCS","facility","both","","","","4014","2007","","","","","","","","","","","","","Gross Charge Type: Standard"
"21400 Clo Trt Orbit Fx-Exc Blo","73200950","CDM","450","RC","21400","HCPCS","facility","both","","","","1782","891","","","","","","","","","","","","","Gross Charge Type: Standard"
"21450 Clo Trt Mandible Fx-No M","73200951","CDM","450","RC","21450","HCPCS","facility","both","","","","803","401.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23540 Clsd Tx Ac Dislocation W","73200954","CDM","450","RC","23540","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24000 Arthrotomy Elbow Inc Exp","73200955","CDM","450","RC","24000","HCPCS","facility","both","","","","7408","3704","","","","","","","","","","","","","Gross Charge Type: Standard"
"25500 Clsd Tx Rad Shaft Fx Wo","73200959","CDM","450","RC","25500","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"25520 Clsd Tx Rad Shaft Fx Wit","73200960","CDM","450","RC","25520","HCPCS","facility","both","","","","1671","835.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26418 Extensor Tendon Repair,F","73200962","CDM","450","RC","26418","HCPCS","facility","both","","","","4181","2090.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26989 Suture Tendon Sheath","73200963","CDM","450","RC","26989","HCPCS","facility","both","","","","299","149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27200 Clsd Tx Coccygeal Fx","73200965","CDM","450","RC","27200","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"27750 Clsd Tx Tibial Shaft Tx","73200967","CDM","450","RC","27750","HCPCS","facility","both","","","","891","445.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27760 Clsd Tx Med Malleous Fx","73200968","CDM","450","RC","27760","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"28540 Clsd Tx Tarsal Bone Disl","73200969","CDM","450","RC","28540","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"30903 Cntrl Nasal Hemorr Ant C","73200970","CDM","450","RC","30903","HCPCS","facility","both","","","","1002","501","","","","","","","","","","","","","Gross Charge Type: Standard"
"31605 Emerg Trach Cricothyroid","73200971","CDM","450","RC","31605","HCPCS","facility","both","","","","2133","1066.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36400 Venipuncture Under Age 3","73200972","CDM","450","RC","36400","HCPCS","facility","both","","","","202","101","","","","","","","","","","","","","Gross Charge Type: Standard"
"36680 Placemnt Needle Intraoss","73200974","CDM","450","RC","36680","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"43247 Upper Gi Endosc W Fb Rem","73200975","CDM","450","RC","43247","HCPCS","facility","both","","","","3278","1639","","","","","","","","","","","","","Gross Charge Type: Standard"
"64405 Inject Anesth Agent Occi","73200976","CDM","450","RC","64405","HCPCS","facility","both","","","","1164","582","","","","","","","","","","","","","Gross Charge Type: Standard"
"96376 Iv Inj Ea Seq Push","73200990","CDM","450","RC","96376","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26952 Amputatn Fingr/Thumb-Flp","73200991","CDM","450","RC","26952","HCPCS","facility","both","","","","6090","3045","","","","","","","","","","","","","Gross Charge Type: Standard"
"14040 Adjacent Tiss Tran 10Sqc","73200992","CDM","450","RC","14040","HCPCS","facility","both","","","","3633","1816.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"15240 Skin Full Grf Fac/Gen/Hf","73200993","CDM","450","RC","15240","HCPCS","facility","both","","","","5407","2703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"33210 Temp Pacing Wire Proced","73201003","CDM","450","RC","33210","HCPCS","facility","both","","","","10197","5098.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"54235 Penile Injection","73201004","CDM","450","RC","54235","HCPCS","facility","both","","","","1157","578.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"58100 Endometrial Biopsy","73201005","CDM","450","RC","58100","HCPCS","facility","both","","","","974","487","","","","","","","","","","","","","Gross Charge Type: Standard"
"54700 Drainage Of Scrotum","73201006","CDM","450","RC","54700","HCPCS","facility","both","","","","4153","2076.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"42330 Removal Salivary Stone","73201011","CDM","450","RC","42330","HCPCS","facility","both","","","","4198","2099","","","","","","","","","","","","","Gross Charge Type: Standard"
"10180 I&D Complex Postop Wound","73201012","CDM","450","RC","10180","HCPCS","facility","both","","","","10236","5118","","","","","","","","","","","","","Gross Charge Type: Standard"
"24505 Treat Humer Fractr W/Man","73201013","CDM","450","RC","24505","HCPCS","facility","both","","","","1677","838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"67700 Blephartmy Drain Abscess","73201021","CDM","450","RC","67700","HCPCS","facility","both","","","","1510","755","","","","","","","","","","","","","Gross Charge Type: Standard"
"46045 Incision Rectal Abscess","73201022","CDM","450","RC","46045","HCPCS","facility","both","","","","4143","2071.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36589 Rem Tnld Cvc W/Oprt/Pump","73201023","CDM","450","RC","36589","HCPCS","facility","both","","","","2532","1266","","","","","","","","","","","","","Gross Charge Type: Standard"
"67938 Remove Eyelid Forgn Body","73201025","CDM","450","RC","67938","HCPCS","facility","both","","","","1762","881","","","","","","","","","","","","","Gross Charge Type: Standard"
"46600 Diagnostic Anoscopy","73201026","CDM","450","RC","46600","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"64400 Inj Trigeminal Nerve","73201027","CDM","450","RC","64400","HCPCS","facility","both","","","","1198","599","","","","","","","","","","","","","Gross Charge Type: Standard"
"52000 Cystoscopy","73201030","CDM","450","RC","52000","HCPCS","facility","both","","","","2864","1432","","","","","","","","","","","","","Gross Charge Type: Standard"
"46255 Remove Int/Ext Hem 1 Grp","73201049","CDM","450","RC","46255","HCPCS","facility","both","","","","4423","2211.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"51705 Chng Cystosto Tube;Simpl","73201050","CDM","450","RC","51705","HCPCS","facility","both","","","","946","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"26735 Treat Finger Fracture","73201060","CDM","450","RC","26735","HCPCS","facility","both","","","","8316","4158","","","","","","","","","","","","","Gross Charge Type: Standard"
"54450 Preputial Stretching","73201070","CDM","450","RC","54450","HCPCS","facility","both","","","","1551","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36590 Rem Tnnl Cvc W/Port/Pump","73201100","CDM","450","RC","36590","HCPCS","facility","both","","","","5244","2622","","","","","","","","","","","","","Gross Charge Type: Standard"
"52005 Cystoscopy & Ureter Cath","73201123","CDM","450","RC","52005","HCPCS","facility","both","","","","9723","4861.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"40804 Removl Foregn Body Mouth","73201140","CDM","450","RC","40804","HCPCS","facility","both","","","","3074","1537","","","","","","","","","","","","","Gross Charge Type: Standard"
"20822 Replantation Digit Compl","73201141","CDM","450","RC","20822","HCPCS","facility","both","","","","19976","9988","","","","","","","","","","","","","Gross Charge Type: Standard"
"67930 Suture Eyelid Wound","73201142","CDM","450","RC","67930","HCPCS","facility","both","","","","6138","3069","","","","","","","","","","","","","Gross Charge Type: Standard"
"40801 Drainage Of Mouth Lesion","73201143","CDM","450","RC","40801","HCPCS","facility","both","","","","3870","1935","","","","","","","","","","","","","Gross Charge Type: Standard"
"21497 Interdental Wiring","73201144","CDM","450","RC","21497","HCPCS","facility","both","","","","2794","1397","","","","","","","","","","","","","Gross Charge Type: Standard"
"23665 Cld Shld Dis/Hum Fx W/Mn","73201145","CDM","450","RC","23665","HCPCS","facility","both","","","","3870","1935","","","","","","","","","","","","","Gross Charge Type: Standard"
"36002 Inj For Pseudoaneurysm","73201146","CDM","450","RC","36002","HCPCS","facility","both","","","","2109","1054.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"64505 Inj Suprapalatine Gangl","73201148","CDM","450","RC","64505","HCPCS","facility","both","","","","1140","570","","","","","","","","","","","","","Gross Charge Type: Standard"
"17250 Chemical Cautery,Tissue","73201149","CDM","450","RC","17250","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"57180 Vaginal Packing","73201150","CDM","450","RC","57180","HCPCS","facility","both","","","","795","397.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11043 Deb Musc/Fascia 20Sqcm/<","73201151","CDM","450","RC","11043","HCPCS","facility","both","","","","2599","1299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"30999 Nasal Surgery Procedure","73201153","CDM","450","RC","30999","HCPCS","facility","both","","","","812","406","","","","","","","","","","","","","Gross Charge Type: Standard"
"49082 Abd Paracentesis","73201200","CDM","450","RC","49082","HCPCS","facility","both","","","","1801","900.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"49083 Abd Paracentesis W/Imag","73201201","CDM","450","RC","49083","HCPCS","facility","both","","","","3815","1907.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"49084 Peritoneal Lavage","73201202","CDM","450","RC","49084","HCPCS","facility","both","","","","1801","900.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"32554 Thoracentsis Wo Img Guid","73201203","CDM","450","RC","32554","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"32555 Thoracentsis W Img Guid","73201204","CDM","450","RC","32555","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"32561 Instillation Chest Tube","73201251","CDM","450","RC","32561","HCPCS","facility","both","","","","2058","1029","","","","","","","","","","","","","Gross Charge Type: Standard"
"33020 Pericardiotomy","73201252","CDM","450","RC","33020","HCPCS","facility","both","","","","1908","954","","","","","","","","","","","","","Gross Charge Type: Standard"
"61210 Burr Hole For Vent Cath","73201253","CDM","450","RC","61210","HCPCS","facility","both","","","","6531","3265.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27664 Repr Leg Tendon W/O Grft","73201254","CDM","450","RC","27664","HCPCS","facility","both","","","","15536","7768","","","","","","","","","","","","","Gross Charge Type: Standard"
"10021 Fine Needle Aspir Biopsy","73201255","CDM","450","RC","10021","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36620 A Line Insertion","73201256","CDM","450","RC","36620","HCPCS","facility","both","","","","1994","997","","","","","","","","","","","","","Gross Charge Type: Standard"
"55899 Genital Surgery Proc","73201257","CDM","450","RC","55899","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"64450 Oth-Inj Oth Periph Nerve","73201550","CDM","450","RC","64450","HCPCS","facility","both","","","","2314","1157","","","","","","","","","","","","","Gross Charge Type: Standard"
"23655 Clsd Should Dis W/Mp&Ane","73201552","CDM","450","RC","23655","HCPCS","facility","both","","","","3069","1534.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65235 Remvl Fb Eye,Anter Chmb","73201553","CDM","450","RC","65235","HCPCS","facility","both","","","","3650","1825","","","","","","","","","","","","","Gross Charge Type: Standard"
"31238 Nasal/Sinus Endoscopy","73201554","CDM","450","RC","31238","HCPCS","facility","both","","","","2964","1482","","","","","","","","","","","","","Gross Charge Type: Standard"
"51102 Drain Bldr W/Cath Insert","73201555","CDM","450","RC","51102","HCPCS","facility","both","","","","4675","2337.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"15050 Skin Pinch Graft","73201818","CDM","450","RC","15050","HCPCS","facility","both","","","","3598","1799","","","","","","","","","","","","","Gross Charge Type: Standard"
"21440 Treat Dental Ridge Fx","73201819","CDM","450","RC","21440","HCPCS","facility","both","","","","3972","1986","","","","","","","","","","","","","Gross Charge Type: Standard"
"92511 Nasopharyngoscopy","73201820","CDM","450","RC","92511","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"66030 Injectn Treatment Of Eye","73201825","CDM","450","RC","66030","HCPCS","facility","both","","","","2762","1381","","","","","","","","","","","","","Gross Charge Type: Standard"
"31525 Dx Laryngoscopy Excl Nb","73201826","CDM","450","RC","31525","HCPCS","facility","both","","","","2535","1267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"90472 Vaccine Inj Ea Addtl","73201827","CDM","771","RC","90472","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Cardiac","73201828","CDM","480","RC","93308","HCPCS","facility","both","","","","1191","595.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Abdominal","73201829","CDM","402","RC","76705","HCPCS","facility","both","","","","1445","722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Chest","73201830","CDM","402","RC","76604","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pregnant Transabdominal","73201831","CDM","402","RC","76815","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pregnant Transvaginal","73201832","CDM","402","RC","76817","HCPCS","facility","both","","","","847","423.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Aaa","73201833","CDM","402","RC","76775","HCPCS","facility","both","","","","1118","559","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Us Biliary","73201834","CDM","402","RC","76705","HCPCS","facility","both","","","","1445","722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Biliary Tract","73201835","CDM","402","RC","76775","HCPCS","facility","both","","","","1118","559","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Us Post Void Residual","73201836","CDM","761","RC","51798","HCPCS","facility","both","","","","362","181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Focused Dvt Study","73201837","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Neck","73201838","CDM","402","RC","76536","HCPCS","facility","both","","","","1177","588.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Axilla","73201839","CDM","402","RC","76882","HCPCS","facility","both","","","","613","306.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Chest Wall","73201840","CDM","402","RC","76604","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pelvic Wall","73201845","CDM","402","RC","76857","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Lower Extremity","73201846","CDM","402","RC","76882","HCPCS","facility","both","","","","613","306.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Msk","73201847","CDM","402","RC","76882","HCPCS","facility","both","","","","613","306.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Thoracic","73201849","CDM","402","RC","76604","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Occular","73201850","CDM","402","RC","76512","HCPCS","facility","both","","","","674","337","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Occular Fb","73201851","CDM","402","RC","76529","HCPCS","facility","both","","","","495","247.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Procedures","73201852","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Vasc Access Place","73201854","CDM","402","RC","76937","HCPCS","facility","both","","","","1729","864.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20950 Fluid Pressure Muscle","73201900","CDM","450","RC","20950","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36593 Declot Vascular Access","73201901","CDM","450","RC","36593","HCPCS","facility","both","","","","1454","727","","","","","","","","","","","","","Gross Charge Type: Standard"
"53060 Drainage Of Urethra Absc","73201903","CDM","450","RC","53060","HCPCS","facility","both","","","","4234","2117","","","","","","","","","","","","","Gross Charge Type: Standard"
"41599 Tongue & Mouth Surgery","73201905","CDM","450","RC","41599","HCPCS","facility","both","","","","565","282.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"69399 Outer Ear Surgery Proced","73201906","CDM","450","RC","69399","HCPCS","facility","both","","","","565","282.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"14061 Tis Trnfr E/N/E/L10.1-30","73201907","CDM","450","RC","14061","HCPCS","facility","both","","","","6156","3078","","","","","","","","","","","","","Gross Charge Type: Standard"
"42999 Throat Surgery Procedure","73201908","CDM","450","RC","42999","HCPCS","facility","both","","","","565","282.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23575 Tx Shoulder Blade Fx Lt","73201909","CDM","450","RC","23575","HCPCS","facility","both","","","","2736","1368","","","","","","","","","","","","","Gross Charge Type: Standard"
"41899 Dental Surgery Proc","73201910","CDM","450","RC","41899","HCPCS","facility","both","","","","3951","1975.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26746 Treat Finger Fx Ea","73201911","CDM","450","RC","26746","HCPCS","facility","both","","","","7602","3801","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 1 Forensic Nurse Exam","73202000","CDM","450","RC","","","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 2 Forensic Nurse Exam","73202001","CDM","450","RC","","","facility","both","","","","696","348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 3 Forensic Nurse Exam","73202002","CDM","450","RC","","","facility","both","","","","990","495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 4 Forensic Nurse Exam","73202003","CDM","450","RC","","","facility","both","","","","1007","503.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 5 Forensic Nurse Exam","73202004","CDM","450","RC","","","facility","both","","","","1012","506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 6 Forensic Nurse Exam","73202005","CDM","450","RC","","","facility","both","","","","1926","963","","","","","","","","","","","","","Gross Charge Type: Standard"
"96411 Chem Iv Push Inj(Ea Add","73202006","CDM","450","RC","96411","HCPCS","facility","both","","","","538","269","","","","","","","","","","","","","Gross Charge Type: Standard"
"96415 Chem Iv Inf Ea Add'l Hr","73202007","CDM","450","RC","96415","HCPCS","facility","both","","","","505","252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"96375 Non-Chem Iv Push Inj,Ea","73202009","CDM","450","RC","96375","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"96367 Non-Che Iv Inf Ad Seq In","73202010","CDM","450","RC","96367","HCPCS","facility","both","","","","371","185.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"96368 Non-Chem Iv Inf-Conc Inf","73202011","CDM","450","RC","96368","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20612 Aspiratn/Inj Gangln Cyst","73202013","CDM","450","RC","20612","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"19020 Mastotomy,Breast","73202015","CDM","450","RC","19020","HCPCS","facility","both","","","","4327","2163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"31231 Nasal Endoscopy Dx","73202020","CDM","450","RC","31231","HCPCS","facility","both","","","","308","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"32556 Insert Cath Pleura W/O I","73202021","CDM","450","RC","32556","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"11045 Deb Subq Tissue Add-On","73202200","CDM","450","RC","11045","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"43753 Tx Gastro Intub W/Asp","73202201","CDM","450","RC","43753","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"30020 Drainage Of Nose Lesion","73202205","CDM","450","RC","30020","HCPCS","facility","both","","","","1722","861","","","","","","","","","","","","","Gross Charge Type: Standard"
"11044 Deb Bone 20 Sq Cm/<","73202206","CDM","450","RC","11044","HCPCS","facility","both","","","","5413","2706.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"76642 Ultrasound Breast Limited","73203001","CDM","402","RC","76642","HCPCS","facility","both","","","","1096","548","","","","","","","","","","","","","Gross Charge Type: Standard"
"31237 Nasal/Sinus Endoscopy","73206890","CDM","450","RC","31237","HCPCS","facility","both","","","","6330","3165","","","","","","","","","","","","","Gross Charge Type: Standard"
"36410 Nonroutine Bl Drw 3+ Yrs","73206891","CDM","450","RC","36410","HCPCS","facility","both","","","","367","183.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"94660 Pos Airway Pressure Cpap","73206893","CDM","450","RC","94660","HCPCS","facility","both","","","","1015","507.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36555 Ins Non-Tunneled Cvc<5Yr","73210001","CDM","450","RC","36555","HCPCS","facility","both","","","","3942","1971","","","","","","","","","","","","","Gross Charge Type: Standard"
"36556 Ins Non-Tunneld Cvc>=5Yr","73210002","CDM","450","RC","36556","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"36569 Ins Picc Wo Prt/Pmp>=5Yr","73210004","CDM","450","RC","36569","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"36580 Rpl Cvc Wo Pt/Pmp 1Site","73210005","CDM","450","RC","36580","HCPCS","facility","both","","","","4064","2032","","","","","","","","","","","","","Gross Charge Type: Standard"
"36584 Rpl Picc Wo Pt/Pmp 1Site","73210006","CDM","450","RC","36584","HCPCS","facility","both","","","","4064","2032","","","","","","","","","","","","","Gross Charge Type: Standard"
"G0008 Admin-Influenza Vaccine","73210008","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"36558 Ins Tnnld Cvc>=5Yr","73210015","CDM","450","RC","36558","HCPCS","facility","both","","","","5911","2955.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"43215 Esophagus Endoscopyw/Fb","73210016","CDM","450","RC","43215","HCPCS","facility","both","","","","2770","1385","","","","","","","","","","","","","Gross Charge Type: Standard"
"10081 I&D Pilonidal Cyst Comp","73210020","CDM","450","RC","10081","HCPCS","facility","both","","","","5839","2919.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27301 I&D Abscess Thigh/Knee","73210021","CDM","450","RC","27301","HCPCS","facility","both","","","","6042","3021","","","","","","","","","","","","","Gross Charge Type: Standard"
"55100 Drain Scrotl Wall Absces","73210022","CDM","450","RC","55100","HCPCS","facility","both","","","","2995","1497.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23930 I&D Up Arm/Elb Abs/Hem","73210023","CDM","450","RC","23930","HCPCS","facility","both","","","","4529","2264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"67935 Sutr Eyeld Fullthickness","73210024","CDM","450","RC","67935","HCPCS","facility","both","","","","6138","3069","","","","","","","","","","","","","Gross Charge Type: Standard"
"23931 I&D Up Arm/Bursa","73210025","CDM","450","RC","23931","HCPCS","facility","both","","","","8069","4034.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"54220 Irrigatn Of Cc-Priapism","73210026","CDM","450","RC","54220","HCPCS","facility","both","","","","3447","1723.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"40652 Cmplx Rpr 1/2 Vert Ht","73210027","CDM","450","RC","40652","HCPCS","facility","both","","","","3563","1781.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"40831 Cmplx Rep Vestbul>2.5Cm","73210028","CDM","450","RC","40831","HCPCS","facility","both","","","","3563","1781.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28192 Fb Removal Foot,Deep","73210029","CDM","450","RC","28192","HCPCS","facility","both","","","","5446","2723","","","","","","","","","","","","","Gross Charge Type: Standard"
"25660 Clsd Tx W/Man Wrist Disl","73210031","CDM","450","RC","25660","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"27825 Fx Disloc W/Skel Tractn","73210032","CDM","450","RC","27825","HCPCS","facility","both","","","","5727","2863.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"41251 Cmplx Rep Post 1/3 Tng","73210033","CDM","450","RC","41251","HCPCS","facility","both","","","","1605","802.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"52281 Cystourethro,Cal/Dil,M/F","73210036","CDM","450","RC","52281","HCPCS","facility","both","","","","6031","3015.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"94664 Demons&Eval Pt Hhn/Ippb","73210037","CDM","450","RC","94664","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"35226 Repair Blood Vessel Lesn","73210038","CDM","450","RC","35226","HCPCS","facility","both","","","","1538","769","","","","","","","","","","","","","Gross Charge Type: Standard"
"24605 Elbow Dislocation W/Anes","73210040","CDM","450","RC","24605","HCPCS","facility","both","","","","4088","2044","","","","","","","","","","","","","Gross Charge Type: Standard"
"36561 Ins Tnnl Cvc W/Port>=5Yr","73210042","CDM","450","RC","36561","HCPCS","facility","both","","","","7099","3549.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27266 Treat Hip Dislocation","73210043","CDM","450","RC","27266","HCPCS","facility","both","","","","3870","1935","","","","","","","","","","","","","Gross Charge Type: Standard"
"21422 Treat Mouth Roof Fractur","73210049","CDM","450","RC","21422","HCPCS","facility","both","","","","6216","3108","","","","","","","","","","","","","Gross Charge Type: Standard"
"50386 Remove Stent Transureth","73210050","CDM","450","RC","50386","HCPCS","facility","both","","","","6292","3146","","","","","","","","","","","","","Gross Charge Type: Standard"
"30000 Drainage Of Nose Lesion","73210051","CDM","450","RC","30000","HCPCS","facility","both","","","","4517","2258.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"92285 Externl Oculr Photogrphy","73210052","CDM","450","RC","92285","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"69020 Drain Outr Ear Canl Lesn","73210053","CDM","450","RC","69020","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"25260 Repair Forarm Tendn/Musc","73210054","CDM","450","RC","25260","HCPCS","facility","both","","","","5860","2930","","","","","","","","","","","","","Gross Charge Type: Standard"
"27252 Hip Disloc-Trauma W/Anes","73210055","CDM","450","RC","27252","HCPCS","facility","both","","","","3693","1846.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"52310 Cystoscopy And Treatment","73210056","CDM","450","RC","52310","HCPCS","facility","both","","","","4294","2147","","","","","","","","","","","","","Gross Charge Type: Standard"
"90460 Immun Admin,<18 1St Comp","73210200","CDM","771","RC","90460","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"24201 Deep Rem Ab Ua/Elbow","73210201","CDM","450","RC","24201","HCPCS","facility","both","","","","7465","3732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"D7140 Extraction Tooth","73210860","CDM","450","RC","D7140","HCPCS","facility","both","","","","2012","1006","","","","","","","","","","","","","Gross Charge Type: Standard"
"D7210 Surgical Rem Tooth","73210861","CDM","450","RC","D7210","HCPCS","facility","both","","","","2012","1006","","","","","","","","","","","","","Gross Charge Type: Standard"
"42720 Drainage Of Throat Abcss","73210862","CDM","450","RC","42720","HCPCS","facility","both","","","","6387","3193.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"41009 Drainage Of Mouth Lesion","73210863","CDM","450","RC","41009","HCPCS","facility","both","","","","1538","769","","","","","","","","","","","","","Gross Charge Type: Standard"
"42300 Drainage Salivary Gland","73210866","CDM","450","RC","42300","HCPCS","facility","both","","","","4079","2039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"64420 Nerve Block Inj Intercos","73211555","CDM","450","RC","64420","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"51710 Change Of Bladder Tube","73220010","CDM","450","RC","51710","HCPCS","facility","both","","","","3054","1527","","","","","","","","","","","","","Gross Charge Type: Standard"
"36576 Rplc Cath Cva W/Prt/Pmp","73220011","CDM","450","RC","36576","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"27599 Unlstd Proc Femr Or Knee","73220012","CDM","450","RC","27599","HCPCS","facility","both","","","","6136","3068","","","","","","","","","","","","","Gross Charge Type: Standard"
"69209 Rem Impacted Ear Wax Uni","73220013","CDM","450","RC","69209","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65150 Reinsert Ocular Implant","73220014","CDM","450","RC","65150","HCPCS","facility","both","","","","10048","5024","","","","","","","","","","","","","Gross Charge Type: Standard"
"46320 Removal Hemorrhoid Clot","73220701","CDM","450","RC","46320","HCPCS","facility","both","","","","4198","2099","","","","","","","","","","","","","Gross Charge Type: Standard"
"41017 Drainage Of Mouth Lesion","73220702","CDM","450","RC","41017","HCPCS","facility","both","","","","3636","1818","","","","","","","","","","","","","Gross Charge Type: Standard"
"26951 Amputatn Finger/Thumb","73220703","CDM","450","RC","26951","HCPCS","facility","both","","","","3870","1935","","","","","","","","","","","","","Gross Charge Type: Standard"
"20604 Arthrcents-Sm Jnt W/Us","73220710","CDM","450","RC","20604","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20606 Arthrcent-Int Jnt W/Us","73220711","CDM","450","RC","20606","HCPCS","facility","both","","","","1259","629.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20611 Arthrcents-Mj Jnt W/Us","73220712","CDM","450","RC","20611","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"37615 Ligation Of Neck Artery","73220719","CDM","450","RC","37615","HCPCS","facility","both","","","","8300","4150","","","","","","","","","","","","","Gross Charge Type: Standard"
"31635 Bronchoscopy W/Fb Removl","73220720","CDM","450","RC","31635","HCPCS","facility","both","","","","4314","2157","","","","","","","","","","","","","Gross Charge Type: Standard"
"21445 Treat Dental Ridge Fract","73220721","CDM","450","RC","21445","HCPCS","facility","both","","","","6832","3416","","","","","","","","","","","","","Gross Charge Type: Standard"
"24620 Treat Elbow Fracture","73220722","CDM","450","RC","24620","HCPCS","facility","both","","","","4437","2218.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"64435 N Block Inj Paracervical","73220723","CDM","450","RC","64435","HCPCS","facility","both","","","","900","450","","","","","","","","","","","","","Gross Charge Type: Standard"
"67028 Injection Eye Drug","73220724","CDM","450","RC","67028","HCPCS","facility","both","","","","1289","644.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23675 Treat Dislocation/Fractu","73220725","CDM","450","RC","23675","HCPCS","facility","both","","","","3375","1687.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"45999 Unlistd Procedure Rectum","73220726","CDM","450","RC","45999","HCPCS","facility","both","","","","2766","1383","","","","","","","","","","","","","Gross Charge Type: Standard"
"49999 Unlstd Abdmn, Pert Omntm","73220727","CDM","450","RC","49999","HCPCS","facility","both","","","","9572","4786","","","","","","","","","","","","","Gross Charge Type: Standard"
"37618 Ligation Of Extremity Ar","73220728","CDM","450","RC","37618","HCPCS","facility","both","","","","3740","1870","","","","","","","","","","","","","Gross Charge Type: Standard"
"67800 Remove Eyelid Lesion","73220729","CDM","450","RC","67800","HCPCS","facility","both","","","","1313","656.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"97597 Debride Skin<Or=20Sq Cm","73220730","CDM","450","RC","97597","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"44799 Unlist Proc Intestine","73220731","CDM","450","RC","44799","HCPCS","facility","both","","","","2738","1369","","","","","","","","","","","","","Gross Charge Type: Standard"
"46999 Unlist Proc Anus","73220732","CDM","450","RC","46999","HCPCS","facility","both","","","","3609","1804.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27768 Cltx Post Ankle Fx W/Mnp","73220735","CDM","450","RC","27768","HCPCS","facility","both","","","","5129","2564.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29700 Removal/Revision Of Cast","73220738","CDM","450","RC","29700","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"27842 Cl Tx Ankle Disloc W/Ane","73220739","CDM","450","RC","27842","HCPCS","facility","both","","","","5050","2525","","","","","","","","","","","","","Gross Charge Type: Standard"
"26765 Open Tx Distal Phalang","73220740","CDM","450","RC","26765","HCPCS","facility","both","","","","6700","3350","","","","","","","","","","","","","Gross Charge Type: Standard"
"94644 Cbt 1St Hour","73220741","CDM","450","RC","94644","HCPCS","facility","both","","","","486","243","","","","","","","","","","","","","Gross Charge Type: Standard"
"37195 Thrombolysis, Rbrl By Iv","73220800","CDM","450","RC","37195","HCPCS","facility","both","","","","2694","1347","","","","","","","","","","","","","Gross Charge Type: Standard"
"96401 Methotrexate Im","73220801","CDM","331","RC","96401","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23525 Cl Tx Scclav Dislc W Man","73221015","CDM","450","RC","23525","HCPCS","facility","both","","","","1561","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"35206 Repair Blood Vssl Dir,Up","73221016","CDM","450","RC","35206","HCPCS","facility","both","","","","6283","3141.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"35207 Rep Blood Vssl Dir;Hand","73221072","CDM","450","RC","35207","HCPCS","facility","both","","","","4590","2295","","","","","","","","","","","","","Gross Charge Type: Standard"
"64455 N Block Inj Plntr Dig Lt","73222725","CDM","450","RC","64455","HCPCS","facility","both","","","","1294","647","","","","","","","","","","","","","Gross Charge Type: Standard"
"26236 Part Exc Bone;Dstl Phlnx","73222726","CDM","450","RC","26236","HCPCS","facility","both","","","","3928","1964","","","","","","","","","","","","","Gross Charge Type: Standard"
"28124 Part Exc Bone;Phalnx Toe","73222728","CDM","450","RC","28124","HCPCS","facility","both","","","","3529","1764.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"36140 Ns Cath-Extremity Artery","73222736","CDM","450","RC","36140","HCPCS","facility","both","","","","4665","2332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65430 Scraping Cornea Dx Smear","73222737","CDM","450","RC","65430","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"65810 Paracent Ant Eye;Rem Vit","73222738","CDM","450","RC","65810","HCPCS","facility","both","","","","6340","3170","","","","","","","","","","","","","Gross Charge Type: Standard"
"42100 Biopsy Of Palate Uvula","73222739","CDM","450","RC","42100","HCPCS","facility","both","","","","2353","1176.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"67715 Canthotomy","73222740","CDM","450","RC","67715","HCPCS","facility","both","","","","5913","2956.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"23625 Cl Tx Gr Tuberosity Fx","73222742","CDM","450","RC","23625","HCPCS","facility","both","","","","2769","1384.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"41005 I&D Absc/Cyst Tongue Fom","73222743","CDM","450","RC","41005","HCPCS","facility","both","","","","935","467.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26410 Rep Et Hand;Wo Fg Ea Tnd","73222744","CDM","450","RC","26410","HCPCS","facility","both","","","","5034","2517","","","","","","","","","","","","","Gross Charge Type: Standard"
"11055 Pare Benign Les; Sgl","73222745","CDM","450","RC","11055","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"11010 Debride Skin At Fx Site","73222746","CDM","450","RC","11010","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"65800 Drainage Of Eye","73222747","CDM","450","RC","65800","HCPCS","facility","both","","","","2762","1381","","","","","","","","","","","","","Gross Charge Type: Standard"
"41016 Eo I&D Absc/Cyst Fom Sub","73222748","CDM","450","RC","41016","HCPCS","facility","both","","","","7642","3821","","","","","","","","","","","","","Gross Charge Type: Standard"
"41008 I&D Absc/Cys Fom;Submand","73222749","CDM","450","RC","41008","HCPCS","facility","both","","","","5482","2741","","","","","","","","","","","","","Gross Charge Type: Standard"
"69005 Dr Ext Ear Abscess/Hemat","73222750","CDM","450","RC","69005","HCPCS","facility","both","","","","4402","2201","","","","","","","","","","","","","Gross Charge Type: Standard"
"27372 Rem Deep Fb Thigh Or Knee","73222751","CDM","450","RC","27372","HCPCS","facility","both","","","","9604","4802","","","","","","","","","","","","","Gross Charge Type: Standard"
"27848 Op Tx Ankle Disloc W Rep","73222752","CDM","450","RC","27848","HCPCS","facility","both","","","","8318","4159","","","","","","","","","","","","","Gross Charge Type: Standard"
"76870 Ultrasound Testicular","73222755","CDM","402","RC","76870","HCPCS","facility","both","","","","1417","708.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10005 Fna Bx W/Us Gdn 1St Les","73222756","CDM","450","RC","10005","HCPCS","facility","both","","","","1977","988.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10006 Fna Bx W/Us Gdn Ea Addl","73222757","CDM","450","RC","10006","HCPCS","facility","both","","","","1977","988.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10009 Fna Bx W/Ct Gdn 1St Les","73222760","CDM","450","RC","10009","HCPCS","facility","both","","","","2394","1197","","","","","","","","","","","","","Gross Charge Type: Standard"
"43762 Rplc Gtube No Revj Trc","73222764","CDM","450","RC","43762","HCPCS","facility","both","","","","1934","967","","","","","","","","","","","","","Gross Charge Type: Standard"
"43763 Rplc Gtube Rev Gstrt Trc","73222765","CDM","450","RC","43763","HCPCS","facility","both","","","","2128","1064","","","","","","","","","","","","","Gross Charge Type: Standard"
"44372 Sm Intstn Endo Perc Jeju","73222766","CDM","450","RC","44372","HCPCS","facility","both","","","","4659","2329.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26756 Perc Sktl Phlng Fx Fnger","73222767","CDM","450","RC","26756","HCPCS","facility","both","","","","10151","5075.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28825 Amputate Toe; Ip Joint","73222768","CDM","450","RC","28825","HCPCS","facility","both","","","","8393","4196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28600 Cl Tmt Jnt Dis; Wo Anes","73222769","CDM","450","RC","28600","HCPCS","facility","both","","","","890","445","","","","","","","","","","","","","Gross Charge Type: Standard"
"32999 Digital Thoracostomy","73222770","CDM","450","RC","32999","HCPCS","facility","both","","","","2176","1088","","","","","","","","","","","","","Gross Charge Type: Standard"
"31577 Largsc W/Rmvl Frn Bdy(S)","73222771","CDM","450","RC","31577","HCPCS","facility","both","","","","1243","621.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"41007 I&D Abs/Cyst Fom; Submtl","73222772","CDM","450","RC","41007","HCPCS","facility","both","","","","5362","2681","","","","","","","","","","","","","Gross Charge Type: Standard"
"42962 Crtl Opa Hemorrh W/ Surg","73222773","CDM","450","RC","42962","HCPCS","facility","both","","","","8402","4201","","","","","","","","","","","","","Gross Charge Type: Standard"
"45399 Unlisted Procedure Colon","73222774","CDM","450","RC","45399","HCPCS","facility","both","","","","2807","1403.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"37799 Unlisted Vasc Procedure","73222775","CDM","450","RC","37799","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"22999 Unlisted Abdomen Muscskl","73222776","CDM","450","RC","22999","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"17999 Unlisted Proc Skin Mm","73222777","CDM","450","RC","17999","HCPCS","facility","both","","","","1360","680","","","","","","","","","","","","","Gross Charge Type: Standard"
"37565 Ligation Intrnl Jug Vein","73222778","CDM","450","RC","37565","HCPCS","facility","both","","","","3429","1714.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"37212 Thrombolytic Venous The","73222779","CDM","450","RC","37212","HCPCS","facility","both","","","","9692","4846","","","","","","","","","","","","","Gross Charge Type: Standard"
"33016 Pericrdiocntesis W/Imgng","73222800","CDM","450","RC","33016","HCPCS","facility","both","","","","3281","1640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"33017 Prcrd Drg6Yr+W/O Cgn Car","73222801","CDM","450","RC","33017","HCPCS","facility","both","","","","3281","1640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"41100 Biopsy Of Tongue;Ant 2/3","73222804","CDM","450","RC","41100","HCPCS","facility","both","","","","1720","860","","","","","","","","","","","","","Gross Charge Type: Standard"
"10030 Guide Cathet Fluid Drain","73222805","CDM","450","RC","10030","HCPCS","facility","both","","","","4645","2322.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"66999 Unl Proc Ant Seg Of Eye","73222806","CDM","450","RC","66999","HCPCS","facility","both","","","","6520","3260","","","","","","","","","","","","","Gross Charge Type: Standard"
"64999 Unlist Proc Nervous Sys","73222807","CDM","450","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11104 Punch Bx Skin Single Les","73222808","CDM","450","RC","11104","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"67599 Unlisted Procedure Orbit","73222809","CDM","450","RC","67599","HCPCS","facility","both","","","","874","437","","","","","","","","","","","","","Gross Charge Type: Standard"
"31899 Unlisted Proc Trachea Br","73222811","CDM","450","RC","31899","HCPCS","facility","both","","","","524","262","","","","","","","","","","","","","Gross Charge Type: Standard"
"31622 Dx Bronchoscope/Wash","73222812","CDM","450","RC","31622","HCPCS","facility","both","","","","4065","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27603 I&D Leg/Ankle Deep Absc","73222813","CDM","450","RC","27603","HCPCS","facility","both","","","","8600","4300","","","","","","","","","","","","","Gross Charge Type: Standard"
"28208 Repr Foot Extensor Tendo","73222814","CDM","450","RC","28208","HCPCS","facility","both","","","","10151","5075.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"56605 Biopsy Of Vulva/Perineum","73222815","CDM","450","RC","56605","HCPCS","facility","both","","","","2370","1185","","","","","","","","","","","","","Gross Charge Type: Standard"
"59300 Episiotomy Or Vag Rep","73222816","CDM","450","RC","59300","HCPCS","facility","both","","","","9266","4633","","","","","","","","","","","","","Gross Charge Type: Standard"
"24999 Unlstd Proc Humer Elbow","73222817","CDM","450","RC","24999","HCPCS","facility","both","","","","754","377","","","","","","","","","","","","","Gross Charge Type: Standard"
"31615 Tracheobronch Old Insc","73222818","CDM","450","RC","31615","HCPCS","facility","both","","","","1256","628","","","","","","","","","","","","","Gross Charge Type: Standard"
"42699 Unlisted Salivary Gland","73222819","CDM","450","RC","42699","HCPCS","facility","both","","","","6520","3260","","","","","","","","","","","","","Gross Charge Type: Standard"
"11982 Remove Drug Impl Nonbio","73222820","CDM","450","RC","11982","HCPCS","facility","both","","","","1350","675","","","","","","","","","","","","","Gross Charge Type: Standard"
"61107 Drill Skull For Implant","73222821","CDM","450","RC","61107","HCPCS","facility","both","","","","7767","3883.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"C5275 Low Cost Skin Subsit App","73222822","CDM","450","RC","C5275","HCPCS","facility","both","","","","2024","1012","","","","","","","","","","","","","Gross Charge Type: Standard"
"21899 Unlistd Proc Neck/Thorax","73222823","CDM","450","RC","21899","HCPCS","facility","both","","","","679","339.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"53600 Dil Ureth Strx;Male 1St","73222824","CDM","450","RC","53600","HCPCS","facility","both","","","","938","469","","","","","","","","","","","","","Gross Charge Type: Standard"
"41018 Xtroral I&D Floor Mastic","73222825","CDM","450","RC","41018","HCPCS","facility","both","","","","4886","2443","","","","","","","","","","","","","Gross Charge Type: Standard"
"11981 Insert Drug Implant","73222826","CDM","450","RC","11981","HCPCS","facility","both","","","","2114","1057","","","","","","","","","","","","","Gross Charge Type: Standard"
"28570 Cl Tx Tal Jnt Dis Wo Ans","73222827","CDM","450","RC","28570","HCPCS","facility","both","","","","754","377","","","","","","","","","","","","","Gross Charge Type: Standard"
"M0243 Casirivi And Imdevi Infu","73222829","CDM","771","RC","M0243","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"57455 Cervic Colp W Cervix Bx","73222830","CDM","450","RC","57455","HCPCS","facility","both","","","","4062","2031","","","","","","","","","","","","","Gross Charge Type: Standard"
"30100 Biopsy Intranasal","73222831","CDM","450","RC","30100","HCPCS","facility","both","","","","4884","2442","","","","","","","","","","","","","Gross Charge Type: Standard"
"36575 Repair Cva Catheter","73222832","CDM","450","RC","36575","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"11422 Exc Bles S/N/Ex G; 1.1-2","73222833","CDM","450","RC","11422","HCPCS","facility","both","","","","3169","1584.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"42800 Biopsy Oropharynx","73222834","CDM","450","RC","42800","HCPCS","facility","both","","","","4886","2443","","","","","","","","","","","","","Gross Charge Type: Standard"
"43999 Unlisted Procedure Stomach","73222835","CDM","450","RC","43999","HCPCS","facility","both","","","","2626","1313","","","","","","","","","","","","","Gross Charge Type: Standard"
"26350 Rep Flxr Tendon Not Zone 2 Wo Grft Ea","73222836","CDM","450","RC","26350","HCPCS","facility","both","","","","10221","5110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"54001 Slit Prepuce Dorsal Or Lat; Not Newborn","73222837","CDM","450","RC","54001","HCPCS","facility","both","","","","6474","3237","","","","","","","","","","","","","Gross Charge Type: Standard"
"69799 Unlisted Procedure Middle Ear","73222838","CDM","450","RC","69799","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26080 Explore/Treat Finger Joint Ea","73222839","CDM","450","RC","26080","HCPCS","facility","both","","","","8275","4137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20526 Carpal Tunnel Injection","73222840","CDM","450","RC","20526","HCPCS","facility","both","","","","605","302.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20560 Ndl Insj W/O Njx 1 Or 2 Musc","73222841","CDM","450","RC","20560","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"45915 Remove Fecal Impaction Or Fb","73222842","CDM","450","RC","45915","HCPCS","facility","both","","","","3746","1873","","","","","","","","","","","","","Gross Charge Type: Standard"
"25270 Rep T/M Extensor Fa/W ; 1' Ea","73222843","CDM","450","RC","25270","HCPCS","facility","both","","","","10221","5110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"59899 Unlisted Procedure Maternity Care & Del","73222844","CDM","450","RC","59899","HCPCS","facility","both","","","","658","329","","","","","","","","","","","","","Gross Charge Type: Standard"
"36510 Insertion Of Catheter Vein","73222847","CDM","450","RC","36510","HCPCS","facility","both","","","","948","474","","","","","","","","","","","","","Gross Charge Type: Standard"
"14060 Tis Trnfr E/N/E/L 10 Sq Cm/<","73222848","CDM","450","RC","14060","HCPCS","facility","both","","","","6156","3078","","","","","","","","","","","","","Gross Charge Type: Standard"
"M0245 Bamlan And Etesev Infusion","73222851","CDM","771","RC","M0245","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"53899 Urology Surgery Procedure","73222852","CDM","450","RC","53899","HCPCS","facility","both","","","","863","431.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"46500 Injection Into Hemorrhoids","73222853","CDM","450","RC","46500","HCPCS","facility","both","","","","2866","1433","","","","","","","","","","","","","Gross Charge Type: Standard"
"64425 Njx Aa&/Strd Ii Ih Nerves","73222854","CDM","450","RC","64425","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"44500 Intro Gastrointestinal Tube","73222855","CDM","450","RC","44500","HCPCS","facility","both","","","","2978","1489","","","","","","","","","","","","","Gross Charge Type: Standard"
"33286 Rmvl Subq Car Rhythm Mntr","73222856","CDM","450","RC","33286","HCPCS","facility","both","","","","3516","1758","","","","","","","","","","","","","Gross Charge Type: Standard"
"50953 Endoscopy Of Ureter","73222857","CDM","450","RC","50953","HCPCS","facility","both","","","","8486","4243","","","","","","","","","","","","","Gross Charge Type: Standard"
"26433 Repair Finger Tendon","73222858","CDM","450","RC","26433","HCPCS","facility","both","","","","10224","5112","","","","","","","","","","","","","Gross Charge Type: Standard"
"G0010 Admin Hepatitis B Vaccine","73222859","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"32557 Insert Cath Pleura W/ Image","73222860","CDM","450","RC","32557","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"69433 Create Eardrum Opening","73222862","CDM","450","RC","69433","HCPCS","facility","both","","","","1636","818","","","","","","","","","","","","","Gross Charge Type: Standard"
"27899 Leg/Ankle Surgery Procedure","73222863","CDM","450","RC","27899","HCPCS","facility","both","","","","905","452.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"M0220 Tixagev And Cilgav Inj","73222864","CDM","771","RC","M0220","HCPCS","facility","both","","","","150.5","75.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"53620 Dilate Urethra Stricture","73222865","CDM","450","RC","53620","HCPCS","facility","both","","","","2428","1214","","","","","","","","","","","","","Gross Charge Type: Standard"
"11719 Trim Nail(S) Any Number","73222866","CDM","450","RC","11719","HCPCS","facility","both","","","","217","108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"M0247 Sotrovimab Infusion","73222867","CDM","771","RC","M0247","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"32110 Explore/Repair Chest","73222868","CDM","450","RC","32110","HCPCS","facility","both","","","","7830","3915","","","","","","","","","","","","","Gross Charge Type: Standard"
"11105 Punch Biopsy Of Skin","73222869","CDM","450","RC","11105","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28545 Treat Foot Dislocation","73222871","CDM","450","RC","28545","HCPCS","facility","both","","","","8838","4419","","","","","","","","","","","","","Gross Charge Type: Standard"
"40799 Lip Surgery Procedure","73222876","CDM","450","RC","40799","HCPCS","facility","both","","","","669","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"M0221 Tixagev And Cilgav Inj Hm","73222877","CDM","771","RC","M0221","HCPCS","facility","both","","","","250.5","125.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"M0222 Bebtelovimab Injection","73222879","CDM","771","RC","M0222","HCPCS","facility","both","","","","350.5","175.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"32100 Exploration Of Chest","73222880","CDM","450","RC","32100","HCPCS","facility","both","","","","7980","3990","","","","","","","","","","","","","Gross Charge Type: Standard"
"97598 Rmvl Devital Tis Addl 20Cm/<","73222881","CDM","450","RC","97598","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"52001 Cystoscopy Removal Of Clots","73222882","CDM","450","RC","52001","HCPCS","facility","both","","","","9723","4861.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"19101 Biopsy Of Breast Open","73222884","CDM","450","RC","19101","HCPCS","facility","both","","","","10154","5077","","","","","","","","","","","","","Gross Charge Type: Standard"
"40805 Removal Foreign Body Mouth","73222885","CDM","450","RC","40805","HCPCS","facility","both","","","","3870","1935","","","","","","","","","","","","","Gross Charge Type: Standard"
"97607 Neg Press Wnd Tx <=50 Sq Cm","73222886","CDM","450","RC","97607","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"96402 Chemo Hormon Antineopl Sq/Im","73222887","CDM","450","RC","96402","HCPCS","facility","both","","","","392","196","","","","","","","","","","","","","Gross Charge Type: Standard"
"11401 Exc Tr-Ext B9+Marg 0.6-1 Cm","73222888","CDM","450","RC","11401","HCPCS","facility","both","","","","1432","716","","","","","","","","","","","","","Gross Charge Type: Standard"
"60300 Aspir/Inj Thyroid Cyst","73222890","CDM","450","RC","60300","HCPCS","facility","both","","","","1874","937","","","","","","","","","","","","","Gross Charge Type: Standard"
"38505 Bx/Exc Lymph Node Needle Superficial","73222891","CDM","450","RC","38505","HCPCS","facility","both","","","","3174","1587","","","","","","","","","","","","","Gross Charge Type: Standard"
"64415 Njx Aa&/Strd Brch Plxs Img","73222892","CDM","450","RC","64415","HCPCS","facility","both","","","","1012","506","","","","","","","","","","","","","Gross Charge Type: Standard"
"64445 Njx Aa&/Strd Sciatic Nrv Img","73222893","CDM","450","RC","64445","HCPCS","facility","both","","","","1466","733","","","","","","","","","","","","","Gross Charge Type: Standard"
"64447 Njx Aa&/Strd Femoral Nrv Img","73222894","CDM","450","RC","64447","HCPCS","facility","both","","","","764","382","","","","","","","","","","","","","Gross Charge Type: Standard"
"11900 Injection Intralesional Up To & Includ 7 Lesions","73222895","CDM","761","RC","11900","HCPCS","facility","both","","","","388","194","","","","","","","","","","","","","Gross Charge Type: Standard"
"11443 Exc Face-Mm B9+Marg 2.1-3 Cm","73222896","CDM","450","RC","11443","HCPCS","facility","both","","","","4101","2050.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"97602 Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess","73222897","CDM","450","RC","97602","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"27240 Cltx Intr/Peri/Sbtrchntc Femoral Fx W/Manj","73222898","CDM","450","RC","27240","HCPCS","facility","both","","","","4463","2231.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11421 Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.6-1.0Cm","73222899","CDM","450","RC","11421","HCPCS","facility","both","","","","3433","1716.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11420 Exc B9 Lesion Mrgn Xcp Sk Tg S/N/H/F/G 0.5 Cm/<","73222900","CDM","450","RC","11420","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"43460 Esopg/Gstr Tamponade W/Balo Sengstaken Type","73222902","CDM","450","RC","43460","HCPCS","facility","both","","","","4363","2181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11102 Tangntl Bx Skin Single Les","73222903","CDM","450","RC","11102","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"11103 Tangntl Bx Skin Ea Sep/Addl","73222904","CDM","450","RC","11103","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"40808 Biopsy Vestibule Mouth","73222905","CDM","450","RC","40808","HCPCS","facility","both","","","","1244","622","","","","","","","","","","","","","Gross Charge Type: Standard"
"31576 Laryngoscopy Flexible W/Biopsy(Ies)","73222907","CDM","450","RC","31576","HCPCS","facility","both","","","","3784","1892","","","","","","","","","","","","","Gross Charge Type: Standard"
"25999 Unlisted Proced Forearm/Wrist","73222908","CDM","450","RC","25999","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"15275 Sub Grft F/S/N/H/F/G/M/D <100Sq Cm 1St 25 Sq Cm","73222909","CDM","450","RC","15275","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"69105 Biopsy External Auditory Canal","73222910","CDM","450","RC","69105","HCPCS","facility","both","","","","3779","1889.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"45307 Proctosgmdsc Rigid W/Rmvl Foreign Body","73222911","CDM","450","RC","45307","HCPCS","facility","both","","","","6082","3041","","","","","","","","","","","","","Gross Charge Type: Standard"
"19328 Removal Of Intact Breast Implant","73222912","CDM","450","RC","19328","HCPCS","facility","both","","","","9324","4662","","","","","","","","","","","","","Gross Charge Type: Standard"
"90480 Imm Admn Sarscov2 Vaccine Single Dose","73222913","CDM","771","RC","90480","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"20670 Removal Implant Superficial Separate Procedure","73222914","CDM","450","RC","20670","HCPCS","facility","both","","","","6460","3230","","","","","","","","","","","","","Gross Charge Type: Standard"
"11403 Exc B9 Lesion Mrgn Xcp Sk Tg T/A/L 2.1-3.0 Cm","73222915","CDM","450","RC","11403","HCPCS","facility","both","","","","2665","1332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"15260  Fth/Gft Free W/Direct Closure N/E/E/L 20 Sq Cm/<","73222916","CDM","450","RC","15260","HCPCS","facility","both","","","","5407","2703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27232 Cltx Fem Fx Prox End Nck W/Manj W/Wo Skel Tracj","73222917","CDM","450","RC","27232","HCPCS","facility","both","","","","866","433","","","","","","","","","","","","","Gross Charge Type: Standard"
"94645 Continuous Inhalation Treatment Ea Addl Hr","73222918","CDM","450","RC","94645","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"59812 Tx Incomplete Abortion Any Trimester Surgical","73222919","CDM","450","RC","59812","HCPCS","facility","both","","","","4517","2258.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simulation - Simple","73300065","CDM","333","RC","77280","HCPCS","facility","both","","","","1272","636","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simulation - Intermediate","73300066","CDM","333","RC","77285","HCPCS","facility","both","","","","1892","946","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simulation - Complex","73300067","CDM","333","RC","77290","HCPCS","facility","both","","","","2551","1275.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Port Film","73300068","CDM","333","RC","77417","HCPCS","facility","both","","","","400","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Basic Dosimetry Calculation","73300069","CDM","333","RC","77300","HCPCS","facility","both","","","","827","413.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Dosimetry-Tld/Diodes","73300074","CDM","333","RC","77331","HCPCS","facility","both","","","","757","378.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rx Device - Simple","73300075","CDM","333","RC","77332","HCPCS","facility","both","","","","779","389.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Continuing Med Physics Consult","73300078","CDM","333","RC","77336","HCPCS","facility","both","","","","1111","555.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Treatment Procedure","73300089","CDM","333","RC","77470","HCPCS","facility","both","","","","3700","1850","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intercavitary - Simple","73300090","CDM","333","RC","77761","HCPCS","facility","both","","","","2752","1376","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intercavitary - Intermediate","73300091","CDM","333","RC","77762","HCPCS","facility","both","","","","3184","1592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intercavitary - Complex","73300092","CDM","333","RC","77763","HCPCS","facility","both","","","","3627","1813.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interstitial - Complex","73300095","CDM","333","RC","77778","HCPCS","facility","both","","","","5914","2957","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface App Of Radioelement","73300096","CDM","333","RC","77789","HCPCS","facility","both","","","","492","246","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suprvsn & Hndlng Of Isotope","73300097","CDM","333","RC","77790","HCPCS","facility","both","","","","503","251.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Srs Cranial Single Session","73300098","CDM","333","RC","77372","HCPCS","facility","both","","","","21017","10508.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Multisrce Photo Stereo Pad Del","73300103","CDM","333","RC","77371","HCPCS","facility","both","","","","29738","14869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imrt Mlc Device","73300105","CDM","333","RC","77338","HCPCS","facility","both","","","","15823","7911.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Med Physics Consult","73300110","CDM","333","RC","77370","HCPCS","facility","both","","","","1151","575.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infus/Install Radioactive Solu","73300111","CDM","333","RC","77750","HCPCS","facility","both","","","","1862","931","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Teletherapy/Total Body","73300140","CDM","333","RC","77321","HCPCS","facility","both","","","","1838","919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rx Device - Complex","73300150","CDM","333","RC","77334","HCPCS","facility","both","","","","1028","514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rx Device - Intermediate","73300151","CDM","333","RC","77333","HCPCS","facility","both","","","","896","448","","","","","","","","","","","","","Gross Charge Type: Standard"
"3-D Radiotherapy Plan","73300176","CDM","333","RC","77295","HCPCS","facility","both","","","","8680","4340","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Guidance/Srs Localization","73300185","CDM","350","RC","77011","HCPCS","facility","both","","","","2790","1395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intensity Modulated Trmt Plann","73300202","CDM","333","RC","77301","HCPCS","facility","both","","","","8247","4123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Ovoids And Tandem","73300203","CDM","490","RC","57155","HCPCS","facility","both","","","","4709","2354.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radiopharmaceutical Therapy","73300213","CDM","342","RC","79101","HCPCS","facility","both","","","","1230","615","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Localization For Implants","73300214","CDM","402","RC","76965","HCPCS","facility","both","","","","2292","1146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radiopharm Inf Radiolbl Antibo","73300217","CDM","342","RC","79403","HCPCS","facility","both","","","","1749","874.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection, Subq/Im","73300218","CDM","260","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radiopharm-Oral Admin","73300222","CDM","342","RC","79005","HCPCS","facility","both","","","","2374","1187","","","","","","","","","","","","","Gross Charge Type: Standard"
"Xray Intraop Sgl Tx Session","73300226","CDM","333","RC","77424","HCPCS","facility","both","","","","7813","3906.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Applicator","73300227","CDM","320","RC","C9726","HCPCS","facility","both","","","","4368","2184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sbrt Multi Fx Or Any Loc,1-5Fx","73300270","CDM","333","RC","77373","HCPCS","facility","both","","","","21017","10508.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Respirator Motion Mgmt Simul","73300300","CDM","333","RC","77293","HCPCS","facility","both","","","","1519","759.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infusion 31 Minutes To 1 Hour","73301116","CDM","260","RC","96360","HCPCS","facility","both","","","","672","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infusion Add'l Hour","73301117","CDM","260","RC","96361","HCPCS","facility","both","","","","323","161.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Treatment Planning","73301700","CDM","350","RC","77014","HCPCS","facility","both","","","","880","440","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73304000","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","73304001","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73304002","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","73304003","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Re-Evaluation Visit Level 5","73304004","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73304006","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","73304007","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73304008","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","73304009","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Re-Eval Delayed Tx Visit Lvl 5","73304010","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Continuing Med Physic Consult","73305010","CDM","333","RC","77336","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Therap Propholac Or Dx Ia","73305091","CDM","920","RC","96373","HCPCS","facility","both","","","","626","313","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Low Mdm 30 Minutes","73305094","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Moderate Mdm 45 Minutes","73305095","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New High Mdm 60 Minutes","73305096","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73305097","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","73305098","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73305099","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","73305100","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Follow Up Visit Level 5","73305101","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73306111","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","73306112","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73306113","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","73306114","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Visit Est Pt Lvl 5","73306115","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imrt Tx-Simple","73306160","CDM","333","RC","77385","HCPCS","facility","both","","","","5006","2503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imrt Tx-Complex","73306161","CDM","333","RC","77386","HCPCS","facility","both","","","","5006","2503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bid Imrt Tx-Simple","73306162","CDM","333","RC","77385","HCPCS","facility","both","","","","5006","2503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bid Imrt Tx-Complex","73306163","CDM","333","RC","77386","HCPCS","facility","both","","","","5006","2503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Isodose Plan-Simple","73306164","CDM","333","RC","77306","HCPCS","facility","both","","","","1576","788","","","","","","","","","","","","","Gross Charge Type: Standard"
"Isodose Plan-Complex","73306165","CDM","333","RC","77307","HCPCS","facility","both","","","","1811","905.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachy Isodose Plan-Simple","73306166","CDM","333","RC","77316","HCPCS","facility","both","","","","3328","1664","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachy Isodose Plan-Intermed","73306167","CDM","333","RC","77317","HCPCS","facility","both","","","","4210","2105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bracy Isodose Plan-Complex","73306168","CDM","333","RC","77318","HCPCS","facility","both","","","","5089","2544.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Guide Localiz-3D","73306169","CDM","333","RC","77387","HCPCS","facility","both","","","","949","474.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple >/=1 Mev","73306170","CDM","333","RC","77402","HCPCS","facility","both","","","","742","371","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intermediate >/=1 Mev","73306172","CDM","333","RC","77407","HCPCS","facility","both","","","","742","371","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex >/=1 Mev","73306175","CDM","333","RC","77412","HCPCS","facility","both","","","","1129","564.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bid Complex >/=1 Mev","73306176","CDM","333","RC","77412","HCPCS","facility","both","","","","1129","564.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdr Brachytx,1Chnl Non-Skin","73306184","CDM","333","RC","77770","HCPCS","facility","both","","","","4748","2374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdr Brcytx,1Ch,Lesion<=Cmskin","73306185","CDM","333","RC","77767","HCPCS","facility","both","","","","4748","2374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdr Brachytx,2-12Chnl,Non-Skin","73306186","CDM","333","RC","77771","HCPCS","facility","both","","","","5458","2729","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdrbid Brcytx,2-12Chnl,Nonskin","73306187","CDM","333","RC","77771","HCPCS","facility","both","","","","5458","2729","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdr Brcytx,2+Ch,Lesion>2Cmskin","73306188","CDM","333","RC","77768","HCPCS","facility","both","","","","5458","2729","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdr Brcytx,12Chnl,Non-Skin","73306189","CDM","333","RC","77772","HCPCS","facility","both","","","","5914","2957","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hdrbid Brcytx,>12Chnl,Non-Skin","73306190","CDM","333","RC","77772","HCPCS","facility","both","","","","5914","2957","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldr Intrstitial Brachy Complex","73306191","CDM","333","RC","77778","HCPCS","facility","both","","","","5914","2957","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec Dosmtry-Tld/Diodes Mod 76","73306201","CDM","333","RC","77331","HCPCS","facility","both","","","","757","378.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simulation - Simple Mod 59","73306204","CDM","333","RC","77280","HCPCS","facility","both","","","","1272","636","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemotherapy Admin Intra-Arterial Push Tq","73306210","CDM","335","RC","96420","HCPCS","facility","both","","","","749","374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7338","CDM","270","RC","","","facility","both","","","","15.51","7.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Bx Bone Deep","73700001","CDM","490","RC","20225","HCPCS","facility","both","","","","7667","3833.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Discission Cataract Yag Laser","73700026","CDM","761","RC","66821","HCPCS","facility","both","","","","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retinal Laser Prophylaxis","73700031","CDM","369","RC","67145","HCPCS","facility","both","","","","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iridotomy/Iridectomy By Laser","73700033","CDM","369","RC","66761","HCPCS","facility","both","","","","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Chalazion Single","73700048","CDM","510","RC","67800","HCPCS","facility","both","","","","1313","656.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Canthoplasty","73700060","CDM","761","RC","67950","HCPCS","facility","both","","","","3833","1916.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trabeculopasty By Laser","73700066","CDM","510","RC","65855","HCPCS","facility","both","","","","2187","1093.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aqueous Paracentesis","73700074","CDM","761","RC","65800","HCPCS","facility","both","","","","2762","1381","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arterial Blood Gas Collection","73700100","CDM","920","RC","36600","HCPCS","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Conjunctival Lesion","73700156","CDM","510","RC","68110","HCPCS","facility","both","","","","2604","1302","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temp Balloon Occlusion Head/Ne","73700205","CDM","360","RC","61623","HCPCS","facility","both","","","","26053","13026.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Vert/Intrathor Cartd,Ini","73700206","CDM","481","RC","0075T","HCPCS","facility","both","","","","26713","13356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cervic Carotid,W/O Prote","73700208","CDM","360","RC","37216","HCPCS","facility","both","","","","28172","14086","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcat Iv Stent Crv Crtd Art Embolic Protecj","73700209","CDM","761","RC","37215","HCPCS","facility","both","","","","32057","16028.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tips Procedure","73700210","CDM","481","RC","37182","HCPCS","facility","both","","","","6671","3335.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Revision Of Tips Procedure","73700211","CDM","360","RC","37183","HCPCS","facility","both","","","","15121","7560.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Occlusive Device Ven/Art","73700215","CDM","481","RC","G0269","HCPCS","facility","both","","","","875","437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep Sft Tiss Bx Thigh/Knee","73700222","CDM","360","RC","27324","HCPCS","facility","both","","","","8256","4128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Abltj Lvr Cryoablation","73700224","CDM","320","RC","47383","HCPCS","facility","both","","","","17525","8762.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Ovarian Cyst(S) Vaginal","73700229","CDM","360","RC","58800","HCPCS","facility","both","","","","5082","2541","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystoscopy","73700233","CDM","490","RC","52000","HCPCS","facility","both","","","","2864","1432","","","","","","","","","","","","","Gross Charge Type: Standard"
"Picc Line Insertion Procedure","73700239","CDM","490","RC","","","facility","both","","","","1405","702.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Arterial Rpharm Rx","73700250","CDM","342","RC","79445","HCPCS","facility","both","","","","1749","874.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venography Extremity","73700271","CDM","481","RC","36005","HCPCS","facility","both","","","","2543","1271.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Aorta,In Add To","73700272","CDM","481","RC","36200","HCPCS","facility","both","","","","5300","2650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmptr Opth Dx Img Ant Segmt","73700300","CDM","920","RC","92132","HCPCS","facility","both","","","","486","243","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmptr Ophth Img Optic Nerve","73700301","CDM","920","RC","92133","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmptr Ophth Dx Img Post Segmt","73700302","CDM","920","RC","92134","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenervation Face Unilat","73700303","CDM","761","RC","64612","HCPCS","facility","both","","","","605","302.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Ecls Initiation Venous","73700304","CDM","369","RC","33946","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Ecls Initiation Artery","73700305","CDM","369","RC","33947","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Artery Expos/Graft Artery","73700306","CDM","369","RC","33987","HCPCS","facility","both","","","","310","155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Left Heart Vent","73700307","CDM","369","RC","33988","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Left Heart Vent","73700308","CDM","369","RC","33989","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Abscess/Drain Subdiaphramat/Phrenic Surgical Code","73700580","CDM","360","RC","49040","HCPCS","facility","both","","","","2446","1223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tube Thoracostomy Includes Water Seal","73700581","CDM","761","RC","32551","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ad Perineal","73700584","CDM","360","RC","56405","HCPCS","facility","both","","","","981","490.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ad Peritoneal","73700585","CDM","360","RC","49020","HCPCS","facility","both","","","","5040","2520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aorta Cath (Femoral Axillary)","73700586","CDM","481","RC","36200","HCPCS","facility","both","","","","5300","2650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Bx Breast Perc Needle Core , Sep","73700595","CDM","761","RC","19100","HCPCS","facility","both","","","","2131","1065.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Bx Muscle","73700597","CDM","490","RC","20206","HCPCS","facility","both","","","","1863","931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Pancreas Percutaneous","73700598","CDM","490","RC","48102","HCPCS","facility","both","","","","2378","1189","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Renal Percutaneous","73700600","CDM","761","RC","50200","HCPCS","facility","both","","","","3012","1506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Thyroid Percutaneous","73700601","CDM","761","RC","60100","HCPCS","facility","both","","","","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Bx Transcatheter","73700602","CDM","481","RC","37200","HCPCS","facility","both","","","","6332","3166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art Abdm Adl Subslect Art","73700603","CDM","490","RC","36248","HCPCS","facility","both","","","","4587","2293.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art Thor Brcep Brnch 1St","73700604","CDM","481","RC","36215","HCPCS","facility","both","","","","4701","2350.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art Thor/Brcep Brch 2Nd","73700605","CDM","481","RC","36216","HCPCS","facility","both","","","","4772","2386","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art Thor/Brcep Brnch 3Rd","73700606","CDM","481","RC","36217","HCPCS","facility","both","","","","4158","2079","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Arteries Abdm Pel Ext 1St","73700607","CDM","490","RC","36245","HCPCS","facility","both","","","","5396","2698","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Arteries Thor Addl 2Nd","73700608","CDM","481","RC","36218","HCPCS","facility","both","","","","2553","1276.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Artery Abdm Pel Ext 2Nd","73700609","CDM","490","RC","36246","HCPCS","facility","both","","","","5038","2519","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Artery Abdm Pel Ext 3Rd","73700610","CDM","490","RC","36247","HCPCS","facility","both","","","","5432","2716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Artery R/L Pulmonary Art","73700611","CDM","481","RC","36014","HCPCS","facility","both","","","","5305","2652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Artery Retro Extremity","73700612","CDM","481","RC","36140","HCPCS","facility","both","","","","4665","2332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Artery Segment Pulmonary","73700614","CDM","481","RC","36015","HCPCS","facility","both","","","","3498","1749","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Super / Inferior Vena Cava","73700617","CDM","481","RC","36010","HCPCS","facility","both","","","","3820","1910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Vein First Order Branch","73700618","CDM","481","RC","36011","HCPCS","facility","both","","","","5310","2655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vein For Venous Sampling","73700619","CDM","481","RC","36500","HCPCS","facility","both","","","","3951","1975.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vein 2Nd Order More Selec","73700620","CDM","481","RC","36012","HCPCS","facility","both","","","","5305","2652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Px Discography Each Level Lumbar","73700624","CDM","761","RC","62290","HCPCS","facility","both","","","","5357","2678.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Asp/Inj Renal Cyst/Pelv","73700625","CDM","490","RC","50390","HCPCS","facility","both","","","","3012","1506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Embolization Extracranial","73700627","CDM","360","RC","61626","HCPCS","facility","both","","","","15598","7799","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcat Permanent Occlusion/Embolization Prq Cns","73700628","CDM","761","RC","61624","HCPCS","facility","both","","","","6602","3301","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extremity Vein Needle/Intracat","73700629","CDM","260","RC","36000","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fistula Or Sinus Tract Inj","73700630","CDM","360","RC","20501","HCPCS","facility","both","","","","1751","875.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Injection Procedure Ductogram","73700634","CDM","360","RC","19030","HCPCS","facility","both","","","","3125","1562.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath & Saline/Contrast Sonohyster/Hysterosalpi","73700637","CDM","761","RC","58340","HCPCS","facility","both","","","","2548","1274","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Perc Dil Bil. Strict W / O Stent","73700641","CDM","490","RC","47555","HCPCS","facility","both","","","","5492","2746","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Foreign Body Retrieval","73700645","CDM","360","RC","37197","HCPCS","facility","both","","","","6376","3188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Diskography Cervical Or Thoracic, Ea","73700670","CDM","360","RC","62291","HCPCS","facility","both","","","","3784","1892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Bx Livertransjuglar","73700679","CDM","360","RC","47001","HCPCS","facility","both","","","","3836","1918","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Abd/Retroperitoneal Percu","73700689","CDM","490","RC","49180","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Bx Bone S Uperficial","73700691","CDM","490","RC","20220","HCPCS","facility","both","","","","5934","2967","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Pleura Percutaneous","73700696","CDM","490","RC","32400","HCPCS","facility","both","","","","2265","1132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Inj Proc Lumbar Myelogram/Ct","73700704","CDM","320","RC","62284","HCPCS","facility","both","","","","2647","1323.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath & Saline/Contrast Sonohyster/Hysterosalpi","73700711","CDM","761","RC","58340","HCPCS","facility","both","","","","2548","1274","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liver Percutan (Separate Proc)","73700721","CDM","761","RC","47000","HCPCS","facility","both","","","","3012","1506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Perc Dil Bil. Strict W / Stent","73700723","CDM","490","RC","47556","HCPCS","facility","both","","","","5682","2841","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Puncture Aspiration Cyst Breast","73700769","CDM","761","RC","19000","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision - Newborn","73700785","CDM","360","RC","","","facility","both","","","","313","156.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Proc For Shoulder Arthro","73700792","CDM","761","RC","23350","HCPCS","facility","both","","","","2689","1344.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lithotripter - Service","73700800","CDM","790","RC","","","facility","both","","","","4686","2343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Rem Fb/Stnt Ureth/Bldr","73700801","CDM","369","RC","52310","HCPCS","facility","both","","","","4294","2147","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Aspiration Cyst Breast","73700822","CDM","761","RC","19000","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repos Gtube Thru Duoden","73700854","CDM","360","RC","43761","HCPCS","facility","both","","","","2047","1023.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube/Needle Jejunostomy","73700856","CDM","360","RC","44015","HCPCS","facility","both","","","","4196","2098","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Convert G To J Tube","73700857","CDM","490","RC","44373","HCPCS","facility","both","","","","3355","1677.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cisternal/Lateral W/O Inj Spx","73700868","CDM","369","RC","61050","HCPCS","facility","both","","","","3366","1683","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cistern Inj. Drug/Oth Dx","73700869","CDM","490","RC","61055","HCPCS","facility","both","","","","3366","1683","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ad-Hematoma,Seroma","73700881","CDM","360","RC","10140","HCPCS","facility","both","","","","4270","2135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ad-Lymph Node Ab","73700883","CDM","490","RC","38300","HCPCS","facility","both","","","","3230","1615","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ad Perc Chole","73700887","CDM","320","RC","47490","HCPCS","facility","both","","","","6440","3220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Breast Tomosynthesis 3D Add On","73700890","CDM","999","RC","","","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ad-Ovarian Abscess","73700892","CDM","360","RC","58822","HCPCS","facility","both","","","","3748","1874","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Lymph Node/Needle","73700901","CDM","761","RC","38505","HCPCS","facility","both","","","","3650","1825","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Angio Renal, 1St Order, Uni","73701000","CDM","481","RC","36251","HCPCS","facility","both","","","","14030","7015","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ophthalmic Laser Proc (Diode)","73701001","CDM","490","RC","66710","HCPCS","facility","both","","","","3652","1826","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Angio Renal, High Order, Uni - Rt","73701040","CDM","481","RC","36253","HCPCS","facility","both","","","","12217","6108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Renal,1St Order,Bilat","73701041","CDM","481","RC","36252","HCPCS","facility","both","","","","15986","7993","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Renal,High Order,Bilat","73701042","CDM","481","RC","36254","HCPCS","facility","both","","","","12217","6108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ivc Filter Placement","73701043","CDM","481","RC","37191","HCPCS","facility","both","","","","24756","12378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ivc Filter Removal","73701045","CDM","481","RC","37193","HCPCS","facility","both","","","","21466","10733","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paracentesis,Abd,W Imaging","73701046","CDM","761","RC","49083","HCPCS","facility","both","","","","3815","1907.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Thrombectomy / Art Vein","73701200","CDM","490","RC","35875","HCPCS","facility","both","","","","7660","3830","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Dilitation Of Ureter","73701216","CDM","490","RC","52351","HCPCS","facility","both","","","","4348","2174","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Portal Vein Cath","73701217","CDM","481","RC","36481","HCPCS","facility","both","","","","838","419","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loopogram","73701225","CDM","360","RC","50690","HCPCS","facility","both","","","","2825","1412.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cyst Asp Spinal Cord","73701242","CDM","490","RC","62268","HCPCS","facility","both","","","","1635","817.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cyst Aspiration,Thyroid","73701245","CDM","360","RC","60300","HCPCS","facility","both","","","","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection 1 Tendon Sheath/Ligament Aponeurosis","73701252","CDM","761","RC","20550","HCPCS","facility","both","","","","735","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Si W/Arth Diag","73701253","CDM","360","RC","G0259","HCPCS","facility","both","","","","915","457.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Si W/ Or W/O Arth Tx","73701254","CDM","761","RC","G0260","HCPCS","facility","both","","","","1531","765.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Misc Proc Nervous System","73701259","CDM","360","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Epi Ct Sgl Lvl-W/Wo Fluoro","73701261","CDM","761","RC","64479","HCPCS","facility","both","","","","4240","2120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esi L/S,Transforamn-W/Wo Fluor","73701262","CDM","761","RC","64483","HCPCS","facility","both","","","","3649","1824.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Facet C/T Sgl W/O Sed","73701265","CDM","761","RC","64490","HCPCS","facility","both","","","","3935","1967.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Facet C/T 2Nd Lv-W/Wo Fluo","73701266","CDM","761","RC","64491","HCPCS","facility","both","","","","3052","1526","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Facet L/S W/O Sed","73701267","CDM","761","RC","64493","HCPCS","facility","both","","","","3734","1867","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj L/S 2Nd Lvl-W/Wo Fluoro","73701268","CDM","761","RC","64494","HCPCS","facility","both","","","","3928","1964","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Greater Occipital Nrv","73701269","CDM","761","RC","64405","HCPCS","facility","both","","","","1164","582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Ilioinguinal Nerve","73701271","CDM","360","RC","64425","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Intercostal Nerve Sgl","73701272","CDM","761","RC","64420","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj L/T Pv Symp W/O Sed","73701274","CDM","761","RC","64520","HCPCS","facility","both","","","","2805","1402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Esi L/S W/Osed Tranforamn","73701275","CDM","761","RC","64483","HCPCS","facility","both","","","","3649","1824.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Epi L/S Ea +Lvl-W/Wo Fluor","73701276","CDM","761","RC","64484","HCPCS","facility","both","","","","3870","1935","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neu Face L/S Ea+Jnt-W/Wo Fluo","73701279","CDM","761","RC","64636","HCPCS","facility","both","","","","3809","1904.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Oth Periph Nerve","73701281","CDM","761","RC","64450","HCPCS","facility","both","","","","2314","1157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Stellate Gang W/Sed","73701284","CDM","761","RC","64510","HCPCS","facility","both","","","","2805","1402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Stellate Gang W/O Sed","73701285","CDM","761","RC","64510","HCPCS","facility","both","","","","2805","1402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Suprascapular Nerve","73701286","CDM","761","RC","64418","HCPCS","facility","both","","","","1743","871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ns-Perc Impl Neuro Trial","73701288","CDM","490","RC","63650","HCPCS","facility","both","","","","13865","6932.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pump-Refill&Maintenance-Non Md","73701290","CDM","261","RC","95990","HCPCS","facility","both","","","","389","194.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pump-Elec Anal-No Reprg Refill","73701291","CDM","360","RC","62367","HCPCS","facility","both","","","","844","422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pump-Elec-Anal-Reprg Only","73701292","CDM","360","RC","62368","HCPCS","facility","both","","","","996","498","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pump-Impl/Repl Dev Int/Epi Drug","73701293","CDM","490","RC","62360","HCPCS","facility","both","","","","19789","9894.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Epidural Blood Patch","73701296","CDM","490","RC","62273","HCPCS","facility","both","","","","2067","1033.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Epi Cath Placement","73701297","CDM","490","RC","62350","HCPCS","facility","both","","","","7219","3609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Epi Cath Removal","73701298","CDM","490","RC","62355","HCPCS","facility","both","","","","2781","1390.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ad-Sft Tissue,Neck Or Thrx","73701319","CDM","490","RC","21501","HCPCS","facility","both","","","","6042","3021","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Biopsy Soft Tissue Neck/Thorax","73701320","CDM","761","RC","21550","HCPCS","facility","both","","","","4085","2042.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Enterocyclis Tube","73701323","CDM","320","RC","44500","HCPCS","facility","both","","","","2978","1489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abscess/Drainage Pervesical Or Prevesical Surgical Code","73701330","CDM","490","RC","51080","HCPCS","facility","both","","","","4066","2033","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Injection Code Cystogram","73701331","CDM","360","RC","51605","HCPCS","facility","both","","","","3240","1620","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate/Us Or Mri/Bx","73701332","CDM","761","RC","55700","HCPCS","facility","both","","","","4838","2419","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Mult Skin Tag 1-15","73701410","CDM","361","RC","11200","HCPCS","facility","both","","","","643","321.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Block","73701411","CDM","761","RC","64486","HCPCS","facility","both","","","","2314","1157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Block Bilateral","73701412","CDM","761","RC","64488","HCPCS","facility","both","","","","2314","1157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Superior Hypogastric Plexus","73701500","CDM","761","RC","64517","HCPCS","facility","both","","","","2943","1471.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Proc Peritoneal-Ven Shunt","73701550","CDM","490","RC","49427","HCPCS","facility","both","","","","1203","601.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ligation Peritoneal-Ven Shunt","73701551","CDM","360","RC","49428","HCPCS","facility","both","","","","4517","2258.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Removal Peritoneal-Ven Shunt","73701552","CDM","490","RC","49429","HCPCS","facility","both","","","","4981","2490.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj,Sclerothy Vasc Malfor,Face","73701661","CDM","490","RC","37799","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Pleural Drainage Cath Repair","73701662","CDM","761","RC","32999","HCPCS","facility","both","","","","2176","1088","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Proc, Contrast Venography","73701722","CDM","481","RC","36005","HCPCS","facility","both","","","","2543","1271.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Proc-Inj Si W/ Or W/O Arth Tx","73701747","CDM","761","RC","G0260","HCPCS","facility","both","","","","1531","765.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Injection Code Sialogram","73701790","CDM","360","RC","42550","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Proc For Elbow Arthrograph","73701793","CDM","761","RC","24220","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Wrist Arthrography","73701794","CDM","761","RC","25246","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Hip Arthrography W/O Anesthesia","73701795","CDM","322","RC","27093","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Njx Cstograpy/Voiding Urethrocstograpy","73701797","CDM","320","RC","51600","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Arthrogram Ankle Surgical Code","73701798","CDM","360","RC","27648","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Ablation Of Kidney","73701820","CDM","360","RC","50593","HCPCS","facility","both","","","","30220","15110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Cell Harvest, Autologous","73701830","CDM","761","RC","38206","HCPCS","facility","both","","","","6417","3208.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Cell Transplant, Auto","73701831","CDM","761","RC","38241","HCPCS","facility","both","","","","5204","2602","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Facet C/T 3Rd+Lv-W/Wo Fluo","73701900","CDM","761","RC","64492","HCPCS","facility","both","","","","2871","1435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj L/S 3Rd+Lvl-W/Wo Fluoro","73701901","CDM","761","RC","64495","HCPCS","facility","both","","","","4302","2151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Inj Proc Lymphangiogram","73701963","CDM","320","RC","38790","HCPCS","facility","both","","","","1065","532.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Epi C/T Sgl Lvl W/Sed","73701997","CDM","490","RC","64479","HCPCS","facility","both","","","","4240","2120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoro - For Spine Proc","73702002","CDM","320","RC","77003","HCPCS","facility","both","","","","1507","753.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Facet C/T Sgl-W/Wo Fluoro","73702030","CDM","761","RC","64490","HCPCS","facility","both","","","","3935","1967.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Facet L/S Sgl-W/Wo Fluoro","73702033","CDM","761","RC","64493","HCPCS","facility","both","","","","3734","1867","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Celiac Plexus","73702041","CDM","761","RC","64530","HCPCS","facility","both","","","","3366","1683","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neu Face C/T Ea+Jnt-W/Wo Fluo","73702045","CDM","761","RC","64634","HCPCS","facility","both","","","","2512","1256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spy Angiogram","73702130","CDM","360","RC","15860","HCPCS","facility","both","","","","1809","904.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ns-Simple Anal W/Reprogr","73702200","CDM","920","RC","95971","HCPCS","facility","both","","","","867","433.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Intrmed Jnt/Bur W/O Us","73702201","CDM","761","RC","20605","HCPCS","facility","both","","","","846","423","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Neuro Subst Subarach","73702202","CDM","490","RC","62280","HCPCS","facility","both","","","","2285","1142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Neurolysis Celiac Plexus","73702204","CDM","490","RC","64680","HCPCS","facility","both","","","","3900","1950","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Bx Shoulder; Superficial","73702538","CDM","369","RC","23065","HCPCS","facility","both","","","","5092","2546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Of Chalazion:Mult Diff Lid","73702539","CDM","369","RC","67805","HCPCS","facility","both","","","","2876","1438","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Endocrine System","73702540","CDM","761","RC","60699","HCPCS","facility","both","","","","10230","5115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Anorectal Wall","73702660","CDM","490","RC","45100","HCPCS","facility","both","","","","3828","1914","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Injection Code Dacroscystogram","73702799","CDM","360","RC","68850","HCPCS","facility","both","","","","2091","1045.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement-Nonselective Ot","73703013","CDM","430","RC","97602","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement-Nonselective Pt","73703016","CDM","420","RC","97602","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Chemical Pleurodesis","73703017","CDM","360","RC","32560","HCPCS","facility","both","","","","5644","2822","","","","","","","","","","","","","Gross Charge Type: Standard"
"Declot Vascular Access","73703036","CDM","940","RC","36593","HCPCS","facility","both","","","","1454","727","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Splenoportogram","73703041","CDM","360","RC","38200","HCPCS","facility","both","","","","5049","2524.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Biliary Brush Bx","73703044","CDM","490","RC","47553","HCPCS","facility","both","","","","5492","2746","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Choledochal Stent","73703045","CDM","360","RC","47801","HCPCS","facility","both","","","","5777","2888.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abscessogram","73703049","CDM","320","RC","49424","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureterography Thru Existing","73703050","CDM","360","RC","50684","HCPCS","facility","both","","","","3830","1915","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Ureterostomy Cath.","73703051","CDM","761","RC","50688","HCPCS","facility","both","","","","4646","2323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp S Uprapubic Cath","73703052","CDM","490","RC","51102","HCPCS","facility","both","","","","4675","2337.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ureteral Dilitation","73703053","CDM","490","RC","52341","HCPCS","facility","both","","","","10638","5319","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Puncture Pump Reservoir","73703056","CDM","490","RC","61070","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lp Therapeutic","73703057","CDM","761","RC","62272","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Arthrocentesis-Maj Jnt W/O Us","73703065","CDM","761","RC","20610","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Change Abscess Cath","73703071","CDM","320","RC","49423","HCPCS","facility","both","","","","3209","1604.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Non-Tunneled Cvc<5Yr","73703131","CDM","490","RC","36555","HCPCS","facility","both","","","","3942","1971","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Non-Tunneled Cvc>=5Yr","73703132","CDM","761","RC","36556","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tnnld Cvc W/O Prt/Pmp<5Yr","73703133","CDM","490","RC","36557","HCPCS","facility","both","","","","7050","3525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Implant Cath/Infusion Pump 36558","73703134","CDM","761","RC","36558","HCPCS","facility","both","","","","5911","2955.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tnnld Cvc W/Port<5Yr","73703135","CDM","490","RC","36560","HCPCS","facility","both","","","","5911","2955.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Implant Cath/Infusion Pump 36561","73703136","CDM","761","RC","36561","HCPCS","facility","both","","","","7099","3549.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Insert Tunneled Cvc W/Pump","73703137","CDM","490","RC","36563","HCPCS","facility","both","","","","17044","8522","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ins Tnnld Caths,I.E. Tessio","73703138","CDM","490","RC","36565","HCPCS","facility","both","","","","10278","5139","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Picc <5Yrs W/O Imaging","73703139","CDM","490","RC","36568","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Picc >=5Yrs W/O Imaging","73703140","CDM","369","RC","36569","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Picc W/Port<5Yr","73703141","CDM","490","RC","36570","HCPCS","facility","both","","","","6242","3121","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Picc W/Port >5Yr","73703142","CDM","761","RC","36571","HCPCS","facility","both","","","","6242","3121","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Implant Cath/Infusion 36575","73703143","CDM","761","RC","36575","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Cva W/Port/Pump","73703144","CDM","490","RC","36576","HCPCS","facility","both","","","","1898","949","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpl Cvc W/O Prt/Pmp Same Site","73703146","CDM","490","RC","36580","HCPCS","facility","both","","","","4064","2032","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpl Tnld Cvc W/O P/P Same Site","73703147","CDM","761","RC","36581","HCPCS","facility","both","","","","10299","5149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Implant Cath/Infustion 36582","73703148","CDM","761","RC","36582","HCPCS","facility","both","","","","10299","5149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Rpl Tnnld Cvc W / Pmp Same Site","73703149","CDM","490","RC","36583","HCPCS","facility","both","","","","17618","8809","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replpicc Same Site Incl Image","73703150","CDM","761","RC","36584","HCPCS","facility","both","","","","4064","2032","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpl Picc W/Prt Thru Same Acces","73703151","CDM","490","RC","36585","HCPCS","facility","both","","","","10299","5149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Tnnld Cvc W/O Port/Pump","73703152","CDM","761","RC","36589","HCPCS","facility","both","","","","2532","1266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Tnnld Cvc W/Port/Pump","73703153","CDM","761","RC","36590","HCPCS","facility","both","","","","5244","2622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Pericath Obstr Sep Access","73703154","CDM","360","RC","36595","HCPCS","facility","both","","","","4118","2059","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Intralum Obst Thru Dvc Lum","73703155","CDM","360","RC","36596","HCPCS","facility","both","","","","1743","871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reposition Cva","73703156","CDM","360","RC","36597","HCPCS","facility","both","","","","1743","871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Insr Tun Cva 2Cath/Sites W Por","73703174","CDM","490","RC","","","facility","both","","","","24960","12480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridmnt Selec-1St 20Sqcm/< Pt","73703175","CDM","420","RC","97597","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wound W/Dme </=50Cm","73703177","CDM","420","RC","97605","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wound W/Dme >50Cm","73703178","CDM","420","RC","97606","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridmnt Selec-Ea Adtl 20Sqcm Ot","73703182","CDM","430","RC","97598","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridmnt Selec-1St 20Sqcm/< Ot","73703184","CDM","430","RC","97597","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Perc Sacral Aug-Uni W/Image Gd","73703190","CDM","490","RC","0200T","HCPCS","facility","both","","","","9267","4633.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Perc Sacral Aug-Bil W/Image Gd","73703191","CDM","490","RC","0201T","HCPCS","facility","both","","","","9267","4633.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision & Drainage Abscess Simple/Single","73703200","CDM","761","RC","10060","HCPCS","facility","both","","","","1305","652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Aspiration Abscess Hematoma Bulla/Cyst","73703201","CDM","761","RC","10160","HCPCS","facility","both","","","","630","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Needle Bx Spinal Cord","73703204","CDM","490","RC","62269","HCPCS","facility","both","","","","2003","1001.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breast Puncture Aspir Cyst-Add","73703207","CDM","360","RC","19001","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Insert Tnnld Pleural Cath W / Cuff","73703210","CDM","761","RC","32550","HCPCS","facility","both","","","","7105","3552.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoro - Other","73703220","CDM","320","RC","77002","HCPCS","facility","both","","","","1371","685.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ns-Complx Anal&Prog </=To 1 Hr","73703223","CDM","920","RC","95972","HCPCS","facility","both","","","","1228","614","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pump-Refill/Maintenance-Md-95991","73703224","CDM","261","RC","95991","HCPCS","facility","both","","","","524","262","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73703226","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Perm Peritoneal Drain Cath","73703241","CDM","490","RC","49422","HCPCS","facility","both","","","","5352","2676","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Rem Of Tunneled Cuffed Pleural Cath","73703242","CDM","761","RC","32552","HCPCS","facility","both","","","","1734","867","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Intraper Drain Cath Perm","73703246","CDM","490","RC","49421","HCPCS","facility","both","","","","6381","3190.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem/Repl Int Uret Stent W/S&I","73703247","CDM","490","RC","50382","HCPCS","facility","both","","","","7006","3503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Rem / Repl Ext Uret Stent W / S&I","73703248","CDM","490","RC","50387","HCPCS","facility","both","","","","7006","3503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percthrombectmy Initial Artery","73703249","CDM","481","RC","37184","HCPCS","facility","both","","","","14793","7396.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percthrombectmy Add Art Samfam","73703250","CDM","481","RC","37185","HCPCS","facility","both","","","","11938","5969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrombectomy Post Interven Art","73703251","CDM","481","RC","37186","HCPCS","facility","both","","","","12870","6435","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Transluminal Mechanical Thrombectomy Vein","73703252","CDM","481","RC","37187","HCPCS","facility","both","","","","14148","7074","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cont Thrombectom Vein Sepvisit","73703253","CDM","360","RC","37188","HCPCS","facility","both","","","","14148","7074","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pta Intracranial-Athro Stenos","73703254","CDM","360","RC","61630","HCPCS","facility","both","","","","17523","8761.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Intracranal Incpta Athro","73703255","CDM","360","RC","61635","HCPCS","facility","both","","","","16291","8145.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pta Intracran-Vasospm Init Ves","73703256","CDM","481","RC","61640","HCPCS","facility","both","","","","17523","8761.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Pta Intracranvasospmaddsmfam","73703257","CDM","360","RC","61641","HCPCS","facility","both","","","","12514","6257","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pta Intracran-Vasospmadddiffam","73703258","CDM","360","RC","61642","HCPCS","facility","both","","","","12514","6257","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burn Debridement Small","73703260","CDM","761","RC","16020","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burn Debridement Medium","73703261","CDM","761","RC","16025","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burn Debridement Large","73703262","CDM","761","RC","16030","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentisis-Int Jnt W/O Us","73703265","CDM","761","RC","20605","HCPCS","facility","both","","","","846","423","","","","","","","","","","","","","Gross Charge Type: Standard"
"Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce","73703266","CDM","750","RC","43752","HCPCS","facility","both","","","","850","425","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Duo/Jej Tube,W Rad S&I","73703267","CDM","360","RC","49441","HCPCS","facility","both","","","","4085","2042.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Insert Colonic Tube W / Rad S&I","73703268","CDM","360","RC","49442","HCPCS","facility","both","","","","6587","3293.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace Duodenostomy/Jejunostomy Tube Perq","73703269","CDM","761","RC","49451","HCPCS","facility","both","","","","2239","1119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replacement Gastro-Jejunostomy Tube Percutaneous","73703270","CDM","750","RC","49452","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Tube Obstruct,W Rad S&I","73703271","CDM","360","RC","49460","HCPCS","facility","both","","","","1343","671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Vnpnxr 3 Years/> Phys/Qhp Skill","73703272","CDM","761","RC","36410","HCPCS","facility","both","","","","367","183.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow;Aspiration Only","73703275","CDM","761","RC","38220","HCPCS","facility","both","","","","2230","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow;Bx,Ndl Or Trocar","73703276","CDM","761","RC","38221","HCPCS","facility","both","","","","2505","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","73703281","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 5-40 Min","73703283","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Of O/P Min Prob Lev 1 -25","73703284","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Of Op Low 20-29 Min L3 -25","73703285","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Guided Rf Ablation Bone","73703300","CDM","360","RC","20982","HCPCS","facility","both","","","","16304","8152","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abltj 1/> Renal Tumor Prq Uni Radiofrequency","73703301","CDM","761","RC","50592","HCPCS","facility","both","","","","12483","6241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abltj 1/> Lvr Tum Prq Rf","73703302","CDM","761","RC","47382","HCPCS","facility","both","","","","10758","5379","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Guided Rf Ablation Lung","73703303","CDM","360","RC","32998","HCPCS","facility","both","","","","13196","6598","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Cystostomy Tube Simple","73703304","CDM","761","RC","51705","HCPCS","facility","both","","","","946","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Block,Intercostal,Sng","73703305","CDM","761","RC","64420","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Place Fiducialrad Tx Nonprostrate","73703350","CDM","360","RC","C9728","HCPCS","facility","both","","","","6916","3458","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Fiducial-Prostate","73703351","CDM","360","RC","55876","HCPCS","facility","both","","","","4805","2402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Sclerosant Multiple Incmptnt Veins","73703352","CDM","490","RC","36471","HCPCS","facility","both","","","","1535","767.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Asp,Paravertebral/Disc,Diag","73703400","CDM","490","RC","62267","HCPCS","facility","both","","","","2356","1178","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Bx Breast 1St Lesion Strtctc","73703401","CDM","761","RC","19081","HCPCS","facility","both","","","","12312","6156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Bx Breast Add Lesion Strtctc","73703402","CDM","761","RC","19082","HCPCS","facility","both","","","","12312","6156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Bx Breast 1St Lesion Us Imag","73703403","CDM","761","RC","19083","HCPCS","facility","both","","","","6240","3120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Bx Breast Add Lesion Us Imag","73703404","CDM","761","RC","19084","HCPCS","facility","both","","","","6240","3120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Bx Breast 1St Lesion Mr Imag","73703405","CDM","761","RC","19085","HCPCS","facility","both","","","","12312","6156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Bx Breast Add Lesion Mr Imag","73703406","CDM","761","RC","19086","HCPCS","facility","both","","","","12312","6156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Device Breast 1St Imag","73703407","CDM","761","RC","19281","HCPCS","facility","both","","","","5195","2597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Device Breast Ea Imag","73703408","CDM","761","RC","19282","HCPCS","facility","both","","","","5195","2597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Dev Breast 1St Strtctc","73703409","CDM","761","RC","19283","HCPCS","facility","both","","","","6726","3363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Dev Breast Add Strtctc","73703410","CDM","761","RC","19284","HCPCS","facility","both","","","","6726","3363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Dev Breast 1St Us Imag","73703411","CDM","761","RC","19285","HCPCS","facility","both","","","","5008","2504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Dev Breast Add Us Imag","73703412","CDM","761","RC","19286","HCPCS","facility","both","","","","5008","2504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Dev Breast 1St Mr Guide","73703413","CDM","761","RC","19287","HCPCS","facility","both","","","","6726","3363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Perq Dev Breast Add Mr Guide","73703414","CDM","761","RC","19288","HCPCS","facility","both","","","","6726","3363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Cath Fluid Colxn Visc","73703415","CDM","761","RC","49405","HCPCS","facility","both","","","","4332","2166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Cath Fluid Peri/Retro","73703416","CDM","361","RC","49406","HCPCS","facility","both","","","","5138","2569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Cath Fluid Trns/Vgnl","73703417","CDM","761","RC","49407","HCPCS","facility","both","","","","4202","2101","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Venous","73703418","CDM","481","RC","37241","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Artery","73703419","CDM","481","RC","37242","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Organ","73703420","CDM","761","RC","37243","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Bleed","73703421","CDM","481","RC","37244","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tr Cath Intra Vsc Stent 1 Art","73703422","CDM","481","RC","37236","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tr Cath Intra Vsc Stent 1 Vein","73703423","CDM","481","RC","37238","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Cath Stent Addl Artery","73703424","CDM","481","RC","37237","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Cath Stent Addl Vein","73703425","CDM","481","RC","37239","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Cath Fluid Peri/Retro","73703426","CDM","361","RC","49406","HCPCS","facility","both","","","","5138","2569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Cath Fluid Colxn Visc","73703427","CDM","360","RC","49405","HCPCS","facility","both","","","","4332","2166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Drain Lymphocele","73703428","CDM","360","RC","49323","HCPCS","facility","both","","","","7420","3710","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Trunk Musc 1-5 Mus","73703434","CDM","761","RC","64646","HCPCS","facility","both","","","","2293","1146.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc For Vagus N Elect Impl","73703525","CDM","761","RC","64568","HCPCS","facility","both","","","","125857","62928.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myelogram Lumbar-Cervical S&I","73703560","CDM","320","RC","62302","HCPCS","facility","both","","","","5681","2840.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myelogram Lumbar-Thoracic S&I","73703561","CDM","320","RC","62303","HCPCS","facility","both","","","","5681","2840.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myelography Lumbar Injection","73703562","CDM","761","RC","62304","HCPCS","facility","both","","","","5681","2840.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myelogram Lumbar-2+Regions S&I","73703563","CDM","320","RC","62305","HCPCS","facility","both","","","","7687","3843.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis-Sml Jnt W/Us","73703650","CDM","761","RC","20604","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Intrmed Jnt/Bur W/Us","73703651","CDM","761","RC","20606","HCPCS","facility","both","","","","1259","629.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Arthrocentesis-Int Jnt W/ Us","73703652","CDM","761","RC","20606","HCPCS","facility","both","","","","1259","629.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis-Maj Jnt W/Us","73703653","CDM","761","RC","20611","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Major Jnt/Bur W/ Us","73703654","CDM","761","RC","20611","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Biopsy,Salivary Gland","73703700","CDM","761","RC","42400","HCPCS","facility","both","","","","2278","1139","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Intercostal Nerve","73703900","CDM","761","RC","64620","HCPCS","facility","both","","","","3826","1913","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dstrj Nulyt Agt Gnclr Nrv","73703901","CDM","369","RC","64624","HCPCS","facility","both","","","","6377","3188.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rf Abltj Nrv Nrvtg Si Jt","73703902","CDM","369","RC","64625","HCPCS","facility","both","","","","6377","3188.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Intravasc Lithotripsy","73703904","CDM","481","RC","C9764","HCPCS","facility","both","","","","14754","7377","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Intra Lithotrip-Stent","73703905","CDM","481","RC","C9765","HCPCS","facility","both","","","","29510","14755","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Intra Lithotrip-Ather","73703906","CDM","481","RC","C9766","HCPCS","facility","both","","","","29510","14755","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Lithotrip-Stent-Ather","73703907","CDM","481","RC","C9767","HCPCS","facility","both","","","","47473","23736.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Into Skin Lesions=<7","73703908","CDM","369","RC","11900","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manip Fing Jnt W An Ea","73703909","CDM","369","RC","26340","HCPCS","facility","both","","","","5028","2514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Chg Not For Burn","73703910","CDM","369","RC","15852","HCPCS","facility","both","","","","4224","2112","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ev Fempop Artl Revsc","73703911","CDM","481","RC","0505T","HCPCS","facility","both","","","","31085","15542.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implt/Rpl Crtd Sns Dev Total","73703919","CDM","369","RC","0266T","HCPCS","facility","both","","","","87944","43972","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchial Allergy Tests","73703920","CDM","924","RC","95070","HCPCS","facility","both","","","","1981","990.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Intermediate S/A/T/E 2.5 Cm/<","73703921","CDM","369","RC","12031","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Abltn Ext Vein 1St Vein","73703922","CDM","490","RC","36478","HCPCS","facility","both","","","","10239","5119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Litohtrip Tibi/Perone","73703923","CDM","320","RC","C9772","HCPCS","facility","both","","","","42936","21468","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Spine","73703924","CDM","369","RC","22899","HCPCS","facility","both","","","","6958","3479","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Musculoskeletal System Op","73703926","CDM","369","RC","20999","HCPCS","facility","both","","","","6958","3479","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stab Phleb Veins Xtr 10-20","73703927","CDM","320","RC","37765","HCPCS","facility","both","","","","11963","5981.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Noncmpnd Sclrsnt 1 Vein","73703928","CDM","320","RC","36465","HCPCS","facility","both","","","","8350","4175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Noncmpnd Sclrsnt Mlt Vn","73703929","CDM","320","RC","36466","HCPCS","facility","both","","","","8350","4175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Femur/Knee","73703931","CDM","369","RC","27599","HCPCS","facility","both","","","","6136","3068","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Lamot/Lam Lumbar","73703934","CDM","369","RC","0275T","HCPCS","facility","both","","","","20321","10160.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abdomen Surgery Procedure","73703935","CDM","369","RC","22999","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Congenital Card Cath","73703936","CDM","481","RC","93563","HCPCS","facility","both","","","","3938","1969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Sclrsnt Spider Veins","73703937","CDM","369","RC","36468","HCPCS","facility","both","","","","1240","620","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pelvis/Hip Joint Surgery","73703969","CDM","369","RC","27299","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mal+Marg 2.1-3 Cm","73703972","CDM","761","RC","11603","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explore Wound Abdomen/Flank/Back","73703973","CDM","369","RC","20102","HCPCS","facility","both","","","","5583","2791.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Trunk Musc 6/>","73703974","CDM","761","RC","64647","HCPCS","facility","both","","","","2709","1354.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Insj W/O Njx 1 Or 2 Musc","73703975","CDM","761","RC","20560","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Insj W/0 Njx 3+ Musc","73703976","CDM","761","RC","20561","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Finger Fracture Each","73703977","CDM","369","RC","26725","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tixagev And Cilgav Inj","73703978","CDM","771","RC","M0220","HCPCS","facility","both","","","","150.5","75.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Lithotr-Stent Tib/Per","73703979","CDM","360","RC","C9773","HCPCS","facility","both","","","","65302","32651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Lithotr-Ather Tib/Per","73703980","CDM","360","RC","C9774","HCPCS","facility","both","","","","65302","32651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc Lith-Sten-Ath Tib/Per","73703981","CDM","360","RC","C9775","HCPCS","facility","both","","","","65302","32651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tas Congenital Car Anomal","73703982","CDM","369","RC","33741","HCPCS","facility","both","","","","5604","2802","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Linq Loop Recorder - Alleviate Hf Study","73703983","CDM","481","RC","33285","HCPCS","facility","both","","","","7773","3886.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Transcath Cls Mitral","73703985","CDM","369","RC","93590","HCPCS","facility","both","","","","60090","30045","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tixagev And Cilgav Inj Hm","73703990","CDM","771","RC","M0221","HCPCS","facility","both","","","","250.5","125.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mrgfus Strtctc Les Abltj","73703991","CDM","330","RC","0398T","HCPCS","facility","both","","","","34539","17269.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bebtelovimab Injection","73703992","CDM","771","RC","M0222","HCPCS","facility","both","","","","350.5","175.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Biliary Tract","73703993","CDM","369","RC","47999","HCPCS","facility","both","","","","4615","2307.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Jenevalve Trilogy Heart Valve System, Align Ar Study","73703995","CDM","278","RC","","","facility","both","","","","45281.25","22640.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Us Trgt Dyn Mbubb Ed Addl","73703997","CDM","402","RC","76979","HCPCS","facility","both","","","","868","434","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dialysis Repeated Eval","73703998","CDM","960","RC","90947","HCPCS","facility","both","","","","1028","514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Hip Dislocation","73703999","CDM","369","RC","27252","HCPCS","facility","both","","","","3251","1625.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blind Cor Sinus Reducer Impl","73704001","CDM","480","RC","C9783","HCPCS","facility","both","","","","28364","14182","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr Trunk 10 Sq Cm/<","73704003","CDM","761","RC","14000","HCPCS","facility","both","","","","7214","3607","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sutr/Staple Req Anes","73704004","CDM","761","RC","15851","HCPCS","facility","both","","","","5377","2688.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Brch Pl Nfs Img","73704005","CDM","761","RC","64416","HCPCS","facility","both","","","","2927","1463.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Ax Nerve Img","73704006","CDM","761","RC","64417","HCPCS","facility","both","","","","1516","758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Sciatic Nrv Img","73704007","CDM","761","RC","64445","HCPCS","facility","both","","","","1466","733","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Femoral Nrv Img","73704008","CDM","761","RC","64447","HCPCS","facility","both","","","","764","382","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Fem Nrv Nfs Img","73704009","CDM","761","RC","64448","HCPCS","facility","both","","","","2574","1287","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Face/Ears/Eyelids/Nose/Lips/Mucosa 0.6-1.0 Cm","73704010","CDM","761","RC","11311","HCPCS","facility","both","","","","388","194","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Of Eyelid Abscess","73704011","CDM","761","RC","67700","HCPCS","facility","both","","","","1313","656.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Brch Plxs Img","73704012","CDM","761","RC","64415","HCPCS","facility","both","","","","1012","506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Ecls Daily Mgmt-Venous","73704013","CDM","940","RC","33948","HCPCS","facility","both","","","","4724","2362","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Ecls Daily Mgmt Artery","73704014","CDM","940","RC","33949","HCPCS","facility","both","","","","4724","2362","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Trluml Periph Athrc W/Rs&I Brchiocphl Ea Vsl","73704015","CDM","481","RC","0237T","HCPCS","facility","both","","","","30401","15200.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj Plntr Dig Lt","73704016","CDM","761","RC","64455","HCPCS","facility","both","","","","1294","647","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insj/Rplcmt Temp Transvns 2Chmbr Pacg Eltrds Spx","73704017","CDM","481","RC","33211","HCPCS","facility","both","","","","10197","5098.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Mal Lesion Trunk/Arm/Leg > 4.0 Cm","73704019","CDM","761","RC","17266","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Av Fistula Creation Uxtr Single Access","73704020","CDM","480","RC","36836","HCPCS","facility","both","","","","42680","21340","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Oropharynx","73704021","CDM","369","RC","42800","HCPCS","facility","both","","","","4886","2443","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Abdomen Peritoneum & Omentum","73704023","CDM","761","RC","49999","HCPCS","facility","both","","","","9572","4786","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cystoscopy & Ureter Catheter","73704024","CDM","761","RC","52005","HCPCS","facility","both","","","","9723","4861.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Liver Imaging W/Vascular Flow","73704025","CDM","341","RC","78202","HCPCS","facility","both","","","","2286","1143","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imm Admn Sarscov2 Vaccine Single Dose","73704026","CDM","771","RC","90480","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Magnetic Resonance Elastography","73704027","CDM","614","RC","76391","HCPCS","facility","both","","","","2256","1128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5Cm/<","73704028","CDM","761","RC","12001","HCPCS","facility","both","","","","923","461.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bldr Irrigation Smpl Lavage &/Instl","73704029","CDM","761","RC","51700","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Artl Cath/Cannula Mntr/Transfusion Spx Prq","73704030","CDM","761","RC","36620","HCPCS","facility","both","","","","1904","952","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pressurized/Nonpressurized Inhalation Treatment","73704031","CDM","761","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Repair F/E/E/N/L/M 2.5Cm/<","73704032","CDM","761","RC","12011","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clsd Tx Shoulder Dislc W/Manipulation W/O Anes","73704033","CDM","761","RC","23650","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Short Leg Splint Calf Foot","73704034","CDM","761","RC","29515","HCPCS","facility","both","","","","886","443","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Of Bartholins Gland Abscess","73704035","CDM","761","RC","56420","HCPCS","facility","both","","","","2107","1053.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Lumbar Spinal Puncture","73704036","CDM","761","RC","62270","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percutaneous Transluminal Coronary Lithotripsy","73704040","CDM","481","RC","92972","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caregiver Training Strategies&Tq 1St 30 Minutes","73704041","CDM","420","RC","97550","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caregiver Training Strategies&Tq Ea Addl 15 Min","73704042","CDM","420","RC","97551","HCPCS","facility","both","","","","68","34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Group Caregiver Training Strategies & Technique","73704043","CDM","420","RC","97552","HCPCS","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheotomy Tube Change Prior To Fistula Tract","73704044","CDM","761","RC","31502","HCPCS","facility","both","","","","590","295","","","","","","","","","","","","","Gross Charge Type: Standard"
"Principal Illness Navigation Services By Certified Or Trained Auxiliary Personnel, 60 Minutes Per Mo","73704045","CDM","942","RC","G0023","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Principal Illness Navigation Services, Additional 30 Minutes Per Calendar Month","73704046","CDM","942","RC","G0024","HCPCS","facility","both","","","","228","114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biliary Endo Prq T-Tube Dx W/Collect Spec Brush","73704047","CDM","320","RC","47552","HCPCS","facility","both","","","","16725","8362.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biliary Ndsc Intraoperative","73704048","CDM","761","RC","47550","HCPCS","facility","both","","","","16725","8362.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrombolysis Cerebral Iv Infusion","73704049","CDM","761","RC","37195","HCPCS","facility","both","","","","2694","1347","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Perianal Abscess Superficial","73704050","CDM","761","RC","46050","HCPCS","facility","both","","","","3297","1648.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Complex F/C/C/M/N/Ax/G/H/F 2.6-7.5 Cm","73704051","CDM","761","RC","13132","HCPCS","facility","both","","","","1523","761.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Repair F/E/E/N/L/M 2.6Cm-5.0 Cm","73704052","CDM","761","RC","12013","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ercp W/Biopsy Single/Multiple","73704053","CDM","761","RC","43261","HCPCS","facility","both","","","","8467","4233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath(Foley)","73704301","CDM","761","RC","51702","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Insert Gastrostomy Tube Percutaneous","73704440","CDM","750","RC","49440","HCPCS","facility","both","","","","4085","2042.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Rpl Gastrostomy Tube W / Rad S&I","73704441","CDM","761","RC","49450","HCPCS","facility","both","","","","2978","1489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Injection / Checking Placement Of J Tube","73704442","CDM","320","RC","49465","HCPCS","facility","both","","","","1610","805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Inj, Epidural, Blood / Clot Patch","73704553","CDM","490","RC","62273","HCPCS","facility","both","","","","2067","1033.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Sclerosing Agent Thera","73704555","CDM","761","RC","20500","HCPCS","facility","both","","","","2414","1207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Peritoneal Venous Shunt","73704600","CDM","490","RC","49425","HCPCS","facility","both","","","","3940","1970","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Peritoneal Venous Shunt","73704601","CDM","490","RC","49426","HCPCS","facility","both","","","","4387","2193.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vppa Deb Bone 20 Sq Cm/<","73704702","CDM","761","RC","11044","HCPCS","facility","both","","","","5413","2706.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vppa Injctn For Pseudoaneurysm","73704704","CDM","490","RC","36002","HCPCS","facility","both","","","","2109","1054.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vppa Rem Tnld Cvc W/O Port/Pmp","73704706","CDM","761","RC","36589","HCPCS","facility","both","","","","2532","1266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Recovery Monitoring-Min","73705021","CDM","710","RC","","","facility","both","","","","23","11.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uterine Fibroid Embolization","73705990","CDM","761","RC","37243","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Sp Inj,Sclerotherapy","73706000","CDM","490","RC","37799","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Vertebroplasty Uni/Bi Injx Cervicothoracic","73706181","CDM","761","RC","22510","HCPCS","facility","both","","","","8056","4028","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","73706182","CDM","761","RC","22511","HCPCS","facility","both","","","","8071","4035.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vertebroplasty Addl Inject","73706183","CDM","360","RC","22512","HCPCS","facility","both","","","","6931","3465.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphoplasty 1 Vrt Bdy,Thoracic","73706184","CDM","761","RC","22513","HCPCS","facility","both","","","","9586","4793","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","73706185","CDM","761","RC","22514","HCPCS","facility","both","","","","15943","7971.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphoplasty Ea Add Vb Thor/Lum","73706186","CDM","761","RC","22515","HCPCS","facility","both","","","","5734","2867","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Trigeminal Nerve","73706702","CDM","360","RC","64400","HCPCS","facility","both","","","","1198","599","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Major Jnt/Bur W/O Us","73706708","CDM","761","RC","20610","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Epi Adh 2+Day-W/Wo Fluor","73706709","CDM","490","RC","62263","HCPCS","facility","both","","","","4804","2402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neu Face C/T Sgl Jt-W/Wo Fluor","73706710","CDM","761","RC","64633","HCPCS","facility","both","","","","3809","1904.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neu Face L/S Sgl Jnt-W/Wo Fluo","73706711","CDM","761","RC","64635","HCPCS","facility","both","","","","5495","2747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Trig Pt 3+ Muscles","73706715","CDM","761","RC","20553","HCPCS","facility","both","","","","908","454","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Neurol Oth Periph Nerve","73706717","CDM","761","RC","64640","HCPCS","facility","both","","","","2242","1121","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Intercostal Nrv Multi","73706720","CDM","761","RC","64421","HCPCS","facility","both","","","","3013","1506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Trig Pt 1-2 Muscles","73706725","CDM","761","RC","20552","HCPCS","facility","both","","","","1244","622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Plexus Cont Nrve Block","73706730","CDM","369","RC","64449","HCPCS","facility","both","","","","2960","1480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Check Cvad W/ Contrast","73706900","CDM","320","RC","36598","HCPCS","facility","both","","","","1063","531.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Fiducial-Thoracic","73706981","CDM","360","RC","32553","HCPCS","facility","both","","","","5090","2545","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Fiducial-Abc,Plv,Retro","73706982","CDM","320","RC","49411","HCPCS","facility","both","","","","1888","944","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rf Pudenal Nerve","73707005","CDM","490","RC","64630","HCPCS","facility","both","","","","1605","802.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Rf Other Nerve Or Branch","73707006","CDM","490","RC","64640","HCPCS","facility","both","","","","2242","1121","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Nerve Block","73707014","CDM","490","RC","64421","HCPCS","facility","both","","","","3013","1506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Pudendal Nerve","73707015","CDM","490","RC","64430","HCPCS","facility","both","","","","1686","843","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Botox Neck","73707021","CDM","490","RC","64616","HCPCS","facility","both","","","","879","439.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pump Dye Study","73707029","CDM","320","RC","75809","HCPCS","facility","both","","","","412","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bleph Up Lid W/Excess Skin-Bila","73707035","CDM","761","RC","15823","HCPCS","facility","both","","","","7167","3583.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Chemodenerv Face Musc Bilat","73707045","CDM","490","RC","64615","HCPCS","facility","both","","","","978","489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Trigger Point Inj, 3 Muscles","73707050","CDM","361","RC","20553","HCPCS","facility","both","","","","908","454","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Ganglion Impar Sympath Ner Blo","73707060","CDM","761","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carpal Tunnel Injection","73707065","CDM","761","RC","20526","HCPCS","facility","both","","","","605","302.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Inf Pump W/Md Fill/Prog, Anal","73707105","CDM","490","RC","62370","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Inf Pump Fill W/Prog And Anal","73707106","CDM","490","RC","62369","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracentesis W/O Img Guid","73707107","CDM","490","RC","32554","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracentesis W/Img Guid","73707108","CDM","761","RC","32555","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Art Inf For Thrombolysis Init","73707109","CDM","481","RC","37211","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ven Inf For Thrombolysis Init","73707110","CDM","481","RC","37212","HCPCS","facility","both","","","","9692","4846","","","","","","","","","","","","","Gross Charge Type: Standard"
"Art/Ven Inf Thrombolysis Subs","73707111","CDM","481","RC","37213","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrombolysis Cessation","73707112","CDM","481","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card Art Inf Thrmbolysis Init","73707113","CDM","481","RC","37211","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card Ven Inf Thrmbolysis Init","73707114","CDM","481","RC","37212","HCPCS","facility","both","","","","9692","4846","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card Art/Ven Inf Thromb.Subs","73707115","CDM","481","RC","37213","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card-Thrombolysis Cessation","73707116","CDM","481","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cessation Thrombolytic Ther W/Catheter Removal","73707117","CDM","761","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Sphenocath Inj Sphenogangl Blk","73707152","CDM","761","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Fluoro For Sphenocath","73707153","CDM","320","RC","76000","HCPCS","facility","both","","","","1896","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Small  Jnt/Bur W/O Us","73707160","CDM","761","RC","20600","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Small  Jnt/Bur W/Us","73707161","CDM","761","RC","20604","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Breast","73707170","CDM","402","RC","19499","HCPCS","facility","both","","","","9371","4685.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cath Pleura W/O Image","73707200","CDM","490","RC","32556","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cath Pleura W/Image","73707201","CDM","369","RC","32557","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneal Lens For Aphakia 1 Eye","73707300","CDM","761","RC","92311","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneal Lens For Aphakia 2Eyes","73707301","CDM","761","RC","92312","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneolscleral Lens","73707302","CDM","761","RC","92313","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneal Lens Aphakia 1 Eye Tc","73707303","CDM","761","RC","92315","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneal Lens Aphakia 2 Eyes Tc","73707304","CDM","761","RC","92316","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corneolscleral Lens Tech","73707305","CDM","761","RC","92317","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Modification Of Lens","73707306","CDM","761","RC","92325","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replacement Of Lens","73707307","CDM","761","RC","92326","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Test Tb Intradermal","73707750","CDM","300","RC","86580","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon","73707800","CDM","761","RC","20551","HCPCS","facility","both","","","","627","313.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Sphenopalatine Ganglion","73707801","CDM","490","RC","64505","HCPCS","facility","both","","","","1140","570","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opthalmic Biometry Lenstar","73707900","CDM","920","RC","92136","HCPCS","facility","both","","","","405","202.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Aspiration Baker's Cyst Sc","73708000","CDM","761","RC","20612","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card-Ivc Filter Placement","73708005","CDM","481","RC","37191","HCPCS","facility","both","","","","24756","12378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card-Ivc Filter Removal","73708007","CDM","481","RC","37193","HCPCS","facility","both","","","","21466","10733","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion","73710004","CDM","391","RC","36430","HCPCS","facility","both","","","","1611","805.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Influenza Vaccine","73710008","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Pneumococcal Vac","73710009","CDM","771","RC","G0009","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin-Hep B Vaccine","73710010","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","73710012","CDM","949","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Port Flush","73710014","CDM","260","RC","96523","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine/Immun Inj-Other","73710015","CDM","771","RC","90471","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addtl-Influ","73710016","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addtl-Pneumo","73710017","CDM","771","RC","G0009","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addtl-Hepatitis","73710018","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addtl-Other","73710019","CDM","771","RC","90472","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ch Visit Port Flush Only","73710020","CDM","761","RC","96523","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrathecal Chemo Inj,Inc Lp","73710021","CDM","331","RC","96450","HCPCS","facility","both","","","","888","444","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Rem Nephrostomy Tube W / Rad S&I","73710022","CDM","490","RC","50389","HCPCS","facility","both","","","","2101","1050.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct Premalg Lesion","73710029","CDM","761","RC","17000","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sclerotx Fluid Collection","73710791","CDM","761","RC","49185","HCPCS","facility","both","","","","4575","2287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Art M-Thrombect &/Nfs","73710792","CDM","761","RC","61645","HCPCS","facility","both","","","","65587","32793.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Card-Angio Venography Extremit","73720001","CDM","481","RC","36005","HCPCS","facility","both","","","","2543","1271.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Sng Angio Aorta, Add To","73720002","CDM","481","RC","36200","HCPCS","facility","both","","","","5300","2650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Sng Cath Vein 2Nd Ord Mo / Sele","73720005","CDM","481","RC","36012","HCPCS","facility","both","","","","5305","2652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Declot Vascular Access","73720010","CDM","761","RC","36593","HCPCS","facility","both","","","","1454","727","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Non-Tunneled Cvc<5Yr","73720012","CDM","761","RC","36555","HCPCS","facility","both","","","","3942","1971","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Non-Tunneled Cvc>=5Yr","73720013","CDM","761","RC","36556","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Test Tb Int Intradermal","73720014","CDM","300","RC","86580","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Draw-Implnt Venous Device","73720015","CDM","761","RC","36591","HCPCS","facility","both","","","","336","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Draw-Cvl/Pvl/Picc","73720016","CDM","761","RC","36592","HCPCS","facility","both","","","","336","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis-Sml Jnt W/O Us","73730789","CDM","761","RC","20600","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tunneled Cv 2X Cath W S","73730790","CDM","369","RC","36566","HCPCS","facility","both","","","","17044","8522","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Lmbr Spi Pnxr W/Fluor/Ct","73730791","CDM","369","RC","62328","HCPCS","facility","both","","","","3876","1938","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther Spi Pnxr Csf Fluor/Ct","73730792","CDM","369","RC","62329","HCPCS","facility","both","","","","3876","1938","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Nrv Nrvtg Si Jt","73730793","CDM","369","RC","64451","HCPCS","facility","both","","","","2318","1159","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Neuroelectrodes","73730794","CDM","761","RC","64561","HCPCS","facility","both","","","","20611","10305.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Gnclr Nrv Brnch","73730795","CDM","761","RC","64454","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Core Ndl Bx Lng/Med Perq","73730796","CDM","320","RC","32408","HCPCS","facility","both","","","","3903","1951.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Access Bil Tree Sm Bwl","73760130","CDM","761","RC","47541","HCPCS","facility","both","","","","9375","4687.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate Biliary Duct/Ampulla","73760131","CDM","761","RC","47542","HCPCS","facility","both","","","","921","460.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoluminal Bx Biliary Tree","73760132","CDM","761","RC","47543","HCPCS","facility","both","","","","2010","1005","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureteral Embolization/Occl","73760133","CDM","761","RC","50705","HCPCS","facility","both","","","","3028","1514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tun Ip Cath Perc","73760134","CDM","481","RC","49418","HCPCS","facility","both","","","","9957","4978.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Dilate Urtrl Strix","73760135","CDM","761","RC","50706","HCPCS","facility","both","","","","1359","679.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Pvb Thoracic Single Inj Site","73760136","CDM","761","RC","64461","HCPCS","facility","both","","","","2807","1403.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Pvb Thoracic 2Nd+ Inj Site","73760137","CDM","761","RC","64462","HCPCS","facility","both","","","","172","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Pvb Thoracic Cont Infusion","73760138","CDM","761","RC","64463","HCPCS","facility","both","","","","2807","1403.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Irrigate Implant Venous Device","73760139","CDM","761","RC","96523","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Perq Dev Soft Tiss 1St Imag","73760140","CDM","761","RC","10035","HCPCS","facility","both","","","","1999","999.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Perq Dev Soft Tiss Add Imag","73760141","CDM","761","RC","10036","HCPCS","facility","both","","","","798","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ir Myelography Lumbar S&I","73760146","CDM","320","RC","72265","HCPCS","facility","both","","","","3078","1539","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision Age=<28 Days","73760148","CDM","361","RC","54160","HCPCS","facility","both","","","","3021","1510.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instillation Chest Tube","73766500","CDM","360","RC","32561","HCPCS","facility","both","","","","2058","1029","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chest Tube Subq Day","73766501","CDM","761","RC","32562","HCPCS","facility","both","","","","2058","1029","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bil Endo W/ Stone Removal","73766502","CDM","761","RC","47554","HCPCS","facility","both","","","","5682","2841","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrvasc Us Noncoronary 1St","73766503","CDM","320","RC","37252","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrvasc Us Noncoronary Addl","73766504","CDM","320","RC","37253","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Cholangio Prq W/Img Gid Rs&I Existing Access","73766505","CDM","761","RC","47531","HCPCS","facility","both","","","","10411","5205.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Cholangiogram New Access","73766506","CDM","360","RC","47532","HCPCS","facility","both","","","","10411","5205.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Biliary Drainage Cath Ext","73766507","CDM","761","RC","47533","HCPCS","facility","both","","","","7169","3584.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Biliary Drain Cathint/Ext","73766508","CDM","761","RC","47534","HCPCS","facility","both","","","","7169","3584.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Plmt Bile Duct Exst Acces","73766509","CDM","490","RC","47538","HCPCS","facility","both","","","","15991","7995.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Plmt Bile New Ac W/O Cath","73766510","CDM","490","RC","47539","HCPCS","facility","both","","","","15737","7868.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Plmt Bile New Acc W/ Cath","73766511","CDM","490","RC","47540","HCPCS","facility","both","","","","15737","7868.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conversion Ext Bil Drg Cath","73766512","CDM","490","RC","47535","HCPCS","facility","both","","","","7595","3797.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exchange Biliary Drg Cath","73766513","CDM","761","RC","47536","HCPCS","facility","both","","","","7595","3797.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Duct Glbldr Calculi","73766514","CDM","490","RC","47544","HCPCS","facility","both","","","","6758","3379","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Nephrostomy Catheter","73766515","CDM","761","RC","50432","HCPCS","facility","both","","","","5257","2628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Ureteral Stnt Prq Ext Acc","73766516","CDM","761","RC","50693","HCPCS","facility","both","","","","8712","4356","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Ureteral Stnt Prq W/Ocath","73766517","CDM","490","RC","50694","HCPCS","facility","both","","","","8712","4356","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Ureteral Stnt Prq W/Cath","73766518","CDM","490","RC","50695","HCPCS","facility","both","","","","8712","4356","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Px Nfrosgrm &/Urtrgrm New","73766519","CDM","490","RC","50430","HCPCS","facility","both","","","","3288","1644","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Px Nfrosgrm &/Urtrgrm Exst","73766520","CDM","761","RC","50431","HCPCS","facility","both","","","","3288","1644","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exchange Nephrostomy Cath","73766521","CDM","761","RC","50435","HCPCS","facility","both","","","","4767","2383.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Nephroureteral Cath New A","73766522","CDM","320","RC","50433","HCPCS","facility","both","","","","4758","2379","","","","","","","","","","","","","Gross Charge Type: Standard"
"Convert Nephrostomy Catheter","73766523","CDM","320","RC","50434","HCPCS","facility","both","","","","4758","2379","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoluminal Bx Urtr Rnl Plvs","73766524","CDM","320","RC","50606","HCPCS","facility","both","","","","4758","2379","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Biliary Drg Cath","73766525","CDM","320","RC","47537","HCPCS","facility","both","","","","1551","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Retro Urethrocystography","73766700","CDM","320","RC","51610","HCPCS","facility","both","","","","2512","1256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foot Or Toe Procedure","73766714","CDM","360","RC","28899","HCPCS","facility","both","","","","2451","1225.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision Of Toe Tendon","73766715","CDM","360","RC","28232","HCPCS","facility","both","","","","4198","2099","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Les S/N/H/F/G; 0.5Cm/<","73766716","CDM","369","RC","11305","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion > 1Cm","73766717","CDM","369","RC","11306","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion 1.1-2.0 Cm","73766718","CDM","369","RC","11307","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shaving Lesion Over 2.0 Cm","73766719","CDM","369","RC","11308","HCPCS","facility","both","","","","634","317","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ir Sclerosing Node/Cyst/Tumor","73766731","CDM","360","RC","49203","HCPCS","facility","both","","","","18477","9238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Keratomileusis","73766751","CDM","360","RC","65760","HCPCS","facility","both","","","","1183","591.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rx Supfcl Wd Dehis-Simp","73766752","CDM","360","RC","12020","HCPCS","facility","both","","","","2150","1075","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abd Paracentesis","73766754","CDM","761","RC","49082","HCPCS","facility","both","","","","1999","999.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Us Guide Rf/Microwave Ablation","73766775","CDM","402","RC","76940","HCPCS","facility","both","","","","1120","560","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cath Dialysis Circuit","73766800","CDM","481","RC","36901","HCPCS","facility","both","","","","3471","1735.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cath Dialys Crct W/Angio","73766801","CDM","481","RC","36902","HCPCS","facility","both","","","","17381","8690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cth Dialys Crct Ang Stnt","73766802","CDM","481","RC","36903","HCPCS","facility","both","","","","35125","17562.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrmbc/Nfs Dialysis Circuit","73766803","CDM","481","RC","36904","HCPCS","facility","both","","","","17381","8690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrmbc/Nfs Dialysis Crct Angio","73766804","CDM","481","RC","36905","HCPCS","facility","both","","","","35125","17562.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrmb/Nfs Dial Crct Angio Stnt","73766805","CDM","481","RC","36906","HCPCS","facility","both","","","","53237","26618.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balo Angiop Ctr Dialysis Seg","73766806","CDM","481","RC","36907","HCPCS","facility","both","","","","6328","3164","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Balo Angiop 1St Vein","73766807","CDM","481","RC","37248","HCPCS","facility","both","","","","6749","3374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Balo Angiop Addl Vein","73766808","CDM","481","RC","37249","HCPCS","facility","both","","","","6749","3374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Interlaminar Crv/Thrc","73766811","CDM","761","RC","62320","HCPCS","facility","both","","","","3366","1683","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Interlaminar Lmbr/Sac","73766812","CDM","490","RC","62322","HCPCS","facility","both","","","","3876","1938","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Intrlmnr Crv/Thrc W/O Neur","73766813","CDM","761","RC","62324","HCPCS","facility","both","","","","3148","1574","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Intrlmnr Lmbr/Sac Cont Inf","73766814","CDM","490","RC","62326","HCPCS","facility","both","","","","3140","1570","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Mammo Bi Incl Cad","73766815","CDM","403","RC","77067","HCPCS","facility","both","","","","830","415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Interlaminar Crv/Thrc, Img","73766816","CDM","761","RC","62321","HCPCS","facility","both","","","","3876","1938","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Interlaminar Lmbr/Sac, Img","73766817","CDM","761","RC","62323","HCPCS","facility","both","","","","3370","1685","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Intrlam C/T W/O Neur, Img","73766818","CDM","490","RC","62325","HCPCS","facility","both","","","","3148","1574","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Intrlam L/S Cont Inf, Img","73766819","CDM","490","RC","62327","HCPCS","facility","both","","","","3148","1574","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application On-Body Injector","73766820","CDM","260","RC","96377","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endovenous Mchnchem 1St Vein","73766821","CDM","761","RC","36473","HCPCS","facility","both","","","","8473","4236.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endovenous Mchnchem Add-On","73766822","CDM","761","RC","36474","HCPCS","facility","both","","","","4238","2119","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Plmt Ctr Dialysis Seg","73766823","CDM","481","RC","36908","HCPCS","facility","both","","","","1739","869.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dialysis Circuit Emboli","73766824","CDM","481","RC","36909","HCPCS","facility","both","","","","1739","869.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx S Wnd Dehisc; Smpl","73766825","CDM","761","RC","12020","HCPCS","facility","both","","","","2150","1075","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablate Bone Tumor(S) Perq","73766827","CDM","360","RC","20983","HCPCS","facility","both","","","","18476","9238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Lesion Cornea Not Ptery","73766828","CDM","360","RC","65400","HCPCS","facility","both","","","","3810","1905","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate Salivary Gland","73766829","CDM","360","RC","42650","HCPCS","facility","both","","","","5466","2733","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr A-Ao Ndgft","73766831","CDM","360","RC","34701","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr A-Ao Ndgft Rpt","73766832","CDM","360","RC","34702","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr A-Unilac Ndgft","73766833","CDM","360","RC","34703","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr A-Unilac Ndgft Rpt","73766834","CDM","360","RC","34704","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evac Rpr A-Biiliac Ndgft","73766835","CDM","360","RC","34705","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr A-Biiliac Rpt","73766836","CDM","360","RC","34706","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr Ilio-Iliac Ndgft","73766837","CDM","360","RC","34707","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr Ilio-Iliac Rpt","73766838","CDM","360","RC","34708","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Xtn Prosth Evasc Rpr","73766839","CDM","360","RC","34709","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dlyd Plmt Xtn Prosth 1St Vsl","73766840","CDM","360","RC","34710","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dlyd Plmt Xtn Prosth Ea Addl","73766841","CDM","360","RC","34711","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Bone Marrow Biopsies & Aspirations","73766843","CDM","761","RC","38222","HCPCS","facility","both","","","","5494","2747","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Fb W/Slit Lamp","73766848","CDM","510","RC","65222","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prob Nasolacrimal Duct Irrigat","73766849","CDM","510","RC","68810","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert/Repl Neurostimulator","73766850","CDM","761","RC","61885","HCPCS","facility","both","","","","32343","16171.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Shoulder","73766851","CDM","369","RC","23929","HCPCS","facility","both","","","","693","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Trunk/Arm/Leg 0.5 Cm/<","73766854","CDM","761","RC","11300","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion 0.6Cm-1.0Cm","73766855","CDM","761","RC","11301","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Stent Via Transur","73766856","CDM","761","RC","50385","HCPCS","facility","both","","","","6403","3201.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystourethroscopy Insrtd Stent","73766860","CDM","761","RC","52332","HCPCS","facility","both","","","","8569","4284.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Us Gdn 1St Les","73766862","CDM","761","RC","10005","HCPCS","facility","both","","","","1977","988.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Us Gdn Ea Addl","73766863","CDM","369","RC","10006","HCPCS","facility","both","","","","1977","988.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Fluor Gdn 1St Les","73766864","CDM","369","RC","10007","HCPCS","facility","both","","","","2177","1088.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Ct Gdn 1St Les","73766866","CDM","369","RC","10009","HCPCS","facility","both","","","","2394","1197","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Ct Gdn Ea Addl","73766867","CDM","369","RC","10010","HCPCS","facility","both","","","","1276","638","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Single Les","73766870","CDM","761","RC","11102","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","73766871","CDM","761","RC","11104","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Single Les","73766872","CDM","761","RC","11106","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rplc Gtube No Revj Trc","73766875","CDM","369","RC","43762","HCPCS","facility","both","","","","1934","967","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rplc Gtube Revj Gstrst Trc","73766876","CDM","369","RC","43763","HCPCS","facility","both","","","","2128","1064","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Xst Trc Ndurlgc Px","73766877","CDM","490","RC","50436","HCPCS","facility","both","","","","7474","3737","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Xst Trc New Access Rcs","73766878","CDM","490","RC","50437","HCPCS","facility","both","","","","8222","4111","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Of Bladder Tube","73766879","CDM","761","RC","51710","HCPCS","facility","both","","","","3054","1527","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ipack Nerve Block","73766880","CDM","761","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Picc >=5Yrs Incl Imaging","73766881","CDM","761","RC","36573","HCPCS","facility","both","","","","6111","3055.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Picc <5Yrs Incl Imaging","73766882","CDM","761","RC","36572","HCPCS","facility","both","","","","5958","2979","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Cntrst Kne Arthg/Ct/Mri","73766883","CDM","369","RC","27369","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo Reposition Peripher Cnula","73766884","CDM","369","RC","33962","HCPCS","facility","both","","","","4141","2070.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision > 28 Days","73766886","CDM","361","RC","54161","HCPCS","facility","both","","","","3200","1600","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluid Pressure Muscle","73766887","CDM","361","RC","20950","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlstd Proc Hemic Or Lymphatic","73766888","CDM","761","RC","38999","HCPCS","facility","both","","","","1344","672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Sclrsnt 1 Incmptnt Vein","73766889","CDM","761","RC","36470","HCPCS","facility","both","","","","1228","614","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disruption Of Fibrin Sheath","73766890","CDM","490","RC","37799","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Lesion Dentoalveolar","73766891","CDM","761","RC","41800","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blind Interatrial Shunt Ide","73766892","CDM","369","RC","C9758","HCPCS","facility","both","","","","56113","28056.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection/Subc/Im","73801802","CDM","920","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","73810","CDM","278","RC","C1776","HCPCS","facility","both","","","","4601.95","2300.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bladder Chemo","73810008","CDM","369","RC","51720","HCPCS","facility","both","","","","2136","1068","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therapeutic Phlebotomy","73810009","CDM","949","RC","99195","HCPCS","facility","both","","","","784","392","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv Infusion Ea Addl Hour","73810015","CDM","335","RC","96415","HCPCS","facility","both","","","","505","252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Sq/Im-Non-Horm","73810022","CDM","331","RC","96401","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Sq/Im-Horm","73810023","CDM","331","RC","96402","HCPCS","facility","both","","","","451","225.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Ivp Initial","73810024","CDM","335","RC","96409","HCPCS","facility","both","","","","896","448","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Ivp-Ea. Add","73810025","CDM","335","RC","96411","HCPCS","facility","both","","","","538","269","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv Initial 1 Hr.","73810026","CDM","335","RC","96413","HCPCS","facility","both","","","","1475","737.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv Infusion Ea Addl Hour","73810027","CDM","335","RC","96415","HCPCS","facility","both","","","","505","252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv Inf Proglong","73810028","CDM","335","RC","96416","HCPCS","facility","both","","","","2430","1215","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv Inf Ea Sequ Hr","73810029","CDM","335","RC","96417","HCPCS","facility","both","","","","1049","524.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Sq/Im","73810030","CDM","260","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Ivp Initial","73810031","CDM","260","RC","96374","HCPCS","facility","both","","","","542","271","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Ivp Ea Add. Drug","73810032","CDM","260","RC","96375","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hydration Iv Initial Hr","73810033","CDM","260","RC","96360","HCPCS","facility","both","","","","672","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hydration Inf Ea Ad Hr","73810034","CDM","260","RC","96361","HCPCS","facility","both","","","","323","161.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Iv Inf Hr","73810035","CDM","260","RC","96365","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Iv Ea Add Hr-To 8","73810036","CDM","260","RC","96366","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Iv Inf Ea Sequ","73810037","CDM","260","RC","96367","HCPCS","facility","both","","","","371","185.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Iv Inf-Concu","73810038","CDM","260","RC","96368","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Draw-Implanted Port","73810043","CDM","300","RC","36591","HCPCS","facility","both","","","","336","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non Chem Ivp Seq Same Dr","73810050","CDM","260","RC","96376","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Casirivi And Imdevi Infusion","73810057","CDM","771","RC","M0243","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bamlan And Etesev Infusion","73810058","CDM","771","RC","M0245","HCPCS","facility","both","","","","582","291","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sotrovimab Infusion","73810059","CDM","771","RC","M0247","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Casiri And Imdev Repeat","73810061","CDM","771","RC","M0240","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iv Peripheral Start Only","73810062","CDM","260","RC","36000","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adm Tocilizu Covid-19 1St","73810063","CDM","771","RC","M0249","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adm Tocilizu Covid-19 2Nd","73810064","CDM","771","RC","M0250","HCPCS","facility","both","","","","450","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tixagev And Cilgav Inj Hm","73810068","CDM","771","RC","M0221","HCPCS","facility","both","","","","250.5","125.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tixagev And Cilgav Inj","73810069","CDM","771","RC","M0220","HCPCS","facility","both","","","","150.5","75.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Inj Sq/Im(Horm Anti)","73810075","CDM","331","RC","96402","HCPCS","facility","both","","","","451","225.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Inj Sq/Im(Non-Horm Anti)","73810076","CDM","331","RC","96401","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sc Non-Chemo Infusn Up To 1Hr","73810080","CDM","260","RC","96369","HCPCS","facility","both","","","","732","366","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sc Non-Chemo Infusn Ea Addl Hr","73810081","CDM","260","RC","96370","HCPCS","facility","both","","","","214","107","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Sc Non-Chemo Infusn Reset Pump","73810082","CDM","260","RC","96371","HCPCS","facility","both","","","","402","201","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Capillary Blood Draw","73810100","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Blood Draw-Cvl/Pvl/Picc","73810101","CDM","761","RC","36592","HCPCS","facility","both","","","","336","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastric Intubtn W/Aspiratn","73810102","CDM","761","RC","43753","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Insert Bladder Straight Cath","73810103","CDM","761","RC","51701","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Insert Bladder Cath,Complex","73810104","CDM","761","RC","51703","HCPCS","facility","both","","","","468","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Us Urine Capacity Measure","73810105","CDM","761","RC","51798","HCPCS","facility","both","","","","362","181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Catheterize For Urine Specimen","73810106","CDM","761","RC","P9612","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Peritoneal Dialysis Op;Per Day","73810107","CDM","830","RC","90945","HCPCS","facility","both","","","","1028","514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv Inf Concur-1X Per Day","73810108","CDM","335","RC","96549","HCPCS","facility","both","","","","791","395.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cadd Non-Chemo Infusion","73810115","CDM","261","RC","C8957","HCPCS","facility","both","","","","973","486.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cisternogram","74000002","CDM","320","RC","70015","HCPCS","facility","both","","","","2435","1217.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Orbits Ltd","74000003","CDM","320","RC","70030","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mandible Ltd","74000004","CDM","320","RC","70100","HCPCS","facility","both","","","","387","193.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mandible Complete","74000005","CDM","320","RC","70110","HCPCS","facility","both","","","","822","411","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mastoids Complete","74000007","CDM","320","RC","70130","HCPCS","facility","both","","","","599","299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Facial Bones Ltd","74000009","CDM","320","RC","70140","HCPCS","facility","both","","","","629","314.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Facial Bones Complete","74000010","CDM","320","RC","70150","HCPCS","facility","both","","","","1068","534","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Nasal Bones","74000011","CDM","320","RC","70160","HCPCS","facility","both","","","","596","298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Dacrocystogram","74000012","CDM","320","RC","70170","HCPCS","facility","both","","","","735","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Orbits Complete","74000014","CDM","320","RC","70200","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sinuses Ltd","74000015","CDM","320","RC","70210","HCPCS","facility","both","","","","953","476.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sinuses Complete","74000016","CDM","320","RC","70220","HCPCS","facility","both","","","","1607","803.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sella Turcica","74000017","CDM","320","RC","70240","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Skull Ltd","74000018","CDM","320","RC","70250","HCPCS","facility","both","","","","1058","529","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Skull Complete","74000019","CDM","320","RC","70260","HCPCS","facility","both","","","","1409","704.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Teeth Single","74000020","CDM","320","RC","70300","HCPCS","facility","both","","","","148","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Teeth Complete","74000021","CDM","320","RC","70320","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tmj Bilat","74000023","CDM","320","RC","70330","HCPCS","facility","both","","","","731","365.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Tmj","74000025","CDM","614","RC","70336","HCPCS","facility","both","","","","4545","2272.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cephlometrogram","74000026","CDM","320","RC","70350","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Panorex","74000027","CDM","320","RC","70355","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-St Neck","74000028","CDM","320","RC","70360","HCPCS","facility","both","","","","877","438.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sialogram","74000033","CDM","320","RC","70390","HCPCS","facility","both","","","","1257","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head Region W/O Contrast","74000034","CDM","351","RC","70450","HCPCS","facility","both","","","","2656","1328","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tmj Open/Closed","74000035","CDM","320","RC","70328","HCPCS","facility","both","","","","683","341.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head W/Wo Contrast","74000036","CDM","351","RC","70470","HCPCS","facility","both","","","","3511","1755.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head Region W/O Contrast","74000037","CDM","350","RC","70480","HCPCS","facility","both","","","","2720","1360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head Region W/ Contrast","74000038","CDM","351","RC","70481","HCPCS","facility","both","","","","3241","1620.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head Region W/Wo Contrast","74000039","CDM","351","RC","70482","HCPCS","facility","both","","","","3726","1863","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Facial W/O Contrast","74000040","CDM","350","RC","70486","HCPCS","facility","both","","","","2719","1359.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Facial W/ Contrast","74000041","CDM","350","RC","70487","HCPCS","facility","both","","","","3125","1562.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Facial W/Wo Contrast","74000042","CDM","350","RC","70488","HCPCS","facility","both","","","","3593","1796.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct St Neck W/O Contrast","74000043","CDM","350","RC","70490","HCPCS","facility","both","","","","1285","642.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct St Neck W/Contrast","74000044","CDM","350","RC","70491","HCPCS","facility","both","","","","3356","1678","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct St Neck W/Wo Contrast","74000045","CDM","350","RC","70492","HCPCS","facility","both","","","","3880","1940","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Orbits W/O Contrast","74000046","CDM","614","RC","70540","HCPCS","facility","both","","","","4934","2467","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Face, Orbit, Head, Neck W/O Contrast","74000047","CDM","614","RC","70551","HCPCS","facility","both","","","","3865","1932.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Face W/ Contrast","74000048","CDM","614","RC","70552","HCPCS","facility","both","","","","5097","2548.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Head W/Wo Contrast","74000049","CDM","614","RC","70553","HCPCS","facility","both","","","","7331","3665.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Fluoroscopy Exam Charge","74000060","CDM","320","RC","77002","HCPCS","facility","both","","","","1371","685.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ribs Unilateral","74000063","CDM","320","RC","71100","HCPCS","facility","both","","","","673","336.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ribs Unilat W/ Pa Cxr","74000064","CDM","320","RC","71101","HCPCS","facility","both","","","","893","446.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ribs Bilat","74000065","CDM","320","RC","71110","HCPCS","facility","both","","","","1225","612.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ribs Bilat W / Pa Cxr","74000066","CDM","320","RC","71111","HCPCS","facility","both","","","","1410","705","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sternum","74000067","CDM","320","RC","71120","HCPCS","facility","both","","","","694","347","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sternoclavicular Joints","74000068","CDM","320","RC","71130","HCPCS","facility","both","","","","799","399.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Chest Wo Contrast","74000069","CDM","350","RC","71250","HCPCS","facility","both","","","","2745","1372.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Chest W/ Contrast","74000070","CDM","352","RC","71260","HCPCS","facility","both","","","","3559","1779.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Chest W/Wo Contrast","74000071","CDM","350","RC","71270","HCPCS","facility","both","","","","3894","1947","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Chest W/O Contrast","74000072","CDM","614","RC","71550","HCPCS","facility","both","","","","3636","1818","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Spine One View","74000074","CDM","320","RC","72020","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cspine Ltd","74000075","CDM","320","RC","72040","HCPCS","facility","both","","","","804","402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cspine Complete","74000076","CDM","320","RC","72050","HCPCS","facility","both","","","","888","444","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cspine Com With Flex/Ext","74000077","CDM","320","RC","72052","HCPCS","facility","both","","","","1195","597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tspine 2 Views","74000079","CDM","320","RC","72070","HCPCS","facility","both","","","","725","362.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tspine Comp","74000080","CDM","320","RC","72072","HCPCS","facility","both","","","","721","360.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thoracolumbar Spine 2 Views","74000081","CDM","320","RC","72080","HCPCS","facility","both","","","","960","480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lspine 2 Views","74000083","CDM","320","RC","72100","HCPCS","facility","both","","","","733","366.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lspine Comp","74000084","CDM","320","RC","72110","HCPCS","facility","both","","","","1056","528","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lspine Comp W/Bend Or Ext","74000085","CDM","320","RC","72114","HCPCS","facility","both","","","","1559","779.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lspine 2 View With Flex/Ext","74000086","CDM","320","RC","72120","HCPCS","facility","both","","","","1141","570.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cervical Spine W / O Contrast","74000087","CDM","350","RC","72125","HCPCS","facility","both","","","","3200","1600","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cervical Spine W / Contrast","74000088","CDM","350","RC","72126","HCPCS","facility","both","","","","3678","1839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cervical Spine W / Wo Contrast","74000089","CDM","350","RC","72127","HCPCS","facility","both","","","","4227","2113.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Thoracic Spine W / O Contrast","74000090","CDM","350","RC","72128","HCPCS","facility","both","","","","3217","1608.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Thoracic Spine W / Contrast","74000091","CDM","350","RC","72129","HCPCS","facility","both","","","","3724","1862","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Thoracic Spine W / Wo Contrast","74000092","CDM","350","RC","72130","HCPCS","facility","both","","","","4280","2140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Lumbar Spine W / O Contrast","74000093","CDM","350","RC","72131","HCPCS","facility","both","","","","3217","1608.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Lumbar Spine W / Contrast","74000094","CDM","350","RC","72132","HCPCS","facility","both","","","","3724","1862","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Lumbar Spine W / Wo Contrast","74000095","CDM","350","RC","72133","HCPCS","facility","both","","","","4280","2140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Cervical Spine W / O Contrast","74000096","CDM","612","RC","72141","HCPCS","facility","both","","","","4000","2000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Cervical Spine W / Contrast","74000097","CDM","612","RC","72142","HCPCS","facility","both","","","","5273","2636.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Thoracic Spine W / O Contrast","74000098","CDM","612","RC","72146","HCPCS","facility","both","","","","4000","2000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Thoracic Spine W / Contrast","74000099","CDM","612","RC","72147","HCPCS","facility","both","","","","5288","2644","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Lumbar Spine W / O Contrast","74000100","CDM","612","RC","72148","HCPCS","facility","both","","","","4000","2000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Lumbar Spine W / Contrast","74000101","CDM","612","RC","72149","HCPCS","facility","both","","","","5288","2644","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Cervical Spine W / Wo Contrast","74000102","CDM","612","RC","72156","HCPCS","facility","both","","","","6545","3272.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Thoracic Spine W / Wo Contrast","74000103","CDM","612","RC","72157","HCPCS","facility","both","","","","6631","3315.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Lumbar Spine W / Wo Contrast","74000104","CDM","612","RC","72158","HCPCS","facility","both","","","","6631","3315.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pelvis","74000105","CDM","320","RC","72170","HCPCS","facility","both","","","","656","328","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pelvis Views","74000106","CDM","320","RC","72190","HCPCS","facility","both","","","","868","434","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Pelvis W / O Contrast","74000107","CDM","352","RC","72192","HCPCS","facility","both","","","","2948","1474","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Pelvis W / Contrast","74000108","CDM","352","RC","72193","HCPCS","facility","both","","","","3388","1694","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Pelvis W / Wo Contrast","74000109","CDM","352","RC","72194","HCPCS","facility","both","","","","3507","1753.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Pelvis W / Contrast","74000110","CDM","614","RC","72196","HCPCS","facility","both","","","","5782","2891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Si Joints","74000112","CDM","320","RC","72202","HCPCS","facility","both","","","","841","420.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sacrum/Coccyx","74000113","CDM","320","RC","72220","HCPCS","facility","both","","","","839","419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Discogram Cervical","74000118","CDM","320","RC","72285","HCPCS","facility","both","","","","3978","1989","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Diskogram Lumbar Spine","74000119","CDM","320","RC","72295","HCPCS","facility","both","","","","4179","2089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Clavicle","74000120","CDM","320","RC","73000","HCPCS","facility","both","","","","593","296.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Scapula","74000121","CDM","320","RC","73010","HCPCS","facility","both","","","","776","388","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Shoulder Ltd","74000122","CDM","320","RC","73020","HCPCS","facility","both","","","","445","222.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Shoulder Comp","74000123","CDM","320","RC","73030","HCPCS","facility","both","","","","638","319","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrogram Shoulder","74000124","CDM","320","RC","73040","HCPCS","facility","both","","","","1834","917","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ac Joints","74000125","CDM","320","RC","73050","HCPCS","facility","both","","","","617","308.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Humerus","74000126","CDM","320","RC","73060","HCPCS","facility","both","","","","674","337","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Elbow Ltd","74000127","CDM","320","RC","73070","HCPCS","facility","both","","","","537","268.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Elbow Comp","74000128","CDM","320","RC","73080","HCPCS","facility","both","","","","902","451","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrogram Elbow","74000129","CDM","320","RC","73085","HCPCS","facility","both","","","","1596","798","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Forearm","74000130","CDM","320","RC","73090","HCPCS","facility","both","","","","659","329.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Upper Ext Infant < 1Year Old","74000131","CDM","320","RC","73092","HCPCS","facility","both","","","","326","163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wrist Ltd","74000132","CDM","320","RC","73100","HCPCS","facility","both","","","","509","254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wrist Comp","74000133","CDM","320","RC","73110","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrogram Wrist","74000134","CDM","320","RC","73115","HCPCS","facility","both","","","","2072","1036","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hand Ltd","74000135","CDM","320","RC","73120","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hand Comp","74000136","CDM","320","RC","73130","HCPCS","facility","both","","","","563","281.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Fingers","74000137","CDM","320","RC","73140","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Ue Bilat W/O Contrast","74000138","CDM","350","RC","73200","HCPCS","facility","both","","","","2592","1296","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Ue Bilat W/ Contrast","74000139","CDM","350","RC","73201","HCPCS","facility","both","","","","3000","1500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Ue Bilat W/Wo Contrast","74000140","CDM","352","RC","73202","HCPCS","facility","both","","","","3447","1723.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Ue Unilat W/Wo Contrast","74000141","CDM","614","RC","73220","HCPCS","facility","both","","","","5078","2539","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Ue  Unilat W/Joint W/O Contrast","74000142","CDM","614","RC","73221","HCPCS","facility","both","","","","3865","1932.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrogram Hip","74000146","CDM","320","RC","73525","HCPCS","facility","both","","","","1596","798","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Knee Ltd","74000150","CDM","320","RC","73560","HCPCS","facility","both","","","","524","262","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Knee 3 Views","74000151","CDM","320","RC","73562","HCPCS","facility","both","","","","670","335","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Knee 4 Views","74000152","CDM","320","RC","73564","HCPCS","facility","both","","","","869","434.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrogram Knee","74000153","CDM","320","RC","73580","HCPCS","facility","both","","","","1581","790.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tibia Fibula","74000154","CDM","320","RC","73590","HCPCS","facility","both","","","","622","311","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lower Ext Infant","74000155","CDM","320","RC","73592","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ankle Ltd","74000156","CDM","320","RC","73600","HCPCS","facility","both","","","","538","269","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ankle Comp","74000157","CDM","320","RC","73610","HCPCS","facility","both","","","","631","315.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ankle Arthrogra","74000158","CDM","320","RC","73615","HCPCS","facility","both","","","","1581","790.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Foot Ltd","74000159","CDM","320","RC","73620","HCPCS","facility","both","","","","592","296","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Foot Comp","74000160","CDM","320","RC","73630","HCPCS","facility","both","","","","633","316.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Heel","74000161","CDM","320","RC","73650","HCPCS","facility","both","","","","560","280","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Toes","74000162","CDM","320","RC","73660","HCPCS","facility","both","","","","502","251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Le Bilat W/O Contrast","74000163","CDM","350","RC","73700","HCPCS","facility","both","","","","2592","1296","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Le Bilat W/ Contrast","74000164","CDM","350","RC","73701","HCPCS","facility","both","","","","3000","1500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Le Bilat W/Wo Contrast","74000165","CDM","350","RC","73702","HCPCS","facility","both","","","","3447","1723.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Le Unilat W/Wo Contrast","74000166","CDM","614","RC","73720","HCPCS","facility","both","","","","5880","2940","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Lower Ext W/O Contrast","74000167","CDM","614","RC","73721","HCPCS","facility","both","","","","3865","1932.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Abdomen Flat / Upright W / Pa Cxr","74000171","CDM","320","RC","74022","HCPCS","facility","both","","","","989","494.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abdomen W / O Contrast","74000172","CDM","352","RC","74150","HCPCS","facility","both","","","","2855","1427.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abdomen W / Contrast","74000173","CDM","350","RC","74160","HCPCS","facility","both","","","","3285","1642.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abdomen W/Wo Contrast","74000174","CDM","350","RC","74170","HCPCS","facility","both","","","","3781","1890.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Abdomen W/O Contrast","74000175","CDM","614","RC","74181","HCPCS","facility","both","","","","3251","1625.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Barium Swallow","74000177","CDM","320","RC","74220","HCPCS","facility","both","","","","1175","587.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Barium Swallow Video","74000178","CDM","320","RC","74230","HCPCS","facility","both","","","","972","486","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Xm Upr Gi Trc 1Cntrst","74000179","CDM","320","RC","74240","HCPCS","facility","both","","","","1705","852.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr X-Ray Xm Upr Gi Trc 2Cntrst","74000182","CDM","320","RC","74246","HCPCS","facility","both","","","","1705","852.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Small Bowel Series","74000185","CDM","320","RC","74250","HCPCS","facility","both","","","","1577","788.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Barium Enema","74000187","CDM","320","RC","74270","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Barium Enema W / Air Contrast","74000188","CDM","320","RC","74280","HCPCS","facility","both","","","","2241","1120.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Or Cholangiogram Intraop","74000191","CDM","320","RC","74300","HCPCS","facility","both","","","","1924","962","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholangiogram Or Addl Vw","74000192","CDM","320","RC","74301","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ercp Biliary System","74000196","CDM","320","RC","74328","HCPCS","facility","both","","","","1889","944.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ercp Pancreatic System","74000197","CDM","320","RC","74329","HCPCS","facility","both","","","","1889","944.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ercp Biliary And Pancreas","74000198","CDM","320","RC","74330","HCPCS","facility","both","","","","1889","944.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Gastrointestinal Tube","74000199","CDM","320","RC","74340","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Enteroclysis","74000201","CDM","320","RC","74251","HCPCS","facility","both","","","","2234","1117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Perc Transhepatic Dil Biliary","74000202","CDM","320","RC","74363","HCPCS","facility","both","","","","1521","760.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ivp","74000203","CDM","320","RC","74400","HCPCS","facility","both","","","","2397","1198.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ivp W / Tomograms","74000206","CDM","320","RC","74415","HCPCS","facility","both","","","","2700","1350","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Urography Retrograde","74000207","CDM","320","RC","74420","HCPCS","facility","both","","","","1930","965","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Nephrostogram","74000208","CDM","320","RC","74425","HCPCS","facility","both","","","","1036","518","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cystogram","74000209","CDM","320","RC","74430","HCPCS","facility","both","","","","1308","654","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Vasogram","74000210","CDM","320","RC","74440","HCPCS","facility","both","","","","1207","603.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Urethrocystogram Retro","74000212","CDM","320","RC","74450","HCPCS","facility","both","","","","1027","513.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Voiding Cystogram","74000213","CDM","320","RC","74455","HCPCS","facility","both","","","","1027","513.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Renal Cyst Study","74000214","CDM","320","RC","74470","HCPCS","facility","both","","","","756","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilation Of Ureters(S)","74000217","CDM","320","RC","74485","HCPCS","facility","both","","","","4591","2295.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hysterosalopingogram","74000219","CDM","320","RC","74740","HCPCS","facility","both","","","","1651","825.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aortography Thoracic","74000222","CDM","320","RC","75600","HCPCS","facility","both","","","","5878","2939","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aortogram Thor Serial","74000223","CDM","320","RC","75605","HCPCS","facility","both","","","","6102","3051","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aortogram Abdomen Serial","74000224","CDM","320","RC","75625","HCPCS","facility","both","","","","5878","2939","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aortagram Abdomen W/ Runoff","74000225","CDM","320","RC","75630","HCPCS","facility","both","","","","5878","2939","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Spinal Sel","74000235","CDM","320","RC","75705","HCPCS","facility","both","","","","6102","3051","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Extr Bilat","74000237","CDM","320","RC","75716","HCPCS","facility","both","","","","5811","2905.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Visc Sel W/Or W/O Fl","74000240","CDM","320","RC","75726","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Adrenal Unilat","74000241","CDM","320","RC","75731","HCPCS","facility","both","","","","5597","2798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Pelvic,Sel Or Supras","74000243","CDM","320","RC","75736","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Pulmonary Unilat","74000244","CDM","320","RC","75741","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Pulmonary Bilat","74000245","CDM","320","RC","75743","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Internal Mammary","74000246","CDM","320","RC","75756","HCPCS","facility","both","","","","3472","1736","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Select Addl","74000247","CDM","320","RC","75774","HCPCS","facility","both","","","","3250","1625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lymphangiogram Extr Unilat","74000249","CDM","320","RC","75801","HCPCS","facility","both","","","","2192","1096","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Lymphangiogram Extremity Bilateral","74000250","CDM","320","RC","75803","HCPCS","facility","both","","","","2192","1096","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Lymphangiogram Abd / Pel Bilateral","74000252","CDM","320","RC","75807","HCPCS","facility","both","","","","3565","1782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Splenoportogram Procedure","74000253","CDM","320","RC","75810","HCPCS","facility","both","","","","5597","2798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Extremity Unilate","74000254","CDM","320","RC","75820","HCPCS","facility","both","","","","2776","1388","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Extremity Bilater","74000255","CDM","320","RC","75822","HCPCS","facility","both","","","","4159","2079.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Angio Venous Ivc","74000256","CDM","320","RC","75825","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Venogram Caval Super","74000257","CDM","320","RC","75827","HCPCS","facility","both","","","","3472","1736","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Renal Unilateral","74000258","CDM","320","RC","75831","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Renal Bilateral","74000259","CDM","320","RC","75833","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venogram Adrenal Unilat","74000260","CDM","320","RC","75840","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venogram Adrenal Bilat","74000261","CDM","320","RC","75842","HCPCS","facility","both","","","","9797","4898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Sinus Or Jugular","74000262","CDM","320","RC","75860","HCPCS","facility","both","","","","3565","1782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venogram Orbital","74000264","CDM","320","RC","75880","HCPCS","facility","both","","","","4855","2427.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Trns Hep Port/Hemodymeva","74000265","CDM","320","RC","75885","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Hepatic Veno W / Pressure","74000266","CDM","320","RC","75889","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venous Sampling W/ Catheter","74000267","CDM","320","RC","75893","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolization Trans Catheter","74000268","CDM","320","RC","75894","HCPCS","facility","both","","","","8216","4108","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromboly,Angio Fol-Up Exis Ca","74000270","CDM","320","RC","75898","HCPCS","facility","both","","","","3239","1619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcath Biopsy","74000278","CDM","320","RC","75970","HCPCS","facility","both","","","","3830","1915","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Change/Exchange Gi/Gu Tube","74000282","CDM","320","RC","75984","HCPCS","facility","both","","","","1000","500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Fluoroscopy < 1Hour","74000284","CDM","320","RC","76000","HCPCS","facility","both","","","","1896","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Foreign Body Single View Child","74000287","CDM","320","RC","76010","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Age Study","74000288","CDM","320","RC","77072","HCPCS","facility","both","","","","183","91.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Length Study","74000289","CDM","320","RC","77073","HCPCS","facility","both","","","","260","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Survey Limited","74000290","CDM","320","RC","77074","HCPCS","facility","both","","","","1524","762","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Survey Complete","74000291","CDM","320","RC","77075","HCPCS","facility","both","","","","1794","897","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Survey Infant","74000292","CDM","320","RC","77076","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fistula Or Sinus Tract","74000294","CDM","320","RC","76080","HCPCS","facility","both","","","","653","326.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo Ductogram Single","74000295","CDM","320","RC","77053","HCPCS","facility","both","","","","905","452.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo Ductogram Multiple","74000296","CDM","320","RC","77054","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo Breast Biopsy Specimen","74000301","CDM","320","RC","76098","HCPCS","facility","both","","","","1220","610","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tomogram","74000302","CDM","320","RC","76100","HCPCS","facility","both","","","","309","154.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Guided Stero Localization","74000306","CDM","350","RC","77011","HCPCS","facility","both","","","","2790","1395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Asp, Bx Or Ad Exam","74000307","CDM","350","RC","77012","HCPCS","facility","both","","","","2790","1395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Treatment Planning","74000309","CDM","350","RC","77014","HCPCS","facility","both","","","","880","440","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct 3D Recon At Scanner","74000310","CDM","350","RC","76376","HCPCS","facility","both","","","","1402","701","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Limited / Localized Follow Up","74000311","CDM","350","RC","76380","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Unlisted Procedure","74000313","CDM","614","RC","76498","HCPCS","facility","both","","","","2326","1163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Sector Brain","74000314","CDM","402","RC","76506","HCPCS","facility","both","","","","1543","771.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Unlisted Procedure","74000316","CDM","402","RC","76999","HCPCS","facility","both","","","","238","119","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us To Localize Fb In Eye","74000318","CDM","402","RC","76529","HCPCS","facility","both","","","","495","247.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Thyroid/Soft Tissu","74000319","CDM","402","RC","76536","HCPCS","facility","both","","","","1177","588.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Chest","74000320","CDM","402","RC","76604","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Abdomen Complete","74000322","CDM","402","RC","76700","HCPCS","facility","both","","","","1737","868.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Abdomen Limited","74000323","CDM","402","RC","76705","HCPCS","facility","both","","","","1445","722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Retroperitoneal","74000324","CDM","402","RC","76770","HCPCS","facility","both","","","","1517","758.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Retroperitoneal Limited","74000325","CDM","402","RC","76775","HCPCS","facility","both","","","","1118","559","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Kidney Transplant","74000326","CDM","402","RC","76776","HCPCS","facility","both","","","","1191","595.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Spinal Canal","74000327","CDM","402","RC","76800","HCPCS","facility","both","","","","1092","546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob Complete >=14 Wks","74000328","CDM","402","RC","76805","HCPCS","facility","both","","","","1209","604.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob Comp Ea Add'l Gestation >=14 Wks","74000329","CDM","402","RC","76810","HCPCS","facility","both","","","","1725","862.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob Limited","74000330","CDM","402","RC","76815","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Transvaginal","74000331","CDM","402","RC","76830","HCPCS","facility","both","","","","1167","583.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Pelvic Non-Ob","74000332","CDM","402","RC","76856","HCPCS","facility","both","","","","1474","737","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Pelvis Nonob Limited","74000333","CDM","402","RC","76857","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Testicular Inc. Doppler","74000334","CDM","402","RC","76870","HCPCS","facility","both","","","","1417","708.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Transrectal","74000335","CDM","402","RC","76872","HCPCS","facility","both","","","","1324","662","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Para Or Thoracentesis Charge","74000338","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Guide Needle Placement","74000340","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Guided Amniocentesis","74000341","CDM","402","RC","76946","HCPCS","facility","both","","","","1682","841","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Guide Intraoperative","74000343","CDM","402","RC","76998","HCPCS","facility","both","","","","1789","894.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thyroiduptake Single","74000345","CDM","341","RC","78012","HCPCS","facility","both","","","","694","347","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thyroid Scan With Uptake Single","74000348","CDM","341","RC","78014","HCPCS","facility","both","","","","2182","1091","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thyroid Scan W / Multiple Uptakes","74000349","CDM","341","RC","78014","HCPCS","facility","both","","","","2182","1091","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thyroid Imaging","74000350","CDM","341","RC","78013","HCPCS","facility","both","","","","1147","573.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thyroid Mets Neck Chest","74000351","CDM","341","RC","78015","HCPCS","facility","both","","","","1520","760","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thyroid Mets Whole Body","74000353","CDM","341","RC","78018","HCPCS","facility","both","","","","3494","1747","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Parathyroid Scan","74000354","CDM","341","RC","78070","HCPCS","facility","both","","","","2738","1369","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Adrenal Tumor Loc","74000355","CDM","341","RC","78075","HCPCS","facility","both","","","","2523","1261.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Marrow Scan Limited","74000357","CDM","341","RC","78102","HCPCS","facility","both","","","","1622","811","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Marrow Scan Multi","74000358","CDM","341","RC","78103","HCPCS","facility","both","","","","1868","934","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Marrow Scan Whole Body","74000359","CDM","341","RC","78104","HCPCS","facility","both","","","","2331","1165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Spleen Scan W / Wo Flow","74000363","CDM","341","RC","78185","HCPCS","facility","both","","","","1358","679","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lymphatics + Lymph Glands","74000366","CDM","341","RC","78195","HCPCS","facility","both","","","","2785","1392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Liver Scan Static Only","74000367","CDM","341","RC","78201","HCPCS","facility","both","","","","2286","1143","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Liver / Spleen Scan","74000370","CDM","341","RC","78215","HCPCS","facility","both","","","","2246","1123","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Liver / Spleen Scan W / Flow","74000371","CDM","341","RC","78216","HCPCS","facility","both","","","","2416","1208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hepatobiliary Scan","74000372","CDM","341","RC","78226","HCPCS","facility","both","","","","2244","1122","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hepatobiliary W / Ef","74000373","CDM","341","RC","78227","HCPCS","facility","both","","","","3110","1555","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nm Salivary Gland Serial","74000375","CDM","341","RC","78231","HCPCS","facility","both","","","","1302","651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gastric Reflux Study","74000377","CDM","341","RC","78262","HCPCS","facility","both","","","","1302","651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gastric Emptyingliquid","74000378","CDM","341","RC","78264","HCPCS","facility","both","","","","2728","1364","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gi Bleed Scan","74000379","CDM","341","RC","78278","HCPCS","facility","both","","","","1949","974.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Meckel's Scan","74000380","CDM","341","RC","78290","HCPCS","facility","both","","","","1949","974.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Shunt Patency","74000381","CDM","341","RC","78291","HCPCS","facility","both","","","","1302","651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Scan Limited","74000383","CDM","341","RC","78300","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Scan Multiple Area","74000384","CDM","341","RC","78305","HCPCS","facility","both","","","","1949","974.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Scan Whole Body","74000385","CDM","341","RC","78306","HCPCS","facility","both","","","","2785","1392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Nm Vascular Flow","74000386","CDM","341","RC","78445","HCPCS","facility","both","","","","876","438","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Scan 3 Phase","74000387","CDM","341","RC","78315","HCPCS","facility","both","","","","3770","1885","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cardiac Shunt Detection","74000390","CDM","341","RC","78428","HCPCS","facility","both","","","","1340","670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Venogram Bilat Nuclear","74000393","CDM","341","RC","78458","HCPCS","facility","both","","","","1593","796.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Myo Rest Or Stress Single Planar","74000394","CDM","341","RC","78453","HCPCS","facility","both","","","","2708","1354","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Myo Rest / Stress Multi Planar Rad","74000395","CDM","341","RC","78454","HCPCS","facility","both","","","","3386","1693","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Myo Rest Or Stress Single Spect","74000396","CDM","341","RC","78451","HCPCS","facility","both","","","","3386","1693","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Myo Rest / Stress Multiple Spect","74000397","CDM","341","RC","78452","HCPCS","facility","both","","","","6336","3168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Muga Scan","74000401","CDM","341","RC","78472","HCPCS","facility","both","","","","2696","1348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lung Scan Perfusion Only","74000406","CDM","341","RC","78580","HCPCS","facility","both","","","","988","494","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pulmonary Quant Diff Function","74000413","CDM","341","RC","78598","HCPCS","facility","both","","","","2536","1268","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Brain Ltd Static W / Flow","74000415","CDM","341","RC","78601","HCPCS","facility","both","","","","4508","2254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Brain Scan Complete","74000416","CDM","341","RC","78605","HCPCS","facility","both","","","","5343","2671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Brain Scan Comp W / Flow","74000417","CDM","341","RC","78606","HCPCS","facility","both","","","","7667","3833.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Brain Scan Vasc Flow Only","74000419","CDM","341","RC","78610","HCPCS","facility","both","","","","873","436.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cisternography Nuclear","74000420","CDM","341","RC","78630","HCPCS","facility","both","","","","1712","856","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Renal Scan Static","74000426","CDM","341","RC","78700","HCPCS","facility","both","","","","1552","776","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kidney Imaging With Flow","74000427","CDM","341","RC","78701","HCPCS","facility","both","","","","1552","776","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Renal Scan Function And Flow","74000429","CDM","341","RC","78707","HCPCS","facility","both","","","","2063","1031.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Renal Funct W / Pharm Int Single","74000433","CDM","341","RC","78708","HCPCS","facility","both","","","","2063","1031.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Uretheral Reflux Study","74000435","CDM","341","RC","78740","HCPCS","facility","both","","","","1708","854","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Testicular W / Flow + Scan","74000437","CDM","341","RC","78761","HCPCS","facility","both","","","","1548","774","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Radiopharm Loc Planar","74000439","CDM","341","RC","78800","HCPCS","facility","both","","","","2255","1127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Nm Tumor Localization Multi","74000440","CDM","341","RC","78801","HCPCS","facility","both","","","","2255","1127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tumor Localization Whole Body","74000441","CDM","341","RC","78804","HCPCS","facility","both","","","","4579","2289.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Radiopharm Loc Spect","74000442","CDM","341","RC","78803","HCPCS","facility","both","","","","4579","2289.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Neck Or Thorax","74000445","CDM","369","RC","21899","HCPCS","facility","both","","","","679","339.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Radiopharmaceutical Therapy, Oral","74000447","CDM","342","RC","79005","HCPCS","facility","both","","","","2374","1187","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Radiopharmaceutical Therapy, Intravenous","74000451","CDM","342","RC","79101","HCPCS","facility","both","","","","1230","615","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Diagnostic Lumbar Spinal Puncture","74000452","CDM","761","RC","62270","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Hysterosonogram W / Wo Colorflow","74000454","CDM","402","RC","76831","HCPCS","facility","both","","","","1310","655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob High Level Scan","74000501","CDM","402","RC","76811","HCPCS","facility","both","","","","1420","710","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Defecography","74000520","CDM","320","RC","74270","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head / St Neck W / Contrast","74000535","CDM","351","RC","70460","HCPCS","facility","both","","","","3053","1526.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoro Exam Cath/Vasc Lab","74000544","CDM","320","RC","76000","HCPCS","facility","both","","","","1896","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Spectroscopy","74000732","CDM","614","RC","76390","HCPCS","facility","both","","","","3841","1920.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Arterial Duplex Ue","74000749","CDM","920","RC","93930","HCPCS","facility","both","","","","2209","1104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Vein Duplex Le Bilat","74000768","CDM","920","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Vein Duplex Ue Unilat","74000773","CDM","920","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Vein Duplex Ue Bilat","74000774","CDM","920","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Vein Duplex Le Unilat","74000775","CDM","920","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Art Duplex Ue Rt","74000776","CDM","920","RC","93931","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Art Duplex Le Bilat","74000778","CDM","920","RC","93925","HCPCS","facility","both","","","","2213","1106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Arterial Duplex Le Unilat","74000779","CDM","920","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"S&I Pta Fibrin Sheath","74000801","CDM","320","RC","75901","HCPCS","facility","both","","","","2112","1056","","","","","","","","","","","","","Gross Charge Type: Standard"
"S&I Mech Rem Of Cath Obstruct","74000803","CDM","320","RC","75902","HCPCS","facility","both","","","","4237","2118.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr 3D Recon At Scanner","74000807","CDM","320","RC","76376","HCPCS","facility","both","","","","1402","701","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Pelvis W / Contrast","74000815","CDM","618","RC","C8918","HCPCS","facility","both","","","","4600","2300","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Pelvis W / Wo Contrast","74000817","CDM","618","RC","C8920","HCPCS","facility","both","","","","5554","2777","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Guide Needle Placmnt/Add'l","74000818","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Pelvis W / O Contrast","74000819","CDM","618","RC","C8919","HCPCS","facility","both","","","","4202","2101","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Adrenal Bilateral","74000824","CDM","320","RC","75733","HCPCS","facility","both","","","","7838","3919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiogram Extr Unilateral","74000830","CDM","320","RC","75710","HCPCS","facility","both","","","","4651","2325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ivc Duplex","74000837","CDM","920","RC","93978","HCPCS","facility","both","","","","1399","699.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Portal Hepatic Duplex","74000840","CDM","920","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Renal Art / Vein Duplex Bilat","74000841","CDM","920","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Art / Ven Dplx, Abd / Plv / Scrot, Ltd","74000842","CDM","921","RC","93976","HCPCS","facility","both","","","","1807","903.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Chest W / Contrast","74000847","CDM","618","RC","C8909","HCPCS","facility","both","","","","3719","1859.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Chest W / O Contrast","74000848","CDM","618","RC","C8910","HCPCS","facility","both","","","","3234","1617","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Chest W / Wo Contrast","74000849","CDM","618","RC","C8911","HCPCS","facility","both","","","","4277","2138.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Lower Ext Bilat W / Contrast","74000850","CDM","616","RC","C8912","HCPCS","facility","both","","","","4830","2415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Lower Ext Bilat W / Wo Contrast","74000852","CDM","616","RC","C8914","HCPCS","facility","both","","","","5554","2777","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Abdomen W / Contrast","74000853","CDM","618","RC","C8900","HCPCS","facility","both","","","","4876","2438","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Abdomen W / O Contrast","74000854","CDM","618","RC","C8901","HCPCS","facility","both","","","","4243","2121.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mra Abdomen W / Wo Contrast","74000855","CDM","618","RC","C8902","HCPCS","facility","both","","","","5610","2805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Breast Lt Birad W / Contrast","74000856","CDM","614","RC","C8903","HCPCS","facility","both","","","","6057","3028.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Breast Bilat W/ Contrast","74000861","CDM","614","RC","C8906","HCPCS","facility","both","","","","6766","3383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Mri Screen, Iac W&W/O Contrast","74000866","CDM","614","RC","70553","HCPCS","facility","both","","","","3491","1745.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lymphangiography Pelvic/Abdominal Unilat Rs&I","74000867","CDM","320","RC","75805","HCPCS","facility","both","","","","3565","1782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Radiologic Exam Esophagus Double Contrast Study","74000868","CDM","320","RC","74221","HCPCS","facility","both","","","","1175","587.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myocrd Img Pet Prfuj W/Metab 2Rtracer Cncrnt Ct","74000869","CDM","404","RC","78433","HCPCS","facility","both","","","","4526","2263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Us Nrv&Acc Strux 1 Xtr Compre W/Img Pr Extremity","74000870","CDM","402","RC","76883","HCPCS","facility","both","","","","784","392","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Abdl Aorta Screen Aaa","74001000","CDM","402","RC","76706","HCPCS","facility","both","","","","1383","691.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Lung Scan V / Q, Aerosol","74001020","CDM","341","RC","78582","HCPCS","facility","both","","","","2830","1415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Renal Funct W / Wo Pharm Int","74001025","CDM","341","RC","78709","HCPCS","facility","both","","","","2063","1031.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct 3D Recon At Workstation","74001040","CDM","350","RC","76377","HCPCS","facility","both","","","","1400","700","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri 3D Recon At Workstation","74001041","CDM","614","RC","76377","HCPCS","facility","both","","","","1400","700","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thoracic Spine Min 4 Views","74001100","CDM","320","RC","72074","HCPCS","facility","both","","","","1177","588.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hip Arthrogram Injection W / Anes","74001101","CDM","320","RC","27095","HCPCS","facility","both","","","","445","222.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Fetal Bpp W / O Non Stress Test","74001102","CDM","402","RC","76819","HCPCS","facility","both","","","","811","405.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo Digital Screening Unilat","74001103","CDM","403","RC","77067","HCPCS","facility","both","","","","830","415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Open Revision Av Fistula","74001104","CDM","490","RC","36832","HCPCS","facility","both","","","","7660","3830","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Or Teeth, Partial Set","74001150","CDM","320","RC","70310","HCPCS","facility","both","","","","331","165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Venogram Caval Super Ep Lab","74001257","CDM","320","RC","75827","HCPCS","facility","both","","","","3472","1736","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Abscess Drainage","74001283","CDM","320","RC","75989","HCPCS","facility","both","","","","4239","2119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoro Less Than 1 Hr - Specia","74001284","CDM","320","RC","76000","HCPCS","facility","both","","","","1896","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Thrombo,Angi Fol-Up Exchan Cat","74001402","CDM","320","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percutan Plcmt Entcly Tube","74001501","CDM","320","RC","74355","HCPCS","facility","both","","","","921","460.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrombo-Angio Foll-Up Exchang Catheterer","74001502","CDM","320","RC","37213","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammography Digital Implants","74001510","CDM","403","RC","77067","HCPCS","facility","both","","","","830","415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therapeutic Inj Procedure","74001556","CDM","320","RC","77003","HCPCS","facility","both","","","","1507","753.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us Follow-Up Per Fetus","74001602","CDM","402","RC","76816","HCPCS","facility","both","","","","447","223.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Thorax Lung Cancer Scr C-","74001861","CDM","350","RC","71271","HCPCS","facility","both","","","","842","421","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rp Loclzj Tum Spect W/Ct 1","74002000","CDM","341","RC","78830","HCPCS","facility","both","","","","4771","2385.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rp Loclzj Tum Spect 2 Areas","74002001","CDM","341","RC","78831","HCPCS","facility","both","","","","4771","2385.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rp Loclzj Tum Spect W/Ct 2","74002002","CDM","341","RC","78832","HCPCS","facility","both","","","","5580","2790","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ad Procedural Charge","74002283","CDM","350","RC","75989","HCPCS","facility","both","","","","4239","2119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Flouro Less Than One Hr","74002284","CDM","320","RC","76000","HCPCS","facility","both","","","","1896","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Density Study Central","74002550","CDM","320","RC","77080","HCPCS","facility","both","","","","1176","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Bone Density Study-Peripheral","74002551","CDM","320","RC","77081","HCPCS","facility","both","","","","663","331.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-C14Py Breath Test","74002964","CDM","300","RC","78267","HCPCS","facility","both","","","","217","108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Orbits W / Contrast","74002967","CDM","614","RC","70542","HCPCS","facility","both","","","","5677","2838.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Face / Orbit / Neck W / Wo Contrast","74002968","CDM","614","RC","70543","HCPCS","facility","both","","","","7093","3546.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mra Head W / O Contrast","74002969","CDM","615","RC","70544","HCPCS","facility","both","","","","5027","2513.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Mra Head W / Contrast","74002970","CDM","615","RC","70545","HCPCS","facility","both","","","","5781","2890.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Mra Head W / Wo Contrast","74002971","CDM","615","RC","70546","HCPCS","facility","both","","","","6646","3323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mra Neck W / O Contrast","74002972","CDM","615","RC","70547","HCPCS","facility","both","","","","4231","2115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mra Neck W / Contrast","74002973","CDM","615","RC","70548","HCPCS","facility","both","","","","4863","2431.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mra Neck W / Wo Contrast","74002974","CDM","615","RC","70549","HCPCS","facility","both","","","","6485","3242.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Chest W/ Contrast","74002975","CDM","614","RC","71551","HCPCS","facility","both","","","","4183","2091.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Chest W/Wo Contrast","74002976","CDM","614","RC","71552","HCPCS","facility","both","","","","5383","2691.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Pelvis W/O Contrast","74002977","CDM","614","RC","72195","HCPCS","facility","both","","","","3724","1862","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Pelvis W/Wo Contrast","74002978","CDM","614","RC","72197","HCPCS","facility","both","","","","6332","3166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Upp Ext Unilat W/O Contrast","74002979","CDM","614","RC","73218","HCPCS","facility","both","","","","3841","1920.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Upp Ext Unilat W/ Contrast","74002980","CDM","614","RC","73219","HCPCS","facility","both","","","","4415","2207.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Upp Ext W/ Joint Unilat W/ Contrast","74002981","CDM","614","RC","73222","HCPCS","facility","both","","","","5111","2555.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Upp Ext W/ Joint Unilat W/Wo Contrast","74002982","CDM","614","RC","73223","HCPCS","facility","both","","","","7171","3585.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Low Ext Unilat W/O Contrast","74002983","CDM","614","RC","73718","HCPCS","facility","both","","","","3865","1932.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Low Ext Unilat W/ Contrast","74002984","CDM","614","RC","73719","HCPCS","facility","both","","","","5111","2555.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Low Joint W Contrast","74002985","CDM","614","RC","73722","HCPCS","facility","both","","","","5111","2555.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Low Joint W/Wo Contrast","74002986","CDM","614","RC","73723","HCPCS","facility","both","","","","6867","3433.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Abdomen W / Contrast","74002987","CDM","614","RC","74182","HCPCS","facility","both","","","","4300","2150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Abdomen W / Wo Contrast","74002988","CDM","614","RC","74183","HCPCS","facility","both","","","","5707","2853.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mri Guidance Needle Placement Rs&I","74002989","CDM","614","RC","77021","HCPCS","facility","both","","","","2832","1416","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cta Head W/Wo Inc Post Proc","74002992","CDM","350","RC","70496","HCPCS","facility","both","","","","4442","2221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Neck W / Wo Inc Post Proc","74002993","CDM","350","RC","70498","HCPCS","facility","both","","","","4462","2231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Chest","74002994","CDM","350","RC","71275","HCPCS","facility","both","","","","4656","2328","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Pelvis W / Wo Inc Post Proc","74002995","CDM","350","RC","72191","HCPCS","facility","both","","","","4515","2257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Upp Ext W/Wo Inc Pp","74002996","CDM","350","RC","73206","HCPCS","facility","both","","","","2549","1274.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Low Ext W/Wo Inc Pp","74002997","CDM","350","RC","73706","HCPCS","facility","both","","","","3968","1984","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Abdomen W/Wo Inc Pp","74002998","CDM","350","RC","74175","HCPCS","facility","both","","","","4376","2188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Aa / Bilat Iliof Low Extremity","74002999","CDM","350","RC","75635","HCPCS","facility","both","","","","3416","1708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Superior Sagital Sinus","74003003","CDM","320","RC","75870","HCPCS","facility","both","","","","3239","1619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Hepatic Venogram No Pressure","74003005","CDM","320","RC","75891","HCPCS","facility","both","","","","5878","2939","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Guide For Tissue Ablation","74003011","CDM","350","RC","77013","HCPCS","facility","both","","","","3328","1664","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rad Phase Ii (Per Minute)","74003027","CDM","710","RC","","","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Breast Puncture Aspiration Cyst Add","74003062","CDM","402","RC","19001","HCPCS","facility","both","","","","713","356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo Screen Conv Diag Unilat","74003063","CDM","401","RC","77065","HCPCS","facility","both","","","","766","383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo Screen Conv Diag Bilat","74003064","CDM","401","RC","77066","HCPCS","facility","both","","","","975","487.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Self Pay Virtual Colon Scrn","74003072","CDM","999","RC","","","facility","both","","","","542","271","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eec Ct Coronary Calcium Scoring","74003075","CDM","999","RC","","","facility","both","","","","295","147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Eec Ct Lung Scan","74003076","CDM","999","RC","","","facility","both","","","","254","127","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eec Ct Abdomen And Pelvis","74003077","CDM","999","RC","","","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Eec Ct Virtual Colonoscopy","74003078","CDM","999","RC","","","facility","both","","","","614","307","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Abbrev Breast Mri","74003097","CDM","999","RC","","","facility","both","","","","399","199.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Head Perfusion","74003950","CDM","350","RC","0042T","HCPCS","facility","both","","","","3643","1821.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Intraluminal Dilation Of Structures Non","74004017","CDM","320","RC","74360","HCPCS","facility","both","","","","1597","798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fine Needle Aspir Bx 1St Les","74004028","CDM","361","RC","10021","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Prostate Volume Study","74004030","CDM","402","RC","76873","HCPCS","facility","both","","","","1162","581","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob Tv","74004031","CDM","402","RC","76817","HCPCS","facility","both","","","","847","423.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob High Level Scan Ea Add Gestation","74004032","CDM","402","RC","76812","HCPCS","facility","both","","","","756","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Pericath Obs Sep Acc,S&I","74004035","CDM","320","RC","75901","HCPCS","facility","both","","","","2112","1056","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Intralum Obs,Rad S&I","74004036","CDM","320","RC","75902","HCPCS","facility","both","","","","4237","2118.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoro Guide Place Or Replace","74004037","CDM","320","RC","77001","HCPCS","facility","both","","","","1548","774","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guide,Place Or Replace","74004038","CDM","402","RC","76937","HCPCS","facility","both","","","","1729","864.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Standing Knees","74004039","CDM","320","RC","73565","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ob Us < 14 Wks Single Fetus","74004040","CDM","402","RC","76801","HCPCS","facility","both","","","","1028","514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus Wk Transabdl Each Gestation","74004041","CDM","402","RC","76802","HCPCS","facility","both","","","","934","467","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Heart, Pulm Vein And Thrombus","74004045","CDM","350","RC","75572","HCPCS","facility","both","","","","2014","1007","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Heart Angiography","74004046","CDM","350","RC","75574","HCPCS","facility","both","","","","750","375","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Hrt W/3D Image Congen","74004049","CDM","350","RC","75573","HCPCS","facility","both","","","","2014","1007","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Digital Screening Mammogram","74004053","CDM","403","RC","77067","HCPCS","facility","both","","","","830","415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Digital Diagnostic Mammogram","74004054","CDM","401","RC","77066","HCPCS","facility","both","","","","975","487.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Digital Diagnostic Mammo Unilat","74004055","CDM","401","RC","77065","HCPCS","facility","both","","","","766","383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammodigital Screening Employee Campaig","74004056","CDM","403","RC","77067","HCPCS","facility","both","","","","830","415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guided Catheter Fluid Drain","74004060","CDM","761","RC","10030","HCPCS","facility","both","","","","4645","2322.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Venography Portography W/O Hem","74004550","CDM","320","RC","75887","HCPCS","facility","both","","","","3239","1619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mra Upper Extremity W/Wo Cont","74004555","CDM","618","RC","C8936","HCPCS","facility","both","","","","4484","2242","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Infant Hips W/ Doctor","74004558","CDM","402","RC","76885","HCPCS","facility","both","","","","539","269.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Infant Hips No Doctor","74004559","CDM","402","RC","76886","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob W/ Nuchal","74004561","CDM","402","RC","76813","HCPCS","facility","both","","","","1117","558.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob W/ Nuchal Ea Add Ges","74004562","CDM","402","RC","76814","HCPCS","facility","both","","","","587","293.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemodialysis Access Flow Study","74004563","CDM","820","RC","90940","HCPCS","facility","both","","","","1516","758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Ob Cord Doppler","74004564","CDM","320","RC","76820","HCPCS","facility","both","","","","834","417","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Renal,1St Order,Uni","74005010","CDM","481","RC","36251","HCPCS","facility","both","","","","14030","7015","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Iliac","74005100","CDM","481","RC","37220","HCPCS","facility","both","","","","18394","9197","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Iliac W/Stent","74005101","CDM","481","RC","37221","HCPCS","facility","both","","","","28713","14356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Iliac,Add-On","74005102","CDM","481","RC","37222","HCPCS","facility","both","","","","11901","5950.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Iliac W/Stent,Add-On","74005103","CDM","481","RC","37223","HCPCS","facility","both","","","","28713","14356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Fem/Popl W/Tla","74005104","CDM","481","RC","37224","HCPCS","facility","both","","","","22413","11206.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Fem/Popl W/Ather","74005105","CDM","481","RC","37225","HCPCS","facility","both","","","","34171","17085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Fem/Popl W/Stent","74005106","CDM","481","RC","37226","HCPCS","facility","both","","","","33686","16843","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Fem/Popl Stnt & Ather","74005107","CDM","481","RC","37227","HCPCS","facility","both","","","","43253","21626.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Tib/Per W/Tla","74005108","CDM","481","RC","37228","HCPCS","facility","both","","","","16768","8384","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Tib/Per W/Ather","74005109","CDM","481","RC","37229","HCPCS","facility","both","","","","26094","13047","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Tib/Per W/Stent","74005110","CDM","481","RC","37230","HCPCS","facility","both","","","","28036","14018","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Revasc, Tib / Per Stent & Ather","74005111","CDM","481","RC","37231","HCPCS","facility","both","","","","43357","21678.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Tib/Per,Add-On","74005112","CDM","481","RC","37232","HCPCS","facility","both","","","","11901","5950.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Tib/Per W/Ather,Add-On","74005113","CDM","481","RC","37233","HCPCS","facility","both","","","","22486","11243","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revasc,Tib/Per Stnt&Ath,Add-On","74005115","CDM","481","RC","37235","HCPCS","facility","both","","","","38586","19293","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Perip Athrc Iliac Art","74005120","CDM","481","RC","0238T","HCPCS","facility","both","","","","26467","13233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Porc-Inj Facet C/T Sgl W/O Sed","74005200","CDM","320","RC","64490","HCPCS","facility","both","","","","3935","1967.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Proc-Inj Facet C/T 2Nd Lvl","74005201","CDM","320","RC","64491","HCPCS","facility","both","","","","3052","1526","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Proc-Inj Facet C/T 3Rd+Lvl","74005202","CDM","320","RC","64492","HCPCS","facility","both","","","","2871","1435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Proc-Inj Facet L/S W/O Sed","74005203","CDM","360","RC","64493","HCPCS","facility","both","","","","3734","1867","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Proc-Inj L/S 2Nd Lvl","74005204","CDM","360","RC","64494","HCPCS","facility","both","","","","3928","1964","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Proc-Inj L/S 3Rd+Lvl","74005205","CDM","320","RC","64495","HCPCS","facility","both","","","","4302","2151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mra W/O&W/Dye Spinal Canal","74006023","CDM","618","RC","C8933","HCPCS","facility","both","","","","4484","2242","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Us Trgt Dyn Mbubb 1St Les","74006024","CDM","402","RC","76978","HCPCS","facility","both","","","","1355","677.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Av Anastomosis Opn; Dir Anyste","74006025","CDM","320","RC","36821","HCPCS","facility","both","","","","9608","4804","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Contrast Enhanced Mammogram Unilat","74006026","CDM","401","RC","77065","HCPCS","facility","both","","","","766","383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Contrast Enhanced Mammogram Bilat","74006027","CDM","401","RC","77066","HCPCS","facility","both","","","","975","487.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo-Diagnostic-Unilat Birads 0","74006030","CDM","401","RC","77065","HCPCS","facility","both","","","","766","383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo-Post Clip Placement-Unilat","74006031","CDM","401","RC","77065","HCPCS","facility","both","","","","766","383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo-Post Clip Placement-Bilat","74006032","CDM","401","RC","77066","HCPCS","facility","both","","","","975","487.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammo-Diagnostic-Bilat Birads 0","74006033","CDM","401","RC","77066","HCPCS","facility","both","","","","975","487.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Venogram Unilat","74006200","CDM","341","RC","78457","HCPCS","facility","both","","","","1593","796.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sentinel Node, Nonimaging","74007000","CDM","340","RC","38792","HCPCS","facility","both","","","","1087","543.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Parathyroid Inj,Non-Imaging","74007001","CDM","340","RC","78808","HCPCS","facility","both","","","","395","197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nonsel Thor Aort+Arch Aortgrm","74007002","CDM","320","RC","36221","HCPCS","facility","both","","","","14991","7495.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sel Cath Cca/Inom+Cervcl Image","74007003","CDM","320","RC","36222","HCPCS","facility","both","","","","18711","9355.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sel Cath Cca/Inom+Cerbr Image","74007004","CDM","320","RC","36223","HCPCS","facility","both","","","","23788","11894","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sel Cath Ica/Inom+Cerebr Image","74007005","CDM","481","RC","36224","HCPCS","facility","both","","","","23857","11928.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sel Cath Inom/Subcl+Vert Image","74007006","CDM","320","RC","36225","HCPCS","facility","both","","","","31690","15845","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sel Cath Vertbrl+Vert Image","74007007","CDM","481","RC","36226","HCPCS","facility","both","","","","31087","15543.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sel Cath Eca+Eca Image","74007008","CDM","481","RC","36227","HCPCS","facility","both","","","","9138","4569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemical Cautery, Tissue","74007061","CDM","761","RC","17250","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Bx Axilla","74007400","CDM","490","RC","24065","HCPCS","facility","both","","","","3125","1562.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Eec Digital Screening Bilat","74007502","CDM","999","RC","77067","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Extremity Comp Unilat","74007600","CDM","402","RC","76881","HCPCS","facility","both","","","","1568","784","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Us Extremity Ltd Anatomic Sp Unilat","74007601","CDM","402","RC","76882","HCPCS","facility","both","","","","613","306.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abd/Pelvis W/O Contrast","74007602","CDM","352","RC","74176","HCPCS","facility","both","","","","5801","2900.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abd/Pelvis W/ Contrast","74007603","CDM","352","RC","74177","HCPCS","facility","both","","","","6668","3334","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Abd/Pelvis W/Wo","74007604","CDM","352","RC","74178","HCPCS","facility","both","","","","7669","3834.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Biophysical Profile (Bpp) W/Nst","74007660","CDM","402","RC","76818","HCPCS","facility","both","","","","910","455","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Ureter Stent Percut S&I","74007700","CDM","761","RC","50384","HCPCS","facility","both","","","","7006","3503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sel Cath Ica/Vertrbl+Image","74007750","CDM","320","RC","36228","HCPCS","facility","both","","","","9138","4569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pet/Ct-Limited Area","74008000","CDM","404","RC","78814","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pet/Ct-Skull Base To Mid Thigh","74008001","CDM","404","RC","78815","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pet/Ct-Whole Body","74008002","CDM","404","RC","78816","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pet Brain Imaging; Meta Eval","74008003","CDM","404","RC","78608","HCPCS","facility","both","","","","5061","2530.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pet/Ct-Skull Base/Midthigh Abor","74008006","CDM","404","RC","78815","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pet/Ct-Whole Body Aborted","74008007","CDM","404","RC","78816","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pet / Ct Limited Area","74008090","CDM","404","RC","78814","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pet / Ct Skull To Thigh","74008091","CDM","404","RC","78815","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pet / Ct Whole Body","74008092","CDM","404","RC","78816","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Cardiac W / Wo Contrast","74008106","CDM","614","RC","75561","HCPCS","facility","both","","","","4296","2148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Cardiac W / O Contrast","74008108","CDM","614","RC","75557","HCPCS","facility","both","","","","3044","1522","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Cardiac W / Wo Contrast W / Stress","74008109","CDM","614","RC","75563","HCPCS","facility","both","","","","4888","2444","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Conv G Tube To Gj Tube W / Rad S&I","74008110","CDM","320","RC","49446","HCPCS","facility","both","","","","4085","2042.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp 3D Recon At Workstation","74008111","CDM","320","RC","76377","HCPCS","facility","both","","","","1400","700","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Abd&Pelvis W/O Contrast","74008139","CDM","352","RC","74176","HCPCS","facility","both","","","","5801","2900.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Chestprochymal Study Sng Only","74008150","CDM","999","RC","","","facility","both","","","","1968","984","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Colonography, Diagnostic W / O Contrast","74008151","CDM","350","RC","74261","HCPCS","facility","both","","","","816","408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Colonography, Diagnostic W / Contrast","74008152","CDM","350","RC","74262","HCPCS","facility","both","","","","905","452.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Colonography, Screening","74008153","CDM","350","RC","74263","HCPCS","facility","both","","","","816","408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Tfrm Epi C/T Ea","74008154","CDM","761","RC","64480","HCPCS","facility","both","","","","1955","977.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ct Heart Calcium Scoring","74008155","CDM","350","RC","75571","HCPCS","facility","both","","","","586","293","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Si Joints-Sacroiliac","74008156","CDM","320","RC","72200","HCPCS","facility","both","","","","489","244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hands And Wrists For Arthritis","74008158","CDM","320","RC","77077","HCPCS","facility","both","","","","773","386.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Nm Parathyroid W Spect","74008164","CDM","341","RC","78072","HCPCS","facility","both","","","","3622","1811","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Plcmnt Radiotherapy Catheter","74008166","CDM","761","RC","19296","HCPCS","facility","both","","","","27689","13844.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pet / Ct Brain Imag Meta Eval Subs","74008203","CDM","404","RC","78608","HCPCS","facility","both","","","","5061","2530.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ct Biopsy Orbital Mass","74008210","CDM","350","RC","21499","HCPCS","facility","both","","","","5353","2676.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Or Tvar Desc Thor Aorta","74008400","CDM","320","RC","75956","HCPCS","facility","both","","","","3468","1734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Or Tvar No Subclav","74008401","CDM","320","RC","75957","HCPCS","facility","both","","","","2614","1307","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Or Tvar Place Prox Ext Prosthesis","74008402","CDM","320","RC","75958","HCPCS","facility","both","","","","1640","820","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Or Tvar Distal Ext Post Repair","74008403","CDM","320","RC","75959","HCPCS","facility","both","","","","1736","868","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Mr - Neuro Ablation","74008404","CDM","761","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Pet/Ct Amyvid Brain Imaging","74008710","CDM","404","RC","78814","HCPCS","facility","both","","","","8818","4409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pet Image Only Ltd Area","74008712","CDM","404","RC","78811","HCPCS","facility","both","","","","10141","5070.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pet Image Only Skull-Thigh","74008713","CDM","404","RC","78812","HCPCS","facility","both","","","","10141","5070.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pet Image Only Full Body","74008714","CDM","404","RC","78813","HCPCS","facility","both","","","","10141","5070.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Brain, Fmri, Physician Administration","74009002","CDM","611","RC","70555","HCPCS","facility","both","","","","4022","2011","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Brain, Fmri, Nonphys Administration","74009003","CDM","611","RC","70554","HCPCS","facility","both","","","","4993","2496.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Ct Self-Pay Cor Art Calc Score","74009130","CDM","999","RC","75571","HCPCS","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dxa Bone Dens-Axial&Fx Assess","74009425","CDM","320","RC","77085","HCPCS","facility","both","","","","1669","834.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Ultrasound Breast Complete","74009502","CDM","402","RC","76641","HCPCS","facility","both","","","","1122","561","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Ultrasound Breast Limited","74009503","CDM","402","RC","76642","HCPCS","facility","both","","","","1096","548","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Fracture Assessment Via Dxa","74009504","CDM","320","RC","77086","HCPCS","facility","both","","","","320","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg- Gastric Empt/Bowel Transit","74009505","CDM","341","RC","78265","HCPCS","facility","both","","","","2728","1364","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Gastric Empt/Bowel Trans, Multi","74009506","CDM","341","RC","78266","HCPCS","facility","both","","","","3088","1544","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Diagnostic Unilat W/Tomo","74009520","CDM","401","RC","G0279","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Diagnostic Implants Unilat W/ Tomo","74009522","CDM","401","RC","G0279","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Diagnostic Bilat W/Tomo","74009523","CDM","401","RC","G0279","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Diagnositc Implants Bilat W/Tomo","74009525","CDM","401","RC","G0279","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Employee Implants W/ Tomo","74009526","CDM","403","RC","77063","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Screening Bilateral W/ Tomo","74009528","CDM","403","RC","77063","HCPCS","facility","both","","","","27","13.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Screening Employee W/ Tomo","74009529","CDM","403","RC","77063","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Digital Screening Unilat W/ Tomo","74009530","CDM","403","RC","77063","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Mrcp","74009536","CDM","614","RC","74181","HCPCS","facility","both","","","","3251","1625.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Intrvasc Us Noncoronary Addl","74009538","CDM","320","RC","37253","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Entire Spi 1 Vw","74009539","CDM","320","RC","72081","HCPCS","facility","both","","","","269","134.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Entire Spi 2/3 Vw","74009540","CDM","320","RC","72082","HCPCS","facility","both","","","","339","169.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Entire Spi 4/5 Vw","74009541","CDM","320","RC","72083","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Entire Spi 6/> Vw","74009542","CDM","320","RC","72084","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - X-Ray Exam Hip Uni 1 View","74009543","CDM","320","RC","73501","HCPCS","facility","both","","","","439","219.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Hip Uni 2-3 Views","74009544","CDM","320","RC","73502","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Hip Uni 4/> Views","74009545","CDM","320","RC","73503","HCPCS","facility","both","","","","681","340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Hips Bi 2 Views","74009546","CDM","320","RC","73521","HCPCS","facility","both","","","","704","352","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Hips Bi 3-4 Views","74009547","CDM","320","RC","73522","HCPCS","facility","both","","","","715","357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Hips Bi 5/> Views","74009548","CDM","320","RC","73523","HCPCS","facility","both","","","","835","417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Of Femur 1","74009549","CDM","320","RC","73551","HCPCS","facility","both","","","","553","276.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-X-Ray Exam Of Femur 2/>","74009550","CDM","320","RC","73552","HCPCS","facility","both","","","","668","334","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Intrvasc Us Noncoronary 1St","74009551","CDM","320","RC","37252","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Intrvasc Us Noncoronary Addl","74009552","CDM","320","RC","37253","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stroke Cta Head W/Wo Inc Post","74009553","CDM","350","RC","70496","HCPCS","facility","both","","","","4442","2221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Nm Pul Quant Diff Funct, Perf","74010600","CDM","341","RC","78597","HCPCS","facility","both","","","","2536","1268","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ct Cta Abd&Plv,W/Wo Inc Post Proc","74010601","CDM","352","RC","74174","HCPCS","facility","both","","","","8882","4441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Csf Shunt Eval Patency","74010606","CDM","341","RC","78645","HCPCS","facility","both","","","","1877","938.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Xy Myelogram Cervical","74029138","CDM","320","RC","72240","HCPCS","facility","both","","","","2483","1241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Nm Parathyroid W Spect","74029140","CDM","341","RC","78071","HCPCS","facility","both","","","","3164","1582","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Bx Back/Flank; Superf","74029142","CDM","761","RC","21920","HCPCS","facility","both","","","","2665","1332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Chest 1 View","74029144","CDM","324","RC","71045","HCPCS","facility","both","","","","468","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Chest 2 Views","74029145","CDM","324","RC","71046","HCPCS","facility","both","","","","563","281.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Chest 3 Views","74029146","CDM","324","RC","71047","HCPCS","facility","both","","","","813","406.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Chest 4+ Views","74029148","CDM","324","RC","71048","HCPCS","facility","both","","","","1016","508","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Abdomen 1 View","74029149","CDM","320","RC","74018","HCPCS","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Abdomen 2 Views","74029150","CDM","320","RC","74019","HCPCS","facility","both","","","","801","400.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-X-Ray Exam Abdomen 3+ Views","74029151","CDM","320","RC","74021","HCPCS","facility","both","","","","910","455","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Mri Cardiac, Velocity Flow Map","74029162","CDM","610","RC","75565","HCPCS","facility","both","","","","1709","854.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Open Mri Brain W_Wo Contrast","74029163","CDM","611","RC","70559","HCPCS","facility","both","","","","2082","1041","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Open Mri Brain Without Contrast","74029164","CDM","611","RC","70557","HCPCS","facility","both","","","","1874","937","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Open Mri Brain With Contrast","74029165","CDM","611","RC","70558","HCPCS","facility","both","","","","1978","989","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Breast,Unilat,W/O Contrast","74029166","CDM","614","RC","77046","HCPCS","facility","both","","","","5506","2753","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Breast,Bilat,W/O Contrast","74029167","CDM","614","RC","77047","HCPCS","facility","both","","","","6150","3075","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Breast C-+ W/Cad Uni","74029168","CDM","610","RC","C8905","HCPCS","facility","both","","","","6396","3198","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Breast C-+ W/Cad Bi","74029169","CDM","610","RC","C8908","HCPCS","facility","both","","","","7104","3552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Use Parenchyma","74029170","CDM","402","RC","76981","HCPCS","facility","both","","","","664","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Use 1St Target Lesion","74029171","CDM","402","RC","76982","HCPCS","facility","both","","","","664","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Use Ea Addl Target Lesion","74029172","CDM","402","RC","76983","HCPCS","facility","both","","","","664","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Xst Trc Ndurlgc Px","74029173","CDM","490","RC","50436","HCPCS","facility","both","","","","7474","3737","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Xst Trc New Access Rcs","74029174","CDM","490","RC","50437","HCPCS","facility","both","","","","8222","4111","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eec Tomo Screen Digital Bilat","74029175","CDM","999","RC","77063","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cad Breast Mri","74029176","CDM","610","RC","C8937","HCPCS","facility","both","","","","323","161.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr A-Iliac Ndgft","74029200","CDM","360","RC","34717","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Rpr N/A A-Iliac Ndgft","74029201","CDM","360","RC","34718","HCPCS","facility","both","","","","4816","2408","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Sm Int F-Thru Std","74029202","CDM","320","RC","74248","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Self-Pay Lung Ca Screen","74029204","CDM","999","RC","71271","HCPCS","facility","both","","","","351","175.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Psych Emer Resp With Med Svc Cpt 90792","74100013","CDM","914","RC","90792","HCPCS","facility","both","","","","667","333.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74110","CDM","270","RC","","","facility","both","","","","179.4","89.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74352","CDM","278","RC","C2625","HCPCS","facility","both","","","","441.6","220.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74372","CDM","278","RC","C1762","HCPCS","facility","both","","","","2002","1001","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74464","CDM","278","RC","C2625","HCPCS","facility","both","","","","441.6","220.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74467","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74468","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74482","CDM","278","RC","C1713","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter Balloon","74500002","CDM","270","RC","","","facility","both","","","","4444.29","2222.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Electrode Lithotripter","74500010","CDM","270","RC","","","facility","both","","","","2178.68","1089.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Membrane Oxygenator","74500017","CDM","270","RC","","","facility","both","","","","2035","1017.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath 9 Or 10Fr","74500019","CDM","270","RC","","","facility","both","","","","853.88","426.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemaquet Ptca 23 Cm 6 7 Or 8F","74500025","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dilator Balloon Tts","74500045","CDM","270","RC","","","facility","both","","","","651.02","325.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iabp Balloon Kit/Complete","74500048","CDM","270","RC","","","facility","both","","","","2729.3","1364.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Needle Aspiration 16Ga","74500051","CDM","270","RC","","","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Solution Acd-A","74500052","CDM","270","RC","","","facility","both","","","","81","40.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bowl 135Cc","74500055","CDM","270","RC","","","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Autolog Bld 300 Ml","74500059","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Autolog Bld 600 Ml","74500060","CDM","272","RC","","","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Vip Swan","74500067","CDM","270","RC","","","facility","both","","","","408","204","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacing Wire","74500095","CDM","272","RC","C1756","HCPCS","facility","both","","","","528.89","264.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Manifold","74500097","CDM","270","RC","","","facility","both","","","","56","28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Disposable Pack Extra","74500105","CDM","270","RC","","","facility","both","","","","456","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Crutch Adult Tall","74500111","CDM","270","RC","","","facility","both","","","","154.22","77.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 24Fr 30Cc 3Way","74500119","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Waste","74500127","CDM","270","RC","","","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Wholey","74500129","CDM","272","RC","C1769","HCPCS","facility","both","","","","232","116","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Connector Y Replc 8932","74500130","CDM","270","RC","","","facility","both","","","","387.09","193.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sorenchg-Son Liner","74500140","CDM","270","RC","","","facility","both","","","","162.5","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Stent Biliary","74500147","CDM","270","RC","","","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Duo Feed","74500150","CDM","270","RC","","","facility","both","","","","86.94","43.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Ercp","74500151","CDM","270","RC","","","facility","both","","","","172.85","86.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire","74500155","CDM","272","RC","C1769","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Jejunostomy Replacement","74500156","CDM","270","RC","","","facility","both","","","","311.54","155.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Pancreatic","74500163","CDM","270","RC","","","facility","both","","","","373.64","186.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Super Peg","74500165","CDM","270","RC","","","facility","both","","","","194.58","97.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dilator Balloon Esoph Tts","74500167","CDM","270","RC","","","facility","both","","","","421.25","210.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bandage Medicopaste","74500178","CDM","270","RC","","","facility","both","","","","188.37","94.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Leg Drain Urinary","74500180","CDM","270","RC","","","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Smart","74500182","CDM","270","RC","","","facility","both","","","","436.77","218.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Mainfold/Walrus","74500184","CDM","270","RC","","","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Motor Drive Unit","74500191","CDM","278","RC","C1768","HCPCS","facility","both","","","","5759.78","2879.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Balloon Ptca","74500195","CDM","272","RC","C1725","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Diagnostic Extra","74500196","CDM","270","RC","","","facility","both","","","","56","28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Introducer","74500198","CDM","270","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Diagnostic","74500199","CDM","272","RC","C1769","HCPCS","facility","both","","","","141","70.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent, Xience","74500200","CDM","278","RC","C1874","HCPCS","facility","both","","","","2768.63","1384.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ptca","74500207","CDM","272","RC","C1769","HCPCS","facility","both","","","","689.31","344.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Traction Bucks Med","74500208","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dilator Biliary Special","74500223","CDM","270","RC","","","facility","both","","","","160.43","80.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Snare Disp Assmb","74500224","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Pacing","74500226","CDM","270","RC","","","facility","both","","","","887","443.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Forcep Radial Jaw Hot Biopsy","74500228","CDM","270","RC","","","facility","both","","","","315.68","157.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Hemostat Absorb Surgicel 4X8In","74500230","CDM","270","RC","","","facility","both","","","","197.69","98.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Ng Ross 12Frx38","74500234","CDM","270","RC","","","facility","both","","","","311.54","155.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Saber Pta Balloon","74500237","CDM","278","RC","C1725","HCPCS","facility","both","","","","253.58","126.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Icd Dual Chmber Momntm El Dr","74500239","CDM","275","RC","C1721","HCPCS","facility","both","","","","17408.7","8704.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Icd Sngl Chmber Momntm El Vr","74500244","CDM","275","RC","C1722","HCPCS","facility","both","","","","15964.88","7982.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Icd Biv Dfib Momntm","74500251","CDM","275","RC","C1882","HCPCS","facility","both","","","","22851","11425.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carillon Mitral Cntr Sys Study","74500252","CDM","270","RC","","","facility","both","","","","30273.75","15136.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Resuscitator Disp","74500266","CDM","270","RC","","","facility","both","","","","520.61","260.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Ercp Bullet Tip .035 Wire","74500276","CDM","270","RC","","","facility","both","","","","503.01","251.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Knee 24In Lg 18,20","74500303","CDM","270","RC","","","facility","both","","","","270.14","135.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Gastrostomy","74500304","CDM","270","RC","","","facility","both","","","","897.35","448.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Shoulder W/Swathe","74500308","CDM","270","RC","","","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cytology Brush Disp","74500324","CDM","270","RC","","","facility","both","","","","155.25","77.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Umbilichg-Cal Art 3.5Fr","74500326","CDM","270","RC","","","facility","both","","","","378.81","189.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Lens Morgan Eye","74500341","CDM","270","RC","","","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Swan Ganz 6Fr","74500348","CDM","270","RC","","","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Introduc 8Fr Sheath 11Cm","74500349","CDM","270","RC","","","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Coude","74500377","CDM","270","RC","","","facility","both","","","","96.26","48.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Shiley Cuffless","74500379","CDM","270","RC","","","facility","both","","","","301.19","150.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shoe Post Op Female Med Velcro","74500386","CDM","270","RC","","","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Chamber Aero","74500404","CDM","270","RC","","","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pad Hypothermia","74500406","CDM","270","RC","","","facility","both","","","","263.93","131.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Resting Hand Prefab","74500413","CDM","270","RC","","","facility","both","","","","224.6","112.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Collar Cerv Chg-Contour Univ","74500416","CDM","270","RC","","","facility","both","","","","439.88","219.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dbl Lumen Udall","74500417","CDM","272","RC","","","facility","both","","","","339.48","169.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley Sil 16Fr 5Cc","74500427","CDM","270","RC","","","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pacing Swan","74500442","CDM","270","RC","","","facility","both","","","","1205","602.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Quadrapolar","74500445","CDM","270","RC","","","facility","both","","","","1616.67","808.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Sump Drain","74500497","CDM","270","RC","","","facility","both","","","","564.08","282.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Swan-G Bipolar Pacing","74500498","CDM","270","RC","","","facility","both","","","","398.48","199.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Thermodilution 7Fr (S-G)","74500502","CDM","270","RC","","","facility","both","","","","1344.47","672.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dilation Ultra Thin","74500524","CDM","270","RC","","","facility","both","","","","884.93","442.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Nephrostomy Drain","74500526","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Shoulder Unv","74500533","CDM","270","RC","","","facility","both","","","","219.42","109.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cast Leg Short Fiberglass","74500534","CDM","270","RC","","","facility","both","","","","510.26","255.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cast Arm Long Fiberglass","74500535","CDM","270","RC","","","facility","both","","","","301.19","150.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cast Leg Long Fiberglass","74500536","CDM","270","RC","","","facility","both","","","","373.64","186.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Glide","74500537","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Brace Hinged Knee","74500540","CDM","270","RC","L1810","HCPCS","facility","both","","","","767.97","383.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Steerable Flex Tip","74500542","CDM","272","RC","C1769","HCPCS","facility","both","","","","473","236.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Leveen Inflator W/Press Gauge","74500547","CDM","270","RC","","","facility","both","","","","263.93","131.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Swan-Ganz Introducer","74500556","CDM","270","RC","","","facility","both","","","","173.88","86.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Vena Cava Filter System","74500570","CDM","270","RC","","","facility","both","","","","4115.16","2057.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sling Arm Medium","74500576","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Lifter Leg","74500588","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Airway","74500593","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Triple Lumen","74500595","CDM","270","RC","","","facility","both","","","","282","141","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Shiley","74500596","CDM","270","RC","","","facility","both","","","","198.72","99.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Introduc 7Fr Cath Sheath","74500599","CDM","270","RC","","","facility","both","","","","243.23","121.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Drain Urinary Anti Flex","74500600","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Triple Lumen Hemodial 6In","74500606","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Trocar 32Fr 16 Inch","74500608","CDM","270","RC","","","facility","both","","","","114.89","57.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Boot L'nard","74500610","CDM","270","RC","","","facility","both","","","","700.7","350.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Wedge","74500625","CDM","270","RC","","","facility","both","","","","159.39","79.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Wrist Right Med","74500635","CDM","270","RC","","","facility","both","","","","333.27","166.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Catheter Scoreflex Nc","74500640","CDM","278","RC","C1725","HCPCS","facility","both","","","","1163","581.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Rotawire","74500641","CDM","278","RC","C1769","HCPCS","facility","both","","","","1163.34","581.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Crossing Hornet 10","74500646","CDM","278","RC","C1769","HCPCS","facility","both","","","","176.99","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Abltn Bi-Direct Safire","74500648","CDM","278","RC","C1733","HCPCS","facility","both","","","","907.7","453.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Vasc U/S Opticross","74500649","CDM","278","RC","C1753","HCPCS","facility","both","","","","1085","542.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Pillow","74500652","CDM","278","RC","","","facility","both","","","","1276.16","638.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sapien X4 - Alliance Trial","74500653","CDM","270","RC","","","facility","both","","","","31050","15525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Corsinus Steer Marinr","74500655","CDM","272","RC","C1730","HCPCS","facility","both","","","","810","405","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Pacing Selectra 3D","74500656","CDM","278","RC","C1893","HCPCS","facility","both","","","","312","156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker Aveir Vr Leadless","74500657","CDM","275","RC","C1786","HCPCS","facility","both","","","","10764","5382","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Delivery Aveir","74500659","CDM","270","RC","","","facility","both","","","","2083.46","1041.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Triple Loop Snare Aveir","74500660","CDM","270","RC","","","facility","both","","","","3570.75","1785.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Dilator Aveir","74500661","CDM","278","RC","C1894","HCPCS","facility","both","","","","269.1","134.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nushield 1 Square Cm Waste","74500662","CDM","278","RC","Q4160","HCPCS","facility","both","","","","326.03","163.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neovasc Reducer System - Cosira Study","74500663","CDM","624","RC","","","facility","both","","","","15525","7762.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nexeon Avx; Decellualarized Femoral Artery; Matracell Trial","74500664","CDM","270","RC","","","facility","both","","","","2764.49","1382.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ensoetm","74500665","CDM","270","RC","","","facility","both","","","","1318","659","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tightrail Guardian Motorized Dilator Sheath","74500667","CDM","270","RC","","","facility","both","","","","4160.7","2080.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circulo Guidewire","74500668","CDM","270","RC","","","facility","both","","","","401.58","200.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flexnav Delivery System","74500669","CDM","270","RC","","","facility","both","","","","2975.63","1487.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Navitor Tavi","74500670","CDM","270","RC","","","facility","both","","","","31244.58","15622.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Brace Wrist Prefab","74500683","CDM","270","RC","","","facility","both","","","","114.89","57.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Collector Fecal Adult","74500686","CDM","270","RC","","","facility","both","","","","55.89","27.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Neg Wound Pressure System","74500688","CDM","270","RC","","","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Collector Specimen","74500701","CDM","270","RC","","","facility","both","","","","186.3","93.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Cath Multi Lumen","74500712","CDM","270","RC","","","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Drainage Bag","74500722","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Trocar 32Fr 16 Inch","74500728","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Temno Biop Dev Ct18/15","74500752","CDM","270","RC","","","facility","both","","","","233.91","116.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wheelchair Cushion Deluxe","74500757","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Wheelchair Cushion Deluxe","74500758","CDM","270","RC","","","facility","both","","","","582.71","291.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pad Foam Cylinder 1/4 Sheet","74500760","CDM","270","RC","","","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dca Cutter","74500764","CDM","270","RC","","","facility","both","","","","7533.77","3766.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Biopsy Klatskin","74500779","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Groshong Picc Cath","74500781","CDM","270","RC","","","facility","both","","","","439.88","219.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cautery High Temp Diag Key Med","74500784","CDM","270","RC","","","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Shiley 10","74500789","CDM","270","RC","","","facility","both","","","","446.09","223.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Thoravac","74500802","CDM","270","RC","","","facility","both","","","","670.68","335.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Extension Plain","74500811","CDM","270","RC","","","facility","both","","","","135.59","67.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Airway Nasopharynl 32Fr","74500821","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dilator Balloon Ercp","74500836","CDM","270","RC","","","facility","both","","","","871.47","435.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Change Major","74500839","CDM","270","RC","","","facility","both","","","","223","111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Change Medium","74500841","CDM","270","RC","","","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Baskest Stone Retrieval Ercp","74500842","CDM","270","RC","","","facility","both","","","","654.12","327.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Drain Stoma","74500908","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Introducer Swan Ganz","74500944","CDM","270","RC","","","facility","both","","","","157","78.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Feeding Gastrostomy","74500946","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Drain Unit Chest","74500948","CDM","270","RC","","","facility","both","","","","494","247","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 8Fr 3Cc","74500953","CDM","270","RC","","","facility","both","","","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Wound Vigilon 4X4","74500955","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Pneumothorax","74500964","CDM","270","RC","","","facility","both","","","","370.53","185.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Duostat","74500965","CDM","270","RC","","","facility","both","","","","249","124.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Thoracentesis 30In","74500970","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley Coude Tip 16Fr 5Cc","74500977","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Humidifier Neb H2O 500Ml Ster","74500984","CDM","270","RC","","","facility","both","","","","134.55","67.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Abd Combined 5X9 Bx","74500985","CDM","270","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Surgicel Hemostat Absorb 2X3","74500989","CDM","270","RC","","","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Enema Fleets","74500996","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ventriculostomy Ext Drng Bag","74501002","CDM","270","RC","","","facility","both","","","","345.69","172.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ventriculostomy Cath","74501004","CDM","270","RC","","","facility","both","","","","217","108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Umbilical Line Supplies","74501013","CDM","270","RC","","","facility","both","","","","619.97","309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley Chg-Carson Mod 16Fr 5Cc","74501014","CDM","270","RC","","","facility","both","","","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Collar Cerv Stiff Neck Short","74501033","CDM","270","RC","","","facility","both","","","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Cuff Fen 8D Disp","74501057","CDM","270","RC","","","facility","both","","","","269.1","134.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Amplatz Super Stiff","74501107","CDM","272","RC","C1769","HCPCS","facility","both","","","","224","112","","","","","","","","","","","","","Gross Charge Type: Standard"
"Quantum Top Fill Flush","74501111","CDM","270","RC","","","facility","both","","","","154.22","77.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Binder Surgical Panel","74501120","CDM","270","RC","","","facility","both","","","","108.68","54.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Trochg-Car 24Fr 16In","74501149","CDM","270","RC","","","facility","both","","","","114.89","57.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bili-Lite Shield Eye Infant","74501155","CDM","270","RC","","","facility","both","","","","33.12","16.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Biopsy Trucut","74501167","CDM","270","RC","","","facility","both","","","","116.96","58.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Water Distilled 3000Ml","74501171","CDM","270","RC","","","facility","both","","","","165.6","82.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Suction Conn","74501176","CDM","270","RC","","","facility","both","","","","134.55","67.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Exercise Hand Aid","74501177","CDM","270","RC","","","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Sump Salem 18Fr","74501178","CDM","270","RC","","","facility","both","","","","69.35","34.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Chest Tube","74501179","CDM","270","RC","","","facility","both","","","","69.35","34.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Stomach 12Fr","74501181","CDM","270","RC","","","facility","both","","","","100.4","50.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Td Swan","74501202","CDM","270","RC","","","facility","both","","","","677","338.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Triple Lumen Hemodial 3In","74501283","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Spinal Needle","74501297","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Electrode Pacing Quik Pace","74501310","CDM","270","RC","","","facility","both","","","","277","138.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Embalectomy Fogarty","74501322","CDM","272","RC","C1757","HCPCS","facility","both","","","","316.71","158.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Collector Fecal Inconti","74501336","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Stocking Knee High-Kendal","74501337","CDM","270","RC","","","facility","both","","","","230.81","115.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Suction Clos 14Fr 13In","74501342","CDM","270","RC","","","facility","both","","","","114.89","57.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Oxy Swan","74501360","CDM","270","RC","","","facility","both","","","","1258.56","629.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Collar Cerv Med Foam","74501393","CDM","270","RC","","","facility","both","","","","135.59","67.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Trap Suction Polyp","74501395","CDM","270","RC","","","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Feeding","74501413","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stapler Skin Prem 35W Disp","74501426","CDM","270","RC","","","facility","both","","","","194.58","97.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Speculum Vaginal Dichg-Sp","74501447","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemaquet Standard","74501467","CDM","278","RC","C1894","HCPCS","facility","both","","","","140","70","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Brush Cytology Colon","74501469","CDM","270","RC","","","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sponge Gelfoam Size 100","74501512","CDM","270","RC","","","facility","both","","","","198.72","99.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kit Jejunostomy","74501516","CDM","270","RC","","","facility","both","","","","450.23","225.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Knee 24In Cool Blue","74501527","CDM","270","RC","","","facility","both","","","","155.25","77.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Shoulder Med","74501539","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pack Peri Gyn A29171","74501543","CDM","270","RC","","","facility","both","","","","358.11","179.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Restraint Wrist Ankle","74501544","CDM","270","RC","","","facility","both","","","","100.4","50.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ring Fallopian Bands","74501554","CDM","270","RC","","","facility","both","","","","220.46","110.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Blanket Adult Warmer","74501557","CDM","270","RC","","","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Trochg-Car 28Fr 16In","74501571","CDM","270","RC","","","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Arrow 8.5","74501574","CDM","270","RC","","","facility","both","","","","132","66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-J Wire","74501585","CDM","270","RC","","","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Binder Abdominal Male","74501597","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cu-64 Dotatate, 1 Mci","74501598","CDM","343","RC","A9592","HCPCS","facility","both","","","","1505.7","752.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Dsp Lvr X Heat Exch W Line","74501599","CDM","270","RC","","","facility","both","","","","403","201.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"18Fgtp1 Tau Research","74501600","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pet Radiopharmaceutical, Diagnosis, For Tumor Id, Noc-Per Dose","74501603","CDM","343","RC","A9597","HCPCS","facility","both","","","","6480","3240","","","","","","","","","","","","","Gross Charge Type: Standard"
"Research - Aortix System","74501604","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vivasight 2 Dlt","74501605","CDM","270","RC","","","facility","both","","","","403","201.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Edwards Evoque Triscupid Valve - Triscend Ii Study","74501606","CDM","270","RC","","","facility","both","","","","45229.5","22614.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Consolidated Bag","74501607","CDM","274","RC","Q0499","HCPCS","facility","both","","","","437.81","218.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hmiii Travel Case","74501608","CDM","274","RC","Q0499","HCPCS","facility","both","","","","215.28","107.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stablization Belt","74501609","CDM","274","RC","Q0508","HCPCS","facility","both","","","","134.55","67.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Standtall Radial Sheath Extensn","74501610","CDM","270","RC","","","facility","both","","","","246.33","123.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Et Tube Bronch Blocker","74501611","CDM","270","RC","","","facility","both","","","","610","305","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bridge Occlusion Balloon","74501613","CDM","278","RC","C2628","HCPCS","facility","both","","","","1364.13","682.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bridge Prep Kit","74501614","CDM","278","RC","C1769","HCPCS","facility","both","","","","425.39","212.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Tightrail Rotating Dilatr","74501615","CDM","278","RC","C1773","HCPCS","facility","both","","","","2613.38","1306.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Tightrail Subc Rot Dilatr","74501616","CDM","278","RC","C1773","HCPCS","facility","both","","","","2018.25","1009.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Venous Valve - Savve Study","74501617","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Catheter Introducer","74501618","CDM","270","RC","","","facility","both","","","","291","145.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Piflufolastat F18 Per 1Mci","74501619","CDM","343","RC","A9595","HCPCS","facility","both","","","","635.25","317.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Catheter Radial Artery","74501623","CDM","270","RC","","","facility","both","","","","130.41","65.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Cent Ven Cath W/Arrow","74501625","CDM","270","RC","","","facility","both","","","","106.61","53.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Colostomy Irrigation","74501626","CDM","270","RC","","","facility","both","","","","373.64","186.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Leg Posterior","74501632","CDM","270","RC","","","facility","both","","","","495.77","247.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cast Arm Short Adult","74501636","CDM","270","RC","","","facility","both","","","","282.56","141.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cast Leg Short Adult","74501638","CDM","270","RC","","","facility","both","","","","362.25","181.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Drainage Cath Ventricular","74501640","CDM","270","RC","","","facility","both","","","","465.75","232.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Cotton Leung Bili 10Fr","74501643","CDM","270","RC","","","facility","both","","","","759.69","379.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Vasoseal","74501663","CDM","270","RC","","","facility","both","","","","780.39","390.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Brace Ankle Air","74501665","CDM","270","RC","","","facility","both","","","","165.6","82.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Kit Inflation Ptca Extra","74501671","CDM","270","RC","","","facility","both","","","","439.88","219.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Biliary","74501673","CDM","270","RC","","","facility","both","","","","759.69","379.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Female Lg Lace Up","74501683","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Female Md Lace Up","74501685","CDM","270","RC","","","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Elevator Arm W/Pockets","74501688","CDM","270","RC","","","facility","both","","","","86.94","43.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Male Lg Lace Up","74501690","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Aligner Body Foam","74501698","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Resuscitator W/Mask","74501701","CDM","270","RC","","","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Soap Body Wash Aloe Vesta","74501704","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Water Ster","74501706","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Pericardiocentesis","74501722","CDM","270","RC","","","facility","both","","","","457","228.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Thoracic Chest Tube Ra24F","74501746","CDM","270","RC","","","facility","both","","","","197.69","98.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Wafer Stoma W/Surfit Flange","74501766","CDM","270","RC","","","facility","both","","","","292.91","146.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pouch Urostomy 1.75In Standard","74501767","CDM","270","RC","","","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Drain Jackson Pratt","74501769","CDM","270","RC","","","facility","both","","","","492.66","246.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Paste Stomahesive Protective","74501770","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sling Arm Immobilizer Lg","74501783","CDM","270","RC","","","facility","both","","","","123.17","61.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Immobilizer Knee","74501801","CDM","270","RC","","","facility","both","","","","208.04","104.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Burn Pad 10Ply 18X18","74501804","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Adapter Cap Locking","74501849","CDM","270","RC","","","facility","both","","","","123.17","61.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Swan-G 7Fr","74501855","CDM","270","RC","","","facility","both","","","","373.64","186.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Airway Nasopharyn 28Fr","74501857","CDM","270","RC","","","facility","both","","","","69.35","34.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Airway Nasopharyn 34Fr","74501859","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stapler Skin Tissue Lt 35W","74501866","CDM","270","RC","","","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Knee 24In Sm 14,16","74501898","CDM","270","RC","","","facility","both","","","","186.3","93.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Knee 24In Med 16,18","74501901","CDM","270","RC","","","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Knee Xlg","74501902","CDM","270","RC","","","facility","both","","","","186.3","93.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Oxygen Mask Venturi Var Per Nt","74501948","CDM","270","RC","","","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sleeve Compression Thigh L-Xl","74501973","CDM","270","RC","","","facility","both","","","","365.36","182.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Knee Donjoy","74501980","CDM","270","RC","","","facility","both","","","","821.79","410.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pillow Shoulder Abduction","74501981","CDM","270","RC","","","facility","both","","","","332.24","166.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Urine Meter W/Bag","74501982","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Multilumen Kit","74502000","CDM","270","RC","","","facility","both","","","","690.35","345.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ez Wrap","74502003","CDM","270","RC","","","facility","both","","","","204.93","102.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Multi Lumen Cent Ven Cath","74502023","CDM","278","RC","C1750","HCPCS","facility","both","","","","924.26","462.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Nebulizer Hand Held Set Up","74502073","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Duoderm 6X6","74502078","CDM","270","RC","","","facility","both","","","","260.82","130.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pouch Drainable 4In 12In L Clr","74502081","CDM","270","RC","","","facility","both","","","","132.48","66.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Blanket Hypothermia","74502121","CDM","270","RC","","","facility","both","","","","155.25","77.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Paceport","74502150","CDM","270","RC","","","facility","both","","","","1344.47","672.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pressure Transducer Summit","74502151","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Airway Nasopharyn 30Fr","74502161","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Emg Monopolar","74502163","CDM","270","RC","","","facility","both","","","","33.12","16.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Sclerotherapy 25G Yellow","74502167","CDM","270","RC","","","facility","both","","","","234.95","117.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Spinal 22Gx3.5","74502169","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Wang Retractable 22G","74502184","CDM","270","RC","","","facility","both","","","","1265.81","632.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Cuff Fen 4D","74502185","CDM","270","RC","","","facility","both","","","","269.1","134.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sleeve Compression Thigh Reg","74502187","CDM","270","RC","","","facility","both","","","","322.92","161.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Custom Birthing Pack","74502216","CDM","270","RC","","","facility","both","","","","224.6","112.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pad Defibrillator 4.5X6In","74502265","CDM","270","RC","","","facility","both","","","","260","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Infusor Pressure 500Cc Disp","74502285","CDM","270","RC","","","facility","both","","","","105","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Drain Unit Chest Adult Blood","74502302","CDM","270","RC","","","facility","both","","","","270.14","135.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Flexiflo Ent Nutri Bag/1 Ea","74502311","CDM","270","RC","","","facility","both","","","","33.12","16.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Wound Gel 3 Oz","74502328","CDM","270","RC","","","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Triple Lumen Arrow Gu","74502335","CDM","270","RC","","","facility","both","","","","399","199.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Thermo Venous 7.5Fr","74502337","CDM","270","RC","","","facility","both","","","","410.9","205.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cco Swan","74502340","CDM","270","RC","","","facility","both","","","","1317","658.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Quad Lumen Catheter","74502356","CDM","278","RC","C1751","HCPCS","facility","both","","","","310","155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Mitraflex Sc 6X6In","74502360","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Allevyn 8X8In","74502371","CDM","270","RC","","","facility","both","","","","86.94","43.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Allevyn 4X4In","74502372","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pad Tucks","74502383","CDM","270","RC","","","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pillow Abduction Med","74502421","CDM","270","RC","","","facility","both","","","","224.6","112.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Anascope","74502442","CDM","270","RC","","","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Button Kit","74502456","CDM","270","RC","","","facility","both","","","","1372.41","686.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pleuravac","74502470","CDM","270","RC","","","facility","both","","","","574.43","287.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pouch Drainabl 1.75In12In Clea","74502521","CDM","270","RC","","","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Gastrostomy 20Fr Otw Flex","74502524","CDM","270","RC","","","facility","both","","","","373.64","186.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pouch Endo Specimen Retrieval","74502531","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Angioject Catheter","74502553","CDM","270","RC","","","facility","both","","","","5048.73","2524.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pack Peri Gyn A29176","74502585","CDM","270","RC","","","facility","both","","","","360.18","180.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Staples Ets","74502596","CDM","270","RC","","","facility","both","","","","1038.11","519.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Probe Gold","74502610","CDM","270","RC","","","facility","both","","","","744.17","372.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Rapid Prime Line","74502665","CDM","270","RC","","","facility","both","","","","133.52","66.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Staple Remover Skin","74502672","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Resuscitator Adult Dmr","74502677","CDM","270","RC","","","facility","both","","","","162.5","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Cath Radial Artery","74502720","CDM","270","RC","","","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Large 9 10 11 12 14 F","74502765","CDM","272","RC","C1894","HCPCS","facility","both","","","","217","108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Horn Long Handled","74502778","CDM","270","RC","","","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Horn Plated","74502779","CDM","270","RC","","","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Male Lg Velcro","74502780","CDM","270","RC","","","facility","both","","","","198.72","99.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Male Med Velcro","74502781","CDM","270","RC","","","facility","both","","","","162.5","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Male Sm Velcro","74502782","CDM","270","RC","","","facility","both","","","","48.65","24.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Sleeve Compression (Knee)","74502805","CDM","270","RC","","","facility","both","","","","223","111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sleeve Compression Thigh Sm","74502806","CDM","270","RC","","","facility","both","","","","286.7","143.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sling","74502813","CDM","270","RC","","","facility","both","","","","96.26","48.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sling Arm Large","74502815","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ptca Specialty","74502823","CDM","272","RC","C1769","HCPCS","facility","both","","","","392","196","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sphinctertome","74502826","CDM","270","RC","","","facility","both","","","","547.52","273.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Wrist Splint Velcro","74502844","CDM","270","RC","","","facility","both","","","","155.25","77.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Material Ocl Med","74502851","CDM","270","RC","","","facility","both","","","","132.48","66.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Wrist Forearm Left Lg","74502858","CDM","270","RC","","","facility","both","","","","86.94","43.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Arm Fiberglass Long","74502859","CDM","270","RC","","","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Leg Fiberglass Short","74502860","CDM","270","RC","","","facility","both","","","","135.59","67.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Wrist Left Med","74502861","CDM","270","RC","","","facility","both","","","","233.91","116.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Steering Handle Extra","74502932","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Biliary Endoprosthesis","74502934","CDM","278","RC","C1876","HCPCS","facility","both","","","","2540.93","1270.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent J&J Coronary","74502937","CDM","270","RC","","","facility","both","","","","8654.67","4327.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Strap Montgomery 7.25X11.5In","74502981","CDM","270","RC","","","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sucker Line","74503000","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture","74503062","CDM","270","RC","","","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Surgicel Hemostat Absorb 2X14","74503132","CDM","270","RC","","","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Ethilon","74503136","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bld Autotransfusor Set","74503236","CDM","270","RC","","","facility","both","","","","1216.13","608.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Monocryl Ea","74503263","CDM","270","RC","","","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suture Nylon","74503272","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Knee 19In Cool Blue","74503278","CDM","270","RC","","","facility","both","","","","99.36","49.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Brush Microbiology Bronch","74503334","CDM","270","RC","","","facility","both","","","","633.42","316.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Nerve Stimulator","74503342","CDM","270","RC","","","facility","both","","","","204.93","102.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suture 0 Silk","74503367","CDM","270","RC","","","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Central Dressing","74503394","CDM","270","RC","","","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Gastric Lavage Ewald","74503400","CDM","270","RC","","","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suture 2 0 Vicryl (Dexon)","74503434","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suture 3 0 Vicryl (Dexon)","74503444","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sutures","74503486","CDM","270","RC","","","facility","both","","","","351.9","175.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Thoracentesis","74503502","CDM","270","RC","","","facility","both","","","","142","71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Thermaldilution","74503524","CDM","270","RC","","","facility","both","","","","1506.96","753.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Traction W/O Skel Set Up","74503576","CDM","270","RC","","","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Traction Bucks Small","74503584","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Transducer Disp","74503590","CDM","270","RC","","","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Oximetry Transducer O2 Infant","74503601","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Transmitter Pdt Carryall","74503605","CDM","270","RC","","","facility","both","","","","896.31","448.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Finger","74503606","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Triflo Inc Spiro S-U","74503813","CDM","270","RC","","","facility","both","","","","334.31","167.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Feed 8Fr W/Tip","74503843","CDM","270","RC","","","facility","both","","","","191.48","95.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Feeding 12Fr 36In","74503845","CDM","270","RC","","","facility","both","","","","106.61","53.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Feeding Pump Set W/Spike","74503851","CDM","270","RC","","","facility","both","","","","114.89","57.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Salem Sump","74503863","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Shiley Cuff #6","74503865","CDM","270","RC","","","facility","both","","","","571.32","285.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Sump Salem W/Valve 14Fr","74503870","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Sump Salem W/Valve 16Fr","74503871","CDM","270","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ube Sump Salem W/Valve 18Fr","74503872","CDM","270","RC","","","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Trach","74503874","CDM","270","RC","","","facility","both","","","","420.21","210.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Cuff 8Dct","74503876","CDM","270","RC","","","facility","both","","","","243.23","121.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Trach Cuff 6Dct W/Dic","74503877","CDM","270","RC","","","facility","both","","","","243.23","121.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Universal Cuff","74503909","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Valve Speaking Trach 15Mm Id","74503919","CDM","270","RC","","","facility","both","","","","489.56","244.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Vent Bolt Press Mon Kit","74503924","CDM","270","RC","","","facility","both","","","","599.27","299.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ventriculostomy Ext Drng Sys","74503927","CDM","270","RC","","","facility","both","","","","583","291.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Wafer Durahesive 1.75 45Mm","74503932","CDM","270","RC","","","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Wafer Surfit 1.75 45Mm","74503935","CDM","270","RC","","","facility","both","","","","106.61","53.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-J Wire Extra Tri-Lum Flex Tip","74503949","CDM","270","RC","","","facility","both","","","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Spring .018X80Cm","74503958","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Spring .025X40Cm","74503959","CDM","270","RC","","","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Drain Urinary Anti Chamber","74503969","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brush Cytology Disp","74503993","CDM","270","RC","","","facility","both","","","","315.68","157.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avanti Sheath","74504001","CDM","272","RC","C1894","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Coude 14Fr 5Cc","74504002","CDM","270","RC","","","facility","both","","","","311.54","155.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Ercp Taper .025 Guidewire","74504015","CDM","270","RC","","","facility","both","","","","759.69","379.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Fogarty Art Embol 5Fr 80Cm","74504017","CDM","272","RC","C1757","HCPCS","facility","both","","","","698.63","349.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Fogarty Art Embol 4Fr Lo","74504021","CDM","272","RC","C1757","HCPCS","facility","both","","","","495.77","247.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 10Fr 3Cc","74504026","CDM","270","RC","","","facility","both","","","","191.48","95.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 12Fr 5Cc","74504027","CDM","270","RC","","","facility","both","","","","183.2","91.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 22Fr 30Cc","74504028","CDM","270","RC","","","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 18Fr 30Cc 3Way","74504044","CDM","270","RC","","","facility","both","","","","198.72","99.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 3W 18Fr","74504045","CDM","270","RC","","","facility","both","","","","312.57","156.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 22Fr 30Cc 3Way","74504051","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Swan-G 7Fr Lumen","74504064","CDM","270","RC","","","facility","both","","","","520.61","260.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Thoracic 28Fr Straight","74504066","CDM","270","RC","","","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Trach Chg-Care #220","74504067","CDM","270","RC","","","facility","both","","","","269.1","134.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drape Microtek #5902","74504096","CDM","270","RC","","","facility","both","","","","160.43","80.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pillow Abduction","74504105","CDM","270","RC","","","facility","both","","","","683.1","341.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Gel Intrasite","74504129","CDM","270","RC","","","facility","both","","","","425.39","212.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Glidewire","74504130","CDM","270","RC","","","facility","both","","","","425.39","212.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Arm Elevator W/Ice Bag","74504147","CDM","270","RC","","","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Biopsy Jamshidi","74504160","CDM","270","RC","","","facility","both","","","","186.3","93.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Epidur 17G X3-1/2","74504165","CDM","270","RC","","","facility","both","","","","227.7","113.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Bld Transfusion","74504179","CDM","270","RC","","","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Bld Warmer","74504181","CDM","270","RC","","","facility","both","","","","209.07","104.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Suture Disp","74504183","CDM","270","RC","","","facility","both","","","","224.6","112.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Snare Cook Dpol-1-12","74504192","CDM","270","RC","","","facility","both","","","","397.44","198.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sponge Gelfoam Ster 12 Sq Cm","74504195","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Cotton Leung Bili 7Fr","74504201","CDM","270","RC","","","facility","both","","","","541.31","270.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cast Boots","74504220","CDM","270","RC","","","facility","both","","","","221.49","110.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Foley 16Fr 30Cc","74504234","CDM","274","RC","A4344","HCPCS","facility","both","","","","130.41","65.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Collar Cerv Soft","74504261","CDM","270","RC","","","facility","both","","","","96.26","48.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shoe Post Op Sm Female Velcro","74504350","CDM","270","RC","","","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Crutch Adult Adjust Alum Med","74504362","CDM","270","RC","","","facility","both","","","","159.39","79.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sup Adapter Tuohy Borst","74504366","CDM","270","RC","","","facility","both","","","","134.55","67.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Basket Stone Removal","74504367","CDM","270","RC","","","facility","both","","","","863.19","431.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Temno Biop Dev Ct18/20","74504368","CDM","270","RC","","","facility","both","","","","233.91","116.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Temno Biop Dev 20/15","74504369","CDM","270","RC","","","facility","both","","","","200.79","100.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Biliary Drain","74504371","CDM","270","RC","","","facility","both","","","","450.23","225.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Emboli Micro Coils","74504377","CDM","270","RC","","","facility","both","","","","297.05","148.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Forcep Biopsy 5.4Fr","74504380","CDM","270","RC","","","facility","both","","","","796.95","398.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Angiographic","74504381","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Indium Octreoscan","74504387","CDM","343","RC","A9572","HCPCS","facility","both","","","","4039","2019.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Set Perc","74504389","CDM","272","RC","C1894","HCPCS","facility","both","","","","349.83","174.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Temno Biop Dev Ct20/15","74504392","CDM","270","RC","","","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Temno Biop Dev 20/9 Add'l","74504393","CDM","270","RC","","","facility","both","","","","140.76","70.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Homer Lok 8.9Cm","74504394","CDM","278","RC","C1769","HCPCS","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Homer Mammo Lok 6.4Cm","74504395","CDM","278","RC","C1769","HCPCS","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Palmaz","74504403","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Temno Biop Dev T18/15 Add'l","74504406","CDM","270","RC","","","facility","both","","","","162.5","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Katzen Inf .035 145","74504410","CDM","270","RC","","","facility","both","","","","712.08","356.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Snare Retriever","74504411","CDM","270","RC","","","facility","both","","","","263.93","131.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Adhesion Barrier","74504470","CDM","278","RC","C1765","HCPCS","facility","both","","","","660.33","330.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Embo Microspheres 300500 Um","74504480","CDM","270","RC","","","facility","both","","","","670.68","335.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Embo Microspheres 500700 Um","74504481","CDM","270","RC","","","facility","both","","","","670.68","335.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Embo Microspheres 700900 Um","74504482","CDM","270","RC","","","facility","both","","","","670.68","335.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Foley","74504503","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Ceretec Per Dose","74504510","CDM","343","RC","A9521","HCPCS","facility","both","","","","1087","543.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Bipolar Vns Lead Mdl 300 20/30","74504515","CDM","278","RC","C1778","HCPCS","facility","both","","","","6555.69","3277.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Peripheral","74504520","CDM","272","RC","C1725","HCPCS","facility","both","","","","456.44","228.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Wall","74504521","CDM","278","RC","C1876","HCPCS","facility","both","","","","5540.36","2770.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Shoulder Cloth","74504543","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Torquevue","74504575","CDM","270","RC","","","facility","both","","","","1253.39","626.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amplatzer Amulet Laao","74504576","CDM","270","RC","","","facility","both","","","","20234.25","10117.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Delivery Steerable Amplatzer 14 Fr","74504577","CDM","270","RC","","","facility","both","","","","1604.25","802.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Ablation,Non-Cardia","74504578","CDM","278","RC","C1888","HCPCS","facility","both","","","","527.85","263.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gore Tag Tbe","74504583","CDM","278","RC","","","facility","both","","","","59512.5","29756.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gore Tbe  Side Branch","74504586","CDM","278","RC","","","facility","both","","","","34471.71","17235.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gore Tbe Extender","74504587","CDM","278","RC","","","facility","both","","","","48613.95","24306.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gore Tbe Aortic Component","74504588","CDM","278","RC","","","facility","both","","","","141422.4","70711.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tactisys Quartz Rf Cable","74504589","CDM","270","RC","","","facility","both","","","","1309.28","654.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cg Future Annuloplasty System","74504590","CDM","270","RC","","","facility","both","","","","2499.53","1249.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tactiflex Se","74504591","CDM","270","RC","","","facility","both","","","","4467","2233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acqcross Qx Integrated Transseptal Dialator/Needle","74504592","CDM","270","RC","","","facility","both","","","","962.55","481.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hydrophyllic Prelude Snap","74504593","CDM","278","RC","C1894","HCPCS","facility","both","","","","54.86","27.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liquogard Tubing","74504594","CDM","270","RC","","","facility","both","","","","853","426.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rapid Eeg Headband","74504595","CDM","270","RC","","","facility","both","","","","938","469","","","","","","","","","","","","","Gross Charge Type: Standard"
"Quadrox-Oxygenator","74504596","CDM","270","RC","","","facility","both","","","","1567.56","783.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotaflow Centrifugal Pump","74504597","CDM","270","RC","","","facility","both","","","","337.41","168.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo/Vad Tubing Pack","74504598","CDM","270","RC","","","facility","both","","","","506.12","253.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nautilus Mc3-Oxygenator","74504599","CDM","270","RC","","","facility","both","","","","4463.96","2231.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centrimag With Amg-Oxy","74504600","CDM","270","RC","","","facility","both","","","","19639.13","9819.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amg-Oxygenator","74504601","CDM","270","RC","","","facility","both","","","","1428.3","714.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centrimag","74504602","CDM","270","RC","","","facility","both","","","","14997.15","7498.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 171-190","74504603","CDM","278","RC","C1889","HCPCS","facility","both","","","","35707.5","17853.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 91-110","74504604","CDM","278","RC","C1889","HCPCS","facility","both","","","","23805","11902.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede, 5 Mm","74504605","CDM","278","RC","C1889","HCPCS","facility","both","","","","1428.3","714.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 51-70","74504606","CDM","278","RC","C1889","HCPCS","facility","both","","","","17853.75","8926.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede, 7 Mm","74504608","CDM","278","RC","C1889","HCPCS","facility","both","","","","1428.3","714.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 9-30","74504609","CDM","278","RC","C1889","HCPCS","facility","both","","","","11902.5","5951.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx 12 71-90","74504610","CDM","278","RC","C1889","HCPCS","facility","both","","","","20829.38","10414.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 131-150","74504611","CDM","278","RC","C1889","HCPCS","facility","both","","","","29756.25","14878.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx 12 31-50","74504612","CDM","278","RC","C1889","HCPCS","facility","both","","","","14878.13","7439.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede, 10 Mm","74504613","CDM","278","RC","C1889","HCPCS","facility","both","","","","1428.3","714.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 111-130","74504614","CDM","278","RC","C1889","HCPCS","facility","both","","","","26780.63","13390.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx, 6 Mm","74504615","CDM","278","RC","C1889","HCPCS","facility","both","","","","1369.31","684.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx, 8 Mm","74504616","CDM","278","RC","C1889","HCPCS","facility","both","","","","1369.31","684.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impede-Fx-12 151-170","74504617","CDM","278","RC","C1889","HCPCS","facility","both","","","","32731.88","16365.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekos+ Catheter","74504618","CDM","278","RC","C1751","HCPCS","facility","both","","","","4041.68","2020.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Edwards Pascal","74504619","CDM","270","RC","","","facility","both","","","","36421.65","18210.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pluvicto","74504620","CDM","344","RC","A9607","HCPCS","facility","both","","","","39315.15","19657.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ambu Ascope Bronch","74504623","CDM","270","RC","","","facility","both","","","","417.11","208.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Chg Wheelchair Cushion 4 """"""","74504626","CDM","270","RC","","","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Farastar - Catheter Connection Cable","74504627","CDM","270","RC","","","facility","both","","","","1364.13","682.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Faradrive - Steerable Sheath","74504628","CDM","278","RC","C1766","HCPCS","facility","both","","","","1666.35","833.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Farapoint - Pfa Point Catheter Study","74504629","CDM","278","RC","C1889","HCPCS","facility","both","","","","3868.83","1934.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Farawave Pfa - Catheter","74504630","CDM","278","RC","C1733","HCPCS","facility","both","","","","7736.63","3868.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Reservoir 12Om Filtered Cardio","74504632","CDM","270","RC","","","facility","both","","","","453.33","226.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pump Tubing","74504633","CDM","270","RC","","","facility","both","","","","689.31","344.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cardioplegia Delivery System","74504635","CDM","270","RC","","","facility","both","","","","495","247.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Hemoconcentrator","74504636","CDM","270","RC","","","facility","both","","","","252","126","","","","","","","","","","","","","Gross Charge Type: Standard"
"Afo Pos Solid Ank Plastic Mo","74504640","CDM","274","RC","L1940","HCPCS","facility","both","","","","873.54","436.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flotufolastat F 18, Diagnostic, 1 Mci","74504641","CDM","343","RC","A9608","HCPCS","facility","both","","","","1047.9","523.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Detour Stent Graft System-Non Or","74504642","CDM","278","RC","C1604","HCPCS","facility","both","","","","25875","12937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheo-Esophageal Voice Prosthesis Classic Nonsterile","74504643","CDM","278","RC","L8509","HCPCS","facility","both","","","","441.95","220.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheo-Esophageal Voice Prosthesis Classic Sterile","74504644","CDM","278","RC","L8509","HCPCS","facility","both","","","","449.19","224.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheo-Esophageal Voice Prosthesis Advantage Nonsterile","74504645","CDM","278","RC","L8509","HCPCS","facility","both","","","","673.79","336.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mr. Frosty Cardioplegia H/E","74504646","CDM","270","RC","","","facility","both","","","","247.37","123.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mr. Frosty Standard H/E","74504647","CDM","270","RC","","","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blue Rhino Trach Set","74504648","CDM","270","RC","","","facility","both","","","","889.07","444.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impella Rp Flex With Smart Assist","74504649","CDM","278","RC","","","facility","both","","","","29756.25","14878.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Harmony Transcatheter Pulmonic Valve & Delivery Kit","74504650","CDM","270","RC","","","facility","both","","","","49395.38","24697.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Saavy Wire","74504651","CDM","270","RC","","","facility","both","","","","1364.13","682.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"S3 Ultra Resilia Tavr Valve","74504652","CDM","270","RC","","","facility","both","","","","40468.5","20234.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Verasight 3D Ice","74504653","CDM","270","RC","","","facility","both","","","","4046.85","2023.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coraflex Microcatheter","74504654","CDM","270","RC","","","facility","both","","","","962.55","481.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coraforce Microcatheter","74504655","CDM","270","RC","","","facility","both","","","","962.55","481.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coracross Catheter","74504657","CDM","270","RC","","","facility","both","","","","1147.82","573.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sentinel Cerebral Protection System","74504658","CDM","278","RC","C1889","HCPCS","facility","both","","","","4761","2380.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Jada Device","74504659","CDM","270","RC","","","facility","both","","","","1542.15","771.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp In111 Dtpa Per 0.5 Mci","74504676","CDM","343","RC","A9548","HCPCS","facility","both","","","","2601","1300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Ga67 Per Mci","74504678","CDM","343","RC","A9556","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp I123 Capsule Per 100 Uci","74504679","CDM","343","RC","A9516","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp I131 Nal Tx Capsules Per Mci","74504681","CDM","343","RC","A9517","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp In111 Labeled Wbc Per Dose","74504683","CDM","343","RC","A9570","HCPCS","facility","both","","","","4126","2063","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Sestamibi Per Dose","74504684","CDM","343","RC","A9500","HCPCS","facility","both","","","","640","320","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Dtpa Per Dose","74504685","CDM","343","RC","A9539","HCPCS","facility","both","","","","1412","706","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Gb Agent Per Dose","74504686","CDM","343","RC","A9537","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Mag3 Per Dose","74504687","CDM","343","RC","A9562","HCPCS","facility","both","","","","756","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Labeled Rbc's Per Dose","74504688","CDM","343","RC","A9560","HCPCS","facility","both","","","","241","120.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Tco4 Per Mci","74504689","CDM","343","RC","A9512","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tl201 Per Mci","74504690","CDM","343","RC","A9505","HCPCS","facility","both","","","","136","68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc 99 Neurolite Per Dose","74504693","CDM","343","RC","A9557","HCPCS","facility","both","","","","1896","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytherapy Needle","74504696","CDM","272","RC","C1715","HCPCS","facility","both","","","","38","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Echotip Procore Needle 25Gx5Cm","74504700","CDM","270","RC","","","facility","both","","","","388.13","194.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc99 Ceretec Labeled Wbc Per Dose","74504716","CDM","343","RC","A9569","HCPCS","facility","both","","","","1996","998","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon,Aga Sizing","74504751","CDM","272","RC","C1725","HCPCS","facility","both","","","","969","484.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bard Permcath","74504761","CDM","278","RC","C1750","HCPCS","facility","both","","","","788.67","394.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Dyn Unif-Infus Sys-30Cm","74504765","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angiodyn Unifuseinfus Sys50Cm","74504766","CDM","278","RC","C1751","HCPCS","facility","both","","","","371.57","185.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Arrowgard Blue Lg Bore Multilum Cvc","74504768","CDM","278","RC","C1752","HCPCS","facility","both","","","","474.03","237.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pressure Wire","74504769","CDM","272","RC","C1769","HCPCS","facility","both","","","","1008","504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Trans Intro 406805/901","74504772","CDM","272","RC","C1893","HCPCS","facility","both","","","","491.63","245.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Trns Intro","74504775","CDM","272","RC","C1893","HCPCS","facility","both","","","","491.63","245.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Laser","74504779","CDM","272","RC","C2629","HCPCS","facility","both","","","","4996.98","2498.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ept Blazer 4500Th/4500Thk2","74504782","CDM","272","RC","C1733","HCPCS","facility","both","","","","3009.78","1504.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser,Lead Cutter","74504786","CDM","270","RC","","","facility","both","","","","239.09","119.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser,Lld Accessory Kit","74504787","CDM","270","RC","","","facility","both","","","","317.75","158.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser,Lld Kit","74504788","CDM","270","RC","","","facility","both","","","","1363.1","681.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle,Transseptal","74504789","CDM","270","RC","","","facility","both","","","","688","344","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotoglide","74504791","CDM","270","RC","","","facility","both","","","","213","106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealing Adaptor","74504792","CDM","272","RC","C1892","HCPCS","facility","both","","","","192","96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Socket Insert Below Knee","74504804","CDM","274","RC","L5655","HCPCS","facility","both","","","","349.83","174.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Postop Nonwgt Br Dsg Abv Knee","74504805","CDM","274","RC","L5460","HCPCS","facility","both","","","","777.29","388.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluciclovine F18, Diag, 1Mci","74504807","CDM","343","RC","A9588","HCPCS","facility","both","","","","782","391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Gallium Ga-68 Dotatate, Diag","74504808","CDM","343","RC","A9587","HCPCS","facility","both","","","","89","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Warm Air Tubes","74504818","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Stereo Needle Guide Add'l","74504850","CDM","270","RC","","","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter, Balloon Mustang","74504860","CDM","272","RC","C1725","HCPCS","facility","both","","","","507.15","253.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle Homer Mammo Lock Ultra","74504865","CDM","278","RC","C1769","HCPCS","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Intervent Supplies (Heart)","74504894","CDM","270","RC","","","facility","both","","","","1383.8","691.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Retrieval Snare Microvena","74504895","CDM","270","RC","","","facility","both","","","","2189.03","1094.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Battery Holster","74504970","CDM","274","RC","Q0498","HCPCS","facility","both","","","","915.98","457.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sutures Package","74505017","CDM","270","RC","","","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grfx/Strvx Skin Sub Per Sqcm","74505020","CDM","278","RC","Q4133","HCPCS","facility","both","","","","181.13","90.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Grafix Skin Sub Waste Sqcm","74505021","CDM","278","RC","Q4133","HCPCS","facility","both","","","","181.13","90.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cath Lantern","74505036","CDM","272","RC","C1887","HCPCS","facility","both","","","","1112.63","556.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Drain Resolve","74505037","CDM","272","RC","C1729","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Drain Resolve Biliary","74505038","CDM","272","RC","C1729","HCPCS","facility","both","","","","122.13","61.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Guide Surefire","74505041","CDM","278","RC","C1887","HCPCS","facility","both","","","","464.72","232.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Port Bard 8F Sl Non Power","74505042","CDM","278","RC","C1788","HCPCS","facility","both","","","","508.19","254.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Stent Biliary Wallflex Covered","74505043","CDM","278","RC","C1876","HCPCS","facility","both","","","","1874.39","937.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Trevo Provue Kit","74505045","CDM","272","RC","C1757","HCPCS","facility","both","","","","8618.45","4309.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Target Xl 360 Soft 6-12Mm","74505051","CDM","270","RC","","","facility","both","","","","2579.22","1289.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Target Xl 360 Std 6-12Mm","74505052","CDM","270","RC","","","facility","both","","","","2579.22","1289.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Target Xl 360 Soft 14-20Mm","74505053","CDM","270","RC","","","facility","both","","","","2814.17","1407.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Target Xl 360 Std 14-24Mm","74505054","CDM","270","RC","","","facility","both","","","","2814.17","1407.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Target Xl Helical 14-24Mm","74505055","CDM","270","RC","","","facility","both","","","","2110.37","1055.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Target Xl Helical 5-12Mm","74505056","CDM","270","RC","","","facility","both","","","","1875.42","937.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"I131 Iodide Sol Rx Per 1 Mci","74505102","CDM","344","RC","A9530","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tissue Sealer Small Jaw Disp","74505103","CDM","270","RC","","","facility","both","","","","670","335","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Flortaucipir F 18 Inj. Tauvid","74505104","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Ptchg-Ca","74505119","CDM","270","RC","","","facility","both","","","","425.39","212.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Picc 4Fr Pqe-4834G","74505160","CDM","278","RC","C1751","HCPCS","facility","both","","","","315.68","157.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Picc 5Fr Dl P5Dg","74505161","CDM","278","RC","C1751","HCPCS","facility","both","","","","422.28","211.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Human Milk Fortifier 50Pk","74505166","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Biopsy Jaws Disposable","74505201","CDM","270","RC","","","facility","both","","","","297","148.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Cook Biopsy","74505202","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,Vortx Dimd 2/3X2.3","74505203","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,Vortx Dimd 2/4X4.1","74505204","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,Vortx Dimd 2/5X5.8","74505205","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,Vortx Dimd 2/6X8.0","74505206","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 10X30","74505207","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 12X30","74505208","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 14X30","74505209","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 14X20","74505210","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 12X20","74505211","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 10X20","74505212","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 8X20","74505213","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 3X12","74505214","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Inlock, 2D Helical 4X15","74505215","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 5X15","74505216","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 6X20","74505217","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 6X10","74505218","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 3X6","74505219","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 5X8","74505220","CDM","270","RC","","","facility","both","","","","473","236.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil,Inlock,2D Helical 4X8","74505221","CDM","270","RC","","","facility","both","","","","944.96","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Port-Bard Mri Mediport","74505223","CDM","278","RC","C1788","HCPCS","facility","both","","","","1503.86","751.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Rotablator Advancer","74505244","CDM","270","RC","","","facility","both","","","","894.24","447.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Capsure Fix","74505246","CDM","275","RC","C1898","HCPCS","facility","both","","","","4025.12","2012.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Catheter","74505305","CDM","272","RC","C1885","HCPCS","facility","both","","","","4096.53","2048.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Micropuncture Cook","74505471","CDM","272","RC","C1894","HCPCS","facility","both","","","","183","91.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Raabe Cook","74505472","CDM","272","RC","C1894","HCPCS","facility","both","","","","189.41","94.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Glidecath Terumo","74505473","CDM","272","RC","C1887","HCPCS","facility","both","","","","119.03","59.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Catheter, Aqua Tempo Cordis","74505474","CDM","272","RC","C1887","HCPCS","facility","both","","","","141.8","70.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Pinnacle Terumo","74505475","CDM","272","RC","C1887","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transducer Disposable Cardiac","74505520","CDM","270","RC","","","facility","both","","","","66","33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Perclose Closer","74505600","CDM","278","RC","C1760","HCPCS","facility","both","","","","1549.4","774.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Periph Wallchg-Stent","74505605","CDM","278","RC","C2625","HCPCS","facility","both","","","","3627.68","1813.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotoblator Advancer","74505606","CDM","272","RC","C1724","HCPCS","facility","both","","","","3540.74","1770.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Ptca Guidant","74505610","CDM","272","RC","C1725","HCPCS","facility","both","","","","461.61","230.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Peripheral Viatrac","74505611","CDM","272","RC","C1725","HCPCS","facility","both","","","","507.15","253.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Guidewire Ptca Medtronic Gt1","74505612","CDM","272","RC","C1769","HCPCS","facility","both","","","","355.01","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Ablation Conductor","74505615","CDM","272","RC","C1733","HCPCS","facility","both","","","","2964.24","1482.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angioseal 6Fr","74505620","CDM","278","RC","C1760","HCPCS","facility","both","","","","668","334","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angioseal 8Fr","74505621","CDM","278","RC","C1760","HCPCS","facility","both","","","","645","322.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Lead, Pacemaker Tendril Dx","74505626","CDM","275","RC","C1898","HCPCS","facility","both","","","","4025.12","2012.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiojet Catheter","74505631","CDM","272","RC","C1757","HCPCS","facility","both","","","","4248.68","2124.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Loop Recorder, Reveal","74505636","CDM","278","RC","C1764","HCPCS","facility","both","","","","10081.94","5040.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph Herculink Otw Bil","74505637","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Myocardial","74505642","CDM","275","RC","C1898","HCPCS","facility","both","","","","4025.12","2012.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Vaginal Delivery Supply Charge","74505756","CDM","270","RC","","","facility","both","","","","638.6","319.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Surefix","74505814","CDM","275","RC","C1898","HCPCS","facility","both","","","","1834.02","917.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Ablation Blazer Ii","74505822","CDM","272","RC","C1733","HCPCS","facility","both","","","","2668.23","1334.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Ablat Halo Irvine/Bio","74505823","CDM","272","RC","C1731","HCPCS","facility","both","","","","2149.7","1074.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Coronary Guidant","74505824","CDM","278","RC","C1876","HCPCS","facility","both","","","","1987.2","993.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Coronary Scimed","74505825","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Stent Coronary Cordis","74505826","CDM","278","RC","C1876","HCPCS","facility","both","","","","4682.34","2341.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Coronary Medtronic","74505827","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Ptca Scimed","74505828","CDM","272","RC","C1725","HCPCS","facility","both","","","","392","196","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Ptca Cordis","74505829","CDM","272","RC","C1725","HCPCS","facility","both","","","","1140.57","570.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Ptca Medtronic","74505830","CDM","272","RC","C1725","HCPCS","facility","both","","","","392","196","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide Scimed","74505831","CDM","272","RC","C1887","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide Cordis","74505832","CDM","272","RC","C1887","HCPCS","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide Medtronic","74505833","CDM","272","RC","C1887","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ptca Scimed","74505834","CDM","272","RC","C1769","HCPCS","facility","both","","","","255","127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ptca Medtronic","74505836","CDM","272","RC","C1769","HCPCS","facility","both","","","","268.07","134.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indaflator Scimed","74505837","CDM","270","RC","","","facility","both","","","","134","67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiojet Pump Set","74505839","CDM","270","RC","","","facility","both","","","","940.82","470.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Ablation Flex St Jude","74505844","CDM","272","RC","C2630","HCPCS","facility","both","","","","3113","1556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Balloon Stonetome","74505857","CDM","270","RC","","","facility","both","","","","1147.82","573.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cre Balloon Dilators","74505859","CDM","270","RC","","","facility","both","","","","991.53","495.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dual Lumen Needle Knife","74505860","CDM","270","RC","","","facility","both","","","","496.8","248.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dual Port Feed Tube Kit","74505861","CDM","270","RC","","","facility","both","","","","132.48","66.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Polyp Ligating Device","74505866","CDM","270","RC","","","facility","both","","","","297.05","148.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tripod","74505871","CDM","270","RC","","","facility","both","","","","173.88","86.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Roth Retrieval Nte","74505876","CDM","270","RC","","","facility","both","","","","668.61","334.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Vac Pump Cannister Ea","74505884","CDM","270","RC","","","facility","both","","","","163.53","81.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc 99 Mdp Per Dose","74505900","CDM","343","RC","A9503","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc 99 Sulfur Colloid Per Dose","74505901","CDM","343","RC","A9541","HCPCS","facility","both","","","","198","99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp Tc 99 Maa Per Dose","74505905","CDM","343","RC","A9540","HCPCS","facility","both","","","","1883","941.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Vesper Venous Stent,Vivid","74505906","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suction Nasogastric","74506003","CDM","270","RC","","","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Resuscitator-Neonatal","74506006","CDM","270","RC","","","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath, Ureteral Stent Inlay 6X26","74506027","CDM","278","RC","C2617","HCPCS","facility","both","","","","646.88","323.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath, Ureteral Stent Inlay 6X24","74506028","CDM","278","RC","C2617","HCPCS","facility","both","","","","388.13","194.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint Aluminum Finger","74506040","CDM","270","RC","","","facility","both","","","","69.35","34.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Spinal 18Gx3.5","74506048","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent","74506057","CDM","270","RC","","","facility","both","","","","593.06","296.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Electrode Fast Patch Defib Ecg","74506062","CDM","270","RC","","","facility","both","","","","130.41","65.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire .021 Dia 480Cm Long","74506071","CDM","272","RC","C1769","HCPCS","facility","both","","","","132.48","66.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Brodmerkel Colon Decompress","74506077","CDM","270","RC","","","facility","both","","","","446.09","223.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Vent Bolt Pressure Monit","74506080","CDM","270","RC","","","facility","both","","","","2388.78","1194.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Biopsy Asp 18 Disp","74506085","CDM","270","RC","","","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bag Leg Dispoz A Bag","74506086","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Code Blue Gastric Lavage Kit","74506087","CDM","270","RC","","","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Klatskin","74506091","CDM","270","RC","","","facility","both","","","","616.86","308.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Snare Polypectomy","74506092","CDM","270","RC","","","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-20 Fr Bard Tube Replacement","74506099","CDM","270","RC","","","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Sclerotherapy","74506100","CDM","270","RC","","","facility","both","","","","221.49","110.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sutures Pack","74506103","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coaccess System 3.5 / 15 / 15","74506130","CDM","270","RC","","","facility","both","","","","3100.86","1550.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Cs Attain Starfix","74506193","CDM","275","RC","C1900","HCPCS","facility","both","","","","8479.76","4239.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Retrieval Balloon Cath","74506201","CDM","270","RC","","","facility","both","","","","541.31","270.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tack Endovascular System","74506212","CDM","278","RC","C1876","HCPCS","facility","both","","","","2321.51","1160.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Wall-Colonic 90Mm","74506213","CDM","278","RC","C1876","HCPCS","facility","both","","","","10033.29","5016.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stent Ultra Esophageal","74506216","CDM","278","RC","C1876","HCPCS","facility","both","","","","8661.92","4330.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Roadrunner","74506221","CDM","272","RC","C1769","HCPCS","facility","both","","","","362.25","181.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Cranial Access","74506250","CDM","270","RC","","","facility","both","","","","629","314.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Bag Heartmate 11","74506262","CDM","274","RC","Q0508","HCPCS","facility","both","","","","556.83","278.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Shower Bag Hrtm Ii,Rep","74506264","CDM","274","RC","Q0501","HCPCS","facility","both","","","","822.83","411.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Sys Contrlr Batt Ea-Rep","74506400","CDM","274","RC","Q0508","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Heartmate Battry Ea-Rep Only","74506401","CDM","274","RC","Q0503","HCPCS","facility","both","","","","1611.5","805.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Add  Fx, Shoe Ank Jt","74506500","CDM","274","RC","L2180","HCPCS","facility","both","","","","188.37","94.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Add With  D/Pf Assist Ea","74506502","CDM","274","RC","L2220","HCPCS","facility","both","","","","134.55","67.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Add With Df Assist Ea","74506503","CDM","274","RC","L2210","HCPCS","facility","both","","","","110.75","55.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Custom W/Ankle Joint","74506505","CDM","274","RC","L1970","HCPCS","facility","both","","","","1082.61","541.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Plastic Prefab","74506507","CDM","274","RC","L1930","HCPCS","facility","both","","","","364.32","182.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Solid Custom","74506508","CDM","274","RC","L1960","HCPCS","facility","both","","","","898.38","449.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Static Prefab","74506509","CDM","274","RC","L4396","HCPCS","facility","both","","","","271.17","135.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3960 Sewho Airplane Abd Pre","74506510","CDM","274","RC","L3960","HCPCS","facility","both","","","","893.21","446.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ankle Rom Limit Joint","74506512","CDM","274","RC","L2200","HCPCS","facility","both","","","","80.73","40.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Big Grip W/C Only","74506514","CDM","273","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blue Knead Ball W/C Only","74506517","CDM","273","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Boot L'nard T Walker","74506518","CDM","274","RC","L4396","HCPCS","facility","both","","","","271.17","135.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Boot Walk Pneu Aircast Prefab","74506519","CDM","274","RC","L4360","HCPCS","facility","both","","","","470.93","235.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Boot,Camboot Eq Non Pneumatic","74506520","CDM","274","RC","L4386","HCPCS","facility","both","","","","257.72","128.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cerv Collar Multipost Adj Cust","74506522","CDM","274","RC","L0190","HCPCS","facility","both","","","","753.48","376.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cerv Collar Semi Rig 2 Pce Cus","74506523","CDM","274","RC","L0172","HCPCS","facility","both","","","","219.42","109.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cerv Foam Collar Cust Non Adj","74506524","CDM","274","RC","L0120","HCPCS","facility","both","","","","48.65","24.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3906 Who W/O Joints Cf","74506526","CDM","274","RC","L3906","HCPCS","facility","both","","","","422.28","211.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3671 So Cap Design W/O Jnt Cf","74506527","CDM","274","RC","L3671","HCPCS","facility","both","","","","497.84","248.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3999 Ue Orthotic No Specified","74506529","CDM","274","RC","L3999","HCPCS","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cranial Orthosis (Helmet) Cust","74506530","CDM","274","RC","A8003","HCPCS","facility","both","","","","965.66","482.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3921 Hfo W/Joint(S) Cf","74506534","CDM","274","RC","L3921","HCPCS","facility","both","","","","309.47","154.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3931 Whfo Nontorsion Jnt Pre","74506536","CDM","274","RC","L3931","HCPCS","facility","both","","","","228.74","114.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3929 Hfo Nontors Jnt Pre Cust","74506537","CDM","274","RC","L3929","HCPCS","facility","both","","","","99.36","49.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3806 Whfo W/Joint(S) Cf","74506540","CDM","274","RC","L3806","HCPCS","facility","both","","","","436.77","218.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3760 Eo W/Jnt Adj Lock Pre","74506546","CDM","274","RC","L3760","HCPCS","facility","both","","","","478.17","239.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3730 Eo Dbl Up Ex/Flx Asst Cf","74506547","CDM","274","RC","L3730","HCPCS","facility","both","","","","1338.26","669.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3740 Eo Dbl Up Adj Lock Cf","74506549","CDM","274","RC","L3740","HCPCS","facility","both","","","","1447.97","723.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Eggs W/C Only","74506550","CDM","273","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3912 Hfo Flex Glove Pre Ots","74506551","CDM","274","RC","L3912","HCPCS","facility","both","","","","85.91","42.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Foot Prost Energy Storing","74506558","CDM","274","RC","L5976","HCPCS","facility","both","","","","912.87","456.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Halo Add, Mri Compatible","74506561","CDM","274","RC","L0859","HCPCS","facility","both","","","","2084.49","1042.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Halo Cervica Inc Jkt/Vest Cust","74506562","CDM","274","RC","L0810","HCPCS","facility","both","","","","3950.6","1975.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3913 Hfo W/O Joints Cf","74506564","CDM","274","RC","L3913","HCPCS","facility","both","","","","259.79","129.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hip Add Flex/Ext/Abduct","74506571","CDM","274","RC","L2624","HCPCS","facility","both","","","","508.19","254.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hip Ortho Abdct Post Op Prefab","74506573","CDM","274","RC","L1686","HCPCS","facility","both","","","","1743.98","871.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3763 Ewho Rigid W/O Jnts Cf","74506575","CDM","274","RC","L3763","HCPCS","facility","both","","","","697.59","348.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3980 Ue Fx Ortho Humeral Pre","74506576","CDM","274","RC","L3980","HCPCS","facility","both","","","","316.71","158.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Isotoner/Edema Gloves","74506577","CDM","273","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Add Laminated/Comp","74506580","CDM","274","RC","L2755","HCPCS","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Add Solid Stirrup","74506582","CDM","274","RC","L2760","HCPCS","facility","both","","","","311.54","155.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Add Varus/Valgus Plastic","74506583","CDM","274","RC","L2275","HCPCS","facility","both","","","","202.86","101.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Soft Interface Above","74506586","CDM","274","RC","L2830","HCPCS","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Soft Interface Bka","74506587","CDM","274","RC","L2820","HCPCS","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Above Post Sock Multi","74506588","CDM","274","RC","L8430","HCPCS","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Add Ab Silesian Bandage","74506600","CDM","274","RC","L5698","HCPCS","facility","both","","","","176.99","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Add Above Sleeve Neoprene","74506601","CDM","274","RC","L5695","HCPCS","facility","both","","","","315.68","157.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Add Below Distal Cushion","74506607","CDM","274","RC","L5668","HCPCS","facility","both","","","","171.81","85.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Add Below Endo Alignable","74506608","CDM","274","RC","L5910","HCPCS","facility","both","","","","594.09","297.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Add Below Total Contact","74506615","CDM","274","RC","L5637","HCPCS","facility","both","","","","557.87","278.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Add Below Waist Belt Web","74506616","CDM","274","RC","L5688","HCPCS","facility","both","","","","106.61","53.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Bk Fit Post Op Rigid Drsg","74506626","CDM","274","RC","L5400","HCPCS","facility","both","","","","1942.7","971.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Below Prost Sock Multi","74506628","CDM","274","RC","L8420","HCPCS","facility","both","","","","41.4","20.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Below Ptb Socket Prefab","74506631","CDM","274","RC","L5450","HCPCS","facility","both","","","","694.49","347.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Orthosis Adj Joint Prefab","74506632","CDM","274","RC","L1832","HCPCS","facility","both","","","","1078.47","539.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Prost Above Shrinker","74506635","CDM","274","RC","L8460","HCPCS","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Prost Ab Sock Single Ply","74506636","CDM","274","RC","L8480","HCPCS","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Prost Below Shrinker","74506637","CDM","274","RC","L8440","HCPCS","facility","both","","","","75.56","37.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Prost Bk Sock Single Ply","74506638","CDM","274","RC","L8470","HCPCS","facility","both","","","","17.6","8.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Knife,Case Rocker W/C Only","74506642","CDM","273","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3702 Eo W/O Jt Cf","74506659","CDM","274","RC","L3702","HCPCS","facility","both","","","","277.38","138.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Reacher,All Featherwght","74506662","CDM","273","RC","","","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3927 Fo Pip Dip No Jt Pre Ots","74506671","CDM","274","RC","L3927","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shoehorn","74506675","CDM","273","RC","","","facility","both","","","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Shoelaces Elastic All Sizes","74506676","CDM","273","RC","","","facility","both","","","","14.49","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Derm/Epidermal Gel Sheet","74506678","CDM","270","RC","A6025","HCPCS","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3995 Add Ue Ortho, Sock, Fx","74506680","CDM","274","RC","L3995","HCPCS","facility","both","","","","60.03","30.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Sock Aid","74506681","CDM","273","RC","","","facility","both","","","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Soft Inner Face For Bka","74506682","CDM","274","RC","L2820","HCPCS","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3925 Fo Pip Dip/Sprng Pre Ots","74506683","CDM","274","RC","L3925","HCPCS","facility","both","","","","51.75","25.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3919 Ho W/O Joints Cf","74506684","CDM","274","RC","L3919","HCPCS","facility","both","","","","259.79","129.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suction Brush","74506686","CDM","273","RC","","","facility","both","","","","17.6","8.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Theraband  (Per Yard)","74506688","CDM","273","RC","","","facility","both","","","","14.49","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Theraplus Soft Spastic Prefab","74506689","CDM","274","RC","L3908","HCPCS","facility","both","","","","85.91","42.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Theraputty","74506690","CDM","273","RC","","","facility","both","","","","14.49","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Thoracic, Rib Belt, Custom","74506691","CDM","274","RC","L0220","HCPCS","facility","both","","","","786.6","393.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Triplan 1 Pc Rigid Prefab","74506695","CDM","274","RC","L0488","HCPCS","facility","both","","","","1600.11","800.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Triplan 2 Pc W/Liner Cust","74506696","CDM","274","RC","L0486","HCPCS","facility","both","","","","2855.57","1427.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3908 Who Cock-Up Pre Ots","74506702","CDM","274","RC","L3908","HCPCS","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Biopsy Probe","74506703","CDM","270","RC","","","facility","both","","","","1318.59","659.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perclose 6Fr","74506709","CDM","278","RC","C1760","HCPCS","facility","both","","","","696","348","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3720 Eo Dbl Up W/Arm Cuff Cf","74506716","CDM","274","RC","L3720","HCPCS","facility","both","","","","698.63","349.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knife, Rocker","74506719","CDM","273","RC","","","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Prefabricated","74506722","CDM","274","RC","L0472","HCPCS","facility","both","","","","619.97","309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3808 Whfo Rigid W/O Jnt(S) Cf","74506741","CDM","274","RC","L3808","HCPCS","facility","both","","","","359.15","179.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wrist Be Prost Test Socket","74506743","CDM","274","RC","L6680","HCPCS","facility","both","","","","345.69","172.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Boot, Walk Cam Low Top","74506750","CDM","274","RC","L4386","HCPCS","facility","both","","","","257.72","128.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Boot, Walk Cam Pre Inflate","74506751","CDM","274","RC","L4386","HCPCS","facility","both","","","","257.72","128.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Boot, Walk Cam W/Dial","74506752","CDM","274","RC","L4386","HCPCS","facility","both","","","","257.72","128.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo Ant Tib Prefab","74506753","CDM","274","RC","L1932","HCPCS","facility","both","","","","1412.78","706.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cervical Miami Collar","74506761","CDM","274","RC","L0174","HCPCS","facility","both","","","","421.25","210.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cervical Miami Padding","74506762","CDM","274","RC","L0984","HCPCS","facility","both","","","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cervical Post Occ/Man Col Adj","74506763","CDM","274","RC","L0180","HCPCS","facility","both","","","","579.6","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hip Post Op Abduct Custom","74506770","CDM","274","RC","L1685","HCPCS","facility","both","","","","1881.63","940.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Dble Solid Stirrup","74506771","CDM","274","RC","L2020","HCPCS","facility","both","","","","1889.91","944.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Kafo Femur Fracture Fx Cast Rig","74506772","CDM","274","RC","L2136","HCPCS","facility","both","","","","1961.33","980.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Adj Motion Jnt Lerman","74506774","CDM","274","RC","L2186","HCPCS","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Bk Fork Strap","74506776","CDM","274","RC","L5684","HCPCS","facility","both","","","","83.84","41.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Cap Med Or Lat","74506779","CDM","274","RC","L2800","HCPCS","facility","both","","","","209.07","104.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Drop Lock","74506780","CDM","274","RC","L2182","HCPCS","facility","both","","","","158.36","79.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Knee Joint Torsion Straight","74506782","CDM","274","RC","L2380","HCPCS","facility","both","","","","192.51","96.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Oroth Elastic/Neopr","74506784","CDM","274","RC","L1820","HCPCS","facility","both","","","","114.89","57.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Knee Socket Insert Wo Lock","74506786","CDM","274","RC","L5679","HCPCS","facility","both","","","","955.31","477.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso, Aspen Back Brace","74506789","CDM","274","RC","L0631","HCPCS","facility","both","","","","1625.99","813","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso Corset Front","74506790","CDM","274","RC","L0972","HCPCS","facility","both","","","","189.41","94.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso Corset Prefab","74506791","CDM","274","RC","L0630","HCPCS","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso Flex Control Back Br","74506792","CDM","274","RC","L0633","HCPCS","facility","both","","","","460.58","230.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso Sag Coronal Prefab","74506793","CDM","274","RC","L0637","HCPCS","facility","both","","","","1701.54","850.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso Sag Coronal Shell Cust","74506794","CDM","274","RC","L0640","HCPCS","facility","both","","","","1658.07","829.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lso Sag Coronal Shell Pre","74506795","CDM","274","RC","L0639","HCPCS","facility","both","","","","1701.54","850.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lumbar Orthosis Flexible","74506796","CDM","274","RC","L0625","HCPCS","facility","both","","","","99.36","49.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lumbar Orthotic Sagett Prefab","74506797","CDM","274","RC","L0627","HCPCS","facility","both","","","","654.12","327.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3650 So 8 Abd Restrnt Pre Ots","74506801","CDM","274","RC","L3650","HCPCS","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Shoe, Amb Post Op Custom","74506802","CDM","274","RC","L3250","HCPCS","facility","both","","","","181.13","90.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Sock Femoral Length","74506805","CDM","274","RC","L2850","HCPCS","facility","both","","","","104.54","52.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tibial Pre Shell Molded Cust","74506809","CDM","274","RC","L2340","HCPCS","facility","both","","","","879.75","439.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Ant Thor Extension","74506810","CDM","274","RC","L1220","HCPCS","facility","both","","","","368.46","184.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Rigid Cust Plastc Lined","74506813","CDM","274","RC","L0484","HCPCS","facility","both","","","","2688.93","1344.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Rigid Custom Lined","74506814","CDM","274","RC","L0482","HCPCS","facility","both","","","","2504.7","1252.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Triplanar Prefab","74506815","CDM","274","RC","L0462","HCPCS","facility","both","","","","1975.82","987.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3807 Whfo W/O Joints Pre Cust","74506817","CDM","274","RC","L3807","HCPCS","facility","both","","","","297.05","148.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syvek Patch-Large","74506827","CDM","270","RC","","","facility","both","","","","274.28","137.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syvek Patch-Small","74506828","CDM","270","RC","","","facility","both","","","","176.99","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter His Bundle Medtronic","74506890","CDM","278","RC","C1887","HCPCS","facility","both","","","","641.7","320.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter His Pacing Boston Sci","74506891","CDM","278","RC","C1887","HCPCS","facility","both","","","","562.01","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Judo Straight Tip","74506892","CDM","278","RC","C1769","HCPCS","facility","both","","","","176.99","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gps Single Kit","74506900","CDM","272","RC","","","facility","both","","","","940.82","470.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Gps Double Kit","74506901","CDM","272","RC","","","facility","both","","","","1633.23","816.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gps Mini Kit","74506902","CDM","272","RC","","","facility","both","","","","707.94","353.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Edwards Latex Free Swan Gans","74506903","CDM","272","RC","","","facility","both","","","","1108","554","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Coil, Microvention Vfc","74507101","CDM","272","RC","","","facility","both","","","","2799.68","1399.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Coil, Microven Hypersoft 3D","74507102","CDM","272","RC","","","facility","both","","","","2750","1375","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr  Coil, Micro Hypsft 1.5-2.5Mm","74507103","CDM","272","RC","","","facility","both","","","","1973.75","986.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Coil, Micro Hypersoft 3-4Mm","74507104","CDM","272","RC","","","facility","both","","","","2045.16","1022.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Coil, Microven Hydroframe","74507105","CDM","272","RC","","","facility","both","","","","3635.96","1817.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Coil, Microven 18 Hydroframe","74507106","CDM","272","RC","","","facility","both","","","","4216.59","2108.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Coil, Microven 10 Hydrosoft","74507107","CDM","272","RC","","","facility","both","","","","2564.73","1282.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cath, Penumbra 5Maxace132","74507108","CDM","272","RC","","","facility","both","","","","3693.92","1846.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cath, Penumbra 5Maxace064","74507109","CDM","272","RC","","","facility","both","","","","3693.92","1846.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cath, Covidien Cello Balloon","74507110","CDM","272","RC","","","facility","both","","","","1493.51","746.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Cath, Renegade 18 150Cm 2 Tip","74507111","CDM","272","RC","","","facility","both","","","","1099.17","549.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Ball, Sceptor Xc 4X11","74507112","CDM","272","RC","","","facility","both","","","","2077.25","1038.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Stent, Wall Flex 8.5F X 75Cm","74507113","CDM","272","RC","","","facility","both","","","","2225.25","1112.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Guide, Surefire 5F 65Cm","74507114","CDM","272","RC","","","facility","both","","","","297.05","148.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Port, Angiodynamics Mini 6.6F","74507115","CDM","272","RC","","","facility","both","","","","408.83","204.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Etrinsa, Biv","74507122","CDM","275","RC","C2621","HCPCS","facility","both","","","","21797.1","10898.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kyphx Express 1St, Kpe1003","74507131","CDM","270","RC","","","facility","both","","","","7942.59","3971.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Drain System, Express Mini 500","74507500","CDM","274","RC","A7041","HCPCS","facility","both","","","","149.04","74.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Introducer Sys, Vena Tech Lp","74507700","CDM","272","RC","C1894","HCPCS","facility","both","","","","486.45","243.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Spyglass Probe","74507900","CDM","270","RC","","","facility","both","","","","419.18","209.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Flurodeoxyglucose F18 45Mi","74508001","CDM","343","RC","A9552","HCPCS","facility","both","","","","186","93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Strap Clavicle Adult Large","74508052","CDM","270","RC","","","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Cock Up","74508078","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Powerline 6Fr Dl","74508150","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Post Op Female Lg Velcro","74508169","CDM","270","RC","","","facility","both","","","","162.5","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sling Arm Small","74508227","CDM","270","RC","","","facility","both","","","","136.62","68.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Humidifer Chamber","74508900","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Nasal Pillows,Lg.","74508905","CDM","270","RC","","","facility","both","","","","110.75","55.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Nasal Pillows,Med.","74508906","CDM","270","RC","","","facility","both","","","","123.17","61.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Nasal Pillows,Sm.","74508907","CDM","270","RC","","","facility","both","","","","123.17","61.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Oscillator Circuit","74508918","CDM","270","RC","","","facility","both","","","","461.61","230.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sup  Implant Adhes Barrier/Intrceed","74508921","CDM","278","RC","C1765","HCPCS","facility","both","","","","1223.58","611.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Implant Mesh Graft Torso/Perin (C1781)","74508931","CDM","278","RC","C1781","HCPCS","facility","both","","","","1870.25","935.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Jagwire","74509027","CDM","270","RC","","","facility","both","","","","511.29","255.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Triple Lumen Arrow 7F","74509028","CDM","270","RC","","","facility","both","","","","541.31","270.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Catheter Kit Mac Ac","74509090","CDM","270","RC","","","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Bowl Set Brat","74509092","CDM","270","RC","","","facility","both","","","","141.8","70.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-System Fecal Management","74509100","CDM","270","RC","","","facility","both","","","","809","404.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Central Ven Oximetry Cath Kit","74509120","CDM","270","RC","","","facility","both","","","","728.64","364.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Foreign Body Hood","74509123","CDM","270","RC","","","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Casting Fiberglass 3In Roll","74509143","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Iupc","74509292","CDM","270","RC","","","facility","both","","","","233","116.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Gripper Huber 20Gx1","74509297","CDM","270","RC","","","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Thoratex Mobile Power Unit","74509450","CDM","274","RC","Q0489","HCPCS","facility","both","","","","14019.08","7009.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Palindrome Tdc","74509555","CDM","278","RC","C1750","HCPCS","facility","both","","","","1321.7","660.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Disposable Angiographic Kit","74509900","CDM","270","RC","","","facility","both","","","","308.43","154.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Pacemaker Service Kit","74509901","CDM","270","RC","","","facility","both","","","","219.42","109.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Orthopedic Appliances 1","74509999","CDM","270","RC","","","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Saturated Wound","74510004","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Mdl282-283Endotkreliance","74510041","CDM","275","RC","C1777","HCPCS","facility","both","","","","3064.64","1532.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Mdl285-286Endotakreliance","74510043","CDM","275","RC","C1895","HCPCS","facility","both","","","","3064.64","1532.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Mdl292-293Endotakreliance","74510044","CDM","275","RC","C1777","HCPCS","facility","both","","","","7500","3750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Mdl295-296Endotakreliance","74510045","CDM","275","RC","C1895","HCPCS","facility","both","","","","3064.64","1532.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kit, Conf Spinal Cmt, Ndless Sys","74510061","CDM","270","RC","","","facility","both","","","","1973.75","986.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Needle, Confidence Intr, 11G, 4In","74510062","CDM","270","RC","","","facility","both","","","","234.95","117.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Needle, Confidence Intr, 11G, 6In","74510063","CDM","270","RC","","","facility","both","","","","234.95","117.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath, Onestep Pruitt, 5Fr X 15","74510135","CDM","272","RC","C1729","HCPCS","facility","both","","","","45.54","22.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath, Onestep Pruitt, 5Fr X 10","74510136","CDM","272","RC","C1729","HCPCS","facility","both","","","","45.54","22.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath, Onestep Pruitt, 5Fr X 7","74510137","CDM","272","RC","C1729","HCPCS","facility","both","","","","121.1","60.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Picc Sl Arrow 4Fr","74510151","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3674 So Airplane W/Wo Jnt Cf","74510227","CDM","274","RC","L3674","HCPCS","facility","both","","","","1301","650.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Afo, Walk Boot Type Cus Fab","74510228","CDM","274","RC","L4631","HCPCS","facility","both","","","","2361.87","1180.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Splint 3In Ocl","74510489","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant,Cardiomems Hf System","74510800","CDM","278","RC","C2624","HCPCS","facility","both","","","","25350","12675","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Essentio Dr","74510801","CDM","275","RC","C1785","HCPCS","facility","both","","","","31850.06","15925.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Essentio Vr","74510802","CDM","275","RC","C1786","HCPCS","facility","both","","","","8023.32","4011.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Vasoseal Es Closure Device","74511051","CDM","272","RC","","","facility","both","","","","970.83","485.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ventilator Setup Charge 94656","74511052","CDM","270","RC","","","facility","both","","","","474.03","237.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter Set","74511055","CDM","270","RC","","","facility","both","","","","463.68","231.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Wire Jcurve","74511057","CDM","270","RC","","","facility","both","","","","133.52","66.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Radifocus Introducer","74511058","CDM","270","RC","","","facility","both","","","","185.27","92.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Suture Monosof 70P16","74511059","CDM","270","RC","","","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Adm Supplies New Born","74511060","CDM","270","RC","","","facility","both","","","","311","155.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Change/Supplies Min","74511063","CDM","270","RC","","","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Admission/Supplies Women's Health","74511064","CDM","270","RC","","","facility","both","","","","155","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Introducer 7 Fr","74511065","CDM","270","RC","","","facility","both","","","","1654.97","827.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Disposable Probe Guide","74511066","CDM","270","RC","","","facility","both","","","","60","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mm Fna Needle Set","74511068","CDM","270","RC","","","facility","both","","","","334.31","167.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kyphx Bone Filler Device, Fo6B","74511085","CDM","270","RC","","","facility","both","","","","338.45","169.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Needle Kit Guide 21G","74511102","CDM","270","RC","","","facility","both","","","","398.48","199.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Huber Bent Needle","74511579","CDM","270","RC","","","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Screw Cortical 3.5Mm R Maxillo","74511586","CDM","270","RC","","","facility","both","","","","50.72","25.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Elut Stent,Resolut,Intgrt","74511888","CDM","278","RC","C1874","HCPCS","facility","both","","","","3004.61","1502.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glidesheath,Radial 6F Nitinol","74511890","CDM","272","RC","C1894","HCPCS","facility","both","","","","194","97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glidesheath,Radial 5F Sskit 25","74511892","CDM","272","RC","C1894","HCPCS","facility","both","","","","175","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glidesheath,Radial 6F Sskit 25","74511893","CDM","272","RC","C1894","HCPCS","facility","both","","","","200.79","100.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glidesheath,Radial 5F Nitinol","74511899","CDM","272","RC","C1894","HCPCS","facility","both","","","","200.79","100.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glidewire .018 & .035 Straight","74511971","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ureteral Open End 5F","74512003","CDM","270","RC","","","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Biopsy Disp","74512005","CDM","270","RC","","","facility","both","","","","306.36","153.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Stapler Skin Regular","74512141","CDM","270","RC","","","facility","both","","","","234.95","117.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suture Retriever","74512208","CDM","270","RC","","","facility","both","","","","162.5","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Kit Urine Collection","74512308","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Go Gear Battery Charger","74512421","CDM","274","RC","Q0495","HCPCS","facility","both","","","","9687.6","4843.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gogear Battery Clips (2 Sets Of 2)","74512422","CDM","274","RC","Q0497","HCPCS","facility","both","","","","1859.55","929.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cath-Icy Start Up Kit Only","74512430","CDM","270","RC","","","facility","both","","","","106.61","53.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bard Powerport Sl Mri 8 Fr","74512431","CDM","278","RC","C1788","HCPCS","facility","both","","","","1420.02","710.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cath-Thermoguard Icy Cath","74512432","CDM","278","RC","C1751","HCPCS","facility","both","","","","1750.19","875.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cath-Coolline Start Up Kit","74512434","CDM","270","RC","","","facility","both","","","","639.63","319.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cath-Icy Cath Only","74512435","CDM","270","RC","","","facility","both","","","","1646.69","823.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cath-Coolline Cath Only","74512437","CDM","270","RC","","","facility","both","","","","956.34","478.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath-Icy Start Up Kit Only","74512450","CDM","270","RC","","","facility","both","","","","639.63","319.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Shoe Flat","74512471","CDM","270","RC","","","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dermabond","74512474","CDM","270","RC","","","facility","both","","","","67","33.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Probe Electrosurgical","74512502","CDM","270","RC","","","facility","both","","","","311.54","155.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Nebulizer Rain Drop","74512616","CDM","270","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Spinal 20 G X 3.5","74512622","CDM","270","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sling Arm Xlg","74512633","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Crutch Youth Adjust Alum","74513003","CDM","270","RC","","","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Oasis Per Sq Sm Wasted-Q4102","74513005","CDM","278","RC","Q4102","HCPCS","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Jtube, Securlok, 14F X 7, 10Ml Bln","74513015","CDM","270","RC","","","facility","both","","","","278.42","139.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Jtube, Securlok, 16F X 7, 10Ml Bln","74513016","CDM","270","RC","","","facility","both","","","","278.42","139.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Jtube, Securlok, 18F X 7, 10Ml Bln","74513018","CDM","270","RC","","","facility","both","","","","278.42","139.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Jtube, Securlok, 22F X 7, 10Ml Bln","74513019","CDM","270","RC","","","facility","both","","","","278.42","139.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Hw Implant Set","74513021","CDM","270","RC","","","facility","both","","","","163958.49","81979.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hw Implant Accessories","74513024","CDM","270","RC","","","facility","both","","","","10336.55","5168.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closure Device,Exoseal","74513030","CDM","278","RC","C1760","HCPCS","facility","both","","","","512.33","256.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closure,Mynx Cad,5Fr Grey","74513032","CDM","278","RC","C1760","HCPCS","facility","both","","","","605.48","302.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closure,Mynx Cad,6/7Fr Green","74513034","CDM","278","RC","C1760","HCPCS","facility","both","","","","605.48","302.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tube Sump Salem 16Fr","74513066","CDM","270","RC","","","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib,Quartet,Quadripolar","74513602","CDM","275","RC","C1900","HCPCS","facility","both","","","","5499.99","2750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cook Needles Eye Snare","74514004","CDM","272","RC","C1773","HCPCS","facility","both","","","","660.33","330.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Cook Byrd Dilator Sheath","74514011","CDM","272","RC","C1893","HCPCS","facility","both","","","","364.32","182.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cook Bulldog Lead Extender","74514015","CDM","270","RC","","","facility","both","","","","372.6","186.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peripheral Athrectomy Catheter","74514060","CDM","272","RC","C1724","HCPCS","facility","both","","","","3540.74","1770.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Dextrus","74514079","CDM","275","RC","C1898","HCPCS","facility","both","","","","1540.08","770.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Filter Wire Embolic Protection","74514085","CDM","272","RC","C1884","HCPCS","facility","both","","","","3313.04","1656.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Bil Luminexx 14X60, 80 Cm","74514757","CDM","278","RC","C1876","HCPCS","facility","both","","","","3615.26","1807.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Bln,Atlas,14X4,75 Cm,7 Fr","74514759","CDM","272","RC","C1725","HCPCS","facility","both","","","","973.94","486.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Kit,Goose Neck,6Fr,20Mm","74514762","CDM","272","RC","C1773","HCPCS","facility","both","","","","660.33","330.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"D300 Rapid Infusor Disposable","74514800","CDM","270","RC","","","facility","both","","","","208.04","104.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg French Kit Cath Introducer","74514801","CDM","270","RC","","","facility","both","","","","85.91","42.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Lg Bore Multilumen Introduce","74514802","CDM","270","RC","","","facility","both","","","","202.86","101.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Insertion Kit Linear","74514803","CDM","270","RC","","","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amplatzer Talisman Pfo Occluder","74514804","CDM","278","RC","C1817","HCPCS","facility","both","","","","13448.79","6724.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Antibacterial Pouch","74514805","CDM","270","RC","","","facility","both","","","","1543","771.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recrdr,Reveal Linq Study","74514808","CDM","278","RC","C1764","HCPCS","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath, Phenom Dis Access","74514821","CDM","278","RC","C1887","HCPCS","facility","both","","","","1453.14","726.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Tubing Disconnect 4","74515000","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pacemaker External","74515198","CDM","270","RC","","","facility","both","","","","1492.47","746.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Renegade","74515200","CDM","278","RC","C1887","HCPCS","facility","both","","","","772.11","386.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Renegade Hi Flo","74515201","CDM","270","RC","","","facility","both","","","","1236.83","618.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Emb Vasc Str, 5 Mm Fbr Plat","74515520","CDM","270","RC","","","facility","both","","","","97.29","48.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Emb Vasc Str, 2 Mm Fbr Plat","74515521","CDM","270","RC","","","facility","both","","","","97.29","48.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Rt & Lt Heart Cath Supply","74515722","CDM","270","RC","","","facility","both","","","","307.4","153.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd S Upply, Left Heart Cath","74515723","CDM","270","RC","","","facility","both","","","","123.17","61.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd S Upply, Right Heart Cath","74515724","CDM","270","RC","","","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temporary Pacing Wire Only","74515727","CDM","275","RC","","","facility","both","","","","853.88","426.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thermal Dilution Swan Only","74515728","CDM","270","RC","","","facility","both","","","","535.1","267.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd S Upply Ptca","74515735","CDM","270","RC","","","facility","both","","","","3225.06","1612.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Supply, Peripheral Diag Proc","74515736","CDM","270","RC","","","facility","both","","","","166.64","83.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Supply, Peripheral Interv Proc","74515737","CDM","270","RC","","","facility","both","","","","923.22","461.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd S Upply, Rotoblator","74515739","CDM","270","RC","","","facility","both","","","","4991.81","2495.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monitoring Swan Supply (Only)","74515743","CDM","270","RC","","","facility","both","","","","336","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Gogear Modular Belt Repl Only","74515751","CDM","274","RC","Q0499","HCPCS","facility","both","","","","799.02","399.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transseptal Approach Supply","74515753","CDM","270","RC","","","facility","both","","","","308.43","154.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Applicator Tip","74515762","CDM","270","RC","","","facility","both","","","","83.84","41.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Graft Delivery Syringe","74515763","CDM","270","RC","","","facility","both","","","","256.68","128.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Peritoneal Dialysis Sol.1.5%","74515767","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Peritoneal Dialysis Sol.2.5%","74515768","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Peritoneal Dialysis Sol.4.25%","74515769","CDM","270","RC","","","facility","both","","","","39.33","19.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Travel Case","74515793","CDM","274","RC","Q0508","HCPCS","facility","both","","","","274.28","137.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sodium Fluoride F-18 =< 30 Mci","74515799","CDM","343","RC","A9580","HCPCS","facility","both","","","","570","285","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr 18F Florbetapir","74515803","CDM","343","RC","A9586","HCPCS","facility","both","","","","3728","1864","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tlso Flex Trnk Sj-Ss Pre Ots","74516081","CDM","274","RC","L0457","HCPCS","facility","both","","","","1236.83","618.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Pta Balloon Chocolate","74516670","CDM","272","RC","C1725","HCPCS","facility","both","","","","931.5","465.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Set, Schon Xl, 15","74517025","CDM","278","RC","C1752","HCPCS","facility","both","","","","378.81","189.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Vivaquad Biv Attainstudy","74517670","CDM","275","RC","C1882","HCPCS","facility","both","","","","41216.81","20608.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Catheter Expressway Extraction Cpt C1757","74518056","CDM","272","RC","C1757","HCPCS","facility","both","","","","669.65","334.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Catheter Solent Prox1 C1757","74518057","CDM","272","RC","C1757","HCPCS","facility","both","","","","2257.34","1128.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Catheter Solent Omni C1757","74518058","CDM","272","RC","C1757","HCPCS","facility","both","","","","1910.61","955.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hemobag Kit","74518060","CDM","270","RC","","","facility","both","","","","600","300","","","","","","","","","","","","","Gross Charge Type: Standard"
"D-Stat,Flowable","74518061","CDM","278","RC","C1760","HCPCS","facility","both","","","","357.08","178.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Niagara","74518064","CDM","278","RC","C1752","HCPCS","facility","both","","","","428.49","214.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Schon","74518065","CDM","278","RC","C1752","HCPCS","facility","both","","","","378.81","189.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crrt Cartridge Change Supply","74518066","CDM","272","RC","","","facility","both","","","","417.11","208.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Picco Supply","74518067","CDM","270","RC","","","facility","both","","","","1379.66","689.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Subq-Icd","74518069","CDM","275","RC","C1722","HCPCS","facility","both","","","","39823","19911.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Adhesiv/Liquid,Anytype,Per Oz-A4364","74518070","CDM","272","RC","A4364","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Belt-A4367","74518071","CDM","270","RC","A4367","HCPCS","facility","both","","","","10.35","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Barr,Solid 4X4-A4372","74518072","CDM","272","RC","A4372","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Pch,W/St Wear Barr-A4389","74518073","CDM","272","RC","A4389","HCPCS","facility","both","","","","14.49","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Barr,Pectn Paste,Per Oz-A4406","74518074","CDM","272","RC","A4406","HCPCS","facility","both","","","","31.05","15.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Pch,Drain,W/Flange-A5063","74518076","CDM","272","RC","A5063","HCPCS","facility","both","","","","17.6","8.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Pch,Urinary W/Barrier-A5071","74518077","CDM","272","RC","A5071","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wound Pouch,Each-A6154","74518078","CDM","272","RC","A6154","HCPCS","facility","both","","","","34.16","17.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Contact Layer >48 Sq In -A6208","74518079","CDM","272","RC","A6208","HCPCS","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ostomy Pch,Drainable W/Barr-A5061","74518080","CDM","272","RC","A5061","HCPCS","facility","both","","","","33.12","16.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Foam Drg<=16 Sq In W/Border-A6212","74518081","CDM","272","RC","A6212","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Foam Drg>16<=48 Sqin W/Border-A6213","74518082","CDM","272","RC","A6213","HCPCS","facility","both","","","","15.53","7.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Foam Drg>48 Sq In W/Border-A6214","74518083","CDM","272","RC","A6214","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Foam Dressing, Filler, Per Gram-A6215","74518084","CDM","272","RC","A6215","HCPCS","facility","both","","","","17.6","8.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Gauze <=16 In No W/Sal W/O Brd-A6222","74518085","CDM","272","RC","A6222","HCPCS","facility","both","","","","7.25","3.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Gauze >16<=48 No W/Sal W/O Brd-A6223","74518086","CDM","272","RC","A6223","HCPCS","facility","both","","","","7.25","3.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Gauze >48 In No W/Sal W/O Brd-A6224","74518087","CDM","272","RC","A6224","HCPCS","facility","both","","","","7.25","3.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrocolld Drg<=16 W/O Brdr-A6234","74518088","CDM","272","RC","A6234","HCPCS","facility","both","","","","10.35","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrocolld Drg >16<=48 W/O Brd-A6235","74518089","CDM","272","RC","A6235","HCPCS","facility","both","","","","10.35","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrocolld Drg > 48 In W/O Brd-A6236","74518090","CDM","272","RC","A6236","HCPCS","facility","both","","","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrocolld Drg<=16 In W/Brdr-A6237","74518091","CDM","272","RC","A6237","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrocolld Drg>16<=48 W/Brdr-A6238","74518092","CDM","272","RC","A6238","HCPCS","facility","both","","","","9.32","4.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrocolld Drg>48 In W/Brdr-A6239","74518093","CDM","272","RC","A6239","HCPCS","facility","both","","","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrogel Drg<=16 In W/O Brd-A6242","74518094","CDM","272","RC","A6242","HCPCS","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrogel Drg<16<=48 W/Brdr-A6243","74518095","CDM","272","RC","A6243","HCPCS","facility","both","","","","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrogel Drg<=16 In W/Brdr -A6245","74518096","CDM","272","RC","A6245","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hydrogel Drg,Gel Filr,Per Floz-A6248","74518097","CDM","272","RC","A6248","HCPCS","facility","both","","","","36.23","18.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Skin Sealnt Protect Moisturizr-A6250","74518098","CDM","272","RC","A6250","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Absorpt Drg>16<=48 W/O Brdr-A6252","74518099","CDM","272","RC","A6252","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Absorpt Drg>48 Sq In W/O Brdr-A6253","74518100","CDM","272","RC","A6253","HCPCS","facility","both","","","","15.53","7.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Absorpt Drg<=16 Sq In W/Wbrdr-A6254","74518101","CDM","272","RC","A6254","HCPCS","facility","both","","","","10.35","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Absorpt Drg>16<=48 In W/Brdr-A6255","74518102","CDM","272","RC","A6255","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wound Fillr Gel/Paste,Per Fl Oz A6261","74518103","CDM","272","RC","A6261","HCPCS","facility","both","","","","81.77","40.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wound Fillr Dry Form,Per Gram-A6262","74518104","CDM","272","RC","A6262","HCPCS","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Gauze,Impreg,No H20/Sal.Per Yd-A6266","74518105","CDM","272","RC","A6266","HCPCS","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Chg Conform Bnd,Widt>=3""""<5"""".Peryd-A6443""","74518106","CDM","272","RC","A6443","HCPCS","facility","both","","","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Chg Light Comprsn Bnd>=""""<3""""<""""5,Peryd-A6449""","74518107","CDM","272","RC","A6449","HCPCS","facility","both","","","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Chg Zinc Paste Bnd Wd>=3""""<5"""",Peryd-A6456""","74518108","CDM","272","RC","A6456","HCPCS","facility","both","","","","14.49","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Tubular Drsng,Any Width,Per Yd -A6457","74518109","CDM","272","RC","A6457","HCPCS","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Viewflex","74518400","CDM","278","RC","C1759","HCPCS","facility","both","","","","2295","1147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Ingevity Mri","74518408","CDM","275","RC","C1898","HCPCS","facility","both","","","","1418","709","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Nicom Lead","74518690","CDM","270","RC","","","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Halo Ablation Catheter","74518691","CDM","270","RC","","","facility","both","","","","2097.95","1048.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Advantio Sr","74518697","CDM","275","RC","C1786","HCPCS","facility","both","","","","8914.46","4457.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Fortify Assura Dr","74518700","CDM","275","RC","C1721","HCPCS","facility","both","","","","30632.9","15316.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Ellipse Dr","74518702","CDM","275","RC","C1721","HCPCS","facility","both","","","","30632.9","15316.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Fortify Assura Vr","74518704","CDM","275","RC","C1722","HCPCS","facility","both","","","","26612.96","13306.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Ellipse Vr","74518706","CDM","275","RC","C1722","HCPCS","facility","both","","","","26612.96","13306.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Quadra Assura Biv","74518708","CDM","275","RC","C1882","HCPCS","facility","both","","","","37714.37","18857.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Unify Assura Biv","74518710","CDM","275","RC","C1882","HCPCS","facility","both","","","","31714.47","15857.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Q-Guide Lead Tunnel Device","74518715","CDM","270","RC","","","facility","both","","","","1796","898","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Acuity Pro","74518716","CDM","278","RC","C1887","HCPCS","facility","both","","","","3114","1557","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Inogen Dr","74518721","CDM","275","RC","C1721","HCPCS","facility","both","","","","28690.2","14345.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Inogen Vr","74518722","CDM","278","RC","C1722","HCPCS","facility","both","","","","90372.06","45186.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Inogen Biv","74518723","CDM","278","RC","C1882","HCPCS","facility","both","","","","90372.06","45186.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Dynagen Biv","74518724","CDM","278","RC","C1882","HCPCS","facility","both","","","","28300.01","14150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Valitude Biv","74518725","CDM","275","RC","C2621","HCPCS","facility","both","","","","17437.68","8718.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Accolade Dr","74518727","CDM","275","RC","C1785","HCPCS","facility","both","","","","11619.95","5809.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Accolade Vr","74518728","CDM","275","RC","C1786","HCPCS","facility","both","","","","8023.32","4011.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide,Crnrysinus Worley Advncd","74518729","CDM","272","RC","C1892","HCPCS","facility","both","","","","576.5","288.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Lateral Vein Worley","74518730","CDM","272","RC","C1893","HCPCS","facility","both","","","","691.38","345.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Micro Asahi Corsair","74518750","CDM","272","RC","C1887","HCPCS","facility","both","","","","800","400","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib,Subcutaneous,Rv","74519053","CDM","275","RC","C1896","HCPCS","facility","both","","","","7970","3985","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr 5Fr Sgl Lumen Picc","74519070","CDM","278","RC","C1751","HCPCS","facility","both","","","","256.68","128.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"5Fr Dual Lumen Picc","74519071","CDM","278","RC","C1751","HCPCS","facility","both","","","","705.87","352.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire,Guidezilla","74519077","CDM","272","RC","C1769","HCPCS","facility","both","","","","370","185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent,Zilver Ptx","74519200","CDM","278","RC","C1874","HCPCS","facility","both","","","","2415.69","1207.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Immobilizer Shoulder Lg","74519206","CDM","270","RC","","","facility","both","","","","329.13","164.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Enema Mineral Oil Adult 4.5Oz","74520014","CDM","270","RC","","","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dressing Change","74520251","CDM","270","RC","","","facility","both","","","","292.91","146.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Non-Ionic Dye","74521208","CDM","270","RC","","","facility","both","","","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Implantable Seed For Rsl","74521306","CDM","278","RC","A4650","HCPCS","facility","both","","","","159.39","79.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter,Celect,Jugular","74521400","CDM","278","RC","C1880","HCPCS","facility","both","","","","2887.65","1443.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Filter, Celect, Universal","74521401","CDM","278","RC","C1880","HCPCS","facility","both","","","","2887.65","1443.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter,Celect,Femoral","74521402","CDM","278","RC","C1880","HCPCS","facility","both","","","","2887.65","1443.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Device Retriever, Celect Filter","74521403","CDM","272","RC","C1773","HCPCS","facility","both","","","","1433.48","716.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 8 X 4","74521562","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 8 X 6","74521563","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 10 X 4","74521564","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 10 X 5","74521565","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 10 X 6","74521566","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 10 X 7","74521567","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 10 X 8","74521568","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 12 X 4","74521569","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 12 X 6","74521570","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Viatorr 12 X 8","74521571","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Smart 8X40X80 Cm","74521572","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 9X40X80 Cm","74521573","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 9X60X80 Cm","74521574","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 9X30X80 Cm","74521575","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 10X60X80 Cm","74521576","CDM","278","RC","C1876","HCPCS","facility","both","","","","3316.14","1658.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 12X40 X80 Cm","74521578","CDM","278","RC","C1876","HCPCS","facility","both","","","","3100.86","1550.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 14X40 X80 Cm","74521580","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Smart 10X40 X80 Cm","74521581","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Selfexp Smart 14 X 60","74521582","CDM","278","RC","C1876","HCPCS","facility","both","","","","3100.86","1550.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Set Angio Pump","74521583","CDM","270","RC","","","facility","both","","","","831.11","415.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Xepeedior Angiojet 6 X 60","74521584","CDM","270","RC","","","facility","both","","","","1321.7","660.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Neuroform 4 X 20","74521587","CDM","278","RC","C1876","HCPCS","facility","both","","","","8798.54","4399.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 10 X 40 Rx Nitinol","74521594","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 5 X 40 Rx Nitinol","74521597","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 6 X 30 Rx Nitinol","74521599","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 6 X 40 Rx Nitinol","74521600","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 7 X 20 Rx Nitinol","74521601","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 7 X 40 Rx Nitinol","74521603","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 8 X 40 Rx Nitinol","74521605","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent Precise 9 X 40 Rx Nitinol","74521608","CDM","278","RC","C1876","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Optiease Ivc 55Cm","74521609","CDM","278","RC","C1880","HCPCS","facility","both","","","","4135.86","2067.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Miniport T / Pu / 8 / 1.6 / 2.6 / 63","74521618","CDM","270","RC","","","facility","both","","","","2008.94","1004.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Guidewire Synchro 1631","74521627","CDM","272","RC","C1769","HCPCS","facility","both","","","","1067.09","533.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Guidewire Ang Stiff .035 X 260","74521628","CDM","272","RC","C1769","HCPCS","facility","both","","","","909.77","454.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Katzen Infusion 035 X 9 X 145","74521629","CDM","270","RC","","","facility","both","","","","636.53","318.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Guidewire Ang Reg .035 X 180","74521633","CDM","272","RC","C1769","HCPCS","facility","both","","","","630.32","315.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Guide 6Fr 100Cm **Custom**","74521635","CDM","270","RC","","","facility","both","","","","461.61","230.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Gd 7F 100Cm **Custom**","74521636","CDM","270","RC","","","facility","both","","","","461.61","230.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Guidewire 018 / 180 / 3 / 70 Ang","74521637","CDM","272","RC","C1769","HCPCS","facility","both","","","","459.54","229.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Guidewire 018 / 180 / 3 / 45 Ang","74521638","CDM","272","RC","C1769","HCPCS","facility","both","","","","407.79","203.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Guide Str Xf 5F 90Cm","74521640","CDM","270","RC","","","facility","both","","","","397.44","198.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Guide Str 5Fr 90Cm","74521641","CDM","270","RC","","","facility","both","","","","397.44","198.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Guide Mpxf 5F 90Cm","74521642","CDM","270","RC","","","facility","both","","","","397.44","198.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Guide Mp 5Fr 90Cm","74521643","CDM","270","RC","","","facility","both","","","","397.44","198.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Reflection Spiral","74521706","CDM","272","RC","C1733","HCPCS","facility","both","","","","3144.33","1572.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closure Device,Boomerang","74521708","CDM","278","RC","C1760","HCPCS","facility","both","","","","546.48","273.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Bentson Wire","74521709","CDM","272","RC","C1769","HCPCS","facility","both","","","","121.1","60.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire,Ptca Terumo","74521710","CDM","272","RC","C1769","HCPCS","facility","both","","","","176","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Peripheral Fluency","74521714","CDM","278","RC","C1874","HCPCS","facility","both","","","","3944.39","1972.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Peripheral I-Cast","74521715","CDM","278","RC","C1874","HCPCS","facility","both","","","","3337.88","1668.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Peripheral Viabahn","74521716","CDM","278","RC","C1874","HCPCS","facility","both","","","","4657.5","2328.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Thermacool","74521719","CDM","272","RC","C2630","HCPCS","facility","both","","","","3098.79","1549.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"D-Stat Hemaband","74521720","CDM","270","RC","","","facility","both","","","","144","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent, Endeavor","74521723","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent,Promus","74521725","CDM","278","RC","C1874","HCPCS","facility","both","","","","2405.34","1202.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiducial Marker,Ea,Nm887-830","74521727","CDM","270","RC","A4648","HCPCS","facility","both","","","","167.67","83.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Fiducial Mark Kt. Nm887712","74521728","CDM","270","RC","A4648","HCPCS","facility","both","","","","368.46","184.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Fiducial Marker Pk Nw887709","74521729","CDM","270","RC","A4648","HCPCS","facility","both","","","","400.55","200.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Hexapolar","74521730","CDM","272","RC","C1730","HCPCS","facility","both","","","","532","266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Decapolar","74521731","CDM","272","RC","C1730","HCPCS","facility","both","","","","689","344.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire,Safesept Transseptal","74521732","CDM","278","RC","C1769","HCPCS","facility","both","","","","440.91","220.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Ret Sys,Celect Flt,11X80","74521733","CDM","278","RC","C1773","HCPCS","facility","both","","","","1421.06","710.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcath,Progreat,2.8Fx110","74521736","CDM","278","RC","C1887","HCPCS","facility","both","","","","1139.54","569.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcath,Progreat,2.8Fx130","74521737","CDM","278","RC","C1887","HCPCS","facility","both","","","","1139.54","569.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Axium 3D 2-25Mm","74521760","CDM","270","RC","","","facility","both","","","","1731.56","865.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Axium 3D Es 1-3.5Mm","74521761","CDM","270","RC","","","facility","both","","","","2187.99","1094","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Axium 3D Ss 4-6Mm Dia","74521762","CDM","270","RC","","","facility","both","","","","1731.56","865.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Axium Helical 1.5-20Mm","74521763","CDM","270","RC","","","facility","both","","","","1319.63","659.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Axium Helix Ss 4-6 Mm Dia","74521764","CDM","270","RC","","","facility","both","","","","1319.63","659.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Coil Axium Helix Es 1-3 Mm Dia","74521765","CDM","270","RC","","","facility","both","","","","1775.03","887.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Device, Enterprise","74521771","CDM","270","RC","","","facility","both","","","","8035.74","4017.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Device, Lvis","74521772","CDM","270","RC","","","facility","both","","","","8123.72","4061.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Device, Lvisj","74521773","CDM","270","RC","","","facility","both","","","","9061.43","4530.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Impella","74521880","CDM","270","RC","","","facility","both","","","","42543","21271.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Snare Ensnare 12X20","74521885","CDM","272","RC","C1773","HCPCS","facility","both","","","","767.97","383.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Access Device, Arstasis","74521886","CDM","270","RC","","","facility","both","","","","437.81","218.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Suture Material","74523042","CDM","270","RC","","","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kyphx Express Introducer, T24A","74524203","CDM","270","RC","","","facility","both","","","","1861.97","930.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100202 Hesv","74525025","CDM","270","RC","","","facility","both","","","","2892.83","1446.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100304 Hesv","74525028","CDM","270","RC","","","facility","both","","","","2411.55","1205.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100306 Hesv","74525029","CDM","270","RC","","","facility","both","","","","2678.58","1339.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100408 Hesv","74525032","CDM","270","RC","","","facility","both","","","","2941.47","1470.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100410 Hesv","74525033","CDM","270","RC","","","facility","both","","","","3208.5","1604.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 140407 Hesv","74525044","CDM","270","RC","","","facility","both","","","","2812.1","1406.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 140510 Hesv","74525046","CDM","270","RC","","","facility","both","","","","3208.5","1604.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 140610 Hesv","74525048","CDM","270","RC","","","facility","both","","","","3208.5","1604.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 140715 Hesv","74525052","CDM","270","RC","","","facility","both","","","","3649.41","1824.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180610 Hesv","74525060","CDM","270","RC","","","facility","both","","","","3517.97","1758.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180710 Hesv","74525061","CDM","270","RC","","","facility","both","","","","3517.97","1758.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180815 Hesv","74525063","CDM","270","RC","","","facility","both","","","","3959.91","1979.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 181015 Hesv","74525065","CDM","270","RC","","","facility","both","","","","3959.91","1979.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100610 Hesv","74525080","CDM","270","RC","","","facility","both","","","","3208.5","1604.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 140515 Hesv","74525081","CDM","270","RC","","","facility","both","","","","3649.41","1824.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100201 Hsv","74525082","CDM","270","RC","","","facility","both","","","","1894.05","947.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100202 Hsv","74525083","CDM","270","RC","","","facility","both","","","","1894.05","947.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100203 Hsv","74525084","CDM","270","RC","","","facility","both","","","","1894.05","947.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100204 Hsv","74525085","CDM","270","RC","","","facility","both","","","","1894.05","947.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100304 Hsv","74525087","CDM","270","RC","","","facility","both","","","","1894.05","947.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100306 Hsv","74525088","CDM","270","RC","","","facility","both","","","","1894.05","947.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100404 Hsv","74525090","CDM","270","RC","","","facility","both","","","","1974.78","987.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100406 Hsv","74525091","CDM","270","RC","","","facility","both","","","","1974.78","987.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100408 Hsv","74525092","CDM","270","RC","","","facility","both","","","","1974.78","987.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100410 Ccv","74525099","CDM","270","RC","","","facility","both","","","","2127.96","1063.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100512 Ccv","74525100","CDM","270","RC","","","facility","both","","","","2233.53","1116.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180512 Ccv","74525101","CDM","270","RC","","","facility","both","","","","2233.53","1116.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180615 Ccv","74525102","CDM","270","RC","","","facility","both","","","","2233.53","1116.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180717 Ccv","74525103","CDM","270","RC","","","facility","both","","","","2233.53","1116.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180820 Ccv","74525104","CDM","270","RC","","","facility","both","","","","2340.14","1170.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 180923 Ccv","74525105","CDM","270","RC","","","facility","both","","","","2340.14","1170.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 181026 Ccv","74525106","CDM","270","RC","","","facility","both","","","","2340.14","1170.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 181128 Ccv","74525107","CDM","270","RC","","","facility","both","","","","2450.88","1225.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 181231 Ccv","74525108","CDM","270","RC","","","facility","both","","","","2450.88","1225.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 181332 Ccv","74525109","CDM","270","RC","","","facility","both","","","","2450.88","1225.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 181434 Ccv","74525110","CDM","270","RC","","","facility","both","","","","2450.88","1225.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100201 H2Hsv","74525114","CDM","270","RC","","","facility","both","","","","2229.39","1114.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100202 H2Hsv","74525115","CDM","270","RC","","","facility","both","","","","2357.73","1178.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100203 H2Hsv","74525116","CDM","270","RC","","","facility","both","","","","2481.93","1240.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100204 H2Hsv","74525117","CDM","270","RC","","","facility","both","","","","2608.2","1304.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100206 H2Hsv","74525118","CDM","270","RC","","","facility","both","","","","2862.81","1431.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100304 H2Hsv","74525119","CDM","270","RC","","","facility","both","","","","2608.2","1304.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100306 H2Hsv","74525120","CDM","270","RC","","","facility","both","","","","2862.81","1431.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100308 H2Hsv","74525121","CDM","270","RC","","","facility","both","","","","3113.28","1556.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100404 H2Hsv","74525122","CDM","270","RC","","","facility","both","","","","2608.2","1304.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100406 H2Hsv","74525123","CDM","270","RC","","","facility","both","","","","2862.81","1431.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100408 H2Hsv","74525124","CDM","270","RC","","","facility","both","","","","3113.28","1556.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 100608 H2Hsv","74525128","CDM","270","RC","","","facility","both","","","","3113.28","1556.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14022530","74525130","CDM","270","RC","","","facility","both","","","","3619.4","1809.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14030330","74525131","CDM","270","RC","","","facility","both","","","","3642.17","1821.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14030430","74525132","CDM","270","RC","","","facility","both","","","","3673.22","1836.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14030630","74525133","CDM","270","RC","","","facility","both","","","","3709.44","1854.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14040630","74525134","CDM","270","RC","","","facility","both","","","","3673.22","1836.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14040830","74525135","CDM","270","RC","","","facility","both","","","","3709.44","1854.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14044530","74525136","CDM","270","RC","","","facility","both","","","","3654.59","1827.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14050730","74525137","CDM","270","RC","","","facility","both","","","","3709.44","1854.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14051230","74525138","CDM","270","RC","","","facility","both","","","","3762.23","1881.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Crc14091430","74525145","CDM","270","RC","","","facility","both","","","","3820.19","1910.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cerv Collar Moldable.","74525206","CDM","274","RC","L0170","HCPCS","facility","both","","","","764.87","382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3764 Ewho W/Joint(S) Cf","74525210","CDM","274","RC","L3764","HCPCS","facility","both","","","","877.68","438.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Hi Press Conquest,75Cm","74525211","CDM","272","RC","C1725","HCPCS","facility","both","","","","655.16","327.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Agilis Hispro7.4F Bundled","74525212","CDM","272","RC","C1887","HCPCS","facility","both","","","","1785.38","892.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Paracentesis Kit 5Fr X 10Cm","74525213","CDM","272","RC","C1729","HCPCS","facility","both","","","","342.59","171.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kit Cement Confidence 5Cc Mini","74525214","CDM","270","RC","","","facility","both","","","","1733.63","866.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Adapter Luer Conf Spnl Cmt Sys","74525215","CDM","270","RC","","","facility","both","","","","437.81","218.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3905 Who W/Nontorsion Jnt Cf","74525216","CDM","274","RC","L3905","HCPCS","facility","both","","","","949.1","474.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3935 Fo Nontorsion Joint Cf","74525220","CDM","274","RC","L3935","HCPCS","facility","both","","","","250.47","125.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3961 Sewho Cap W/O Jnts Cf","74525223","CDM","274","RC","L3961","HCPCS","facility","both","","","","1607.36","803.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3967 Sewho Airplan W/O Jnt Cf","74525224","CDM","274","RC","L3967","HCPCS","facility","both","","","","1898.19","949.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3971 Sewho Cap W/Jnt(S) Cf","74525225","CDM","274","RC","L3971","HCPCS","facility","both","","","","1800.9","900.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3973 Sewho Airplane W/Jnt Cf","74525226","CDM","274","RC","L3973","HCPCS","facility","both","","","","1898.19","949.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3975 Sewhfo Cap W/O Jnt Cf Cust","74525227","CDM","274","RC","L3975","HCPCS","facility","both","","","","1607.36","803.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3976 Sewhfo Airpln W/O Jnt Cf","74525228","CDM","274","RC","L3976","HCPCS","facility","both","","","","1607.36","803.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3977 Sewhfo Cap W/Jnt(S) Cf","74525229","CDM","274","RC","L3977","HCPCS","facility","both","","","","1800.9","900.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3978 Sewhfo Airplane W/Jnt Cf","74525230","CDM","274","RC","L3978","HCPCS","facility","both","","","","1898.19","949.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cath-Thermoguard Coolline Cath","74525232","CDM","270","RC","","","facility","both","","","","1593.9","796.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cerv Collar Flex Thermoplastic","74525235","CDM","274","RC","L0130","HCPCS","facility","both","","","","237.02","118.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Stent, Epic Selfexpnd Vas C1876","74525277","CDM","278","RC","C1876","HCPCS","facility","both","","","","2587.5","1293.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3765 Ewhfo Rigid W/O Jnts Cf","74525311","CDM","274","RC","L3765","HCPCS","facility","both","","","","1227.51","613.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3766 Ewhfo W/Joint(S) Cf","74525314","CDM","274","RC","L3766","HCPCS","facility","both","","","","1298.93","649.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcoil, Presidio, Pc410041230","74525637","CDM","270","RC","","","facility","both","","","","5223.65","2611.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcoil, Presidio, Pc410051730","74525638","CDM","270","RC","","","facility","both","","","","5937.8","2968.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcoil, Presidio, Pc410062630","74525639","CDM","270","RC","","","facility","both","","","","5324.04","2662.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcoil, Presidio, Pc410073030","74525640","CDM","270","RC","","","facility","both","","","","5372.69","2686.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Microcoil, Presidio, Pc410082930","74525641","CDM","270","RC","","","facility","both","","","","4919.36","2459.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Nebulizer Handheld","74526037","CDM","270","RC","","","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iodide-131 Cap Generic Per Mci","74527116","CDM","343","RC","A9517","HCPCS","facility","both","","","","214","107","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Cath Jejun Peg/Pej Pigtail","74527133","CDM","270","RC","","","facility","both","","","","112.82","56.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Bal Cre W/Guide Eso/Ply","74527136","CDM","270","RC","","","facility","both","","","","661.37","330.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Balloon Cre Esoph","74527137","CDM","270","RC","","","facility","both","","","","583.74","291.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Balloon Cre Pulm","74527138","CDM","270","RC","","","facility","both","","","","764.87","382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Balloon Ercp Dil","74527140","CDM","270","RC","","","facility","both","","","","689.31","344.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Balloon Stone Retr","74527141","CDM","270","RC","","","facility","both","","","","439.88","219.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Bronch Stchg-Ent","74527142","CDM","270","RC","","","facility","both","","","","3431.03","1715.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Brush Bronch Micro 90Cm","74527144","CDM","270","RC","","","facility","both","","","","60.03","30.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Brush Cyt 2.3Mm X150Cm","74527145","CDM","270","RC","","","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Basket Stone","74527146","CDM","270","RC","","","facility","both","","","","775.22","387.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Bx Sys Autocore M00512931","74527147","CDM","270","RC","","","facility","both","","","","140.76","70.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Cln/Duod Stchg-Ent","74527148","CDM","270","RC","","","facility","both","","","","3813.98","1906.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Ercp Cyt Brush","74527149","CDM","270","RC","","","facility","both","","","","314.64","157.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Ercp Bili Cann","74527150","CDM","270","RC","","","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Guide/Jagwire","74527153","CDM","270","RC","","","facility","both","","","","449.19","224.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Infl Dev Breeze Rapid X","74527154","CDM","270","RC","","","facility","both","","","","215.28","107.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Inj Sys Rapid Refill","74527155","CDM","270","RC","","","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Intro Kit","74527156","CDM","270","RC","","","facility","both","","","","727.61","363.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Peg Kit","74527157","CDM","270","RC","","","facility","both","","","","301.19","150.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Ligating Poly Loop","74527158","CDM","270","RC","","","facility","both","","","","255.65","127.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Wang Needle 21Ga","74527161","CDM","270","RC","","","facility","both","","","","259.79","129.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Sphincto Nknf 00545840","74527163","CDM","270","RC","","","facility","both","","","","525.78","262.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Overtube","74527164","CDM","270","RC","","","facility","both","","","","378.81","189.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Peg Tube Y-Port Repl 20Fr","74527165","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Perc Trach Kit","74527166","CDM","270","RC","","","facility","both","","","","879.75","439.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Probe Gold 10Fr","74527167","CDM","270","RC","","","facility","both","","","","69.35","34.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Probe Gold 7Fr","74527168","CDM","270","RC","","","facility","both","","","","495.77","247.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Clipping Device","74527170","CDM","270","RC","","","facility","both","","","","450.23","225.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Snare Capt Oval","74527171","CDM","270","RC","","","facility","both","","","","79.7","39.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Snvmcinc Autotome","74527172","CDM","270","RC","","","facility","both","","","","656.19","328.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Snvmcinc Tapertome","74527173","CDM","270","RC","","","facility","both","","","","656.19","328.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Spot Tattoo Ink 5Ml","74527174","CDM","270","RC","","","facility","both","","","","62.1","31.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Trach Stchg-Ent","74527175","CDM","270","RC","","","facility","both","","","","3431.03","1715.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Tube Ball Peg Repl","74527176","CDM","270","RC","","","facility","both","","","","110.75","55.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Tube Jejunal","74527177","CDM","270","RC","","","facility","both","","","","259.79","129.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Endo Bili Stchg-Ent","74527180","CDM","270","RC","","","facility","both","","","","270.14","135.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytx Seed Strnd,Iodine-125","74527181","CDM","278","RC","C2638","HCPCS","facility","both","","","","187.34","93.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytx Seed Nonstd,Iodin-125","74527183","CDM","278","RC","C2639","HCPCS","facility","both","","","","133.52","66.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytx Seed Strnd,Pallad-103","74527185","CDM","278","RC","C2640","HCPCS","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytx Seed,Nonstd,Palld-103","74527187","CDM","278","RC","C2641","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytx Seed Stranded Ces-131","74527191","CDM","278","RC","C2642","HCPCS","facility","both","","","","421.25","210.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytx Seed Nonstrd Ces-131","74527193","CDM","278","RC","C2643","HCPCS","facility","both","","","","421.25","210.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Device,Pipeline Fa-77425-16","74527199","CDM","270","RC","","","facility","both","","","","14978.52","7489.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device,Pipeline Fa-77425-18","74527204","CDM","270","RC","","","facility","both","","","","14978.52","7489.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device,Pipeline Fa-77450-16","74527205","CDM","270","RC","","","facility","both","","","","14978.52","7489.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device,Pipeline Fa-77475-16","74527206","CDM","270","RC","","","facility","both","","","","14978.52","7489.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Epic Selfexpnd Vasc120Mm","74527276","CDM","278","RC","C1876","HCPCS","facility","both","","","","4684.41","2342.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hmiii Implant Kit","74527400","CDM","270","RC","","","facility","both","","","","134449.61","67224.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Hmii Tunneling Tools","74527401","CDM","270","RC","","","facility","both","","","","3027.38","1513.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hmiii Backup Controller","74527402","CDM","278","RC","Q0506","HCPCS","facility","both","","","","7219.13","3609.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Hm Modular Cable","74527403","CDM","278","RC","Q0477","HCPCS","facility","both","","","","6496.7","3248.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hm 14V Batteries(Set Of 4)","74527404","CDM","278","RC","Q0506","HCPCS","facility","both","","","","3280.95","1640.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Heartmate Holster Vest","74527405","CDM","278","RC","Q0498","HCPCS","facility","both","","","","699.66","349.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Heartmate Shower Bag (2)","74527406","CDM","278","RC","Q0501","HCPCS","facility","both","","","","796.95","398.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hmii Mobile Power Unit","74527407","CDM","278","RC","Q0479","HCPCS","facility","both","","","","10302.39","5151.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Bioline Cardiohelp Disposable","74527502","CDM","270","RC","","","facility","both","","","","13778.96","6889.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Vascular Kit","74527503","CDM","270","RC","","","facility","both","","","","257.72","128.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Avalon Cannula","74527504","CDM","270","RC","","","facility","both","","","","3085.34","1542.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Fem Track Cannula","74527505","CDM","270","RC","","","facility","both","","","","837.32","418.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Fem Flex Cannula","74527506","CDM","270","RC","","","facility","both","","","","463.68","231.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Trach Pediatric Pdc/Plc","74529100","CDM","270","RC","","","facility","both","","","","112.82","56.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Trach Adult Bivona","74529106","CDM","270","RC","","","facility","both","","","","227.7","113.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Trach Shiley Proximal Ext","74529109","CDM","270","RC","","","facility","both","","","","189.41","94.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Innercannula For Trach","74529112","CDM","270","RC","","","facility","both","","","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cardioplegia Table Line","74529116","CDM","270","RC","","","facility","both","","","","160.43","80.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Dlp Pressure Display Set","74529117","CDM","270","RC","","","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cardiov Proced Pk","74529118","CDM","270","RC","","","facility","both","","","","240","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Flowmeter Peak Tru Zone","74530300","CDM","270","RC","","","facility","both","","","","96.26","48.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Introducer Sheath Denny","74530327","CDM","270","RC","","","facility","both","","","","200.79","100.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Horn 7F Percut Dual","74530328","CDM","270","RC","","","facility","both","","","","619.97","309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Loop","74530330","CDM","270","RC","","","facility","both","","","","1002.92","501.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Snare Goose Neck Kit","74530331","CDM","278","RC","C1773","HCPCS","facility","both","","","","2103.12","1051.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coils Tornado","74530338","CDM","270","RC","","","facility","both","","","","349.83","174.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coils Complex Helical","74530339","CDM","270","RC","","","facility","both","","","","1293.75","646.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Fibered Gdc 18 Vortex","74530341","CDM","270","RC","","","facility","both","","","","2103.12","1051.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Vortex 3M Diamond","74530342","CDM","270","RC","","","facility","both","","","","3487.95","1743.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Introducer Flexible X 24","74530345","CDM","270","RC","","","facility","both","","","","212.18","106.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Cath Marking 100Cmpiggsw","74530346","CDM","270","RC","","","facility","both","","","","453.33","226.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Small Dressing Kit-Wound Vac","74533904","CDM","270","RC","","","facility","both","","","","108.68","54.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Medium Dressing Kit-Wound Vac","74533905","CDM","270","RC","","","facility","both","","","","139.73","69.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Large Dressing Kit-Wound Vac","74533906","CDM","270","RC","","","facility","both","","","","165.6","82.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Canister Kit W/Isolyser-Wound Vac","74533908","CDM","270","RC","","","facility","both","","","","142.83","71.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wound Vac Soft Foam (10 X 15)","74533911","CDM","270","RC","","","facility","both","","","","173.88","86.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pediatric Straight Cath Kit","74535127","CDM","270","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Attain Prforma Quadripolr","74536000","CDM","275","RC","C1900","HCPCS","facility","both","","","","5589","2794.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Protego S","74536004","CDM","275","RC","C1777","HCPCS","facility","both","","","","29921.85","14960.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Protego Sd","74536005","CDM","275","RC","C1895","HCPCS","facility","both","","","","31418.46","15709.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Consulta Biv","74539070","CDM","275","RC","C2621","HCPCS","facility","both","","","","21797.1","10898.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Femostop","74540011","CDM","270","RC","","","facility","both","","","","381.92","190.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ptca Guiding Catheter","74540044","CDM","272","RC","C1887","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath Arthrectomy Foxhollow","74540050","CDM","272","RC","C1714","HCPCS","facility","both","","","","5793.93","2896.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Chest Tube Insertion","74540058","CDM","270","RC","","","facility","both","","","","492.66","246.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Picc Insertion Supplies","74540059","CDM","270","RC","","","facility","both","","","","279.45","139.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Umbilical Line Insert Supplies","74540060","CDM","270","RC","","","facility","both","","","","449.19","224.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath Ash Split 32Cm","74540062","CDM","278","RC","C1750","HCPCS","facility","both","","","","1552.5","776.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ash Split 28Cm","74540063","CDM","278","RC","C1750","HCPCS","facility","both","","","","1552.5","776.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wall 14 / 60Mm B1","74540080","CDM","278","RC","C1876","HCPCS","facility","both","","","","3655.62","1827.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wall 16 / 60Mm B1","74540081","CDM","278","RC","C1876","HCPCS","facility","both","","","","3624.57","1812.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon 164 Xxl 14552","74540084","CDM","272","RC","C1725","HCPCS","facility","both","","","","507.15","253.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tracker 18 133101","74540090","CDM","270","RC","","","facility","both","","","","1496.61","748.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tracker","74540091","CDM","270","RC","","","facility","both","","","","1147.82","573.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Palmaz 10 Mm P104M","74540092","CDM","278","RC","C1877","HCPCS","facility","both","","","","2858.67","1429.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Transjugular Bx Gun","74540101","CDM","270","RC","","","facility","both","","","","1206.81","603.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wall 08 / 40Mm H840","74540102","CDM","278","RC","C1876","HCPCS","facility","both","","","","3602.84","1801.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wall 18 / 60Mm B186","74540109","CDM","278","RC","C1876","HCPCS","facility","both","","","","3700.13","1850.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Filter Greenfield Stnls St","74540113","CDM","278","RC","C1880","HCPCS","facility","both","","","","3734.28","1867.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Savvy Pta Bln 10566","74540115","CDM","272","RC","C1725","HCPCS","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Introducer Tipss","74540133","CDM","270","RC","","","facility","both","","","","1191.29","595.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotoblator Burr","74540155","CDM","272","RC","C1724","HCPCS","facility","both","","","","3754","1877","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotoblator Wire","74540156","CDM","272","RC","C1769","HCPCS","facility","both","","","","571","285.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide Guidant","74540157","CDM","272","RC","C1887","HCPCS","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ptca Guidant","74540158","CDM","272","RC","C1769","HCPCS","facility","both","","","","321","160.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indaflator Guidant","74540159","CDM","270","RC","","","facility","both","","","","320","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Intravascular Ultrasound","74540160","CDM","272","RC","C1753","HCPCS","facility","both","","","","2602","1301","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Laser 1.4 Concentric","74540161","CDM","272","RC","C1885","HCPCS","facility","both","","","","3561","1780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Rosen 1.5 Mm","74540190","CDM","270","RC","","","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Newton 15 Mm J","74540191","CDM","270","RC","","","facility","both","","","","63","31.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Bentson","74540192","CDM","270","RC","","","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire 3 Mm J","74540194","CDM","270","RC","","","facility","both","","","","205","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Device Inflation","74540195","CDM","270","RC","","","facility","both","","","","409.86","204.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Temno Bx Sys Act","74540196","CDM","270","RC","","","facility","both","","","","132","66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle Bx Franseen 18G","74540199","CDM","270","RC","","","facility","both","","","","105.57","52.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle Bx Fran Dfbn 18G","74540201","CDM","272","RC","","","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cement Delivery System","74540313","CDM","270","RC","","","facility","both","","","","1765.71","882.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Obw/20/8/2/20Mm","74540317","CDM","272","RC","","","facility","both","","","","687.24","343.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath 5Fx 100 Cm 21 Cm Marker","74540320","CDM","270","RC","","","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath 5F Hohn Sl","74540321","CDM","278","RC","C1751","HCPCS","facility","both","","","","705.87","352.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Castaneda Otw Brush","74540322","CDM","270","RC","","","facility","both","","","","2620.62","1310.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Prowler 14 / 2 Tip","74540326","CDM","270","RC","","","facility","both","","","","1572.17","786.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Tracker 18 / 2 Cm Ext","74540328","CDM","270","RC","","","facility","both","","","","939.78","469.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micromewi 2.9F / 150 / 10","74540329","CDM","270","RC","","","facility","both","","","","713.12","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micromewi 2.9F / 150 / 5","74540330","CDM","270","RC","","","facility","both","","","","713.12","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Otw Teratola Device","74540331","CDM","272","RC","C1757","HCPCS","facility","both","","","","2379.47","1189.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Unifuse 5/90/30","74540332","CDM","270","RC","","","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Tracker 18 / 2 Cm Ext","74540333","CDM","270","RC","","","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare 35Mm Loop Snare","74540342","CDM","272","RC","C1773","HCPCS","facility","both","","","","988.43","494.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent 29Mm X 8Mm X 80Cm","74540348","CDM","278","RC","C1876","HCPCS","facility","both","","","","3474.5","1737.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent 39Mm X 8Mm X 80Cm","74540350","CDM","278","RC","C1876","HCPCS","facility","both","","","","3648.38","1824.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 10 X 24 / 75 Cm","74540351","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 5 X 16 / 75Cm","74540354","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 6 X 16 / 75Cm","74540356","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 7 X 15 / 75Cm","74540358","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 7 X 40 / 75Cm","74540360","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 8 X 26 / 75Cm","74540361","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 8 X 39 / 75Cm","74540362","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Ave 9 X 38 / 75Cm","74540364","CDM","278","RC","C1876","HCPCS","facility","both","","","","4627.49","2313.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wallstent 12 X 90 / 110 Cm","74540366","CDM","278","RC","C1876","HCPCS","facility","both","","","","6047.51","3023.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wallstent 14 X 90 / 110 Cm","74540367","CDM","278","RC","C1876","HCPCS","facility","both","","","","5447.21","2723.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wallstent 16 X 90 / 110 Cm","74540368","CDM","278","RC","C1876","HCPCS","facility","both","","","","5720.45","2860.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Mwce18S7 / 2 Tornado","74540377","CDM","270","RC","","","facility","both","","","","311.54","155.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Berenstein Lc 2.5 / 30","74540378","CDM","270","RC","","","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 010 / 4 X 4 Soft","74540380","CDM","270","RC","","","facility","both","","","","1787.45","893.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 010 / 4 X 10 2D","74540383","CDM","270","RC","","","facility","both","","","","1845.41","922.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 010 / 5 X 15 2D","74540384","CDM","270","RC","","","facility","both","","","","1845.41","922.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 010 / 7 X 25 2D","74540387","CDM","270","RC","","","facility","both","","","","1945.8","972.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 010 / 8 X 30 2D","74540388","CDM","270","RC","","","facility","both","","","","1945.8","972.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 018 / 9 X 30 2D","74540392","CDM","270","RC","","","facility","both","","","","1945.8","972.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 018 / 12 X 30 2D","74540394","CDM","270","RC","","","facility","both","","","","2043.09","1021.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 018 / 20 X 30","74540396","CDM","270","RC","","","facility","both","","","","2120.72","1060.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 018 / 20 X 30 2D","74540399","CDM","270","RC","","","facility","both","","","","2180.75","1090.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 10 Soft Sr 2 X 2","74540400","CDM","270","RC","","","facility","both","","","","2480.9","1240.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 10 Soft Sr 2 X 4","74540401","CDM","270","RC","","","facility","both","","","","2480.9","1240.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 10 Soft Sr 2 X 3","74540403","CDM","270","RC","","","facility","both","","","","2554.38","1277.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cutting Balloon","74540410","CDM","272","RC","C1725","HCPCS","facility","both","","","","1941","970.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 103D 3 X 4","74540414","CDM","270","RC","","","facility","both","","","","3267.5","1633.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 103D 3 X 6","74540415","CDM","270","RC","","","facility","both","","","","3267.5","1633.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 103D 4 X 6","74540416","CDM","270","RC","","","facility","both","","","","3267.5","1633.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 103D 4 X 8","74540417","CDM","270","RC","","","facility","both","","","","3364.79","1682.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 103D 6 X 10","74540418","CDM","270","RC","","","facility","both","","","","3462.08","1731.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coils Gdc 103D 5 X 8","74540422","CDM","270","RC","","","facility","both","","","","3602.84","1801.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Spinnaker 1.5Fl","74540425","CDM","270","RC","","","facility","both","","","","1472.81","736.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Spinnaker 1.5Fxl","74540426","CDM","270","RC","","","facility","both","","","","1472.81","736.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Spinnaker 1.8Fl","74540427","CDM","270","RC","","","facility","both","","","","1373.45","686.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Micro Spinnaker 1.8Fxl","74540428","CDM","270","RC","","","facility","both","","","","1373.45","686.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Snare Gooseneck 7 Mm","74540439","CDM","272","RC","C1773","HCPCS","facility","both","","","","1962.36","981.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolic Pva 150250","74540440","CDM","270","RC","","","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Rosch Uchida Tj Set","74540441","CDM","270","RC","","","facility","both","","","","1095.03","547.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Biopsy Forcep-Hot","74540443","CDM","270","RC","","","facility","both","","","","133.52","66.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Glueliquid Embolic System","74540459","CDM","270","RC","","","facility","both","","","","5554.85","2777.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammotome Probe Handheld 8G","74540462","CDM","270","RC","","","facility","both","","","","796.95","398.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Sheath, Ksaw73890Rbshtlhc","74540463","CDM","270","RC","","","facility","both","","","","469.89","234.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Sheath, Checkflo 16Fx35Cm Lrg","74540470","CDM","270","RC","","","facility","both","","","","465.75","232.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Port, Pwr Duo Mri Chrono, 9.5F","74540476","CDM","278","RC","C1788","HCPCS","facility","both","","","","1503.86","751.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diag Decapolar Courna","74540483","CDM","272","RC","C1730","HCPCS","facility","both","","","","1566.99","783.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diagnostic Quad Josep","74540489","CDM","272","RC","C1730","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diagnostic Stablemapr","74540491","CDM","272","RC","C1731","HCPCS","facility","both","","","","2149.7","1074.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diagnostic Ultra Ice","74540492","CDM","272","RC","C1759","HCPCS","facility","both","","","","2665.13","1332.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Catheter, Diagnostic Decapolar","74540495","CDM","272","RC","C1730","HCPCS","facility","both","","","","713.12","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Mapping Ensite","74540496","CDM","272","RC","C1732","HCPCS","facility","both","","","","8792.33","4396.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Endotak Endur Ez","74540509","CDM","275","RC","C1895","HCPCS","facility","both","","","","9739.35","4869.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapt/Exten,Pacing/Neuro Lead","74540511","CDM","278","RC","C1883","HCPCS","facility","both","","","","971.87","485.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Reliance Sing-Coil","74540512","CDM","275","RC","C1777","HCPCS","facility","both","","","","31418.46","15709.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Fineline Ii Ez","74540518","CDM","275","RC","C1898","HCPCS","facility","both","","","","2492.28","1246.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Tendril Sdx","74540521","CDM","275","RC","C1898","HCPCS","facility","both","","","","1834.02","917.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Capsurefix Novu","74540522","CDM","275","RC","C1898","HCPCS","facility","both","","","","1595","797.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kyphx Exp Introducer, T24C","74540562","CDM","270","RC","","","facility","both","","","","972.9","486.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Safe Sheath","74540584","CDM","272","RC","C1892","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mullins Sheath","74540585","CDM","272","RC","C1893","HCPCS","facility","both","","","","332.24","166.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Introducer, Peelaway","74540586","CDM","270","RC","","","facility","both","","","","173.88","86.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wholey Wire","74540587","CDM","270","RC","","","facility","both","","","","223","111.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glide Wire","74540588","CDM","272","RC","C1769","HCPCS","facility","both","","","","326","163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon,Venogram","74540596","CDM","272","RC","C1725","HCPCS","facility","both","","","","507.15","253.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Medtronic 6931","74540597","CDM","275","RC","C1898","HCPCS","facility","both","","","","1834.02","917.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Kit Gastro Flexifold W / Dilator 18Fr","74540601","CDM","270","RC","","","facility","both","","","","248.4","124.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Cs Quickflex","74540605","CDM","275","RC","C1900","HCPCS","facility","both","","","","5498.96","2749.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mr Mammo Tome Bx Kit 8G 115Mm","74540625","CDM","270","RC","","","facility","both","","","","1731.56","865.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ackerman Bone Bx Needle","74540626","CDM","270","RC","","","facility","both","","","","835.25","417.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bard 6Fr Powerline","74540627","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Lc Beads, Yellow Lbl, 100300 Um","74540670","CDM","278","RC","C1884","HCPCS","facility","both","","","","4949.37","2474.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Lc Beads, Red Lbl, 500700 Um","74540672","CDM","278","RC","C1884","HCPCS","facility","both","","","","4949.37","2474.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ndl, Yueh Cent Cath, 5Fr, 19Gx7Cm","74540681","CDM","272","RC","C1729","HCPCS","facility","both","","","","121.1","60.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter, Frontrunner Micro","74540703","CDM","270","RC","","","facility","both","","","","885.96","442.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Intracardiac Acunav","74540705","CDM","272","RC","C1759","HCPCS","facility","both","","","","3000","1500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Catheter, Localisa Reference","74540706","CDM","270","RC","","","facility","both","","","","922.19","461.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode,Ensite Navx","74540717","CDM","270","RC","","","facility","both","","","","2850","1425","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit,Dsys","74540718","CDM","270","RC","","","facility","both","","","","3158.82","1579.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peripheral Balloon","74540723","CDM","272","RC","C1725","HCPCS","facility","both","","","","730","365","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Abviser","74540724","CDM","270","RC","","","facility","both","","","","2355.66","1177.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Balloon Toray","74540750","CDM","270","RC","","","facility","both","","","","4309.74","2154.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Acuity","74540751","CDM","275","RC","C1900","HCPCS","facility","both","","","","8479.76","4239.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Bag, Collect, Cn2 Angiflus*","74540779","CDM","270","RC","","","facility","both","","","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Cath, Flexima Apd, 6Frx25Cm","74540780","CDM","272","RC","C1729","HCPCS","facility","both","","","","183.2","91.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ndl, Bx Trocar, 18Gax10Cm","74540781","CDM","272","RC","","","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Ndl, Bx Trocar, 18Gax20Cm","74540783","CDM","272","RC","","","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp System, Fluid Mgt, Angiflush Iii","74540880","CDM","270","RC","","","facility","both","","","","168.71","84.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Drainage Set Thalquick, 24 X 41","74540901","CDM","272","RC","C1729","HCPCS","facility","both","","","","256.68","128.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Drainage Set Thalquick, 16 X 41","74540902","CDM","272","RC","C1729","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resuscitator Child Manual Disp","74549080","CDM","270","RC","","","facility","both","","","","148.01","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radial Edge Forcep","74549081","CDM","270","RC","","","facility","both","","","","99.36","49.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punctal Plug Supply-Permanent","74550003","CDM","270","RC","","","facility","both","","","","95.22","47.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Fathom .016","74550004","CDM","272","RC","C1769","HCPCS","facility","both","","","","669.65","334.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath,Ven,Powerline 6Fr","74550193","CDM","278","RC","C1751","HCPCS","facility","both","","","","970.83","485.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occluder Deliv Sys,Amplatzer","74550194","CDM","270","RC","","","facility","both","","","","1312.38","656.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Occluder,Amplatzer Duct 9Fr","74550195","CDM","270","RC","","","facility","both","","","","2790.36","1395.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter,Duramax","74550196","CDM","272","RC","C1750","HCPCS","facility","both","","","","582.71","291.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Neph/Uret Stent 8/22","74550218","CDM","278","RC","C2617","HCPCS","facility","both","","","","607.55","303.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Micro Dasher .014","74550220","CDM","272","RC","C1769","HCPCS","facility","both","","","","704.84","352.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire V-18 .018","74550228","CDM","272","RC","C1769","HCPCS","facility","both","","","","468.86","234.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Guide Crossover Ii","74550237","CDM","272","RC","C1887","HCPCS","facility","both","","","","565.11","282.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Flex Biliary Dr 10F","74550255","CDM","272","RC","C1729","HCPCS","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoravent Chest Tube","74550257","CDM","272","RC","C1729","HCPCS","facility","both","","","","359.15","179.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Flex Bil 08F 27-154","74550258","CDM","272","RC","C1729","HCPCS","facility","both","","","","412.97","206.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sheath Peelaway 14Fr","74550261","CDM","272","RC","C1894","HCPCS","facility","both","","","","276.35","138.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Angioflush Iii","74550266","CDM","270","RC","","","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Nitinol .018 80Cm","74550267","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 7-2","74550268","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 6-2","74550270","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Nephrostomy 10Fr","74550272","CDM","272","RC","C1729","HCPCS","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 4-2 5 /75","74550274","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 4-2 5/120","74550275","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 8-4","74550279","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil 4Mmx30Mm","74550281","CDM","270","RC","","","facility","both","","","","333.27","166.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Picc Sl Cook 5Fr","74550283","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Glide .018 Ang","74550284","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 7-4","74550285","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 9-2","74550286","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 5-2","74550288","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Vortex 2Mmx4Mm","74550289","CDM","270","RC","","","facility","both","","","","424.35","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Vortex 2Mmx5Mm","74550290","CDM","270","RC","","","facility","both","","","","424.35","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil 2Mmx10Mm","74550291","CDM","270","RC","","","facility","both","","","","333.27","166.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Tracker 18","74550292","CDM","270","RC","","","facility","both","","","","1069.16","534.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain Dawson Muel 8.5 Fr","74550293","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Inf Pro-Infusion","74550298","CDM","270","RC","","","facility","both","","","","484.38","242.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil 2Mmx3Mm","74550299","CDM","270","RC","","","facility","both","","","","424.35","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Vortex 3Mm","74550300","CDM","270","RC","","","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Helical 2/20","74550301","CDM","270","RC","","","facility","both","","","","333.27","166.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Diamond 6-4","74550308","CDM","272","RC","C1725","HCPCS","facility","both","","","","1114.7","557.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brite Sheath","74550310","CDM","278","RC","C1894","HCPCS","facility","both","","","","175.95","87.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Sizing 70Cm","74550312","CDM","270","RC","","","facility","both","","","","510.26","255.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Sizing 100Cm Straight","74550313","CDM","270","RC","","","facility","both","","","","463.68","231.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Sizing 100Cm Pigtail","74550314","CDM","270","RC","","","facility","both","","","","463.68","231.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Glide 65 Cm C3 5Fr","74550323","CDM","272","RC","C1887","HCPCS","facility","both","","","","292.91","146.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Guide Hockey","74550325","CDM","272","RC","C1887","HCPCS","facility","both","","","","484.38","242.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Measuring Graduated","74550327","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sheath Checkflow 10Fr","74550328","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Nephrostomy 12Fr","74550330","CDM","272","RC","C1729","HCPCS","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Biliary 10Fr Soft","74550331","CDM","272","RC","C1729","HCPCS","facility","both","","","","447.12","223.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Picc Dl Arrow 5Fr","74550335","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Teratola Motor Drive","74550336","CDM","270","RC","","","facility","both","","","","424.35","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Teratola 65Cm","74550337","CDM","272","RC","C1757","HCPCS","facility","both","","","","1884.74","942.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain 8.5 Ult","74550339","CDM","272","RC","C1729","HCPCS","facility","both","","","","386.06","193.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Micro 1.0","74550344","CDM","272","RC","C1887","HCPCS","facility","both","","","","358.11","179.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Micro 1.5-5","74550345","CDM","270","RC","","","facility","both","","","","358.11","179.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Micro 2.1","74550346","CDM","270","RC","","","facility","both","","","","358.11","179.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Picc Dl Vaxcel 5Fr","74550347","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drain 8Fr","74550348","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drain 10Fr","74550349","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drain 12Fr","74550350","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain 14Fr","74550351","CDM","272","RC","C1729","HCPCS","facility","both","","","","412.97","206.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Nitinol .018 75Cm","74550353","CDM","272","RC","C1769","HCPCS","facility","both","","","","268.07","134.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain Apdl 8Fr","74550359","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain Apdl 10Fr","74550360","CDM","272","RC","C1729","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Inf Katzen 6Cm","74550361","CDM","272","RC","C1769","HCPCS","facility","both","","","","779.36","389.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Glide .018 45 Ang","74550363","CDM","272","RC","C1769","HCPCS","facility","both","","","","565.11","282.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Glide .018 70 Ang","74550364","CDM","272","RC","C1769","HCPCS","facility","both","","","","565.11","282.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Glide .035 Ss Long Taper","74550365","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain Chest 14Fr","74550367","CDM","272","RC","C1729","HCPCS","facility","both","","","","453.33","226.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Glide .035 Shapeable","74550369","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Nester 6Mm","74550370","CDM","270","RC","","","facility","both","","","","387.09","193.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Nester 8 Mm","74550371","CDM","270","RC","","","facility","both","","","","387.09","193.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Nester 10Mm","74550372","CDM","270","RC","","","facility","both","","","","387.09","193.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Nester 4Mm","74550373","CDM","270","RC","","","facility","both","","","","387.09","193.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Nester 12Mm","74550374","CDM","270","RC","","","facility","both","","","","387.09","193.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Guide Mani","74550376","CDM","272","RC","C1887","HCPCS","facility","both","","","","771.08","385.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Micro Taper .014","74550382","CDM","272","RC","C1769","HCPCS","facility","both","","","","582.71","291.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Glide .035 Ss Short Taper","74550384","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Accustick","74550385","CDM","270","RC","","","facility","both","","","","267.03","133.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Inf Katzen 12 Cm","74550386","CDM","270","RC","","","facility","both","","","","779.36","389.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Inf Ps 90Cm X 20Cm","74550387","CDM","270","RC","","","facility","both","","","","955.31","477.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pva 355-500","74550388","CDM","270","RC","","","facility","both","","","","723.47","361.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pva 250-355","74550389","CDM","270","RC","","","facility","both","","","","763.83","381.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pva 500-710","74550390","CDM","270","RC","","","facility","both","","","","763.83","381.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Glide 100Cm Angle/Taper","74550393","CDM","278","RC","C1887","HCPCS","facility","both","","","","292.91","146.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Glidewire Ang .025X180","74550396","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Ureteral Stent 8/26","74550397","CDM","278","RC","C2617","HCPCS","facility","both","","","","607.55","303.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Ureteral Stent 8/24","74550398","CDM","278","RC","C2617","HCPCS","facility","both","","","","607.55","303.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Neph/Uret Stent 8/24","74550400","CDM","278","RC","C2617","HCPCS","facility","both","","","","364.32","182.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Snare","74550404","CDM","272","RC","","","facility","both","","","","333.27","166.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Inf Ps 135Cm X 20Cm","74550405","CDM","270","RC","","","facility","both","","","","955.31","477.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Wholey","74550407","CDM","278","RC","C1769","HCPCS","facility","both","","","","405.72","202.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Micro Coil Pusher","74550409","CDM","272","RC","C1769","HCPCS","facility","both","","","","484.38","242.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Snare 25Mm","74550410","CDM","272","RC","C1773","HCPCS","facility","both","","","","660.33","330.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Angiojet","74550411","CDM","272","RC","C1757","HCPCS","facility","both","","","","462.65","231.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Ureteral Stent 8/20","74550412","CDM","278","RC","C2617","HCPCS","facility","both","","","","607.55","303.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Ureteral Stent 8/22","74550413","CDM","278","RC","C2617","HCPCS","facility","both","","","","607.55","303.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Stone Removal","74550414","CDM","270","RC","","","facility","both","","","","874.58","437.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cope Catheter Introducer","74550416","CDM","272","RC","C1894","HCPCS","facility","both","","","","367.43","183.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Inf Ps 90Cm X 30Cm","74550418","CDM","270","RC","","","facility","both","","","","955.31","477.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Serial Cast-Finger","74550430","CDM","274","RC","L3933","HCPCS","facility","both","","","","48.65","24.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Transcyte And Exudry","74550439","CDM","270","RC","","","facility","both","","","","3989.93","1994.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp:I-131 Nal Dx Cap Per Mci","74550486","CDM","343","RC","A9528","HCPCS","facility","both","","","","54","27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp:Tc-99 Myoview Per Study","74550496","CDM","343","RC","A9502","HCPCS","facility","both","","","","340","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter,Amplatzer Delivery","74550500","CDM","270","RC","","","facility","both","","","","1038.11","519.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Drain Duan 5Fr","74550515","CDM","272","RC","C1729","HCPCS","facility","both","","","","342.59","171.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Glide Str 5F 65Cm","74550516","CDM","270","RC","","","facility","both","","","","269.1","134.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Groshing 7Fr","74550517","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Neph / Uret Stent 8/26","74550519","CDM","278","RC","C2617","HCPCS","facility","both","","","","488.52","244.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Nephrostomy 8Fr","74550522","CDM","272","RC","C1729","HCPCS","facility","both","","","","156.29","78.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Sizing 70Cm Pigtail","74550523","CDM","270","RC","","","facility","both","","","","471.96","235.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Vortex 4Mm","74550524","CDM","270","RC","","","facility","both","","","","340.52","170.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Micro 3.0","74550525","CDM","270","RC","","","facility","both","","","","338.45","169.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Picc Sl Vaxcel 5Fr","74550526","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sheath Peelaway 16Fr","74550527","CDM","272","RC","C1892","HCPCS","facility","both","","","","263.93","131.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kit Cystagastrostomy 90","74550529","CDM","270","RC","","","facility","both","","","","642.74","321.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpm Pads Jace Universal K100","74550598","CDM","274","RC","L3999","HCPCS","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Dressing Stick,Economy 26 Inch""""""","74550605","CDM","273","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handles,Builtup-Kings W/C Only","74550635","CDM","273","RC","","","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hand Helper Delux,Wht W/C Only","74550637","CDM","273","RC","","","facility","both","","","","33.12","16.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mirror Inspection,Flexible","74550663","CDM","273","RC","","","facility","both","","","","61.07","30.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Guard Clear 8.5X10","74550683","CDM","273","RC","","","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Spkng Trach 15Mm Id","74550852","CDM","274","RC","L8501","HCPCS","facility","both","","","","220.46","110.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wheels,Walker Rubber","74550858","CDM","270","RC","E0155","HCPCS","facility","both","","","","135.59","67.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pfo Occluder","74550863","CDM","270","RC","","","facility","both","","","","8229.29","4114.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Retrieval Filterwire","74550864","CDM","270","RC","","","facility","both","","","","272.21","136.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire,Filter","74550866","CDM","270","RC","","","facility","both","","","","3373.07","1686.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Syncra-Bi-V","74550870","CDM","275","RC","C2621","HCPCS","facility","both","","","","21797.1","10898.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Mammotome Needle / Probe","74550878","CDM","270","RC","","","facility","both","","","","1188","594","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Micro Clip Tissue Marker","74550879","CDM","278","RC","A4648","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter Outback Ltd Reentry","74550888","CDM","270","RC","","","facility","both","","","","3480.71","1740.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Probe Mammotome 11 Gauge","74550891","CDM","270","RC","","","facility","both","","","","847.67","423.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon 7X4 Hyperform 150Cm","74550893","CDM","272","RC","","","facility","both","","","","2737.58","1368.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Balloon Ob/5/2/65/.025/8.5","74550895","CDM","270","RC","","","facility","both","","","","879.75","439.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Basket Retriever S-Strand","74550904","CDM","272","RC","","","facility","both","","","","6763.73","3381.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Excelsior Sl10 2Tip 150Cm","74550907","CDM","272","RC","","","facility","both","","","","1654.97","827.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Prowler 14-Angled 2-Tip","74550908","CDM","272","RC","","","facility","both","","","","1845.41","922.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Prowler 14J 2-Tip","74550909","CDM","272","RC","","","facility","both","","","","1757.43","878.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Renegade 115X20 1-Tip","74550910","CDM","272","RC","","","facility","both","","","","1111.59","555.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Renegade Hi-Flow 135X10","74550911","CDM","272","RC","C1887","HCPCS","facility","both","","","","1630.13","815.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil 4X8 Ultrasoft Gdc-10","74550912","CDM","272","RC","","","facility","both","","","","2703.42","1351.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Pusher 177Cm 016","74550913","CDM","272","RC","","","facility","both","","","","519.57","259.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolic Embogold 100-300Um 2Ml","74550914","CDM","272","RC","","","facility","both","","","","778.32","389.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolic Embogold 300-500Um 2Ml","74550915","CDM","272","RC","","","facility","both","","","","778.32","389.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolic Embogold 500-700Um 2Ml","74550916","CDM","272","RC","","","facility","both","","","","778.32","389.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolic Embogold 700-900Um 2Ml","74550917","CDM","272","RC","","","facility","both","","","","778.32","389.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Embolic Embosphere 9001200Um2Ml","74550918","CDM","272","RC","","","facility","both","","","","778.32","389.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Trapease 90Cm","74550919","CDM","278","RC","C1880","HCPCS","facility","both","","","","2639.25","1319.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Guide 0.008Inx200Cm Mirage","74550920","CDM","272","RC","","","facility","both","","","","1147.82","573.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle 21Gx4Cm","74550922","CDM","272","RC","","","facility","both","","","","989.46","494.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sheath Ksaw8-38-90-Rb-Shtl-Hc","74550925","CDM","272","RC","","","facility","both","","","","453.33","226.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Transend .014X190Cm","74550927","CDM","272","RC","","","facility","both","","","","638.6","319.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath 20 Marker Band 65Cm","74550928","CDM","272","RC","","","facility","both","","","","360.18","180.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath 6.6F Pasv Single Lumen Ik","74550941","CDM","278","RC","C1751","HCPCS","facility","both","","","","814.55","407.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foot Wrap Rigid Sole-Lge/Reg","74550950","CDM","270","RC","","","facility","both","","","","224.6","112.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chitoseal","74550952","CDM","270","RC","","","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire,Attain 6218","74550967","CDM","272","RC","C1769","HCPCS","facility","both","","","","399.51","199.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occluder,Apmplatzer Septal","74550971","CDM","278","RC","C1817","HCPCS","facility","both","","","","12881","6440.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sheath,Attain 6216","74550972","CDM","272","RC","C1894","HCPCS","facility","both","","","","198.72","99.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent-Neuroform 3.0X15Mm","74550975","CDM","270","RC","","","facility","both","","","","9880.11","4940.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent-Neuroform 3.0X20Mm","74550976","CDM","270","RC","","","facility","both","","","","9880.11","4940.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent-Neuroform 3.5X15Mm","74550977","CDM","270","RC","","","facility","both","","","","9880.11","4940.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent-Neuroform 3.5X20Mm","74550978","CDM","270","RC","","","facility","both","","","","9880.11","4940.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent-Neuroform 4.0X20Mm","74550980","CDM","270","RC","","","facility","both","","","","9880.11","4940.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent-Neuroform 4.5X20Mm","74550982","CDM","270","RC","","","facility","both","","","","9880.11","4940.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft Helical 2Mmx2Cm","74550983","CDM","270","RC","","","facility","both","","","","2394.99","1197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft Helical 2Mmx3Cm","74550984","CDM","270","RC","","","facility","both","","","","2394.99","1197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft Helical 2Mmx4Cm","74550985","CDM","270","RC","","","facility","both","","","","2394.99","1197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft Helical 2Mmx6Cm","74550986","CDM","270","RC","","","facility","both","","","","2430.18","1215.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft 2D 3Mmx3Cm","74550987","CDM","270","RC","","","facility","both","","","","2394.99","1197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft 2D 3Mmx4Cm","74550988","CDM","270","RC","","","facility","both","","","","2394.99","1197.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft 2D 3Mmx6Cm","74550989","CDM","270","RC","","","facility","both","","","","2430.18","1215.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft 2D 4Mmx4Cm","74550990","CDM","270","RC","","","facility","both","","","","2430.18","1215.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft 2D 4Mmx8Cm","74550992","CDM","270","RC","","","facility","both","","","","2453.99","1227","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Soft 2D 5Mmx8Cm","74550994","CDM","270","RC","","","facility","both","","","","2453.99","1227","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 2D 3Mmx8Cm","74550995","CDM","270","RC","","","facility","both","","","","2430.18","1215.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 2D 4Mmx10Cm","74550997","CDM","270","RC","","","facility","both","","","","2548.17","1274.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 2D 5Mmx10Cm","74550998","CDM","270","RC","","","facility","both","","","","2549.21","1274.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 2D 6Mmx15Cm","74551000","CDM","270","RC","","","facility","both","","","","2689.97","1344.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 2D 7Mmx20Cm","74551002","CDM","270","RC","","","facility","both","","","","2689.97","1344.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 2D 8Mmx20Cm","74551004","CDM","270","RC","","","facility","both","","","","2713.77","1356.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Firm 2D 10Mmx30Cm","74551014","CDM","270","RC","","","facility","both","","","","2881.44","1440.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Firm 2D 12Mmx30Cm","74551015","CDM","270","RC","","","facility","both","","","","2881.44","1440.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Ext Frm 2D 18Mmx30Cm","74551018","CDM","270","RC","","","facility","both","","","","2901.11","1450.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Ext Frm 2D 20Mmx30Cm","74551019","CDM","270","RC","","","facility","both","","","","3047.04","1523.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 3D 3Mmx6Cm","74551021","CDM","270","RC","","","facility","both","","","","3042.9","1521.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Std 3D 5Mmx10Cm","74551025","CDM","270","RC","","","facility","both","","","","3204.36","1602.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Firm 3D 10Mmx30Cm","74551033","CDM","270","RC","","","facility","both","","","","3688.74","1844.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Firm 3D 12Mmx30Cm","74551034","CDM","270","RC","","","facility","both","","","","3688.74","1844.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Firm 3D 14Mmx30Cm","74551035","CDM","270","RC","","","facility","both","","","","3688.74","1844.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil Mtrx Ext Frm 3D 20Mmx30Cm","74551038","CDM","270","RC","","","facility","both","","","","3743.6","1871.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor-Disposable","74551048","CDM","270","RC","","","facility","both","","","","243","121.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inspiratory Muscle Traine","74551110","CDM","270","RC","","","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peak Flow Meter Device","74551111","CDM","270","RC","","","facility","both","","","","111.78","55.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacing Device","74551114","CDM","270","RC","","","facility","both","","","","79.7","39.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brach Seed,High Dose Irid 192","74551133","CDM","278","RC","C1717","HCPCS","facility","both","","","","915","457.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rooke Peri Operative Boot","74551136","CDM","270","RC","","","facility","both","","","","282.56","141.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drive Line Stabilizers","74551139","CDM","274","RC","Q0508","HCPCS","facility","both","","","","170.78","85.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec Care Nur Admiss/Supplies","74551200","CDM","270","RC","","","facility","both","","","","570","285","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytherapy Seed,Gold 198","74551253","CDM","278","RC","C1716","HCPCS","facility","both","","","","229.77","114.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brachytherapy Seed Yttrium-90","74551257","CDM","278","RC","C2616","HCPCS","facility","both","","","","17077.5","8538.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Hemoglide 14.5Frx19 St","74551260","CDM","278","RC","C1750","HCPCS","facility","both","","","","981.18","490.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hohn 6Fr Dl","74551261","CDM","278","RC","C1751","HCPCS","facility","both","","","","748.31","374.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hm Ii Pm Patient Cable,Repl","74551265","CDM","274","RC","Q0508","HCPCS","facility","both","","","","2198.34","1099.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hmii Li Ion Battery Ea","74551266","CDM","274","RC","Q0496","HCPCS","facility","both","","","","1724.31","862.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Trufill Dcs Syringe 11","74551267","CDM","270","RC","","","facility","both","","","","506.12","253.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, Galaxy Cx, Cf & Cr","74551268","CDM","270","RC","","","facility","both","","","","2232.5","1116.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr - Sp Coil, Galaxy Hx","74551269","CDM","270","RC","","","facility","both","","","","1706.72","853.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Control Heartmate,Rep Only","74551803","CDM","274","RC","Q0482","HCPCS","facility","both","","","","6809.27","3404.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Battery Holster,Replacement On","74551816","CDM","274","RC","Q0498","HCPCS","facility","both","","","","919.08","459.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stabilization Belt Hrtmte,Rep","74551818","CDM","274","RC","Q0499","HCPCS","facility","both","","","","233.91","116.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Closure Device,Boomerang","74551850","CDM","278","RC","C1760","HCPCS","facility","both","","","","1536.98","768.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Universl Btry Chrgr,Repl Only","74551860","CDM","274","RC","Q0495","HCPCS","facility","both","","","","16629.35","8314.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Ekos","74551902","CDM","278","RC","C1751","HCPCS","facility","both","","","","3433.1","1716.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diamondback","74551903","CDM","278","RC","C1724","HCPCS","facility","both","","","","4934","2467","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diamondback Firmwire","74551904","CDM","270","RC","","","facility","both","","","","408","204","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter,Diamondback Tubing","74551905","CDM","270","RC","","","facility","both","","","","926.33","463.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amplatzer Plug","74551906","CDM","270","RC","","","facility","both","","","","1908","954","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Us Eagle 2.9 F 150 Ivus","74551921","CDM","278","RC","C1753","HCPCS","facility","both","","","","2668.23","1334.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Micrus Cable, Ccb000262-20","74552000","CDM","270","RC","","","facility","both","","","","986.36","493.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,343202","74552002","CDM","270","RC","","","facility","both","","","","2735.51","1367.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,343304","74552008","CDM","270","RC","","","facility","both","","","","2764.49","1382.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Che 100408-30","74552012","CDM","270","RC","","","facility","both","","","","2818.31","1409.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Che 100410-30","74552013","CDM","270","RC","","","facility","both","","","","2818.31","1409.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Che 100510-30","74552014","CDM","270","RC","","","facility","both","","","","2683.76","1341.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100201-30","74552016","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100202-30","74552017","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100203-30","74552018","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100204-30","74552019","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100206-30","74552020","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100302-30","74552021","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100304-30","74552022","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100306-30","74552023","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100404-30","74552025","CDM","270","RC","","","facility","both","","","","2889.72","1444.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100406-30","74552026","CDM","270","RC","","","facility","both","","","","2889.72","1444.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Cfs 100408-30","74552027","CDM","270","RC","","","facility","both","","","","2620.62","1310.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Che 100615-30","74552032","CDM","270","RC","","","facility","both","","","","2222.15","1111.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil, 346407Sr","74552050","CDM","270","RC","","","facility","both","","","","2576.12","1288.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,348615","74552070","CDM","270","RC","","","facility","both","","","","2824.52","1412.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,347408Sr","74552072","CDM","270","RC","","","facility","both","","","","2847.29","1423.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,348820","74552077","CDM","270","RC","","","facility","both","","","","2889.72","1444.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 10020030","74552094","CDM","270","RC","","","facility","both","","","","3161.93","1580.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 10030030","74552095","CDM","270","RC","","","facility","both","","","","3161.93","1580.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 100400-30","74552096","CDM","270","RC","","","facility","both","","","","3161.93","1580.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 100500-30","74552101","CDM","270","RC","","","facility","both","","","","3331.67","1665.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 100600-30","74552102","CDM","270","RC","","","facility","both","","","","3331.67","1665.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 100700-30","74552103","CDM","270","RC","","","facility","both","","","","3331.67","1665.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 100800-30","74552109","CDM","270","RC","","","facility","both","","","","3414.47","1707.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 100900-30","74552110","CDM","270","RC","","","facility","both","","","","3414.47","1707.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent,Snf34520","74552130","CDM","270","RC","","","facility","both","","","","9549.95","4774.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent,Snf34020","74552131","CDM","270","RC","","","facility","both","","","","9549.95","4774.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent,Snf34030","74552133","CDM","270","RC","","","facility","both","","","","9761.09","4880.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Durata/Optisure","74552150","CDM","278","RC","C1895","HCPCS","facility","both","","","","8364","4182","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Durata Single Coil","74552151","CDM","278","RC","C1777","HCPCS","facility","both","","","","8266.55","4133.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Paps1,Cann/Tub/Filt","74552152","CDM","270","RC","","","facility","both","","","","533.03","266.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Psc026,026 Catheter","74552153","CDM","278","RC","C1757","HCPCS","facility","both","","","","316.71","158.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Psc032,032 Catheter","74552154","CDM","278","RC","C1757","HCPCS","facility","both","","","","2057.58","1028.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Psc041,041 Catheter","74552155","CDM","278","RC","C1757","HCPCS","facility","both","","","","2057.58","1028.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Pss026,026 Separatr","74552156","CDM","278","RC","C1773","HCPCS","facility","both","","","","4309.74","2154.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Pss032,032 Separatr","74552157","CDM","278","RC","C1773","HCPCS","facility","both","","","","4309.74","2154.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Pss041,041 Separatr","74552158","CDM","278","RC","C1773","HCPCS","facility","both","","","","4309.74","2154.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Pst1,Asp Tubing","74552159","CDM","270","RC","","","facility","both","","","","928.4","464.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tamponade Balloon","74552202","CDM","270","RC","","","facility","both","","","","564.08","282.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Yueh Centesis Needle","74552203","CDM","270","RC","","","facility","both","","","","55.89","27.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Catheter Qbd-6X3","74552205","CDM","270","RC","","","facility","both","","","","441.95","220.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Monolith Lithotripter","74552206","CDM","270","RC","","","facility","both","","","","954.27","477.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Eus Needle 22Gx5.2Fr","74552207","CDM","270","RC","","","facility","both","","","","619.97","309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Uos Needle 25Gx5.2Fr","74552208","CDM","270","RC","","","facility","both","","","","619.97","309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Jagtome 44 Rx","74552213","CDM","270","RC","","","facility","both","","","","841.46","420.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Jagtome 49 Rx","74552214","CDM","270","RC","","","facility","both","","","","841.46","420.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Jagtome 39 Rx","74552215","CDM","270","RC","","","facility","both","","","","841.46","420.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Hydratome 44 Rx","74552216","CDM","270","RC","","","facility","both","","","","1008.09","504.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Hydratome 49 Rx","74552217","CDM","270","RC","","","facility","both","","","","1008.09","504.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Biop Forcep Rad Jaw 4 Jum","74552219","CDM","270","RC","","","facility","both","","","","85.91","42.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Microbiology Brush","74552220","CDM","270","RC","","","facility","both","","","","80.73","40.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gi Endo Bedside Supply Chg","74552221","CDM","270","RC","","","facility","both","","","","531.99","266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kypx Express Addl Fx,Kpe 1004","74552330","CDM","270","RC","","","facility","both","","","","4887.27","2443.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Probe Percryo 2.4Mm","74552331","CDM","272","RC","C2618","HCPCS","facility","both","","","","2075.18","1037.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Percryo 1.7Mm","74552332","CDM","272","RC","C2618","HCPCS","facility","both","","","","2075.18","1037.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Seprafilm","74552341","CDM","278","RC","C1765","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Dynamic Xt","74552344","CDM","272","RC","C1730","HCPCS","facility","both","","","","753.48","376.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer,Steerable","74552345","CDM","272","RC","C1766","HCPCS","facility","both","","","","2228","1114","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Quick Cross","74552347","CDM","278","RC","C1887","HCPCS","facility","both","","","","598.23","299.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter, Fox Hollow","74552348","CDM","272","RC","C1714","HCPCS","facility","both","","","","4853.12","2426.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cryo-Ablation Catheter","74552349","CDM","272","RC","C1733","HCPCS","facility","both","","","","4058","2029","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spider X Embolic Protection","74552352","CDM","272","RC","C1884","HCPCS","facility","both","","","","2656.85","1328.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Twin Pass Support","74552354","CDM","272","RC","C1725","HCPCS","facility","both","","","","824.9","412.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Venture","74552355","CDM","272","RC","C1887","HCPCS","facility","both","","","","1938.56","969.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Outback Re-Entry Cath","74552356","CDM","278","RC","C1757","HCPCS","facility","both","","","","1988.24","994.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fad Discogram Kit","74552372","CDM","270","RC","","","facility","both","","","","1581.48","790.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp:I-123 Mibg","74552374","CDM","343","RC","A9582","HCPCS","facility","both","","","","4328","2164","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Virtuoso Dr Rf","74552379","CDM","275","RC","C1721","HCPCS","facility","both","","","","90372.06","45186.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Sprint Single-Coil","74552388","CDM","275","RC","C1777","HCPCS","facility","both","","","","8874","4437","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Micra Leadless Vr","74552393","CDM","275","RC","C1786","HCPCS","facility","both","","","","11605.46","5802.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Selox","74552405","CDM","275","RC","C1898","HCPCS","facility","both","","","","1063","531.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Tendril St","74552407","CDM","275","RC","C1898","HCPCS","facility","both","","","","1338","669","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle,Uniblate,15Cm","74552409","CDM","272","RC","","","facility","both","","","","3832.61","1916.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hypothermia Large Kit Pad","74553000","CDM","270","RC","","","facility","both","","","","3398","1699","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dermagraft Per Sq Cm","74553005","CDM","278","RC","Q4106","HCPCS","facility","both","","","","135.59","67.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Theraskin Per Sq Cm","74553007","CDM","278","RC","Q4121","HCPCS","facility","both","","","","91.08","45.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Theraskin Waste Per Sq Cm","74553008","CDM","278","RC","Q4121","HCPCS","facility","both","","","","91.08","45.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Throm,Trellis,Bvt8-080-30","74553013","CDM","272","RC","C1757","HCPCS","facility","both","","","","3832.61","1916.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Boston Sci Express Ld","74553031","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Boston Sci Express Sd","74553032","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Cordis Smart Control","74553033","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Hickman Dl Dacr Cuff,9.5F","74553034","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tube,Feed,Corflo,10Frx55","74553040","CDM","270","RC","","","facility","both","","","","48.65","24.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oasis Wound Matrix Per Sq Cm","74553045","CDM","278","RC","Q4102","HCPCS","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Watchman Closure Device","74553050","CDM","270","RC","","","facility","both","","","","25799","12899.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Watchman Flx, Pinnacle Study","74553051","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle,Confidence Intr,13G,4In","74554000","CDM","270","RC","","","facility","both","","","","371.57","185.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray,Oncontrol Biops Sys 152Mm","74554002","CDM","278","RC","C1830","HCPCS","facility","both","","","","219.42","109.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tru-Close Pneumothorax Kit","74554007","CDM","270","RC","","","facility","both","","","","498.87","249.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Smart Touch","74554022","CDM","272","RC","C2630","HCPCS","facility","both","","","","5852.93","2926.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp I-123 Ioflupane Per Dose","74554695","CDM","343","RC","A9584","HCPCS","facility","both","","","","4573","2286.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Cxi","74556001","CDM","272","RC","C1887","HCPCS","facility","both","","","","331.2","165.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Formula 414 Rx","74556603","CDM","278","RC","C1876","HCPCS","facility","both","","","","4625.42","2312.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Introducer Coaccess","74557712","CDM","272","RC","","","facility","both","","","","189.41","94.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder,Confirm","74557714","CDM","278","RC","C1764","HCPCS","facility","both","","","","15036.48","7518.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder Reveal Linq Ii","74557715","CDM","278","RC","C1764","HCPCS","facility","both","","","","5767.02","2883.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Vascular Ultrasound Cath","74558011","CDM","272","RC","C1753","HCPCS","facility","both","","","","2737.58","1368.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gogear Bttry Clip,Repl Only","74558014","CDM","274","RC","Q0497","HCPCS","facility","both","","","","2540.93","1270.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gogear Car Cable,Repl Only","74558015","CDM","274","RC","Q0478","HCPCS","facility","both","","","","471.96","235.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gogear Travel Case,Rep Only","74558016","CDM","274","RC","Q0508","HCPCS","facility","both","","","","360","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopatch Anti Microbial Dressi","74560700","CDM","270","RC","","","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diag Attain Steerable","74560836","CDM","272","RC","C1887","HCPCS","facility","both","","","","550","275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diag Attain Left Hear","74560837","CDM","272","RC","C1887","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Diag Attain Deflectab","74560838","CDM","272","RC","C1887","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Verity Adx Xl Dr","74561058","CDM","275","RC","C1785","HCPCS","facility","both","","","","11619.95","5809.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Fineline Ii Ste","74561065","CDM","275","RC","C1898","HCPCS","facility","both","","","","1917.86","958.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pleurx Pleural Cath Drain Kit","74561128","CDM","270","RC","","","facility","both","","","","171.81","85.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ats Abd Wound Vac Lg Canister","74561129","CDM","270","RC","","","facility","both","","","","172.85","86.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Neurostim Test Kit","74561130","CDM","278","RC","C1897","HCPCS","facility","both","","","","4288.01","2144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphenocath Catheter","74561140","CDM","270","RC","","","facility","both","","","","241.16","120.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Implant Neuro Stimul Electrode","74561200","CDM","278","RC","L8680","HCPCS","facility","both","","","","700.7","350.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub,Apligraf Per Sq Cm","74561201","CDM","278","RC","Q4101","HCPCS","facility","both","","","","79.7","39.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub,Apligraf Waste Sq Cm","74561202","CDM","278","RC","Q4101","HCPCS","facility","both","","","","79.7","39.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aquacel 6X6","74561290","CDM","270","RC","","","facility","both","","","","65.21","32.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aquacel 8X12","74561291","CDM","270","RC","","","facility","both","","","","99.36","49.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bravo Ph Capsule","74562000","CDM","270","RC","","","facility","both","","","","712.08","356.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ndl,Ossflx Steer,1.0","74562050","CDM","270","RC","","","facility","both","","","","3616.29","1808.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotaflow Vad Implant","74562206","CDM","270","RC","","","facility","both","","","","1522","761","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter,Penumbra Cat 3","74562207","CDM","272","RC","C1887","HCPCS","facility","both","","","","1384.83","692.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter, Penumbra Cat 6","74562208","CDM","272","RC","C1887","HCPCS","facility","both","","","","2250.09","1125.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter, Penumbra Cat 8","74562209","CDM","272","RC","C1887","HCPCS","facility","both","","","","3440.34","1720.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Separator, Penumbra Cat 3","74562210","CDM","272","RC","C1757","HCPCS","facility","both","","","","1147.82","573.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Separator, Penumbra Cat 6","74562211","CDM","272","RC","C1757","HCPCS","facility","both","","","","1285.47","642.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Separator, Penumbra Cat 8","74562212","CDM","272","RC","C1757","HCPCS","facility","both","","","","2988.05","1494.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hmiii Contoller","74562215","CDM","274","RC","Q0481","HCPCS","facility","both","","","","14021.15","7010.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Viance","74562218","CDM","278","RC","C1887","HCPCS","facility","both","","","","2003.76","1001.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Enteer","74562219","CDM","278","RC","C1887","HCPCS","facility","both","","","","2953.89","1476.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire,Enteer","74562220","CDM","278","RC","C1769","HCPCS","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Penumbra Cat 12","74562222","CDM","278","RC","C1887","HCPCS","facility","both","","","","8106.12","4053.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Separator, Penumbra Cat 12","74562223","CDM","278","RC","C1757","HCPCS","facility","both","","","","2315.3","1157.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Encircle Device, Research Tmvr","74562224","CDM","270","RC","","","facility","both","","","","41658.75","20829.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder,Reveal Xt","74563006","CDM","278","RC","C1764","HCPCS","facility","both","","","","9289.13","4644.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Capsure","74563020","CDM","275","RC","C1898","HCPCS","facility","both","","","","1418","709","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brevera Biopsy Needle-9G 13Cm","74563199","CDM","270","RC","","","facility","both","","","","1515","757.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle Brst Loc 20Gx9Cm","74563200","CDM","278","RC","C1769","HCPCS","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle Brst Loc 20Gx7Cm","74563201","CDM","278","RC","C1769","HCPCS","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Needle Brst Loc Leloc 18Gx1Cm","74563202","CDM","278","RC","C1769","HCPCS","facility","both","","","","243.23","121.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180200-30","74563203","CDM","270","RC","","","facility","both","","","","2714.81","1357.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180300-30","74563204","CDM","270","RC","","","facility","both","","","","2734.47","1367.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180500-30","74563206","CDM","270","RC","","","facility","both","","","","2803.82","1401.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180600-30","74563207","CDM","270","RC","","","facility","both","","","","2839.01","1419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180700-30","74563208","CDM","270","RC","","","facility","both","","","","2857.64","1428.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180800-30","74563209","CDM","270","RC","","","facility","both","","","","2884.55","1442.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 180900-30","74563210","CDM","270","RC","","","facility","both","","","","2909.39","1454.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181000-30","74563211","CDM","270","RC","","","facility","both","","","","2936.3","1468.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181100-30","74563212","CDM","270","RC","","","facility","both","","","","2941.47","1470.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181200-30","74563213","CDM","270","RC","","","facility","both","","","","2974.59","1487.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181300-30","74563214","CDM","270","RC","","","facility","both","","","","2974.59","1487.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181300-30","74563215","CDM","270","RC","","","facility","both","","","","2999.43","1499.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181300-30","74563216","CDM","270","RC","","","facility","both","","","","3026.34","1513.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181600-30","74563217","CDM","270","RC","","","facility","both","","","","3051.18","1525.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,Csp 181800-30","74563219","CDM","270","RC","","","facility","both","","","","3078.09","1539.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp:Tc-99 Dtpa Aerosol Per Stud","74566229","CDM","343","RC","A9567","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Rp:Tc-99 Dmsa Per Dose","74566230","CDM","343","RC","A9551","HCPCS","facility","both","","","","766","383","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Evera Mri Dr","74567155","CDM","275","RC","C1721","HCPCS","facility","both","","","","27210.15","13605.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Evera Mri Vr","74567156","CDM","275","RC","C1722","HCPCS","facility","both","","","","29812.14","14906.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Assurity Sr","74567157","CDM","275","RC","C1786","HCPCS","facility","both","","","","16906.73","8453.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Assurity Dr","74567159","CDM","275","RC","C1785","HCPCS","facility","both","","","","31850.06","15925.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Allure Biv","74567161","CDM","275","RC","C2621","HCPCS","facility","both","","","","17785.44","8892.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead, Defib Crt Lv Acuity","74567163","CDM","275","RC","C1900","HCPCS","facility","both","","","","4449","2224.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Icd Reliance Single Coil","74567164","CDM","275","RC","C1777","HCPCS","facility","both","","","","7762.5","3881.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Allure Biv Multipace","74567183","CDM","275","RC","C2621","HCPCS","facility","both","","","","14550.03","7275.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Quadra Assura Biv Mp","74567184","CDM","275","RC","C1882","HCPCS","facility","both","","","","37714.37","18857.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib,Quartet,Quad Mp","74567185","CDM","275","RC","C1900","HCPCS","facility","both","","","","5499.99","2750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Micra Leadless Av","74567186","CDM","275","RC","C1786","HCPCS","facility","both","","","","14088","7044","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer,Micra Sheath","74567187","CDM","278","RC","C1894","HCPCS","facility","both","","","","819","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder,Reveal Linq","74569079","CDM","278","RC","C1764","HCPCS","facility","both","","","","8975","4487.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Generator Universal","74570149","CDM","270","RC","","","facility","both","","","","132.48","66.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Xpeedior Angiojet 130","74570200","CDM","272","RC","C1757","HCPCS","facility","both","","","","2950.79","1475.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Snare Gooseneck 15 15Mm Kit","74570201","CDM","272","RC","C1773","HCPCS","facility","both","","","","866.3","433.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pleurx Pleural Catheter","74570202","CDM","272","RC","C1729","HCPCS","facility","both","","","","720.36","360.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Pleurx Pleural Cath Drain Kit","74570203","CDM","272","RC","C1729","HCPCS","facility","both","","","","363.29","181.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Starclose,Closure","74570225","CDM","278","RC","C1760","HCPCS","facility","both","","","","698.63","349.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Wallstent 7F 10X94X110","74570500","CDM","278","RC","C1876","HCPCS","facility","both","","","","3445.52","1722.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Hohn 7Fr Dl","74570602","CDM","278","RC","C1751","HCPCS","facility","both","","","","705.87","352.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Viabil Bil Cvrd 10X6","74570854","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Viabil Bil Cvrd 10X8","74570855","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Viabil Cvrd 10X8 W/Hole","74570859","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Dilator,Fascial/Ureth,8-24X37","74570882","CDM","272","RC","C2627","HCPCS","facility","both","","","","610.65","305.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tube,Feed,Transgast-Jeju,18X22","74570883","CDM","272","RC","C2627","HCPCS","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tube,Feed,Transgast-Jeju,18X45","74570884","CDM","272","RC","C2627","HCPCS","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Tube,Feed,Transgast-Jeju,22X45","74570885","CDM","272","RC","C2627","HCPCS","facility","both","","","","588.92","294.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent,Biliary,Luer Lock,14F","74570886","CDM","278","RC","C2617","HCPCS","facility","both","","","","233.91","116.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Trufill Liq Embolic Sys/Cordis","74570889","CDM","270","RC","","","facility","both","","","","4515.71","2257.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Merci Microcatheter 18L","74570891","CDM","270","RC","","","facility","both","","","","1270.98","635.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maquet Ecmo Kit","74570895","CDM","270","RC","","","facility","both","","","","3900.92","1950.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecmo Transducer","74570896","CDM","270","RC","","","facility","both","","","","520.61","260.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Fineline","74571701","CDM","275","RC","C1898","HCPCS","facility","both","","","","1880.6","940.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemaker Isoflex","74571706","CDM","275","RC","C1898","HCPCS","facility","both","","","","4025.12","2012.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Access System,Axera","74571720","CDM","270","RC","","","facility","both","","","","490.59","245.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Stent,Intracran,Wingspan","74571802","CDM","270","RC","","","facility","both","","","","13245.93","6622.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Balloon,Intracran,Gateway","74571803","CDM","270","RC","","","facility","both","","","","2964.24","1482.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ch-Grsurgicell Absorbable Hemostat","74571806","CDM","270","RC","","","facility","both","","","","220.46","110.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lasso Catheter","74571807","CDM","272","RC","C1730","HCPCS","facility","both","","","","2701.35","1350.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Device Merci Retrieval X5","74571812","CDM","270","RC","","","facility","both","","","","5857.07","2928.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Guide Concentric Balloon","74571814","CDM","270","RC","","","facility","both","","","","2462.27","1231.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Guide Merci Balloon 9Fr","74571815","CDM","270","RC","","","facility","both","","","","1865.07","932.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Merci Micro 14X","74571816","CDM","270","RC","","","facility","both","","","","1270.98","635.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Latitude Curette,A11B","74571817","CDM","270","RC","","","facility","both","","","","583.74","291.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx One Step Addl Fx,Kpt1504","74571818","CDM","270","RC","","","facility","both","","","","4899.69","2449.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Express Addl Fx,Kpe1002","74571819","CDM","270","RC","","","facility","both","","","","5212.26","2606.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Express 1St Fx,Kpe1001","74571820","CDM","270","RC","","","facility","both","","","","7740.77","3870.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx One Step 1St Fx,Kpt1505","74571821","CDM","270","RC","","","facility","both","","","","7785.27","3892.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Bone Cement Mixer,C01B","74571822","CDM","278","RC","C1713","HCPCS","facility","both","","","","525.78","262.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Bone Biopsy Dvc,F05A","74571823","CDM","270","RC","","","facility","both","","","","395.37","197.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Bone Biopsy Dvc,F07A","74571824","CDM","270","RC","","","facility","both","","","","395.37","197.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Device Introducer,A10A","74571825","CDM","270","RC","","","facility","both","","","","1194.39","597.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Elevate Bone Tamp,K16A","74571826","CDM","270","RC","","","facility","both","","","","2554.38","1277.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Elevate Bone Tamp,K16B","74571827","CDM","270","RC","","","facility","both","","","","2465.37","1232.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Exact Bone Tamp,K17A","74571828","CDM","270","RC","","","facility","both","","","","2554.38","1277.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Exact Bone Tamp,K17B","74571829","CDM","270","RC","","","facility","both","","","","2235.6","1117.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Kyphx Bone Cement,C01A","74571830","CDM","278","RC","C1713","HCPCS","facility","both","","","","306.36","153.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Hickman #60069-2","74571840","CDM","278","RC","C1750","HCPCS","facility","both","","","","1140.57","570.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Carotid Precise Nitinol","74571843","CDM","278","RC","C1876","HCPCS","facility","both","","","","3749.81","1874.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Embolic Protection Sys/Angiogu","74571844","CDM","272","RC","C1884","HCPCS","facility","both","","","","3969.23","1984.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Direct Sl","74571846","CDM","272","RC","C1893","HCPCS","facility","both","","","","1320","660","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Aim Cann","74571847","CDM","272","RC","C1887","HCPCS","facility","both","","","","954.27","477.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Pronto Extract","74571849","CDM","272","RC","C1757","HCPCS","facility","both","","","","1324.8","662.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Snare Gooseneck 10Mm","74571850","CDM","272","RC","C1773","HCPCS","facility","both","","","","823.86","411.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Haskel Tips Set","74571851","CDM","270","RC","","","facility","both","","","","1938.56","969.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Viatorr 8X8","74571852","CDM","278","RC","C1874","HCPCS","facility","both","","","","9452.66","4726.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hemoglide Bd-Pc2 Cath Ki-24Cm","74571853","CDM","278","RC","C1750","HCPCS","facility","both","","","","924.26","462.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hemoglide Bd-Pc2 Cath Ki-31Cm","74571854","CDM","278","RC","C1750","HCPCS","facility","both","","","","924.26","462.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Hemoglide Bd-Pc2 Cath Ki-35Cm","74571855","CDM","278","RC","C1750","HCPCS","facility","both","","","","924.26","462.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Vena Tech Lp","74571856","CDM","278","RC","C1880","HCPCS","facility","both","","","","2372.22","1186.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Stent Smart 12X80X80Cm","74571857","CDM","278","RC","C1876","HCPCS","facility","both","","","","3824.33","1912.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter,Supreme 20","74571858","CDM","270","RC","","","facility","both","","","","2574.05","1287.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Cour Quad","74571861","CDM","272","RC","C1730","HCPCS","facility","both","","","","713.12","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Langston","74571865","CDM","272","RC","C1887","HCPCS","facility","both","","","","363.29","181.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ep Lab D-Stat","74571867","CDM","270","RC","","","facility","both","","","","410.9","205.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Catheter,Bayliss","74571868","CDM","270","RC","","","facility","both","","","","1496.61","748.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sheath,Bayliss","74571869","CDM","270","RC","","","facility","both","","","","1422.09","711.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Closure Angioseal","74571870","CDM","278","RC","C1760","HCPCS","facility","both","","","","1019.48","509.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Closure Perclose","74571871","CDM","278","RC","C1760","HCPCS","facility","both","","","","464.72","232.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Closure Starclose","74571872","CDM","278","RC","C1760","HCPCS","facility","both","","","","574.43","287.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath,Picc Power 5F Dual,130Cm","74571873","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Picc Power 5F Dual,75Cm","74571874","CDM","278","RC","C1751","HCPCS","facility","both","","","","320.85","160.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Navistar Bi-Dir Tc Carto3","74571880","CDM","278","RC","C1732","HCPCS","facility","both","","","","7886","3943","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Ultrsnd Eagle Eye Vlcano","74571881","CDM","278","RC","C1753","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Carto3 Siemenssoundstar","74571883","CDM","278","RC","C1759","HCPCS","facility","both","","","","3872","1936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Electrodes,Carto 3 Lasso2515","74571884","CDM","278","RC","C1731","HCPCS","facility","both","","","","3000","1500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Revolution Volcano","74571886","CDM","278","RC","C1753","HCPCS","facility","both","","","","1334.12","667.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Carto3 Bidir Thermoez","74571887","CDM","278","RC","C1732","HCPCS","facility","both","","","","8871","4435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Carto3 Bi Dir Curve","74571888","CDM","278","RC","C1730","HCPCS","facility","both","","","","713.12","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Carto 3 Ref Patch 6Pack","74571889","CDM","272","RC","","","facility","both","","","","584","292","","","","","","","","","","","","","Gross Charge Type: Standard"
"Theraspheres Yttrium-90","74571900","CDM","278","RC","C2616","HCPCS","facility","both","","","","75431","37715.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Atherectomy","74571991","CDM","278","RC","C1724","HCPCS","facility","both","","","","8258.27","4129.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath,Thrombectomy,Angiojet Dvx","74571992","CDM","278","RC","C1757","HCPCS","facility","both","","","","2508.84","1254.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath,Dragonfly Ilumiem","74571999","CDM","270","RC","","","facility","both","","","","1664.28","832.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Guide Envoy,670-258-00","74572010","CDM","272","RC","C1887","HCPCS","facility","both","","","","608.58","304.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100151Hs-V","74572018","CDM","272","RC","","","facility","both","","","","1897.16","948.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100152H2Hs-V","74572019","CDM","272","RC","","","facility","both","","","","2319.44","1159.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100152Hs-V","74572020","CDM","272","RC","","","facility","both","","","","1897.16","948.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100153Hs-V","74572021","CDM","272","RC","","","facility","both","","","","1897.16","948.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100202Cssr-V","74572022","CDM","272","RC","","","facility","both","","","","2835.9","1417.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100202Hfrm-V","74572023","CDM","272","RC","","","facility","both","","","","4313.88","2156.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100254Cssr-V","74572024","CDM","272","RC","","","facility","both","","","","2876.27","1438.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100254Hfrm-V","74572025","CDM","272","RC","","","facility","both","","","","4354.25","2177.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100306Cssr-V","74572026","CDM","272","RC","","","facility","both","","","","2917.67","1458.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,10036Hfrm-V","74572027","CDM","272","RC","","","facility","both","","","","4396.68","2198.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100405Hfrm-V","74572028","CDM","272","RC","","","facility","both","","","","4375.98","2187.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100408Cssr-V","74572029","CDM","272","RC","","","facility","both","","","","2959.07","1479.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Sp Coil,100408Hfrm-V","74572030","CDM","272","RC","","","facility","both","","","","4438.08","2219.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100510Hfrm-V","74572031","CDM","272","RC","","","facility","both","","","","4477.41","2238.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100515Hfrm-V","74572032","CDM","272","RC","","","facility","both","","","","4580.91","2290.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100612Hfrm-V","74572033","CDM","272","RC","","","facility","both","","","","4518.81","2259.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100619Hfrm-V","74572034","CDM","272","RC","","","facility","both","","","","4664.75","2332.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100715Hfrm-V","74572035","CDM","272","RC","","","facility","both","","","","4580.91","2290.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100728Hfrm-V","74572036","CDM","272","RC","","","facility","both","","","","4848.98","2424.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100817Hfrm-V","74572037","CDM","272","RC","","","facility","both","","","","4622.31","2311.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100833Hfrm-V","74572038","CDM","272","RC","","","facility","both","","","","4950.41","2475.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,100931Hfrm-V","74572039","CDM","272","RC","","","facility","both","","","","4910.04","2455.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,101036Hfrm-V","74572040","CDM","272","RC","","","facility","both","","","","5012.51","2506.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,180619Hfrm-V","74572041","CDM","272","RC","","","facility","both","","","","5360.27","2680.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,180723Hfrm-V","74572042","CDM","272","RC","","","facility","both","","","","5453.42","2726.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,180827Hfrm-V","74572043","CDM","272","RC","","","facility","both","","","","5526.9","2763.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,180931Hfrm-V","74572044","CDM","272","RC","","","facility","both","","","","5649.03","2824.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,180931Hfrm-V","74572045","CDM","272","RC","","","facility","both","","","","5761.85","2880.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,181139Hfrm-V","74572046","CDM","272","RC","","","facility","both","","","","5823.95","2911.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,181243Hfrm-V","74572047","CDM","272","RC","","","facility","both","","","","5905.71","2952.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,181347Hfrm-V","74572048","CDM","272","RC","","","facility","both","","","","5988.51","2994.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,181445Hfrm-V","74572049","CDM","272","RC","","","facility","both","","","","5844.65","2922.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C036","74572050","CDM","272","RC","","","facility","both","","","","4540.55","2270.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0310","74572051","CDM","272","RC","","","facility","both","","","","4622.31","2311.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0408R","74572052","CDM","272","RC","","","facility","both","","","","4580.91","2290.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0412","74572053","CDM","272","RC","","","facility","both","","","","4664.75","2332.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0510","74572054","CDM","272","RC","","","facility","both","","","","4622.31","2311.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0610","74572055","CDM","272","RC","","","facility","both","","","","4622.31","2311.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0615","74572056","CDM","272","RC","","","facility","both","","","","4724.78","2362.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0620","74572057","CDM","272","RC","","","facility","both","","","","4828.28","2414.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0710","74572058","CDM","272","RC","","","facility","both","","","","4622.31","2311.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0720","74572059","CDM","272","RC","","","facility","both","","","","4828.28","2414.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0820","74572060","CDM","272","RC","","","facility","both","","","","4828.28","2414.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0820","74572061","CDM","272","RC","","","facility","both","","","","5032.17","2516.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0925","74572062","CDM","272","RC","","","facility","both","","","","4928.67","2464.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C0935","74572063","CDM","272","RC","","","facility","both","","","","5083.92","2541.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1030","74572064","CDM","272","RC","","","facility","both","","","","5032.17","2516.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1040","74572065","CDM","272","RC","","","facility","both","","","","5134.64","2567.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1135","74572066","CDM","272","RC","","","facility","both","","","","5083.92","2541.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1145","74572067","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1235","74572068","CDM","272","RC","","","facility","both","","","","5083.92","2541.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1245","74572069","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1335","74572070","CDM","272","RC","","","facility","both","","","","5083.92","2541.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1348","74572071","CDM","272","RC","","","facility","both","","","","5218.47","2609.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1440","74572072","CDM","272","RC","","","facility","both","","","","5134.64","2567.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1450","74572073","CDM","272","RC","","","facility","both","","","","5240.21","2620.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1545","74572074","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1557","74572075","CDM","272","RC","","","facility","both","","","","5309.55","2654.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1645","74572076","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1660","74572077","CDM","272","RC","","","facility","both","","","","5340.6","2670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1845","74572078","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C1857","74572079","CDM","272","RC","","","facility","both","","","","5309.55","2654.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2045","74572080","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2060","74572081","CDM","272","RC","","","facility","both","","","","5340.6","2670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2245","74572082","CDM","272","RC","","","facility","both","","","","5187.42","2593.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2260","74572083","CDM","272","RC","","","facility","both","","","","5340.6","2670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2448","74572084","CDM","272","RC","","","facility","both","","","","5218.47","2609.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2457","74572085","CDM","272","RC","","","facility","both","","","","5309.55","2654.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0306","74572086","CDM","272","RC","","","facility","both","","","","4950.41","2475.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0310","74572087","CDM","272","RC","","","facility","both","","","","5032.17","2516.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0408","74572088","CDM","272","RC","","","facility","both","","","","4992.84","2496.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0412","74572089","CDM","272","RC","","","facility","both","","","","5074.61","2537.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0509","74572090","CDM","272","RC","","","facility","both","","","","5012.51","2506.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0513","74572091","CDM","272","RC","","","facility","both","","","","5095.31","2547.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0610","74572092","CDM","272","RC","","","facility","both","","","","5032.17","2516.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0615","74572093","CDM","272","RC","","","facility","both","","","","5134.64","2567.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0620","74572094","CDM","272","RC","","","facility","both","","","","5240.21","2620.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0715","74572095","CDM","272","RC","","","facility","both","","","","5134.64","2567.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0720","74572096","CDM","272","RC","","","facility","both","","","","5240.21","2620.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0820","74572097","CDM","272","RC","","","facility","both","","","","5240.21","2620.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0830","74572098","CDM","272","RC","","","facility","both","","","","5445.14","2722.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C0925","74572099","CDM","272","RC","","","facility","both","","","","5340.6","2670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1020","74572100","CDM","272","RC","","","facility","both","","","","5240.21","2620.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1020","74572101","CDM","272","RC","","","facility","both","","","","5240.21","2620.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1030","74572102","CDM","272","RC","","","facility","both","","","","5445.14","2722.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1040","74572103","CDM","272","RC","","","facility","both","","","","5649.03","2824.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1135","74572104","CDM","272","RC","","","facility","both","","","","5546.57","2773.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1145","74572105","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1235","74572106","CDM","272","RC","","","facility","both","","","","5546.57","2773.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1245","74572107","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1335","74572108","CDM","272","RC","","","facility","both","","","","5546.57","2773.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1348","74572109","CDM","272","RC","","","facility","both","","","","5813.6","2906.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1440","74572110","CDM","272","RC","","","facility","both","","","","5649.03","2824.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1450","74572111","CDM","272","RC","","","facility","both","","","","5855","2927.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1545","74572112","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1557","74572113","CDM","272","RC","","","facility","both","","","","5997.83","2998.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1645","74572114","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1660","74572115","CDM","272","RC","","","facility","both","","","","6058.89","3029.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C18450","74572116","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C1857","74572117","CDM","272","RC","","","facility","both","","","","5997.83","2998.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C2045","74572118","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C2060","74572119","CDM","272","RC","","","facility","both","","","","6058.89","3029.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C2245","74572120","CDM","272","RC","","","facility","both","","","","5750.46","2875.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C2260","74572121","CDM","272","RC","","","facility","both","","","","6058.89","3029.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C2448","74572122","CDM","272","RC","","","facility","both","","","","5813.6","2906.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004C2457","74572123","CDM","272","RC","","","facility","both","","","","5997.83","2998.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J1","74572124","CDM","272","RC","","","facility","both","","","","3350.3","1675.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J10","74572125","CDM","272","RC","","","facility","both","","","","5176.04","2588.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J11","74572126","CDM","272","RC","","","facility","both","","","","5218.47","2609.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J12","74572127","CDM","272","RC","","","facility","both","","","","5257.8","2628.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J13","74572128","CDM","272","RC","","","facility","both","","","","5300.24","2650.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J14","74572129","CDM","272","RC","","","facility","both","","","","5340.6","2670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J15","74572130","CDM","272","RC","","","facility","both","","","","5380.97","2690.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J2","74572131","CDM","272","RC","","","facility","both","","","","3566.61","1783.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J3","74572132","CDM","272","RC","","","facility","both","","","","3779.82","1889.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J4","74572133","CDM","272","RC","","","facility","both","","","","3996.14","1998.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J5","74572134","CDM","272","RC","","","facility","both","","","","4211.42","2105.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J6","74572135","CDM","272","RC","","","facility","both","","","","4426.7","2213.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J7","74572136","CDM","272","RC","","","facility","both","","","","4643.01","2321.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J8","74572137","CDM","272","RC","","","facility","both","","","","4857.26","2428.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J9","74572138","CDM","272","RC","","","facility","both","","","","5074.61","2537.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Sp Coil, 4006U0201","74572139","CDM","272","RC","","","facility","both","","","","3524.18","1762.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0202","74572140","CDM","272","RC","","","facility","both","","","","3738.42","1869.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Sp Coil, 4006U0203","74572141","CDM","272","RC","","","facility","both","","","","3954.74","1977.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0204","74572142","CDM","272","RC","","","facility","both","","","","4170.02","2085.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0302","74572143","CDM","272","RC","","","facility","both","","","","3738.42","1869.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0303","74572144","CDM","272","RC","","","facility","both","","","","3954.74","1977.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0304","74572145","CDM","272","RC","","","facility","both","","","","4170.02","2085.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Coil,4006U0305","74572146","CDM","272","RC","","","facility","both","","","","4386.33","2193.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0306","74572147","CDM","272","RC","","","facility","both","","","","4600.58","2300.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0307","74572148","CDM","272","RC","","","facility","both","","","","4817.93","2408.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0308","74572149","CDM","272","RC","","","facility","both","","","","5032.17","2516.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0309","74572150","CDM","272","RC","","","facility","both","","","","5248.49","2624.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0310","74572151","CDM","272","RC","","","facility","both","","","","5351.99","2676","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0404","74572152","CDM","272","RC","","","facility","both","","","","4170.02","2085.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0406","74572153","CDM","270","RC","","","facility","both","","","","4600.58","2300.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0408","74572154","CDM","272","RC","","","facility","both","","","","5032.17","2516.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0410","74572155","CDM","272","RC","","","facility","both","","","","5351.99","2676","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0412","74572156","CDM","272","RC","","","facility","both","","","","5474.12","2737.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0414","74572157","CDM","272","RC","","","facility","both","","","","5555.88","2777.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0416","74572158","CDM","272","RC","","","facility","both","","","","5640.75","2820.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0418","74572159","CDM","272","RC","","","facility","both","","","","5721.48","2860.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006U0420","74572160","CDM","272","RC","","","facility","both","","","","5803.25","2901.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100152-30","74572161","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100153-30","74572162","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100201-20","74572163","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100202-30","74572164","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100203-20","74572165","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100204-30","74572166","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100206-30","74572167","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100254-30","74572168","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100256-30","74572169","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100304-30","74572170","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100306-30","74572171","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100406-30","74572172","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100408-30","74572173","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100151-30","74572174","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Cpl100252-30","74572175","CDM","272","RC","","","facility","both","","","","2581.29","1290.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc1401230-30","74572176","CDM","272","RC","","","facility","both","","","","3687.71","1843.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140225-30","74572177","CDM","272","RC","","","facility","both","","","","3360.65","1680.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140303-30","74572178","CDM","272","RC","","","facility","both","","","","3380.31","1690.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140304-30","74572179","CDM","272","RC","","","facility","both","","","","3410.33","1705.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140306-30","74572180","CDM","272","RC","","","facility","both","","","","3442.41","1721.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140406-30","74572181","CDM","272","RC","","","facility","both","","","","3410.33","1705.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140408-30","74572182","CDM","272","RC","","","facility","both","","","","3442.41","1721.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140445-30","74572183","CDM","272","RC","","","facility","both","","","","3390.66","1695.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140507-30","74572184","CDM","272","RC","","","facility","both","","","","3442.41","1721.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140512-30","74572185","CDM","272","RC","","","facility","both","","","","3492.09","1746.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140609-30","74572186","CDM","272","RC","","","facility","both","","","","3483.81","1741.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140615-30","74572187","CDM","272","RC","","","facility","both","","","","3544.88","1772.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140711-30","74572188","CDM","272","RC","","","facility","both","","","","3504.51","1752.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140717-30","74572189","CDM","272","RC","","","facility","both","","","","3566.61","1783.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140812-30","74572190","CDM","272","RC","","","facility","both","","","","3524.18","1762.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140820-30","74572191","CDM","272","RC","","","facility","both","","","","3585.24","1792.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140914-30","74572192","CDM","272","RC","","","facility","both","","","","3544.88","1772.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc140922-30","74572193","CDM","272","RC","","","facility","both","","","","3595.59","1797.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc141016-30","74572194","CDM","272","RC","","","facility","both","","","","3566.61","1783.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc141025-30","74572195","CDM","272","RC","","","facility","both","","","","3647.34","1823.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc141118-30","74572196","CDM","272","RC","","","facility","both","","","","3585.24","1792.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc141127-30","74572197","CDM","272","RC","","","facility","both","","","","3667.01","1833.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Crc141219-30","74572198","CDM","272","RC","","","facility","both","","","","3605.94","1802.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035422030","74572199","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035422040","74572200","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035422060","74572201","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035422540","74572202","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035423040","74572203","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035423060","74572204","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Coil,M0035423080","74572205","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035423100","74572206","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035424060","74572207","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035424080","74572208","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035424100","74572209","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035424150","74572210","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035425100","74572211","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035425150","74572212","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432010","74572213","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432020","74572214","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432030","74572215","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432040","74572216","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432060","74572217","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432080","74572218","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432530","74572219","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432540","74572220","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035432560","74572221","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035433040","74572222","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035433060","74572223","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035433080","74572224","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035433100","74572225","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035434060","74572226","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035434080","74572227","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035434150","74572228","CDM","272","RC","","","facility","both","","","","2368.08","1184.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035461030","74572229","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035461130","74572230","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035461230","74572231","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035461330","74572232","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035461430","74572233","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035461540","74572234","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035463060","74572235","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035463080","74572236","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035464080","74572237","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035464100","74572238","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035464150","74572239","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035465150","74572240","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035465200","74572241","CDM","272","RC","","","facility","both","","","","3156.75","1578.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035466150","74572242","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035466200","74572243","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035466300","74572244","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035467150","74572245","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035467200","74572246","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035467300","74572247","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035468200","74572248","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035468300","74572249","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035469200","74572250","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035469300","74572251","CDM","272","RC","","","facility","both","","","","3552.12","1776.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035471030","74572252","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035471130","74572253","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035471230","74572254","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035471330","74572255","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035471430","74572256","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035472040","74572257","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035473060","74572258","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035473080","74572259","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035473100","74572260","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035474060","74572261","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035474080","74572262","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035474100","74572263","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035474150","74572264","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035475100","74572265","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035475150","74572266","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035475200","74572267","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035476100","74572268","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil, M0035476150","74572269","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035476200","74572270","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035476300","74572271","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035477150","74572272","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035477200","74572273","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035477300","74572274","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035478200","74572275","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035478300","74572276","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035479200","74572277","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,M0035479300","74572278","CDM","272","RC","","","facility","both","","","","3353.4","1676.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-10-30-Helix","74572279","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-2-4-Helix","74572280","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-2-6-Helix","74572281","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-2-8-Helix","74572282","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-3-4-Helix","74572283","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-3-8-Helix","74572284","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-4-10-Helix","74572285","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-4-8-Helix","74572286","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-5-15-Helix","74572287","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-5-20-Helix","74572288","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-6-20-Helix","74572289","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-7-30-Helix","74572290","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-8-30-Helix","74572291","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Nv-9-30-Helix","74572292","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4100412-30","74572293","CDM","272","RC","","","facility","both","","","","4673.03","2336.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4100517-30","74572294","CDM","272","RC","","","facility","both","","","","4730.99","2365.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4100626-30","74572295","CDM","272","RC","","","facility","both","","","","4768.25","2384.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4100730-30","74572296","CDM","272","RC","","","facility","both","","","","4815.86","2407.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4100829-30","74572297","CDM","272","RC","","","facility","both","","","","4860.36","2430.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4181950-30","74572298","CDM","272","RC","","","facility","both","","","","6420.11","3210.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pc4182050-30","74572299","CDM","272","RC","","","facility","both","","","","6420.11","3210.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pv-12-30-Helix","74572300","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pv-14-30-Helix","74572301","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pv-16-40-Helix","74572302","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pv-18-40-Helix","74572303","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Pv-20-50-Helix","74572304","CDM","272","RC","","","facility","both","","","","1337.22","668.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Chgr-Den Tunneler 18F,15"""",42-3100""","74572308","CDM","272","RC","","","facility","both","","","","187.34","93.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Detacher Concerto Coils,Id-1-5","74572310","CDM","272","RC","","","facility","both","","","","105.57","52.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Detachment Handle Dh1","74572311","CDM","272","RC","","","facility","both","","","","516.47","258.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Detachment Izds Connect Cables","74572312","CDM","272","RC","","","facility","both","","","","101.43","50.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Drain Set Thal-Quick,14X41","74572318","CDM","272","RC","C1729","HCPCS","facility","both","","","","340.52","170.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Drain Set Thal-Quick,18X41","74572319","CDM","272","RC","C1729","HCPCS","facility","both","","","","340.52","170.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Filt Antecub Shth,4439985","74572323","CDM","272","RC","","","facility","both","","","","402.62","201.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr- Sp Microcath,Progreat, 2.4Fx110","74572336","CDM","272","RC","C1887","HCPCS","facility","both","","","","673.79","336.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Microcath,Progreat,2.4Fx130","74572337","CDM","272","RC","C1887","HCPCS","facility","both","","","","673.79","336.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra Seperator,Psf026","74572340","CDM","272","RC","C1773","HCPCS","facility","both","","","","6143.76","3071.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra Seperator,Psf054","74572341","CDM","272","RC","C1773","HCPCS","facility","both","","","","6143.76","3071.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Elite 15Mm,8402","74572344","CDM","272","RC","C1773","HCPCS","facility","both","","","","1433.48","716.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Solitaire 4X15,Sfr-4-15","74572351","CDM","272","RC","","","facility","both","","","","14890.55","7445.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Solitaire 4X20,Sfr-4-20","74572352","CDM","272","RC","","","facility","both","","","","14890.55","7445.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Solitaire 6X20,Sfr-6-20","74572353","CDM","272","RC","","","facility","both","","","","14890.55","7445.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Solitaire 6X30,Sfr-6-30","74572354","CDM","272","RC","","","facility","both","","","","14890.55","7445.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Wire Synchro 2 Soft","74572361","CDM","272","RC","C1769","HCPCS","facility","both","","","","1245.11","622.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon,Artic Front Cryo","74572370","CDM","272","RC","C1733","HCPCS","facility","both","","","","8776.8","4388.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Flexcath","74572371","CDM","272","RC","C1766","HCPCS","facility","both","","","","2061.72","1030.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Achieve","74572372","CDM","272","RC","C1730","HCPCS","facility","both","","","","1944.77","972.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cables,Achieve","74572373","CDM","272","RC","","","facility","both","","","","441.95","220.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Manual Retraction Kit","74572374","CDM","272","RC","","","facility","both","","","","294.98","147.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Guide Navien Rfx072-105-08Mp","74572380","CDM","272","RC","C1887","HCPCS","facility","both","","","","1831.95","915.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Device Pipeline 10-20Mm Length","74572385","CDM","270","RC","","","facility","both","","","","23216.09","11608.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Device Pipeline 25-35Mm Length","74572386","CDM","270","RC","","","facility","both","","","","24886.58","12443.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexltis 1.5X1.5 Prsqcm Wst","74572391","CDM","278","RC","Q4137","HCPCS","facility","both","","","","575.46","287.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexl Tiss 12Mm Orsqcn Wst","74572392","CDM","278","RC","Q4137","HCPCS","facility","both","","","","477.14","238.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexl Tiss 15Mm Prsqcm Wst","74572393","CDM","278","RC","Q4137","HCPCS","facility","both","","","","260.82","130.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexl Tiss 2X3 Prsqcm Wste","74572394","CDM","278","RC","Q4137","HCPCS","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexl Tiss 4X4 Prsqcm Wste","74572395","CDM","278","RC","Q4137","HCPCS","facility","both","","","","112.82","56.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexl Tiss 4X8 Prsqcm Wste","74572396","CDM","278","RC","Q4137","HCPCS","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Pump","74572401","CDM","270","RC","","","facility","both","","","","135705.06","67852.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Surgical Tools","74572402","CDM","270","RC","","","facility","both","","","","8689.86","4344.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Driveline Ext Cable","74572403","CDM","270","RC","","","facility","both","","","","3511.76","1755.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Outflow Graft","74572404","CDM","270","RC","","","facility","both","","","","3900.92","1950.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Controller","74572406","CDM","270","RC","Q0481","HCPCS","facility","both","","","","12481.07","6240.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Battery Charger","74572407","CDM","270","RC","Q0495","HCPCS","facility","both","","","","11897.33","5948.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Monitor","74572408","CDM","270","RC","","","facility","both","","","","19405.22","9702.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Controller Ac Adaptor","74572409","CDM","270","RC","Q0508","HCPCS","facility","both","","","","1952.01","976","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Controller Dc Adaptor","74572410","CDM","270","RC","Q0508","HCPCS","facility","both","","","","3511.76","1755.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Lithium Battery","74572411","CDM","270","RC","Q0506","HCPCS","facility","both","","","","1466.6","733.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Data Cable","74572413","CDM","270","RC","","","facility","both","","","","879.75","439.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Monitor Ac Adaptor","74572414","CDM","270","RC","","","facility","both","","","","2341.17","1170.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Patient Pack","74572415","CDM","270","RC","Q0498","HCPCS","facility","both","","","","831.11","415.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Waist Pack","74572416","CDM","270","RC","Q0499","HCPCS","facility","both","","","","831.11","415.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Shoulder Pack","74572417","CDM","270","RC","Q0498","HCPCS","facility","both","","","","879.75","439.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hw Shoulder Bag","74572418","CDM","270","RC","Q0501","HCPCS","facility","both","","","","586.85","293.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Metacross .035 Pta Rx Balloon","74572420","CDM","272","RC","C1725","HCPCS","facility","both","","","","163.53","81.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Zilver Self-Expanding","74572430","CDM","278","RC","C1876","HCPCS","facility","both","","","","3270.6","1635.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Crossboss","74572501","CDM","278","RC","C1724","HCPCS","facility","both","","","","3540.74","1770.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Catheter,Stingray","74572502","CDM","278","RC","C1725","HCPCS","facility","both","","","","2479.86","1239.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide Extension","74572521","CDM","272","RC","C1887","HCPCS","facility","both","","","","786","393","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0202","74572526","CDM","272","RC","","","facility","both","","","","3567.65","1783.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0203","74572527","CDM","272","RC","","","facility","both","","","","3762.23","1881.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0204","74572528","CDM","272","RC","","","facility","both","","","","3958.88","1979.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0303","74572529","CDM","272","RC","","","facility","both","","","","3762.23","1881.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0304","74572530","CDM","272","RC","","","facility","both","","","","3958.88","1979.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0305","74572531","CDM","272","RC","","","facility","both","","","","4151.39","2075.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0306","74572532","CDM","272","RC","","","facility","both","","","","4347","2173.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0308","74572533","CDM","272","RC","","","facility","both","","","","4737.2","2368.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0310","74572534","CDM","272","RC","","","facility","both","","","","5126.36","2563.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0404","74572535","CDM","272","RC","","","facility","both","","","","3958.88","1979.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0406","74572536","CDM","272","RC","","","facility","both","","","","4347","2173.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0408","74572537","CDM","272","RC","","","facility","both","","","","4737.2","2368.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4006C0410","74572538","CDM","272","RC","","","facility","both","","","","5126.36","2563.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2860","74572539","CDM","272","RC","","","facility","both","","","","5386.14","2693.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4002C2860","74572540","CDM","272","RC","","","facility","both","","","","5386.14","2693.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,4004J25","74572541","CDM","272","RC","","","facility","both","","","","5238.14","2619.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Microcath Penumbra Pxslim130","74572545","CDM","272","RC","C1887","HCPCS","facility","both","","","","1729.49","864.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Evera Xt Dr","74572550","CDM","275","RC","C1721","HCPCS","facility","both","","","","39057.8","19528.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Evera S Dr","74572551","CDM","275","RC","C1721","HCPCS","facility","both","","","","86068.53","43034.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Evera Xt Vr","74572552","CDM","275","RC","C1722","HCPCS","facility","both","","","","35377.34","17688.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath Penumbra Pns6F125Ber","74572567","CDM","278","RC","C1757","HCPCS","facility","both","","","","665.51","332.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Penumbra,Paps2,Cann/Tub/Filt","74572569","CDM","272","RC","","","facility","both","","","","585.81","292.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Microcath Penumbra Vel160Str","74572570","CDM","272","RC","","","facility","both","","","","1729.49","864.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,15Cm-17G,Lk15","74572575","CDM","270","RC","","","facility","both","","","","3679.43","1839.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,20Cm-17G,Lk20","74572576","CDM","270","RC","","","facility","both","","","","3679.43","1839.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,15Cm-17G,Ln15","74572577","CDM","270","RC","","","facility","both","","","","3679.43","1839.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,20Cm-17G,Ln20","74572578","CDM","270","RC","","","facility","both","","","","3679.43","1839.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,15Cm-17G,Pr15","74572579","CDM","270","RC","","","facility","both","","","","3679.43","1839.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,20Cm-17G,Pr20","74572580","CDM","270","RC","","","facility","both","","","","3555","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Ablate Probe,25Cm-13G,Sr25","74572581","CDM","270","RC","","","facility","both","","","","3679.43","1839.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Short Term Dialysis Cath Spply","74572590","CDM","278","RC","C1752","HCPCS","facility","both","","","","680","340","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Advisa Dr Mri","74572600","CDM","275","RC","C1785","HCPCS","facility","both","","","","11619.95","5809.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Microspheres,30-60 Um,10Ml","74572602","CDM","270","RC","","","facility","both","","","","2881.44","1440.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Microspheres,50-100 Um,10Ml","74572603","CDM","270","RC","","","facility","both","","","","2881.44","1440.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Iperia Mri Dr; Df4","74572615","CDM","275","RC","C1721","HCPCS","facility","both","","","","41216.81","20608.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Inventra Mri Dx","74572616","CDM","275","RC","C1722","HCPCS","facility","both","","","","20803.5","10401.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon,Drug Eluting Peripherl","74572621","CDM","278","RC","C2623","HCPCS","facility","both","","","","1789.52","894.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby4C2 50-60Cm Length","74572641","CDM","270","RC","","","facility","both","","","","2634.08","1317.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby4C 25-40Cm Length","74572642","CDM","270","RC","","","facility","both","","","","2477.79","1238.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby4C 20Cm Length","74572643","CDM","270","RC","","","facility","both","","","","2321.51","1160.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby4C 12-15Cm Length","74572644","CDM","270","RC","","","facility","both","","","","2166.26","1083.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby2C 10Cm Length","74572645","CDM","270","RC","","","facility","both","","","","2011.01","1005.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby2C 5-6Cm Length","74572646","CDM","270","RC","","","facility","both","","","","1543.19","771.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby4C 2-4Cm Length","74572647","CDM","270","RC","","","facility","both","","","","1386.9","693.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rby4C 1Cm Length","74572648","CDM","270","RC","","","facility","both","","","","1231.65","615.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Coil,Rh1 Detach Handle","74572649","CDM","270","RC","","","facility","both","","","","391.23","195.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neoprene,Colditz Hand Basd Ots","74572659","CDM","274","RC","L3924","HCPCS","facility","both","","","","155.25","77.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter,Tacticath","74572665","CDM","272","RC","C2630","HCPCS","facility","both","","","","3280.95","1640.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gore Dryseal Sheath 12F-16F","74572672","CDM","272","RC","C1894","HCPCS","facility","both","","","","462","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gore Stent Graft Balloon Cath","74572673","CDM","272","RC","C1725","HCPCS","facility","both","","","","841.46","420.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gore Rlt Endoprosthesis","74572674","CDM","270","RC","","","facility","both","","","","13117.59","6558.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gore Pla Endoprosthesis","74572675","CDM","270","RC","","","facility","both","","","","3662.87","1831.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gore Plc Endoprosthesis","74572676","CDM","270","RC","","","facility","both","","","","5223.65","2611.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Gore Pll Endoprosthesis","74572677","CDM","270","RC","","","facility","both","","","","3662.87","1831.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prevena Disp Incisn Manage Sys","74572678","CDM","272","RC","A6550","HCPCS","facility","both","","","","877.68","438.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnioexcel Tiss 12Mm Per Sq Cm","74572679","CDM","278","RC","Q4137","HCPCS","facility","both","","","","477.14","238.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnioexcel Tiss 15Mm Per Sq Cm","74572680","CDM","278","RC","Q4137","HCPCS","facility","both","","","","260.82","130.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnexcl Tiss 1.5X1.5 Per Sq Cm","74572681","CDM","278","RC","Q4137","HCPCS","facility","both","","","","575.46","287.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnioexcel Tiss 2X3 Per Sq Cm","74572682","CDM","278","RC","Q4137","HCPCS","facility","both","","","","262.89","131.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnioexcel Tiss 4X4 Per Sq Cm","74572683","CDM","278","RC","Q4137","HCPCS","facility","both","","","","112.82","56.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnioexcel Tiss 4X8 Per Sq Cm","74572684","CDM","278","RC","Q4137","HCPCS","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Microwave Ablation","74572685","CDM","278","RC","C1886","HCPCS","facility","both","","","","2598.89","1299.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe/Needle, Cryo","74572686","CDM","272","RC","C2618","HCPCS","facility","both","","","","1444.86","722.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sling Hemi Arm","74572687","CDM","274","RC","A4565","HCPCS","facility","both","","","","75.56","37.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Givmohr Sling","74572688","CDM","274","RC","L3670","HCPCS","facility","both","","","","171.81","85.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bandit Strp Forearm Prefab Ots","74572690","CDM","274","RC","L3762","HCPCS","facility","both","","","","170.78","85.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Whfo No Jnt Prefab Ots","74572694","CDM","274","RC","L3809","HCPCS","facility","both","","","","242.19","121.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neoprene, Colditz, Hand Ots","74572695","CDM","274","RC","L3924","HCPCS","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Mini Cranial Fix Monteris","74572699","CDM","270","RC","","","facility","both","","","","1765.71","882.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neurobl Driver Probe Robotic","74572700","CDM","270","RC","","","facility","both","","","","3934.04","1967.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent, Synergy","74572702","CDM","278","RC","C1874","HCPCS","facility","both","","","","2741","1370.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allograft Amnioexcel Per Sq Cm","74572703","CDM","278","RC","Q4137","HCPCS","facility","both","","","","109.71","54.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Accolade Mri Vr","74572704","CDM","275","RC","C1786","HCPCS","facility","both","","","","8023.32","4011.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Accolade Mri Dr","74572705","CDM","275","RC","C1785","HCPCS","facility","both","","","","11227","5613.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snap Kit","74576981","CDM","270","RC","","","facility","both","","","","365.36","182.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tandem Heart Rvad Implant","74576992","CDM","270","RC","","","facility","both","","","","27949","13974.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hmii Pc Controller Battery","74576993","CDM","270","RC","Q0506","HCPCS","facility","both","","","","912.87","456.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impella 5.0 Pump","74576994","CDM","270","RC","","","facility","both","","","","33327","16663.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impella Pump 5.5","74576995","CDM","270","RC","","","facility","both","","","","51750","25875","","","","","","","","","","","","","Gross Charge Type: Standard"
"Triclip G4 System","74576996","CDM","270","RC","","","facility","both","","","","42849","21424.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Innova Bm Stent, Boston Sci","74577000","CDM","278","RC","C1876","HCPCS","facility","both","","","","1571.13","785.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Amplia Mri Quad Df4","74577001","CDM","275","RC","C1882","HCPCS","facility","both","","","","41216.81","20608.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Amplia Mri Df","74577002","CDM","275","RC","C1882","HCPCS","facility","both","","","","41216.81","20608.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon,Sterling","74577004","CDM","272","RC","C1725","HCPCS","facility","both","","","","417.11","208.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Cannula Cement","74577008","CDM","278","RC","C1713","HCPCS","facility","both","","","","278.42","139.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Cannula Access","74577009","CDM","270","RC","","","facility","both","","","","231.84","115.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Hand Drill","74577010","CDM","270","RC","","","facility","both","","","","371.57","185.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Mixer Cement","74577011","CDM","278","RC","C1713","HCPCS","facility","both","","","","2482.97","1241.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Balloon Kit","74577012","CDM","270","RC","","","facility","both","","","","3213.68","1606.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Biopsy Kit","74577013","CDM","270","RC","","","facility","both","","","","220.46","110.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Gun/Tips","74577015","CDM","270","RC","","","facility","both","","","","1530.77","765.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kypho Curved Needle","74577016","CDM","270","RC","","","facility","both","","","","1477.98","738.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotaflow Pump Head","74577019","CDM","270","RC","","","facility","both","","","","580.64","290.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"3/8 Inch Pump Tubing","74577020","CDM","270","RC","","","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Optisite Cannula","74577021","CDM","270","RC","","","facility","both","","","","334.31","167.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Visia Mri Df4/Df1","74577022","CDM","275","RC","C1722","HCPCS","facility","both","","","","30429","15214.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide Ext Trapliner","74577023","CDM","278","RC","C1887","HCPCS","facility","both","","","","946","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Microcatheter Mamba","74577024","CDM","278","RC","C1887","HCPCS","facility","both","","","","874.58","437.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rp Pluvicto Per Dose","74577025","CDM","344","RC","A9699","HCPCS","facility","both","","","","59874","29937","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mrgfus Neuro Patient Acc Set","74577026","CDM","270","RC","","","facility","both","","","","3570.75","1785.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Mapping Carto Octaray","74577027","CDM","278","RC","C1732","HCPCS","facility","both","","","","2642","1321","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clinical Trials Research Device - Token Charge","74577028","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Empower Pacemaker And Delivery, Modular Atp Study","74577029","CDM","278","RC","C1786","HCPCS","facility","both","","","","12794.67","6397.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Empower Retrieval Catheter & Components - Modular Atp Study","74577030","CDM","278","RC","C1786","HCPCS","facility","both","","","","4165.88","2082.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath,Visi Dilator","74579081","CDM","272","RC","C1893","HCPCS","facility","both","","","","441.95","220.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thai Quick Chest Tube Kit","74579083","CDM","270","RC","","","facility","both","","","","208.04","104.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trialysis Cath Triplelumen 20","74579084","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trialysis Cath Triplelumen 15","74579085","CDM","270","RC","","","facility","both","","","","476.1","238.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Medtronic Lumbar Drainage Kit","74579086","CDM","270","RC","","","facility","both","","","","336.38","168.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prisma Flex M 100 Set Up","74579090","CDM","270","RC","","","facility","both","","","","364","182","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon,Drug Peripherl 150Mm","74579092","CDM","278","RC","C2623","HCPCS","facility","both","","","","2374.29","1187.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Berenstein 40Cm","74580026","CDM","278","RC","C1725","HCPCS","facility","both","","","","253.58","126.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coyote Balloon","74580046","CDM","278","RC","C1725","HCPCS","facility","both","","","","461.61","230.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"E0191 Heel/Elbow Protecto","74580052","CDM","274","RC","E0191","HCPCS","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"E1399 Miscellaneous Equip","74580053","CDM","274","RC","E1399","HCPCS","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"A9300 Exercise Equipment","74580061","CDM","274","RC","A9300","HCPCS","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"L0456 Tlso Flex Trnk Sj-Ss P","74580072","CDM","274","RC","L0456","HCPCS","facility","both","","","","1045.35","522.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"L0464 3 Mod Sacro Scap Pre","74580073","CDM","274","RC","L0464","HCPCS","facility","both","","","","1561.82","780.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"L0621 Si Belt","74580074","CDM","274","RC","L0621","HCPCS","facility","both","","","","108.68","54.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"L1620-Ho Abd Contrl Hip Jt","74580075","CDM","274","RC","L1620","HCPCS","facility","both","","","","178.02","89.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"L1831-Ko, Positional Orth","74580076","CDM","274","RC","L1831","HCPCS","facility","both","","","","361.22","180.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3030 Orthotics","74580077","CDM","274","RC","L3030","HCPCS","facility","both","","","","305.33","152.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3040 Foot Arch Suprt,Rem","74580078","CDM","274","RC","L3040","HCPCS","facility","both","","","","56.93","28.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3923-Hfo-Without Joints","74580079","CDM","274","RC","L3923","HCPCS","facility","both","","","","108.68","54.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"L1845-Ko Dbl Up,Med/Later","74580080","CDM","274","RC","L1845","HCPCS","facility","both","","","","1083.65","541.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"L1906-Afo-Multilig Ankle","74580081","CDM","274","RC","L1906","HCPCS","facility","both","","","","141.8","70.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"L4350 Afo Stirrup","74580082","CDM","274","RC","L4350","HCPCS","facility","both","","","","101.43","50.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"L2114-Afo-Fracture Semi-R","74580083","CDM","274","RC","L2114","HCPCS","facility","both","","","","770.04","385.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3332 Heel Lift","74580085","CDM","274","RC","L3332","HCPCS","facility","both","","","","25.88","12.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"L3350 Heel Wedge","74580086","CDM","274","RC","L3350","HCPCS","facility","both","","","","22.77","11.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mustang Balloon","74580107","CDM","272","RC","C1725","HCPCS","facility","both","","","","519.57","259.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"One Step Centesis Cath","74580108","CDM","272","RC","C1729","HCPCS","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protege Everflex 100Mm Stent","74580120","CDM","278","RC","C1876","HCPCS","facility","both","","","","1480.05","740.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rosen 35-180Cm","74580125","CDM","278","RC","C1887","HCPCS","facility","both","","","","98.33","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Destination","74580128","CDM","278","RC","C1887","HCPCS","facility","both","","","","334.31","167.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Turbohawk Atherectomy Cath","74580145","CDM","278","RC","C1714","HCPCS","facility","both","","","","4656.47","2328.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Viabahn Stent 6Mm X 10Cm","74580147","CDM","278","RC","C1874","HCPCS","facility","both","","","","3868.83","1934.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mini Access Kit","74580173","CDM","272","RC","C1894","HCPCS","facility","both","","","","121.1","60.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tr Band Regular 24Cm X Xrf06","74580176","CDM","270","RC","","","facility","both","","","","228.74","114.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tr Band Large 29Cm X Xrf062","74580177","CDM","270","RC","","","facility","both","","","","133","66.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plasmablade 3.0Mm (Suction)","74580183","CDM","270","RC","","","facility","both","","","","444.02","222.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nm Tilmanocept Dx Up To 0.5Mci","74580187","CDM","343","RC","A9520","HCPCS","facility","both","","","","945","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lutonix Drug Eluting Balloon","74580188","CDM","272","RC","C2623","HCPCS","facility","both","","","","3347.19","1673.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drainage G-Tube 18Fr Mic","74580189","CDM","272","RC","C1729","HCPCS","facility","both","","","","124.2","62.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mic Gj Tube 18F","74580190","CDM","272","RC","C1729","HCPCS","facility","both","","","","377.78","188.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"4F Sl Bard Non-Power Picc","74580191","CDM","278","RC","C1751","HCPCS","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuwave Ablation Probe","74580194","CDM","278","RC","C1886","HCPCS","facility","both","","","","2556.45","1278.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penumbra Benchmark 071 System","74580196","CDM","272","RC","C1887","HCPCS","facility","both","","","","2379.47","1189.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penumbra 6F Neuronmax Straight","74580197","CDM","272","RC","C1894","HCPCS","facility","both","","","","1184.04","592.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Covidien Echelon Microcatheter","74580201","CDM","270","RC","","","facility","both","","","","1019.48","509.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penumbra Max Aspiration Tubing","74580204","CDM","270","RC","","","facility","both","","","","702.77","351.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penumbra Neuron Select Cath","74580205","CDM","270","RC","","","facility","both","","","","299.12","149.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ev3 Spiderfx Protection Device","74580206","CDM","270","RC","","","facility","both","","","","2869.02","1434.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glove,Finger Flexion All-Sizes","74580207","CDM","270","RC","A4570","HCPCS","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Profore Padding Bandage","74580208","CDM","270","RC","A6441","HCPCS","facility","both","","","","10.35","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Profore Adherent Bandage","74580209","CDM","270","RC","A6454","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cook 6F Shuttle Slip Cath","74580210","CDM","270","RC","","","facility","both","","","","200.79","100.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cooled Rfa Kit","74580211","CDM","272","RC","A4649","HCPCS","facility","both","","","","1203.71","601.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cooled Rfa Multi Kit","74580212","CDM","272","RC","A4649","HCPCS","facility","both","","","","1785.38","892.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cooled Rfa Probe","74580213","CDM","272","RC","A4649","HCPCS","facility","both","","","","641.7","320.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Lv Attain Stability Quad","74580215","CDM","278","RC","C1900","HCPCS","facility","both","","","","6360","3180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ascope 4 Broncho Slim 3.8/1.2","74581101","CDM","270","RC","","","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"1 Bottle H2Mf +10 (50Ml)","74581103","CDM","270","RC","","","facility","both","","","","456.44","228.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interstim External Stimulator","74581107","CDM","270","RC","","","facility","both","","","","641.7","320.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"1 Bottle Rtf H2Mf 26","74581108","CDM","270","RC","","","facility","both","","","","292.91","146.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"1 Bottle Rtf H2Mf 28","74581109","CDM","270","RC","","","facility","both","","","","379.85","189.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Filter To Rmve Cytokines","74581110","CDM","270","RC","","","facility","both","","","","415.04","207.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ocs Heart Perfusion Set","74581113","CDM","270","RC","","","facility","both","","","","77366.25","38683.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icd Single Chmbr Cobalt Mri Vr","74581114","CDM","278","RC","C1722","HCPCS","facility","both","","","","14028.39","7014.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icd Dual Chmbr Cobalt Mri Dr","74581115","CDM","278","RC","C1721","HCPCS","facility","both","","","","14781","7390.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icd Biv Defib Cobalt Mri Quad","74581116","CDM","278","RC","C1882","HCPCS","facility","both","","","","20528","10264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder Lux Dx","74581117","CDM","278","RC","C1764","HCPCS","facility","both","","","","5290","2645","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vascade Closure Device","74581119","CDM","278","RC","C1760","HCPCS","facility","both","","","","660","330","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nushield 1 Square Cm","74581151","CDM","278","RC","Q4160","HCPCS","facility","both","","","","326.03","163.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lutetium Lu 177 Per Mci Waste","74581152","CDM","344","RC","A9513","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Solve Wise Crt 1000 Elec","74581153","CDM","270","RC","","","facility","both","","","","8927.91","4463.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Wise Crt 2K Delivery Cat","74581154","CDM","270","RC","","","facility","both","","","","2380.5","1190.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Wise Crt Mod 3K Pul Gen Bat","74581155","CDM","270","RC","","","facility","both","","","","5951.25","2975.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Wise Crt 4100 Pul Gen Trn","74581156","CDM","270","RC","","","facility","both","","","","12497.63","6248.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Juxtaflow Sys,Void Stdy","74581157","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kerecis Omega3 Per Sq Cm","74581158","CDM","278","RC","Q4158","HCPCS","facility","both","","","","193.55","96.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kerecis Omega3 Per Sq Cm Waste","74581159","CDM","278","RC","Q4158","HCPCS","facility","both","","","","193.55","96.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Cytosorb","74581160","CDM","270","RC","","","facility","both","","","","1785.38","892.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gen, Neuro, Carot Sinus Baro","74581162","CDM","278","RC","C1825","HCPCS","facility","both","","","","46575","23287.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Suprapubic/Cystoscopic","74581163","CDM","278","RC","C2627","HCPCS","facility","both","","","","804.2","402.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead, Pacing Lead Tempo","74581164","CDM","270","RC","","","facility","both","","","","634.46","317.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath, Shockwave Coronary Ivl","74581165","CDM","278","RC","C1761","HCPCS","facility","both","","","","11750","5875","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve, Sterile Shockwave Ivl","74581166","CDM","270","RC","","","facility","both","","","","48.65","24.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icd Dual Chamber Entrant Mri","74581167","CDM","278","RC","C1721","HCPCS","facility","both","","","","13092.75","6546.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icd Single Chamber Entrant Mri","74581168","CDM","278","RC","C1722","HCPCS","facility","both","","","","10695","5347.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icd Biv Entrant Hf Crt-D","74581169","CDM","278","RC","C1882","HCPCS","facility","both","","","","16068.38","8034.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Versacrossrf Trnseptl Wire Kit","74581170","CDM","270","RC","","","facility","both","","","","1437","718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Brst Loc 20Gx5Cm","74581171","CDM","278","RC","C1769","HCPCS","facility","both","","","","32.09","16.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroestradiol F18, 1Mci","74581172","CDM","343","RC","A9591","HCPCS","facility","both","","","","1377","688.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial [18F] Nav-4694 (Flutafuranol)","74581173","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial [18F] Mk-6240","74581174","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Pq Bypass Torus Stent Graft","74581175","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trial Merit Wrapsody Endovasc Stent","74581176","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Circa S-Cath Esoph Temp","74581177","CDM","270","RC","","","facility","both","","","","962.55","481.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe, Robotic, Water-Jet","74581178","CDM","278","RC","C2596","HCPCS","facility","both","","","","2975.63","1487.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med/Surg Supply - General","74597000","CDM","270","RC","","","facility","both","","","","3621","1810.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med/Surg Supply - Sterile","74597001","CDM","272","RC","","","facility","both","","","","1008.73","504.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med/Surg Supply - Pacemaker","74597003","CDM","275","RC","","","facility","both","","","","6555","3277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med/Surg Supply - Intraoc Lens","74597004","CDM","276","RC","","","facility","both","","","","380","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med/Surg Supply - Other Implnt","74597005","CDM","278","RC","","","facility","both","","","","817.03","408.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penumbra Catrx Kit W Canister","74598001","CDM","272","RC","C1757","HCPCS","facility","both","","","","2651","1325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Glidepath","74599029","CDM","278","RC","C1750","HCPCS","facility","both","","","","464.72","232.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cath,Thrombectomy Xpeedior","74599030","CDM","278","RC","C1757","HCPCS","facility","both","","","","2172.47","1086.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caths-Infus/Unifuse 5Fr-135-20","74599505","CDM","278","RC","C1751","HCPCS","facility","both","","","","138.69","69.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle 18Gx15Cm Biopsy Temno","74599547","CDM","270","RC","","","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Cath Dorado 8-4-80","74599550","CDM","272","RC","C1725","HCPCS","facility","both","","","","478.17","239.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare, Ensnare 4-8Mm","74599551","CDM","278","RC","C1773","HCPCS","facility","both","","","","1043.28","521.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare, Ensnare 18-30Mm","74599552","CDM","278","RC","C1773","HCPCS","facility","both","","","","577.53","288.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Herculink Elite 5X18X135","74599555","CDM","278","RC","C1876","HCPCS","facility","both","","","","1278.23","639.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent,Herculink Elite 6X15X135","74599556","CDM","278","RC","C1876","HCPCS","facility","both","","","","1278.23","639.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smart Stent 6X60X120","74599564","CDM","278","RC","C1876","HCPCS","facility","both","","","","874.58","437.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ansel Sheath 6F X 45 Cm","74599565","CDM","272","RC","C1894","HCPCS","facility","both","","","","110.75","55.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ansel Sheath 5F X 55 Cm","74599566","CDM","272","RC","C1894","HCPCS","facility","both","","","","108.68","54.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Midline Infusion Cath","74599570","CDM","278","RC","C1751","HCPCS","facility","both","","","","224.6","112.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bard Cv Power Port 6F Sl Slim","74599571","CDM","278","RC","C1788","HCPCS","facility","both","","","","441.95","220.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"4F Sl Bard Power Picc","74599572","CDM","278","RC","C1751","HCPCS","facility","both","","","","121.1","60.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"5F Sl Bard Non-Power Picc","74599573","CDM","278","RC","C1751","HCPCS","facility","both","","","","113.85","56.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bard Ultraverse .018 Balloon","74599574","CDM","272","RC","C1725","HCPCS","facility","both","","","","278.42","139.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ebus Needle","74599584","CDM","270","RC","","","facility","both","","","","361.22","180.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Catheter Bs 5Fr","74599615","CDM","272","RC","C1887","HCPCS","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Glidesheath Terumo 6Fr Radial","74599626","CDM","272","RC","C1894","HCPCS","facility","both","","","","112.82","56.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Repair Biotenodesis Arthrx","74599700","CDM","270","RC","","","facility","both","","","","642.74","321.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ice Cryoablation Needle","74599723","CDM","278","RC","C2618","HCPCS","facility","both","","","","1488.33","744.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Target Detachable Coils","74599725","CDM","270","RC","","","facility","both","","","","2184.89","1092.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyx Hd500 Kit,Aneurys","74599730","CDM","272","RC","","","facility","both","","","","2678.58","1339.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder,Biomonitor","74599736","CDM","278","RC","C1764","HCPCS","facility","both","","","","5933.66","2966.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implt Grafix Core,3X4 Cm","74599755","CDM","278","RC","Q4132","HCPCS","facility","both","","","","181.13","90.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disposable Ambu Scope","74599760","CDM","272","RC","","","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Assurity Mri Sr Rf","74599781","CDM","275","RC","C1786","HCPCS","facility","both","","","","3834.68","1917.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Microwav Ablation Probe 13-17G","74599791","CDM","270","RC","","","facility","both","","","","2474.69","1237.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amplatzer Laao, Amulet Study","74599793","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead, Pacemaker Tendril Mri","74599794","CDM","275","RC","C1898","HCPCS","facility","both","","","","524.75","262.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead, Defib Plexa Mri","74599795","CDM","275","RC","C1777","HCPCS","facility","both","","","","3900","1950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead, Defib Plexa Mri Df1","74599796","CDM","275","RC","C1895","HCPCS","facility","both","","","","4036.5","2018.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Etrinsa Dr-T","74599798","CDM","275","RC","C1785","HCPCS","facility","both","","","","4036.5","2018.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Assurity Mri Dr Rf","74599799","CDM","275","RC","C1785","HCPCS","facility","both","","","","4709.25","2354.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Soft Protect Helmet Pref","74599804","CDM","290","RC","A8000","HCPCS","facility","both","","","","842.49","421.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Drug Elute Stent,Resolut,Onyx","74599805","CDM","278","RC","C1874","HCPCS","facility","both","","","","1650","825","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Col Cerv Sup Adj Bar/Thor Cust","74599806","CDM","274","RC","L0200","HCPCS","facility","both","","","","595.13","297.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Ilivia Mri Dr-T Df4/Df1","74599807","CDM","275","RC","C1721","HCPCS","facility","both","","","","15238","7619","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Intica Mri Dx","74599808","CDM","275","RC","C1722","HCPCS","facility","both","","","","14462.06","7231.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Ilivia Mri Df","74599809","CDM","275","RC","C1722","HCPCS","facility","both","","","","14462.06","7231.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Ilivia Mri Hf-T Qp Df","74599810","CDM","275","RC","C1882","HCPCS","facility","both","","","","21424.5","10712.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib,Sentus Quadripolar","74599811","CDM","278","RC","C1900","HCPCS","facility","both","","","","2489.18","1244.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Edora Dr-T Mri","74599812","CDM","275","RC","C1785","HCPCS","facility","both","","","","4709.25","2354.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Edora Sr-T Mri","74599813","CDM","275","RC","C1786","HCPCS","facility","both","","","","3834.68","1917.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Percepta Crt-P","74599814","CDM","275","RC","C2621","HCPCS","facility","both","","","","8745.75","4372.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"L1951-Prefab Spiral Afo","74599816","CDM","274","RC","L1951","HCPCS","facility","both","","","","992.57","496.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent, Tryton Side Branch","74599817","CDM","278","RC","C1876","HCPCS","facility","both","","","","1749.15","874.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Denali Ivc Filter","74599819","CDM","278","RC","C1880","HCPCS","facility","both","","","","1597.01","798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Absorpt Drg <=16 Sq In W/O B","74599836","CDM","270","RC","A6251","HCPCS","facility","both","","","","7.25","3.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Sealant Tract Lung Bx","74599840","CDM","278","RC","C2613","HCPCS","facility","both","","","","489","244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Balloon, Ptca Biotronik","74599842","CDM","272","RC","C1725","HCPCS","facility","both","","","","121.1","60.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Azur 35D System","74599845","CDM","270","RC","","","facility","both","","","","1618.74","809.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Azur 18D System","74599846","CDM","270","RC","","","facility","both","","","","1590.8","795.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Framing Azur 35D","74599847","CDM","270","RC","","","facility","both","","","","1518.35","759.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Framing Azur 18D","74599848","CDM","270","RC","","","facility","both","","","","1227.51","613.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Azur Cx  018","74599849","CDM","270","RC","","","facility","both","","","","1203.71","601.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Azur Cx System 035","74599850","CDM","270","RC","","","facility","both","","","","1423.13","711.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Azur Controller Detachment","74599851","CDM","270","RC","","","facility","both","","","","1343.43","671.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker, Edora Mri Crt-P","74599854","CDM","275","RC","C2621","HCPCS","facility","both","","","","8745.75","4372.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg 5F Dl Bard Power Picc","74599855","CDM","278","RC","C1751","HCPCS","facility","both","","","","104.54","52.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Defib, Vigiliant Mri Dr Df4","74599866","CDM","275","RC","C1721","HCPCS","facility","both","","","","16965","8482.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Defib,Perciva Mini Mri Dr Df4","74599867","CDM","275","RC","C1721","HCPCS","facility","both","","","","17558.78","8779.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Defib, Vigilant Mri Vr Df4","74599868","CDM","278","RC","C1722","HCPCS","facility","both","","","","16045.61","8022.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Defib, Perciva Mini Mri Vr Df4","74599869","CDM","278","RC","C1722","HCPCS","facility","both","","","","16045.61","8022.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Defib, Vigilant Mri Df4, Biv","74599870","CDM","278","RC","C1882","HCPCS","facility","both","","","","23400","11700","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pacemaker, Visionist Mri Crt-P","74599871","CDM","275","RC","C2621","HCPCS","facility","both","","","","7670","3835","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Implant, Pivsd Occluder","74599872","CDM","270","RC","","","facility","both","","","","8799.57","4399.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Occluder Delivery System Ampl","74599873","CDM","270","RC","","","facility","both","","","","998.78","499.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Elipse Mri Dr Df4","74599874","CDM","275","RC","C1721","HCPCS","facility","both","","","","17827.88","8913.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib, Elipse Mri Vr Df4","74599875","CDM","278","RC","C1722","HCPCS","facility","both","","","","16347.83","8173.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Roxwood Anchor","74599876","CDM","278","RC","C1887","HCPCS","facility","both","","","","1250.28","625.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Trapper For Cto","74599877","CDM","278","RC","C1725","HCPCS","facility","both","","","","427","213.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Hm Iii Mobile Power Unit","74599881","CDM","270","RC","","","facility","both","","","","9343.98","4671.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Fiducial Marker Mri Compatible","74599883","CDM","278","RC","A4648","HCPCS","facility","both","","","","296.01","148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter,Zelante Angiojet","74599884","CDM","278","RC","C1757","HCPCS","facility","both","","","","3351.33","1675.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter, Angiojet Avx","74599885","CDM","278","RC","C1757","HCPCS","facility","both","","","","1002.92","501.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Balloon, Angiosculpt","74599886","CDM","278","RC","C1725","HCPCS","facility","both","","","","1524.56","762.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Hydrogel Spacer,Spaceoar","74599887","CDM","270","RC","","","facility","both","","","","3392.73","1696.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent, Buma","74599888","CDM","278","RC","C1784","HCPCS","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Osteocool Fra Probe","74599889","CDM","278","RC","C1886","HCPCS","facility","both","","","","4648.19","2324.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Impl Stnth Vocal Cord","74599890","CDM","278","RC","C1878","HCPCS","facility","both","","","","841.46","420.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrepid Tmvr System, Apollo","74599891","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Loop Recorder, Confirm Rx","74599892","CDM","278","RC","C1764","HCPCS","facility","both","","","","6519.47","3259.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Neox 1K, 1Cm","74599893","CDM","278","RC","Q4148","HCPCS","facility","both","","","","244.26","122.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tee Probe, Imacor Claritee","74599894","CDM","270","RC","","","facility","both","","","","1785.38","892.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plasmablade 3.0Mm (Coagcap)","74599895","CDM","270","RC","","","facility","both","","","","656.19","328.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pta Balloon Admiral X120","74599898","CDM","278","RC","C1725","HCPCS","facility","both","","","","1761.57","880.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Embo Contour Particles 150-250","74599899","CDM","270","RC","","","facility","both","","","","215.28","107.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sheath Endophys Pressure","74599901","CDM","270","RC","","","facility","both","","","","1122.98","561.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter, Angiogard 6X180 Cm","74599902","CDM","270","RC","","","facility","both","","","","1785.38","892.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Cath,Neuroform Stabalizer","74599903","CDM","270","RC","","","facility","both","","","","794.88","397.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Balloon Stent,Lifestream","74599904","CDM","278","RC","C1874","HCPCS","facility","both","","","","3222.99","1611.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter,Sofia 6F 125 Cm","74599905","CDM","270","RC","","","facility","both","","","","1809.18","904.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Microcatheter,Ax Catalyst 5","74599906","CDM","270","RC","","","facility","both","","","","1807.11","903.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Coil, Comp400 Ext Soft 3X4 Mm","74599907","CDM","270","RC","","","facility","both","","","","2409.48","1204.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter, Pta Balloon Advance","74599908","CDM","278","RC","C1725","HCPCS","facility","both","","","","385.02","192.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Microcatheter, Ax Catalyst 6","74599909","CDM","270","RC","","","facility","both","","","","2464.34","1232.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Delivery Sys, Onyx Syr Adt Apl","74599910","CDM","270","RC","","","facility","both","","","","2678.58","1339.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter, Arc Mini","74599911","CDM","270","RC","","","facility","both","","","","1261.67","630.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Savi Scout Reflector","74599913","CDM","278","RC","A4648","HCPCS","facility","both","","","","806","403","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Insole Peg Assist L3003","74599914","CDM","274","RC","L3003","HCPCS","facility","both","","","","175.95","87.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib,Claria Mri Quad Df4","74599915","CDM","278","RC","C1882","HCPCS","facility","both","","","","24219","12109.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Rp:Tc-99 Pyp Per Dose","74599918","CDM","343","RC","A9538","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent, Vascular","74599920","CDM","278","RC","C1874","HCPCS","facility","both","","","","1043.28","521.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Aquapheresis-Filter Only","74599921","CDM","270","RC","","","facility","both","","","","1572.17","786.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-1 Bottle H2Mf +6 (30Ml)","74599922","CDM","270","RC","","","facility","both","","","","291.87","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiomems Guidewire","74599923","CDM","278","RC","C1769","HCPCS","facility","both","","","","441.95","220.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Sheath, Optiseal Peelable","74599924","CDM","278","RC","C1892","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Catheter Precision Infusion","74599925","CDM","270","RC","","","facility","both","","","","4036.5","2018.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Add Spinal Orthosis No Specifi","74599926","CDM","274","RC","L0999","HCPCS","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Rp:Tc-99 Hdp","74599927","CDM","343","RC","A9561","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Bard 9.6Fr Powerflow Iv Port","74599929","CDM","278","RC","C1788","HCPCS","facility","both","","","","2315.3","1157.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-H2Mf Cr (10Ml)","74599930","CDM","270","RC","","","facility","both","","","","63.14","31.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-1/2 Bottle H2Mf +6 (15Ml)","74599931","CDM","270","RC","","","facility","both","","","","145.94","72.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Azure Mri Dr","74599932","CDM","275","RC","C1785","HCPCS","facility","both","","","","7700","3850","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Azure Mri Sr","74599933","CDM","275","RC","C1786","HCPCS","facility","both","","","","3834.68","1917.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Needle Gore Tips Guiding Cath","74599934","CDM","278","RC","C1887","HCPCS","facility","both","","","","316.71","158.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Set Gore Tips Shunt Liver Acc","74599935","CDM","278","RC","C1887","HCPCS","facility","both","","","","639.63","319.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Gore Tips Introducer","74599936","CDM","278","RC","C1887","HCPCS","facility","both","","","","424.35","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Graft Sys Endopros Viatorr Tip","74599937","CDM","278","RC","C1874","HCPCS","facility","both","","","","6660.23","3330.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Penumbra Revasculariz","74599939","CDM","278","RC","C1757","HCPCS","facility","both","","","","6177.92","3088.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Osteocool Bone Access Kit 10G","74599942","CDM","278","RC","C1886","HCPCS","facility","both","","","","505.08","252.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent, Bare Metal Cobra Pzf","74599943","CDM","278","RC","","","facility","both","","","","774.18","387.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Tightrail Minirot Dilat","74599944","CDM","272","RC","C1773","HCPCS","facility","both","","","","2281.14","1140.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg 1 Bottle H2Mf +8 (40Ml)","74599947","CDM","270","RC","","","facility","both","","","","389.16","194.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pressure Sensing Sheath Kit 6F","74599957","CDM","278","RC","C1894","HCPCS","facility","both","","","","1203.71","601.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pressure Sensing Sheath Kit 8F","74599958","CDM","278","RC","C1894","HCPCS","facility","both","","","","1283.4","641.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor Esophgeal Esosure","74599959","CDM","270","RC","","","facility","both","","","","634.46","317.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paragonix Sherpa-Pak","74599960","CDM","270","RC","","","facility","both","","","","17107","8553.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liva Nova Inspire Pack","74599961","CDM","270","RC","","","facility","both","","","","592.02","296.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Heart Valve Clip","74599962","CDM","270","RC","","","facility","both","","","","36225","18112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lutetium Lu 177 Per Mci","74599963","CDM","344","RC","A9513","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epifix Per Sq Cm","74599964","CDM","278","RC","Q4186","HCPCS","facility","both","","","","372.6","186.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epifix Per Sq Cm Waste","74599965","CDM","278","RC","Q4186","HCPCS","facility","both","","","","372.6","186.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puraply Per Sqcm","74599966","CDM","278","RC","Q4195","HCPCS","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puraply Per Sqcm Waste","74599967","CDM","278","RC","Q4195","HCPCS","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puraply Am Per Sqcm","74599968","CDM","278","RC","Q4196","HCPCS","facility","both","","","","326.03","163.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puraply Am Per Sqcm Wasted","74599969","CDM","278","RC","Q4196","HCPCS","facility","both","","","","326.03","163.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centera Thv, Exceed Study","74599970","CDM","270","RC","","","facility","both","","","","38683.13","19341.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flowtriever System","74599971","CDM","270","RC","","","facility","both","","","","13092.75","6546.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clottriever System","74599972","CDM","278","RC","C1757","HCPCS","facility","both","","","","9522","4761","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablation Probe 17 Ga, 15 Cm","74599973","CDM","278","RC","C1888","HCPCS","facility","both","","","","2664.09","1332.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valeo Biliary Stent","74599974","CDM","278","RC","C1876","HCPCS","facility","both","","","","1163.34","581.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealant Hemostatic Nonimplant","74599975","CDM","270","RC","","","facility","both","","","","242.19","121.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drg Elute Stent Eluvia 40-60Mm","74599976","CDM","278","RC","C1874","HCPCS","facility","both","","","","3088.44","1544.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drg Elute Stnt Eluvia 80-120Mm","74599977","CDM","278","RC","C1874","HCPCS","facility","both","","","","3895.74","1947.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Heu Tc-99M Add-On/Dose","74599978","CDM","343","RC","Q9969","HCPCS","facility","both","","","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tacticath Bidir Rf Ablation","74599979","CDM","270","RC","","","facility","both","","","","3632.85","1816.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tacticath Unidir Rf Ablation","74599980","CDM","270","RC","","","facility","both","","","","3465.18","1732.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pascal Device, Clasp Study","74599982","CDM","270","RC","","","facility","both","","","","35707.5","17853.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Eluting Stent, Biotronik","74599983","CDM","278","RC","C1874","HCPCS","facility","both","","","","1283.4","641.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shockwave Lithotripsy Balloon","74599984","CDM","278","RC","C1725","HCPCS","facility","both","","","","3700.13","1850.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acurate Tavr Study Device","74599985","CDM","270","RC","","","facility","both","","","","33327","16663.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handpiece Ligasure Impact","74599987","CDM","270","RC","","","facility","both","","","","1002.92","501.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Clip/Rings Gyn","74599988","CDM","270","RC","","","facility","both","","","","176.99","88.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biotronik Papyrus Stent","74599989","CDM","278","RC","C1874","HCPCS","facility","both","","","","4036.5","2018.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"M3 Sapien, Research Tmvr","74599991","CDM","270","RC","","","facility","both","","","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manta Vasc Closure Device","74599992","CDM","278","RC","","","facility","both","","","","969","484.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiohelp Hls Circuit","74599995","CDM","270","RC","","","facility","both","","","","15848","7924","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crescent Cannula","74599996","CDM","270","RC","","","facility","both","","","","2975.63","1487.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Next Gen Cannula","74599997","CDM","270","RC","","","facility","both","","","","462.65","231.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leukofilter Art Lg6","74599998","CDM","270","RC","","","facility","both","","","","385.02","192.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gun 18G 175Mm Full-Auto","74599999","CDM","270","RC","","","facility","both","","","","288.77","144.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74622","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Insertion Of Iud","74700034","CDM","761","RC","58300","HCPCS","facility","both","","","","442","221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74762","CDM","270","RC","","","facility","both","","","","71.25","35.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74771","CDM","278","RC","C1713","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74775","CDM","278","RC","C1713","HCPCS","facility","both","","","","1564","782","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Probe Chg-Prostate","74804398","CDM","272","RC","C1770","HCPCS","facility","both","","","","589.95","294.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74813","CDM","278","RC","C1713","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74849","CDM","270","RC","","","facility","both","","","","933.8","466.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74897","CDM","270","RC","","","facility","both","","","","298.08","149.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74899","CDM","278","RC","C1776","HCPCS","facility","both","","","","5141.36","2570.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacer Lead Stylet","74900034","CDM","270","RC","","","facility","both","","","","275","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Pacemakr Capsure Sp Novus","74900178","CDM","275","RC","C1898","HCPCS","facility","both","","","","4226.94","2113.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead,Defib Sprint 6947","74900404","CDM","275","RC","C1895","HCPCS","facility","both","","","","43152.26","21576.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker,Adapta Dr","74900700","CDM","275","RC","C1785","HCPCS","facility","both","","","","33442.92","16721.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Acid-Lead","74907234","CDM","270","RC","","","facility","both","","","","33940.76","16970.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","74968","CDM","278","RC","C1776","HCPCS","facility","both","","","","2856.14","1428.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","75212","CDM","270","RC","","","facility","both","","","","1003.31","501.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ecg 12-Lead Tracing Only","75300001","CDM","730","RC","93005","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg 24 Up To 48Hr Holter Monr-Hookup And Record","75300004","CDM","731","RC","93225","HCPCS","facility","both","","","","418","209","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Ecg-12 Lead Er Dept Trac","75300005","CDM","730","RC","93005","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg 24 Up To 48Hr Holter Monitor Scan Analysis","75300018","CDM","731","RC","93226","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Ecg>48Hr<7D Recording","75300052","CDM","730","RC","93242","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uos Ext Ecg>48Hr<7D Scan A/R","75300053","CDM","999","RC","93243","HCPCS","facility","both","","","","978","489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Ecg>7D<15D Recording","75300054","CDM","730","RC","93246","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uos Ext Ecg>7D<15D Scan A/R","75300055","CDM","999","RC","93247","HCPCS","facility","both","","","","978","489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Event Monitor & Analysis","75300502","CDM","730","RC","93271","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Counseling And Risk Factor Reduc","75400022","CDM","510","RC","99401","HCPCS","facility","both","","","","246","123","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Eval Cardiac Rehab -O/P","75400024","CDM","943","RC","93798","HCPCS","facility","both","","","","281","140.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg 3 Day Cardiac Mainten Prg","75400150","CDM","943","RC","","","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiovascular Therapy Inpatient","75400151","CDM","940","RC","","","facility","both","","","","218","109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self-Pay Phase Iii Rehab Unit Counter","75400157","CDM","460","RC","","","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-2 Day Cardiac Mainten Prog","75400158","CDM","943","RC","","","facility","both","","","","30","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cardiovascular Therapy Outpatient","75400550","CDM","943","RC","93798","HCPCS","facility","both","","","","281","140.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pul Strgth/Endur Indiv,Ea 15Mn","75400621","CDM","460","RC","G0237","HCPCS","facility","both","","","","116","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pul Resp Funct Indiv, Ea 15 Mn","75400622","CDM","460","RC","G0238","HCPCS","facility","both","","","","116","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Pulmonary Rehabilitation Grp","75400623","CDM","460","RC","G0239","HCPCS","facility","both","","","","116","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pr W/O Cont. Pulse Ox Mntr","75400626","CDM","948","RC","94625","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pr With Cont. Pulse Ox Mntr","75400627","CDM","948","RC","94626","HCPCS","facility","both","","","","210","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pritikin Icr With Exercise","75400631","CDM","943","RC","G0422","HCPCS","facility","both","","","","281","140.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pritikin Icr W/O Exercise Each Session","75400632","CDM","943","RC","G0423","HCPCS","facility","both","","","","281","140.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phase Ii Unmonitored Session","75400701","CDM","943","RC","93797","HCPCS","facility","both","","","","281","140.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlist Proc Skin Mm","75402726","CDM","481","RC","17999","HCPCS","facility","both","","","","1360","680","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-P.A.D. Rehab","75402728","CDM","943","RC","93668","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7560","CDM","270","RC","","","facility","both","","","","41.31","20.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Or Per Minute-Womens Health","75600001","CDM","360","RC","","","facility","both","","","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Labor Care/Induction Per Day","75600002","CDM","722","RC","","","facility","both","","","","2042","1021","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Non-Stress Test/Fetal Monitoring","75600003","CDM","721","RC","59025","HCPCS","facility","both","","","","856","428","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligate Fallop Tube Abd/Vag; Pp","75600005","CDM","369","RC","58605","HCPCS","facility","both","","","","2972","1486","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Vag Del Out Of Dept/Recov/Supp","75600016","CDM","722","RC","","","facility","both","","","","7136","3568","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Oxytocin Challenge Test/Fetal","75600018","CDM","721","RC","59020","HCPCS","facility","both","","","","838","419","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg D&C Procedure&Recovery","75600026","CDM","722","RC","","","facility","both","","","","2332","1166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Amniocentesis Proc/Fetal Monitor","75600051","CDM","720","RC","59000","HCPCS","facility","both","","","","4079","2039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Non-Delivery Recovery Lvl 1","75600080","CDM","710","RC","","","facility","both","","","","2012","1006","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Non-Delivery Recovery Lvl 2","75600081","CDM","722","RC","","","facility","both","","","","4080","2040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg C-Section Recovery Level 1","75600089","CDM","710","RC","","","facility","both","","","","2012","1006","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Level I - L&D Er Dept Visit","75600091","CDM","450","RC","99281","HCPCS","facility","both","","","","260","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Level V - L&D Er Dept Visit","75600095","CDM","450","RC","99285","HCPCS","facility","both","","","","2867","1433.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Amnioinfusion","75600100","CDM","720","RC","59070","HCPCS","facility","both","","","","542","271","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg External Cephalic Version","75600101","CDM","722","RC","59412","HCPCS","facility","both","","","","3374","1687","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubal Ligation W/C-Sect","75600103","CDM","722","RC","","","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Scalp Blood","75600108","CDM","720","RC","59030","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abortion Induction W/Supp Vag","75600180","CDM","720","RC","59855","HCPCS","facility","both","","","","3025","1512.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Curettage,Postpartum","75600181","CDM","720","RC","59160","HCPCS","facility","both","","","","5266","2633","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treatment Of Missed Abortion","75600250","CDM","720","RC","59820","HCPCS","facility","both","","","","4517","2258.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trtmnt Missed Abortion 2Nd Tri","75600251","CDM","720","RC","59821","HCPCS","facility","both","","","","4517","2258.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg C-Section Recovery Level 2","75600316","CDM","722","RC","","","facility","both","","","","4080","2040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ultrasound L&D","75600400","CDM","402","RC","76815","HCPCS","facility","both","","","","999","499.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cordocentesis (Cpt 59012)","75600508","CDM","369","RC","59012","HCPCS","facility","both","","","","2203","1101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Vaginal Del/Recovery/Supplies","75600601","CDM","722","RC","","","facility","both","","","","7136","3568","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Amniocentesis Therapeutic","75600610","CDM","720","RC","59001","HCPCS","facility","both","","","","9159","4579.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrauterine Blood Transfusion","75600700","CDM","720","RC","36460","HCPCS","facility","both","","","","2127","1063.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Doppler Interrogation Of Mca","75600701","CDM","320","RC","76821","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Or Base-Womens Health","75600702","CDM","360","RC","","","facility","both","","","","4285","2142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Deliver Placenta/Recover/Suppl","75600703","CDM","720","RC","59414","HCPCS","facility","both","","","","3756","1878","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg C/S Del Out Of Dept/Recov/Supp","75600704","CDM","722","RC","","","facility","both","","","","9575","4787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cerclage Removal W/O Anes","75601000","CDM","369","RC","59899","HCPCS","facility","both","","","","658","329","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Circlage Removal W/Anes","75601001","CDM","761","RC","59871","HCPCS","facility","both","","","","3304","1652","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Fetal Fluid Drainiage","75601002","CDM","720","RC","59074","HCPCS","facility","both","","","","3277","1638.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Fetal Shunt Placement","75601003","CDM","720","RC","59076","HCPCS","facility","both","","","","3277","1638.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sterile Speculum Exam","75601040","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Cerclage Insertion","75602019","CDM","720","RC","59320","HCPCS","facility","both","","","","4678","2339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Lactation Class","75606301","CDM","942","RC","S9443","HCPCS","facility","both","","","","50","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lactation Consult","75606302","CDM","942","RC","G0463","HCPCS","facility","both","","","","125","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Needle Placement","75610051","CDM","402","RC","76941","HCPCS","facility","both","","","","560","280","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Echo","75610054","CDM","402","RC","76825","HCPCS","facility","both","","","","2198","1099","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fern Testing-Poct","75610055","CDM","300","RC","Q0114","HCPCS","facility","both","","","","82","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Drug Implant","75610056","CDM","510","RC","11981","HCPCS","facility","both","","","","2114","1057","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cervical Dilator","75610057","CDM","369","RC","59200","HCPCS","facility","both","","","","1337","668.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Episiotomy Or Vaginal Repair","75610058","CDM","369","RC","59300","HCPCS","facility","both","","","","9266","4633","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Seat/Bed Test Inft Thru 12 Mo 60 Min","75610059","CDM","410","RC","94780","HCPCS","facility","both","","","","95","47.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Seat/Bed Test Inft Thru 12 Mo Ea Addl 30 Min","75610060","CDM","410","RC","94781","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Recov Rm Delivery-Add'l 30","75700119","CDM","710","RC","","","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Critical Care Recovery Per Hour","75700171","CDM","710","RC","","","facility","both","","","","1839","919.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Recovery/15Min Critical","75700172","CDM","710","RC","","","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pacu Base Endo/Gi","75700254","CDM","710","RC","","","facility","both","","","","452","226","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pacu Base Diag Svcs","75700255","CDM","710","RC","","","facility","both","","","","452","226","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Care Base Phase I","75700350","CDM","710","RC","","","facility","both","","","","413","206.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg-Care Phase I Addl Minutes","75700351","CDM","710","RC","","","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Extended Bo Recovery, Per Hr","75704000","CDM","710","RC","","","facility","both","","","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacu Recovery First 30 Mins","75704002","CDM","710","RC","","","facility","both","","","","1384.04","692.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacu Recovery Phase I Each Addl 15 Mins","75704003","CDM","710","RC","","","facility","both","","","","666.41","333.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacu Recovery Phase Ii Each Addl 15 Mins","75704004","CDM","710","RC","","","facility","both","","","","600.29","300.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Phase I Each Addl 15 Mins","75704005","CDM","710","RC","","","facility","both","","","","626.11","313.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery First 30 Mins","75704006","CDM","710","RC","","","facility","both","","","","954.48","477.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Phase Ii Each Addl 15 Mins","75704007","CDM","710","RC","","","facility","both","","","","470.71","235.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Pacer & A Lead","75800006","CDM","481","RC","33206","HCPCS","facility","both","","","","18905","9452.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Ext(Art Insert)Add't To","75800015","CDM","481","RC","36140","HCPCS","facility","both","","","","4665","2332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angio Left Or Right Pulmon Art","75800016","CDM","481","RC","36014","HCPCS","facility","both","","","","5305","2652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Angio Right Heart Or Pulmonary Artery","75800018","CDM","481","RC","36013","HCPCS","facility","both","","","","6123","3061.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Pacer & V Lead","75800019","CDM","481","RC","33207","HCPCS","facility","both","","","","18905","9452.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair 1 Electrode","75800021","CDM","481","RC","33218","HCPCS","facility","both","","","","3897","1948.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair 2 Electrodes","75800023","CDM","481","RC","33220","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Svc Or Ivc","75800033","CDM","481","RC","36010","HCPCS","facility","both","","","","3820","1910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Pacer & 2 Leads","75800034","CDM","481","RC","33208","HCPCS","facility","both","","","","23369","11684.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Svc Or Ivc In Additio To","75800035","CDM","481","RC","36010","HCPCS","facility","both","","","","3820","1910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Angio Thoracic/Brach 1St Subclavian","75800036","CDM","481","RC","36215","HCPCS","facility","both","","","","4701","2350.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Angio Thorac Or Brachioc 2Nd Od Ima","75800037","CDM","481","RC","36216","HCPCS","facility","both","","","","4772","2386","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Ang/Ven 1St Order Renal Jugular Vein","75800038","CDM","481","RC","36011","HCPCS","facility","both","","","","5310","2655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ang/Ven/1St(Renal,Jugul)Add To","75800039","CDM","481","RC","36011","HCPCS","facility","both","","","","5310","2655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ang/Thor Brach 1St(Subcl)Add","75800045","CDM","481","RC","36215","HCPCS","facility","both","","","","4701","2350.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ang/Thor/Brach 2Nd(Ima)Add To","75800046","CDM","481","RC","36216","HCPCS","facility","both","","","","4772","2386","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Removal Of Pacemaker","75800048","CDM","481","RC","33233","HCPCS","facility","both","","","","9782","4891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Removal Of Lead:Single","75800049","CDM","481","RC","33234","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Removal Of Leads:Dual","75800050","CDM","481","RC","33235","HCPCS","facility","both","","","","6763","3381.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Aorta Cath","75800052","CDM","360","RC","","","facility","both","","","","4132","2066","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Pacer: Single Chamber","75800100","CDM","480","RC","33212","HCPCS","facility","both","","","","17235","8617.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Relocation Of Pacer Pocket","75800131","CDM","481","RC","33222","HCPCS","facility","both","","","","3610","1805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Lead One","75800148","CDM","481","RC","33216","HCPCS","facility","both","","","","16024","8012","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Insert Lead Two","75800155","CDM","481","RC","33217","HCPCS","facility","both","","","","16530","8265","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cdupgrade Pacer To Dual","75800160","CDM","481","RC","33214","HCPCS","facility","both","","","","27644","13822","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Pacer: Dual Chamber","75800162","CDM","481","RC","33213","HCPCS","facility","both","","","","18583","9291.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Angio Abd/Pel Ext/1St/Order In/Addition","75800196","CDM","481","RC","36245","HCPCS","facility","both","","","","5396","2698","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Abd/Pel Ext/2Nd Ord Addt","75800197","CDM","481","RC","36246","HCPCS","facility","both","","","","5038","2519","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Abd/Pel/Ext 3Rd Ord/Addt","75800198","CDM","481","RC","36247","HCPCS","facility","both","","","","5432","2716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ang Abd/Pel/Ext/2Nd/3Rd/In Add","75800199","CDM","481","RC","36248","HCPCS","facility","both","","","","4587","2293.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Addt 2Nd/3Rd Tho Brac Bc","75800200","CDM","481","RC","36218","HCPCS","facility","both","","","","2553","1276.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Aorta","75800201","CDM","481","RC","36200","HCPCS","facility","both","","","","5300","2650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Abd/Pelvic/Ext 3Rd Order","75800205","CDM","481","RC","36247","HCPCS","facility","both","","","","5432","2716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Abd Pelvic Ext 1St Order","75800230","CDM","481","RC","36245","HCPCS","facility","both","","","","5396","2698","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Abd Pelvic Ext 2Nd Order","75800231","CDM","481","RC","36246","HCPCS","facility","both","","","","5038","2519","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Add 2Nd Or 3Rd Order Branch","75800232","CDM","481","RC","36248","HCPCS","facility","both","","","","4587","2293.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Extremity","75800235","CDM","481","RC","36140","HCPCS","facility","both","","","","4665","2332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Angiojet In Addition To Cath","75800251","CDM","481","RC","92973","HCPCS","facility","both","","","","10211","5105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ivus","75800254","CDM","481","RC","92978","HCPCS","facility","both","","","","3938","1969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ivus Each Additional Vessel","75800255","CDM","481","RC","92979","HCPCS","facility","both","","","","2650","1325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Icd Generatorsingle Chamber","75800300","CDM","481","RC","33240","HCPCS","facility","both","","","","31031","15515.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Icd Generatordual Chamber","75800301","CDM","481","RC","33230","HCPCS","facility","both","","","","31031","15515.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Single Chamber Icd And Lead","75800302","CDM","481","RC","33249","HCPCS","facility","both","","","","42696","21348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Dual Chamber Icd And Lead","75800303","CDM","481","RC","33249","HCPCS","facility","both","","","","42696","21348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Standard Pump Perfusion Setup","75800498","CDM","272","RC","","","facility","both","","","","5704","2852","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perfusion Tech Per Minute","75800499","CDM","360","RC","","","facility","both","","","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Pfo Procedure","75800519","CDM","481","RC","93580","HCPCS","facility","both","","","","27590","13795","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Stent(S) Pl Carotid W / O Dis Embolic","75800521","CDM","481","RC","37216","HCPCS","facility","both","","","","28172","14086","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Removal Of Icd","75800633","CDM","481","RC","33241","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Removal Of Icd Leads","75800634","CDM","481","RC","33244","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Icd Skin Pocket Relocation","75800635","CDM","481","RC","33223","HCPCS","facility","both","","","","3011","1505.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Coronary Sinus Lead","75800638","CDM","481","RC","33225","HCPCS","facility","both","","","","16059","8029.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Cath For Thromboly","75800641","CDM","490","RC","37213","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Embolization Intra / Spinal Cord","75800644","CDM","490","RC","61624","HCPCS","facility","both","","","","6602","3301","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Transcatheter","75800646","CDM","490","RC","37200","HCPCS","facility","both","","","","6332","3166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Extremity Unilateral","75800653","CDM","320","RC","75820","HCPCS","facility","both","","","","2776","1388","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venous Extremity Bilateral","75800654","CDM","320","RC","75822","HCPCS","facility","both","","","","4159","2079.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Venogram Caval Super","75800658","CDM","320","RC","75827","HCPCS","facility","both","","","","3472","1736","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angio Venography Extremity","75800660","CDM","490","RC","36005","HCPCS","facility","both","","","","2543","1271.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcatheter Retrieval Percut","75800661","CDM","481","RC","37197","HCPCS","facility","both","","","","6376","3188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulmonary Nonselective","75800662","CDM","320","RC","75746","HCPCS","facility","both","","","","4855","2427.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcath Biopsy","75800668","CDM","320","RC","75970","HCPCS","facility","both","","","","3830","1915","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Perc Portal Vein Cath","75800672","CDM","490","RC","36481","HCPCS","facility","both","","","","838","419","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection For Pseudoaneurysm","75800676","CDM","761","RC","36002","HCPCS","facility","both","","","","2109","1054.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Replace Coronary Sinus Lead","75800678","CDM","481","RC","33224","HCPCS","facility","both","","","","16059","8029.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Reposition Coronary Sinus Lead","75800679","CDM","481","RC","33226","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Reposition Lead","75800680","CDM","481","RC","33215","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Nonsel Iliac / Fem W / Card Cath","75800692","CDM","481","RC","G0278","HCPCS","facility","both","","","","2752","1376","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Intra-Aortic Balloon","75800701","CDM","481","RC","33968","HCPCS","facility","both","","","","4376","2188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc Knee Manipultn W/Gen Anes","75800702","CDM","360","RC","27570","HCPCS","facility","both","","","","3273","1636.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc Shoulder Manipultn W/Anes","75800704","CDM","360","RC","23700","HCPCS","facility","both","","","","3273","1636.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Venous","75800705","CDM","490","RC","37241","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Artery","75800706","CDM","490","RC","37242","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Organ","75800707","CDM","761","RC","37243","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Bleed","75800708","CDM","490","RC","37244","HCPCS","facility","both","","","","38990","19495","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Noncoronary;1St Artery","75800709","CDM","481","RC","37236","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Noncoronary;1St Vein","75800710","CDM","481","RC","37238","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Noncoronary Add Artery","75800711","CDM","481","RC","37237","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Noncoronary Add Vein","75800712","CDM","481","RC","37239","HCPCS","facility","both","","","","13966","6983","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Ligation Of Av Fistula","75801220","CDM","481","RC","37607","HCPCS","facility","both","","","","9353","4676.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Nontunneled Cvc <5Yr","75801420","CDM","481","RC","36555","HCPCS","facility","both","","","","3942","1971","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Non-Tunneled Cvc>=5Yr","75801421","CDM","481","RC","36556","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Picc <5Yrs W/O Imaging","75801422","CDM","481","RC","36568","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Picc >=5Yrs W/O Imaging","75801423","CDM","369","RC","36569","HCPCS","facility","both","","","","4322","2161","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpl Cvc W/O Prt/Pmp Same Site","75801424","CDM","481","RC","36580","HCPCS","facility","both","","","","4064","2032","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replpicc Same Site Incl Image","75801425","CDM","481","RC","36584","HCPCS","facility","both","","","","4064","2032","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rplc Cath Of Cva W/Prt/Pmp","75801428","CDM","481","RC","36578","HCPCS","facility","both","","","","4118","2059","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Tnnld Cvc W/O Port/Pump","75801429","CDM","481","RC","36589","HCPCS","facility","both","","","","2532","1266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Reposition Cva","75801430","CDM","481","RC","36597","HCPCS","facility","both","","","","1743","871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Intralum Obst Thru Dvc Lum","75801432","CDM","481","RC","36596","HCPCS","facility","both","","","","1743","871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Removal Tnnld Cvc W / Port / Pump","75801433","CDM","481","RC","36590","HCPCS","facility","both","","","","5244","2622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tnnld Cvc W/O Prt/Pmp>=5Yr","75801434","CDM","481","RC","36558","HCPCS","facility","both","","","","5911","2955.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpl Tnld Cvc W/O P/P Same Site","75801436","CDM","481","RC","36581","HCPCS","facility","both","","","","10299","5149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tnnld Cvc W/Port>=5 Yr","75801438","CDM","481","RC","36561","HCPCS","facility","both","","","","7099","3549.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rplc Tnnld Cvc W/Prt Same Site","75801441","CDM","481","RC","36582","HCPCS","facility","both","","","","10299","5149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"U/S Guide For Venous Access","75801445","CDM","402","RC","76937","HCPCS","facility","both","","","","1729","864.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Distal Embolic Protect Dev","75801446","CDM","480","RC","37799","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromb,Mechanical,Venous","75801447","CDM","480","RC","37187","HCPCS","facility","both","","","","14148","7074","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Thromb, Mechanical, Venous Recheck","75801448","CDM","480","RC","37188","HCPCS","facility","both","","","","14148","7074","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoro Guide,Place Or Replace","75801449","CDM","480","RC","77001","HCPCS","facility","both","","","","1548","774","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc Knee Dislocation W/Anes","75801450","CDM","360","RC","27552","HCPCS","facility","both","","","","2757","1378.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc Hip Disloc-Spontan W/Anes","75801452","CDM","360","RC","27257","HCPCS","facility","both","","","","4923","2461.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc Shoulder Disloc W/Anes","75801453","CDM","360","RC","23655","HCPCS","facility","both","","","","3069","1534.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Holding In Or Minutes","75801454","CDM","710","RC","","","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iliac Pta","75802000","CDM","481","RC","37220","HCPCS","facility","both","","","","18394","9197","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Iliac Pta W / Stent","75802001","CDM","481","RC","37221","HCPCS","facility","both","","","","28713","14356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Iliac Pta Addt'l Vessel","75802002","CDM","481","RC","37222","HCPCS","facility","both","","","","11901","5950.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Iliac Pta W / Stent Add Vessel","75802003","CDM","481","RC","37223","HCPCS","facility","both","","","","28713","14356.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Fem / Pop Pta W / Tla","75802004","CDM","481","RC","37224","HCPCS","facility","both","","","","22413","11206.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Fem / Pop Pta W / Ather","75802005","CDM","481","RC","37225","HCPCS","facility","both","","","","34171","17085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Fem / Pop Pta W / Stent","75802006","CDM","481","RC","37226","HCPCS","facility","both","","","","33686","16843","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Fem / Pop Pta Stnt & Ather","75802007","CDM","481","RC","37227","HCPCS","facility","both","","","","43253","21626.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Tp Pta W / Tla","75802008","CDM","481","RC","37228","HCPCS","facility","both","","","","16768","8384","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Tp Pta W / Ather","75802009","CDM","481","RC","37229","HCPCS","facility","both","","","","26094","13047","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Tp Pta W / Stent","75802010","CDM","481","RC","37230","HCPCS","facility","both","","","","28036","14018","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Tp Pta Add Vessel","75802012","CDM","481","RC","37232","HCPCS","facility","both","","","","11901","5950.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Tp Pta W / Ather Add Vessel","75802013","CDM","481","RC","37233","HCPCS","facility","both","","","","22486","11243","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Insert Tun Ip Cath Perc","75802016","CDM","481","RC","49418","HCPCS","facility","both","","","","9957","4978.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Right Heart Cath","75802017","CDM","481","RC","93451","HCPCS","facility","both","","","","15692","7846","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Left Hrt Cath W / Ventrclgrphy","75802018","CDM","481","RC","93452","HCPCS","facility","both","","","","25716","12858","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd R&L Hrt Cath W / Ventriclgrphy","75802019","CDM","481","RC","93453","HCPCS","facility","both","","","","29491","14745.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Coronary Artery Angio S&I","75802020","CDM","481","RC","93454","HCPCS","facility","both","","","","12825","6412.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Coronary Art / Grft Angio S&I","75802021","CDM","481","RC","93455","HCPCS","facility","both","","","","12825","6412.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Rhrt Coronary Artery Angio","75802022","CDM","481","RC","93456","HCPCS","facility","both","","","","28510","14255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Rhrt Art / Grft Angio","75802023","CDM","481","RC","93457","HCPCS","facility","both","","","","30359","15179.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Lhrt Artery / Ventricle Angio","75802024","CDM","481","RC","93458","HCPCS","facility","both","","","","25716","12858","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Lhrt Art / Grft Angio","75802025","CDM","481","RC","93459","HCPCS","facility","both","","","","27564","13782","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd R&L Hrt Art / Ventricle Angio","75802026","CDM","481","RC","93460","HCPCS","facility","both","","","","29491","14745.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd R&L Hrt Art / Grft Angio","75802027","CDM","481","RC","93461","HCPCS","facility","both","","","","31336","15668","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Lhrt Cath Trnsptl Puncture","75802028","CDM","481","RC","93462","HCPCS","facility","both","","","","4972","2486","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Drug Admin & Hemodynmic Meas","75802029","CDM","481","RC","93463","HCPCS","facility","both","","","","3702","1851","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Exercise W / Hemodynamic Meas","75802030","CDM","481","RC","93464","HCPCS","facility","both","","","","4455","2227.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Inject L Ventr / Atrail Angio","75802033","CDM","481","RC","93565","HCPCS","facility","both","","","","3712","1856","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Inject R Ventr / Atrail Angio","75802034","CDM","481","RC","93566","HCPCS","facility","both","","","","3712","1856","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Inject S Uprvlv Aortography","75802035","CDM","481","RC","93567","HCPCS","facility","both","","","","3932","1966","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Inject Pulm Art Hrt Cath","75802036","CDM","481","RC","93568","HCPCS","facility","both","","","","4818","2409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Trluml Perip Athrc Renal Arter","75802037","CDM","481","RC","0234T","HCPCS","facility","both","","","","24017","12008.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr-Cd Trluml Perip Athrc Iliac Arter","75802041","CDM","481","RC","0238T","HCPCS","facility","both","","","","26467","13233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Vad Artery Access","75802045","CDM","481","RC","33990","HCPCS","facility","both","","","","11979","5989.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iliac Pta","75802660","CDM","481","RC","37220","HCPCS","facility","both","","","","18394","9197","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iliac Pta Addt'l Vessel","75802662","CDM","481","RC","37222","HCPCS","facility","both","","","","11901","5950.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fem/Pop Pta W/Ather","75802665","CDM","481","RC","37225","HCPCS","facility","both","","","","34171","17085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fem/Pop Pta Stnt & Ather","75802667","CDM","481","RC","37227","HCPCS","facility","both","","","","43253","21626.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Pm Gen-3+Chamb-Exist Ld","75802700","CDM","481","RC","33221","HCPCS","facility","both","","","","22842","11421","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Icd Gen-3+Cham-Exist Ld","75802701","CDM","481","RC","33231","HCPCS","facility","both","","","","41079","20539.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgr Trnscth Tx Art Inf Thromb Init","75802702","CDM","481","RC","37211","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnscth Tx Ven Inf Thromb Init","75802703","CDM","481","RC","37212","HCPCS","facility","both","","","","9692","4846","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnscth Art/Ven Inf Thromb Sub","75802704","CDM","481","RC","37213","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnscth Thrpy Thromb Cessation","75802705","CDM","481","RC","37214","HCPCS","facility","both","","","","12349","6174.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pci Angioplasty 1 Vsl","75802750","CDM","481","RC","92920","HCPCS","facility","both","","","","18805","9402.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Parachute Study Device","75802758","CDM","481","RC","","","facility","both","","","","37626","18813","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Pulse Generator","75802773","CDM","481","RC","33241","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins/Rep Subq Defibrillator","75802774","CDM","481","RC","33270","HCPCS","facility","both","","","","123782","61891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insj Subq Impltbl Dfb Elctrd","75802775","CDM","481","RC","33271","HCPCS","facility","both","","","","9782","4891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Of Subq Defibrillator","75802776","CDM","481","RC","33272","HCPCS","facility","both","","","","5330","2665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem&Replc Cvd Gen Sing Lead","75802777","CDM","481","RC","33262","HCPCS","facility","both","","","","35322","17661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem&Replc Cvd Gen Dual Lead","75802778","CDM","481","RC","33263","HCPCS","facility","both","","","","35322","17661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem&Replc Cvd Gen Mult Lead","75802779","CDM","481","RC","33264","HCPCS","facility","both","","","","41079","20539.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove&Replace Ppm Gen-1 Cham","75810030","CDM","481","RC","33227","HCPCS","facility","both","","","","21531","10765.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove&Replace Ppm Gen-2 Cham","75810031","CDM","481","RC","33228","HCPCS","facility","both","","","","21531","10765.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove&Replace Ppm Gen-3+ Cham","75810032","CDM","481","RC","33229","HCPCS","facility","both","","","","23333","11666.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem&Replc Cvd Gen Sing Lead","75810033","CDM","481","RC","33262","HCPCS","facility","both","","","","35322","17661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem&Replc Cvd Gen Dual Lead","75810034","CDM","481","RC","33263","HCPCS","facility","both","","","","35322","17661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem&Replc Cvd Gen Mult Lead","75810035","CDM","481","RC","33264","HCPCS","facility","both","","","","41079","20539.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Prlng Admn Rx Agnt 1St","75810036","CDM","490","RC","61650","HCPCS","facility","both","","","","3743","1871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evasc Prlng Admn Rx Agnt Add","75810037","CDM","490","RC","61651","HCPCS","facility","both","","","","3743","1871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrvasc Us Noncoronary 1St","75810038","CDM","481","RC","37252","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrvasc Us Noncoronary Addl","75810039","CDM","481","RC","37253","HCPCS","facility","both","","","","1641","820.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Neurostim Generator","75810041","CDM","761","RC","61888","HCPCS","facility","both","","","","15100","7550","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Clsr Tcat L Atr Apndge","75810042","CDM","481","RC","33340","HCPCS","facility","both","","","","10440","5220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Balo Angiop 1St Artery","75810043","CDM","481","RC","37246","HCPCS","facility","both","","","","6749","3374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trluml Balo Angiop Addl Artery","75810044","CDM","481","RC","37247","HCPCS","facility","both","","","","6749","3374.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep Trunk; 2.6-7.5Cm","75810050","CDM","369","RC","13101","HCPCS","facility","both","","","","2079","1039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"C Rep Trunk; Ea Addtl 5 Cm/<","75810051","CDM","369","RC","13102","HCPCS","facility","both","","","","1074","537","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcat Impl Wrls P-Art Prs Snr","75810052","CDM","481","RC","33289","HCPCS","facility","both","","","","86839","43419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcat Insj/Rpl Perm Ldls Pm","75810053","CDM","481","RC","33274","HCPCS","facility","both","","","","49062","24531","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tcat Rmvl Perm Ldls Pm","75810054","CDM","481","RC","33275","HCPCS","facility","both","","","","26826","13413","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insj Subq Car Rhythm Mntr","75810055","CDM","481","RC","33285","HCPCS","facility","both","","","","12794","6397","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Subq Car Rhythm Mntr","75810056","CDM","481","RC","33286","HCPCS","facility","both","","","","3516","1758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Vad Art&Vein Access","75810058","CDM","481","RC","33991","HCPCS","facility","both","","","","11979","5989.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temp Artery Biopsy","75810059","CDM","481","RC","37609","HCPCS","facility","both","","","","9378","4689","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pericardiocentesis W/Imaging","75810100","CDM","481","RC","33016","HCPCS","facility","both","","","","3281","1640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prcrd Drg 6Yr+ W/O Cgen Car","75810101","CDM","481","RC","33017","HCPCS","facility","both","","","","3281","1640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"R Hrt Cath Chd Nml Nt Cnj","75810104","CDM","481","RC","93593","HCPCS","facility","both","","","","13867","6933.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"R Hrt Cath Chd Abnl Nt Cnj","75810105","CDM","481","RC","93594","HCPCS","facility","both","","","","13867","6933.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Or First 30 Mins - Trauma","75810108","CDM","360","RC","","","facility","both","","","","5075.84","2537.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Or Each Addl 15 Mins - Trauma","75810109","CDM","360","RC","","","facility","both","","","","2311.7","1155.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Or First 30 Mins - Ng Only","75810112","CDM","360","RC","","","facility","both","","","","4639.77","2319.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Or Each Addl 15 Mins - Ng Only","75810113","CDM","360","RC","","","facility","both","","","","2027.76","1013.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Or First 30 Mins - Cardiac Ng Only","75810114","CDM","360","RC","","","facility","both","","","","3977.14","1988.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Or Each Addl 15 Mins - Cardiac Ng Only","75810115","CDM","360","RC","","","facility","both","","","","1828.63","914.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Min Out Of Unit Heart Or","75900043","CDM","370","RC","","","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes-Out Of Unit Heart Or Base","75900044","CDM","370","RC","","","facility","both","","","","1561","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epidural In L&D","75900250","CDM","370","RC","","","facility","both","","","","1416","708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Guided Needle Place","75902007","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anesthesia - Women's Health","75903005","CDM","370","RC","","","facility","both","","","","1416","708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Out Of Unit Minutes","75903006","CDM","370","RC","","","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes-Out Of Unit Or Base Chrge","75903007","CDM","370","RC","","","facility","both","","","","1443","721.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Nerve Block (L&D)","75908220","CDM","370","RC","","","facility","both","","","","1416","708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Setup Women Health","75920000","CDM","370","RC","","","facility","both","","","","1443","721.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Per Min Women Health","75920001","CDM","370","RC","","","facility","both","","","","34","17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes General First 30 Mins","75920002","CDM","370","RC","","","facility","both","","","","1362.98","681.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes General Each Addl 15 Mins","75920003","CDM","370","RC","","","facility","both","","","","588.77","294.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Block First 30 Mins","75920004","CDM","370","RC","","","facility","both","","","","1311.61","655.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Block Each Addl 15 Mins","75920005","CDM","370","RC","","","facility","both","","","","642.39","321.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Epi First 30 Mins","75920006","CDM","370","RC","","","facility","both","","","","1432.22","716.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Epi Each Addl 15 Mins","75920007","CDM","370","RC","","","facility","both","","","","716.12","358.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Mac First 30 Mins","75920008","CDM","370","RC","","","facility","both","","","","1850.79","925.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Mac Each Addl 15 Mins","75920009","CDM","370","RC","","","facility","both","","","","736.55","368.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Spinal First 30 Mins","75920010","CDM","370","RC","","","facility","both","","","","1479.98","739.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Spinal Each Addl 15 Mins","75920011","CDM","370","RC","","","facility","both","","","","674.57","337.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Trauma First 30 Mins","75920012","CDM","370","RC","","","facility","both","","","","1359.27","679.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Trauma Each Addl 15 Mins","75920013","CDM","370","RC","","","facility","both","","","","621.51","310.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Cardiac First 30 Mins","75920014","CDM","370","RC","","","facility","both","","","","1372.94","686.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anes Cardiac Each Addl 15 Mins","75920015","CDM","370","RC","","","facility","both","","","","583.31","291.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","75951","CDM","270","RC","","","facility","both","","","","164.89","82.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New High Mdm 60 Minutes","76100007","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Training Follow Up","76100008","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt Init Nutrn Ther; Each 15M","76100009","CDM","942","RC","97802","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt Reassess Nutr Ther; Ea 15M","76100010","CDM","942","RC","97803","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opt Dsmes Individ 30 Min Sessn","76100011","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opt Dsmes Group 30 Min Sessn","76100012","CDM","942","RC","G0109","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carb Count Educ-Indiv 30 Min","76100013","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med Nutri Ther Grp 30 Min","76100015","CDM","942","RC","G0109","HCPCS","facility","both","","","","48","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insulin Pump Train Ind 30 Min","76100017","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gestational Diabetes Ind-30 Mn","76100018","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dm Intensive Ind 30 Min","76100019","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insulin Init Train Ind 30 Min","76100020","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Monitor Ind 30 Min","76100021","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cont Gluc Mntr Phys/Qhp Eqp","76100025","CDM","920","RC","95250","HCPCS","facility","both","","","","887","443.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grp Medical Nutrition Therapy; Each 30 Mins","76100027","CDM","942","RC","97804","HCPCS","facility","both","","","","59","29.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diab Ed Consult Lvl1 1-30 Min","76100028","CDM","942","RC","","","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diab Ed Consult Lvl2 31-60 Min","76100029","CDM","942","RC","","","facility","both","","","","90","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diab Ed Consult Lvl3 +61 Min","76100030","CDM","942","RC","","","facility","both","","","","137","68.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cont Gluc Mntr Pt Prov Eqp","76100031","CDM","920","RC","95249","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76164","CDM","270","RC","","","facility","both","","","","312.8","156.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76166","CDM","270","RC","C1758","HCPCS","facility","both","","","","1839.25","919.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76276","CDM","270","RC","L4386","HCPCS","facility","both","","","","161.96","80.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76554","CDM","278","RC","C1713","HCPCS","facility","both","","","","101.2","50.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76557","CDM","270","RC","","","facility","both","","","","13.58","6.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76562","CDM","270","RC","","","facility","both","","","","8.24","4.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76563","CDM","270","RC","","","facility","both","","","","11.61","5.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76566","CDM","278","RC","C1768","HCPCS","facility","both","","","","844.25","422.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76584","CDM","270","RC","","","facility","both","","","","187.83","93.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76756","CDM","270","RC","","","facility","both","","","","168.95","84.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76757","CDM","270","RC","","","facility","both","","","","172.21","86.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76761","CDM","270","RC","","","facility","both","","","","11.21","5.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76768","CDM","272","RC","C1887","HCPCS","facility","both","","","","713.11","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76770","CDM","272","RC","C1887","HCPCS","facility","both","","","","713.11","356.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76777","CDM","270","RC","","","facility","both","","","","11.73","5.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","76860","CDM","270","RC","","","facility","both","","","","352.75","176.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77102","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77103","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77112","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","775","CDM","270","RC","","","facility","both","","","","21.76","10.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77562","CDM","276","RC","V2632","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77617","CDM","270","RC","","","facility","both","","","","381.45","190.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77619","CDM","270","RC","","","facility","both","","","","294.96","147.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77621","CDM","270","RC","","","facility","both","","","","297.66","148.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77749","CDM","270","RC","","","facility","both","","","","96.6","48.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77853","CDM","272","RC","C1894","HCPCS","facility","both","","","","416.25","208.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77864","CDM","270","RC","","","facility","both","","","","20.03","10.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77955","CDM","270","RC","","","facility","both","","","","2.75","1.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","77977","CDM","270","RC","","","facility","both","","","","13.98","6.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","78031","CDM","278","RC","C1713","HCPCS","facility","both","","","","8189","4094.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","78198","CDM","270","RC","","","facility","both","","","","59.34","29.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","78214","CDM","270","RC","","","facility","both","","","","14.41","7.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","78248","CDM","270","RC","L1832","HCPCS","facility","both","","","","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7873","CDM","278","RC","C1768","HCPCS","facility","both","","","","1604.35","802.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7883","CDM","270","RC","","","facility","both","","","","19.66","9.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7884","CDM","270","RC","","","facility","both","","","","51.7","25.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79170","CDM","278","RC","C1713","HCPCS","facility","both","","","","381.8","190.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79215","CDM","278","RC","C1713","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79216","CDM","278","RC","C1713","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79217","CDM","278","RC","C1713","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79268","CDM","270","RC","","","facility","both","","","","809.6","404.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7935","CDM","270","RC","","","facility","both","","","","942.99","471.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79527","CDM","272","RC","C1769","HCPCS","facility","both","","","","123.97","61.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79611","CDM","270","RC","","","facility","both","","","","3.21","1.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79612","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79613","CDM","270","RC","","","facility","both","","","","2","1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79614","CDM","270","RC","","","facility","both","","","","2.38","1.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79616","CDM","270","RC","","","facility","both","","","","25.55","12.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","7969","CDM","278","RC","C1713","HCPCS","facility","both","","","","188.87","94.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79711","CDM","270","RC","","","facility","both","","","","31.89","15.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79712","CDM","270","RC","","","facility","both","","","","61.79","30.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79714","CDM","270","RC","","","facility","both","","","","169.1","84.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79844","CDM","278","RC","C1713","HCPCS","facility","both","","","","759","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79855","CDM","278","RC","Q4100","HCPCS","facility","both","","","","1555.2","777.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79856","CDM","278","RC","Q4100","HCPCS","facility","both","","","","1602.5","801.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79857","CDM","278","RC","Q4100","HCPCS","facility","both","","","","1641.75","820.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79919","CDM","270","RC","","","facility","both","","","","6.96","3.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79942","CDM","270","RC","L4387","HCPCS","facility","both","","","","207.18","103.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","79944","CDM","270","RC","L4387","HCPCS","facility","both","","","","199.23","99.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80025","CDM","270","RC","","","facility","both","","","","273.81","136.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80028","CDM","270","RC","","","facility","both","","","","10.36","5.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80037","CDM","270","RC","","","facility","both","","","","6.83","3.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80121","CDM","270","RC","","","facility","both","","","","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80403","CDM","278","RC","C1713","HCPCS","facility","both","","","","534.43","267.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80404","CDM","278","RC","C1713","HCPCS","facility","both","","","","534.43","267.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80418","CDM","278","RC","C1713","HCPCS","facility","both","","","","203","101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80419","CDM","278","RC","C1713","HCPCS","facility","both","","","","203","101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80420","CDM","278","RC","C1713","HCPCS","facility","both","","","","203","101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80421","CDM","278","RC","C1713","HCPCS","facility","both","","","","203","101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80428","CDM","278","RC","C1713","HCPCS","facility","both","","","","139.29","69.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80429","CDM","278","RC","C1713","HCPCS","facility","both","","","","143.52","71.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80430","CDM","278","RC","C1713","HCPCS","facility","both","","","","157.62","78.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80431","CDM","278","RC","C1713","HCPCS","facility","both","","","","139.29","69.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80434","CDM","278","RC","C1713","HCPCS","facility","both","","","","164.96","82.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80435","CDM","278","RC","C1713","HCPCS","facility","both","","","","190.62","95.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80438","CDM","278","RC","C1713","HCPCS","facility","both","","","","534.43","267.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80812","CDM","270","RC","","","facility","both","","","","418.86","209.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80836","CDM","270","RC","","","facility","both","","","","1796.56","898.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","80837","CDM","270","RC","","","facility","both","","","","1748.3","874.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unna Boot","81000017","CDM","761","RC","29580","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit-Debrd Selec-1St 20Sqcm/<","81000018","CDM","510","RC","97597","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit-Debrd Select-Ea Addtl 20Sqcm","81000019","CDM","510","RC","97598","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Npwt Non-Disposable </=50Sqcm","81000021","CDM","510","RC","97605","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Npwt Non-Disposable >50Sqcm","81000022","CDM","510","RC","97606","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","81000023","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","81000024","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Supply-Speciality Dressing","81000026","CDM","270","RC","","","facility","both","","","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit-Debride Nonselect","81000027","CDM","510","RC","97602","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Bengn Hyperkerat Sngl","81000030","CDM","761","RC","11055","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Debrid 6 Or>Any Method","81000031","CDM","761","RC","11721","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Benign Hyperkerat 2-4","81000032","CDM","761","RC","11056","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Debrid 1-5 By Any Method","81000033","CDM","761","RC","11720","HCPCS","facility","both","","","","478","239","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Benign Hyperk>4","81000034","CDM","761","RC","11057","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Unna Boot","81000040","CDM","510","RC","29700","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemical Cautery,Tissue","81000041","CDM","761","RC","17250","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foam Drg>16<=48 Sqin W/O Brdr","81000042","CDM","270","RC","A6210","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foam Drg>48 Sq In W/O Bordr","81000043","CDM","270","RC","A6211","HCPCS","facility","both","","","","64.17","32.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collagen Drsg,16 Sq In Or<","81000044","CDM","270","RC","A6021","HCPCS","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collagen Drsg>16 Or <48 Sq In","81000045","CDM","270","RC","A6022","HCPCS","facility","both","","","","46.58","23.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collagen Drsg,>48 Sq In","81000046","CDM","270","RC","A6023","HCPCS","facility","both","","","","372.6","186.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Heel Prevention Waffle Boot","81000047","CDM","270","RC","","","facility","both","","","","81.77","40.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Heel Treatment Protect Boot","81000048","CDM","270","RC","","","facility","both","","","","188","94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Mepilex Foam Drsg<16 Sq In","81000050","CDM","270","RC","A6209","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mist Ultrasound Therapy","81000060","CDM","402","RC","97610","HCPCS","facility","both","","","","1017","508.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Skin Abscess-Complic","81000100","CDM","761","RC","10061","HCPCS","facility","both","","","","1501","750.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&Fb Removal Subq-Simple","81000101","CDM","761","RC","10120","HCPCS","facility","both","","","","1381","690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&Fb Removal Subq-Comp","81000102","CDM","761","RC","10121","HCPCS","facility","both","","","","6803","3401.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Complex Postop Wound","81000103","CDM","761","RC","10180","HCPCS","facility","both","","","","10236","5118","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debrd Inf Skin-10% Body","81000104","CDM","761","RC","11000","HCPCS","facility","both","","","","680","340","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridment Of Open Fx/D","81000105","CDM","761","RC","11012","HCPCS","facility","both","","","","3844","1922","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debrd Skin&Subq 20Sqcm/<","81000106","CDM","761","RC","11042","HCPCS","facility","both","","","","1736","868","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue Add-On","81000107","CDM","761","RC","11045","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avul Nail Plate Simp-1","81000108","CDM","761","RC","11730","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Nail&Matrx-Perm Rml","81000109","CDM","761","RC","11750","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"App Rigid Tot Contact Lg","81000110","CDM","761","RC","29445","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impacted Cerumen Removal","81000111","CDM","761","RC","69210","HCPCS","facility","both","","","","373","186.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Additional Cleansing Of Skin","81000113","CDM","761","RC","11001","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Skin At Fx Site","81000114","CDM","761","RC","11010","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Skin Musc At Fx Site","81000115","CDM","761","RC","11011","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia 20 Sq Cm/<","81000116","CDM","761","RC","11043","HCPCS","facility","both","","","","2599","1299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone 20 Sq Cm/<","81000117","CDM","761","RC","11044","HCPCS","facility","both","","","","5413","2706.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia Add-On","81000118","CDM","761","RC","11046","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone Add-On","81000119","CDM","761","RC","11047","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Nail (S)","81000122","CDM","761","RC","11719","HCPCS","facility","both","","","","217","108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Nail Plate Add-On","81000123","CDM","761","RC","11732","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Multlay Comprs Lwr Leg","81000124","CDM","761","RC","29581","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Anal Ext Tag/Papilla","81000125","CDM","761","RC","46220","HCPCS","facility","both","","","","7767","3883.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implt Trilayer Mrtix Per Cm Sq","81000152","CDM","278","RC","Q4124","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oasis Trilayer Cm Sq Wasted","81000153","CDM","278","RC","Q4124","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Mult Compr Lwr Leg-Bilat","81000200","CDM","761","RC","29581","HCPCS","facility","both","","","","1196","598","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wound Prep F/N/Hf/G","81000201","CDM","761","RC","15004","HCPCS","facility","both","","","","2429","1214.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Trunk=<2.5Cm","81000202","CDM","761","RC","12001","HCPCS","facility","both","","","","923","461.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Trunk 2.5-7.5Cm","81000203","CDM","761","RC","12002","HCPCS","facility","both","","","","1551","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Trunk 7.6-12.5Cm","81000204","CDM","761","RC","12004","HCPCS","facility","both","","","","1708","854","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Trunk 12.6-20Cm","81000205","CDM","761","RC","12005","HCPCS","facility","both","","","","1877","938.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Turnk 20.1-30Cm","81000206","CDM","761","RC","12006","HCPCS","facility","both","","","","2067","1033.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Face=<2.5Cm","81000207","CDM","761","RC","12011","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Repair F/E/E/N/L/M 2.6Cm-5.0 Cm","81000208","CDM","761","RC","12013","HCPCS","facility","both","","","","1278","639","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Face 5.1-7.5Cm","81000209","CDM","761","RC","12014","HCPCS","facility","both","","","","1403","701.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Face 7.6-12.5Cm","81000210","CDM","761","RC","12015","HCPCS","facility","both","","","","1542","771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Rep Face 12.6-20Cm","81000211","CDM","761","RC","12016","HCPCS","facility","both","","","","1773","886.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adjt Tis Trnsfr/Reargmt Scalp/Arm/Leg 10 Sq Cm/<","81000217","CDM","761","RC","14020","HCPCS","facility","both","","","","8296","4148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wound Prep Trk/Arm/Leg","81000220","CDM","761","RC","15002","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alginate Drsg>16<=48 Sq In","81000221","CDM","270","RC","A6197","HCPCS","facility","both","","","","72.45","36.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alginate Dressing <=16 Sq In","81000222","CDM","270","RC","A6196","HCPCS","facility","both","","","","40.37","20.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alginate Dressing>48 Sq In","81000223","CDM","270","RC","A6198","HCPCS","facility","both","","","","67.28","33.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Contact Layer Drg<=16Sqin","81000225","CDM","270","RC","A6206","HCPCS","facility","both","","","","38.3","19.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Contact Layer Drg>16<=48Sqin","81000226","CDM","270","RC","A6207","HCPCS","facility","both","","","","83.84","41.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alginate Drsg,Filler,Per 6Inch","81000227","CDM","270","RC","A6199","HCPCS","facility","both","","","","77.63","38.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub T/A/L-1St 25Sqcm-Proc","81000250","CDM","940","RC","15271","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub T/A/L-Add 25Sqcm-Proc","81000251","CDM","940","RC","15272","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub T/A/L-1St 100Sqc-Proc","81000252","CDM","940","RC","15273","HCPCS","facility","both","","","","10703","5351.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub T/A/L-Add 100Sqc-Proc","81000253","CDM","940","RC","15274","HCPCS","facility","both","","","","10703","5351.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub F/N/Hf-1St 25Sqc-Proc","81000254","CDM","940","RC","15275","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub F/N/Hf-Add 25Sqc-Proc","81000255","CDM","940","RC","15276","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub F/N/Hf-1St 100Sq-Proc","81000256","CDM","940","RC","15277","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub F/N/Hf-Add 100Sq-Proc","81000257","CDM","940","RC","15278","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg </=0.5Cm","81000300","CDM","361","RC","11400","HCPCS","facility","both","","","","2039","1019.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 0.6-1 Cm","81000301","CDM","361","RC","11401","HCPCS","facility","both","","","","1646","823","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 1.1-2 Cm","81000302","CDM","761","RC","11402","HCPCS","facility","both","","","","2299","1149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 2.1-3 Cm","81000303","CDM","761","RC","11403","HCPCS","facility","both","","","","2665","1332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg </=0.5Cm","81000304","CDM","761","RC","11420","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg 0.6-1Cm","81000305","CDM","761","RC","11421","HCPCS","facility","both","","","","3433","1716.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg 1.1-2Cm","81000306","CDM","761","RC","11422","HCPCS","facility","both","","","","3169","1584.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg 2.1-3Cm","81000307","CDM","761","RC","11423","HCPCS","facility","both","","","","4687","2343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg </=0.5Cm","81000308","CDM","761","RC","11440","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 0.6-1 Cm","81000309","CDM","761","RC","11441","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 1.1-2 Cm","81000310","CDM","761","RC","11442","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 2.1-3 Cm","81000311","CDM","761","RC","11443","HCPCS","facility","both","","","","4101","2050.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lay Clos Hnd/Ft=/<2.5Cm","81000313","CDM","369","RC","12041","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lay Cls Hnd/Ft 2.6-7.5Cm","81000314","CDM","369","RC","12042","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Layr Closr Face=/<2.5Cm","81000315","CDM","369","RC","12051","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Layr Closr Face 2.6-5Cm","81000316","CDM","369","RC","12052","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Rep Trunk 1.1-2.5Cm","81000317","CDM","450","RC","13100","HCPCS","facility","both","","","","967","483.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Rep Face 1.1-2.5Cm","81000319","CDM","369","RC","13131","HCPCS","facility","both","","","","1321","660.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Rep Face 2.6-7.5Cm","81000320","CDM","369","RC","13132","HCPCS","facility","both","","","","1523","761.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Rep Eyeld 1.1-2.5Cm","81000322","CDM","369","RC","13151","HCPCS","facility","both","","","","2029","1014.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputation Toe,Mtp Jnt","81000351","CDM","761","RC","28820","HCPCS","facility","both","","","","8393","4196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Partial Amputation Toe,Ip Jnt","81000352","CDM","761","RC","28825","HCPCS","facility","both","","","","8393","4196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 3.1-4 Cm","81000400","CDM","761","RC","11404","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg > 4.0 Cm","81000401","CDM","761","RC","11406","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg 3.1-4","81000402","CDM","761","RC","11424","HCPCS","facility","both","","","","5630","2815","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp B9+Marg>4Cm","81000403","CDM","761","RC","11426","HCPCS","facility","both","","","","6893","3446.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face -Mm B9+Marg>4 Cm","81000405","CDM","761","RC","11446","HCPCS","facility","both","","","","5241","2620.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mlg+Marg 0.6-1Cm","81000406","CDM","761","RC","11601","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mlg+Marg 1.1-2 Cm","81000407","CDM","761","RC","11602","HCPCS","facility","both","","","","1711","855.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mlg+Marg 2.1-3Cm","81000408","CDM","761","RC","11603","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mlg+Marg 3.1-4Cm","81000409","CDM","761","RC","11604","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mlg+Marg>4Cm","81000410","CDM","761","RC","11606","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp Mlg+Marg 0.5<","81000411","CDM","761","RC","11620","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-Fnk-Sp Mlg+Marg 0.6-1","81000412","CDM","761","RC","11621","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp Mlg+Marg 1.1-2","81000413","CDM","761","RC","11622","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp Mlg+Marg 2.1-3","81000414","CDM","761","RC","11623","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp Mlg+Marg 3.1-4","81000415","CDM","761","RC","11624","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp Mlg+Mar> 4 Cm","81000416","CDM","761","RC","11626","HCPCS","facility","both","","","","9285","4642.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face -Mm Malig+Marg 0.5<","81000417","CDM","761","RC","11640","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Malig+Marg 0.6-1","81000418","CDM","761","RC","11641","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm-Malig+Marg 1.1-2","81000419","CDM","761","RC","11642","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Malig+Marg 2.1-3","81000420","CDM","761","RC","11643","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Malig+Marg 3.1-4","81000421","CDM","761","RC","11644","HCPCS","facility","both","","","","5044","2522","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Mlg+Marg> 4Cm","81000422","CDM","761","RC","11646","HCPCS","facility","both","","","","5900","2950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lc Sksub T/A/L-1St 24Sqcm-Proc","81000423","CDM","940","RC","C5271","HCPCS","facility","both","","","","2261","1130.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lc Sksub T/A/L-Add 25Sqcm-Proc","81000424","CDM","940","RC","C5272","HCPCS","facility","both","","","","1136","568","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lc Sksub F/N/Hf-1St 25Sqc-Proc","81000427","CDM","940","RC","C5275","HCPCS","facility","both","","","","2024","1012","","","","","","","","","","","","","Gross Charge Type: Standard"
"Npwt Disposable </=50Sqcm","81000440","CDM","761","RC","97607","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Npwt Disposable >50Sqcm","81000441","CDM","761","RC","97608","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Arms Legs Trunk <101Sqcm","81000450","CDM","761","RC","15100","HCPCS","facility","both","","","","6020","3010","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hands Feet Face <101Sqcm","81000451","CDM","761","RC","15120","HCPCS","facility","both","","","","9917","4958.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epidermal Graph Trunk/Arm/Leg","81000452","CDM","361","RC","15110","HCPCS","facility","both","","","","5407","2703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epidermal Graph Feet/Hand/Face","81000453","CDM","361","RC","15115","HCPCS","facility","both","","","","5407","2703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy,Bone,Open;Superficial","81000454","CDM","361","RC","20240","HCPCS","facility","both","","","","10236","5118","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autograft Cellutome T/A/L","81000455","CDM","361","RC","15111","HCPCS","facility","both","","","","4753","2376.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autograft Cellutome F/H/F Add On","81000456","CDM","361","RC","15116","HCPCS","facility","both","","","","4753","2376.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tenotomy Per Toe Single Tendon","81000460","CDM","761","RC","28010","HCPCS","facility","both","","","","5944","2972","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Single Les","81000461","CDM","761","RC","11102","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","81000462","CDM","761","RC","11104","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Single Les","81000463","CDM","761","RC","11106","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Ea Sep/Addl","81000464","CDM","761","RC","11103","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Sep/Addl","81000465","CDM","761","RC","11105","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skin Ea Sep/Addl","81000466","CDM","761","RC","11107","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ftsg Face/Genit/Hf =< 20 Sq Cm","81000471","CDM","369","RC","15240","HCPCS","facility","both","","","","5407","2703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sutr&Stapl Xreq Anes","81000476","CDM","761","RC","15854","HCPCS","facility","both","","","","1725","862.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sutr/Stapl Xreq Anes","81000477","CDM","761","RC","15853","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unna Boot - Bilateral","81000478","CDM","761","RC","29580","HCPCS","facility","both","","","","1196","598","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81060","CDM","270","RC","","","facility","both","","","","1991.25","995.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81061","CDM","270","RC","","","facility","both","","","","1749.33","874.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81423","CDM","270","RC","","","facility","both","","","","1028.52","514.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81436","CDM","270","RC","","","facility","both","","","","1020.77","510.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81437","CDM","270","RC","","","facility","both","","","","1022.72","511.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81482","CDM","270","RC","","","facility","both","","","","982.64","491.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81488","CDM","278","RC","C1763","HCPCS","facility","both","","","","1695.1","847.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81545","CDM","270","RC","","","facility","both","","","","372.6","186.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81554","CDM","270","RC","","","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81558","CDM","270","RC","","","facility","both","","","","214.87","107.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81559","CDM","270","RC","","","facility","both","","","","214.87","107.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81560","CDM","270","RC","","","facility","both","","","","214.87","107.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81562","CDM","270","RC","","","facility","both","","","","214.86","107.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81565","CDM","270","RC","","","facility","both","","","","260.74","130.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81566","CDM","270","RC","","","facility","both","","","","107.64","53.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81570","CDM","270","RC","","","facility","both","","","","762.92","381.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81572","CDM","270","RC","","","facility","both","","","","14.53","7.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81581","CDM","270","RC","","","facility","both","","","","15.27","7.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81615","CDM","270","RC","","","facility","both","","","","77.05","38.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81618","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81619","CDM","278","RC","C2625","HCPCS","facility","both","","","","351.62","175.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81621","CDM","270","RC","","","facility","both","","","","70.67","35.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","8164","CDM","270","RC","","","facility","both","","","","5.68","2.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81856","CDM","270","RC","","","facility","both","","","","79.35","39.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81859","CDM","270","RC","","","facility","both","","","","228.16","114.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81862","CDM","270","RC","","","facility","both","","","","228.16","114.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","81923","CDM","270","RC","","","facility","both","","","","760.1","380.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82006","CDM","278","RC","C1713","HCPCS","facility","both","","","","631.99","316","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82007","CDM","270","RC","","","facility","both","","","","135.7","67.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","821","CDM","270","RC","","","facility","both","","","","28.75","14.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82267","CDM","272","RC","C1725","HCPCS","facility","both","","","","2047","1023.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82347","CDM","272","RC","C1729","HCPCS","facility","both","","","","153.79","76.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82352","CDM","270","RC","","","facility","both","","","","1934.99","967.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82358","CDM","270","RC","","","facility","both","","","","212.02","106.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82438","CDM","272","RC","C1773","HCPCS","facility","both","","","","1522.6","761.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","825","CDM","270","RC","","","facility","both","","","","28.75","14.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82530","CDM","270","RC","","","facility","both","","","","11.29","5.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82531","CDM","278","RC","C1750","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82584","CDM","270","RC","","","facility","both","","","","52.9","26.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82614","CDM","270","RC","","","facility","both","","","","2060.8","1030.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82696","CDM","270","RC","","","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82697","CDM","270","RC","","","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82699","CDM","270","RC","","","facility","both","","","","717.83","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","827","CDM","270","RC","","","facility","both","","","","84.87","42.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82701","CDM","270","RC","","","facility","both","","","","717.85","358.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82702","CDM","270","RC","","","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82812","CDM","270","RC","","","facility","both","","","","95.96","47.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82821","CDM","270","RC","","","facility","both","","","","364.83","182.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82823","CDM","272","RC","C1769","HCPCS","facility","both","","","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82824","CDM","272","RC","C1894","HCPCS","facility","both","","","","935.65","467.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","82882","CDM","270","RC","","","facility","both","","","","2161.44","1080.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83003","CDM","272","RC","C1894","HCPCS","facility","both","","","","522.33","261.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83027","CDM","278","RC","C1751","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83199","CDM","272","RC","C1769","HCPCS","facility","both","","","","114.31","57.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83320","CDM","278","RC","C1776","HCPCS","facility","both","","","","1542.53","771.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83321","CDM","278","RC","C1776","HCPCS","facility","both","","","","1542.53","771.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83326","CDM","278","RC","C1776","HCPCS","facility","both","","","","2828.68","1414.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83329","CDM","278","RC","C1776","HCPCS","facility","both","","","","396.89","198.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83423","CDM","278","RC","C1776","HCPCS","facility","both","","","","15394.94","7697.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83479","CDM","278","RC","C1713","HCPCS","facility","both","","","","1883.97","941.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83488","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83630","CDM","272","RC","C1729","HCPCS","facility","both","","","","41.22","20.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","83632","CDM","278","RC","C1781","HCPCS","facility","both","","","","4938.1","2469.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","84133","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","84134","CDM","270","RC","","","facility","both","","","","699.2","349.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","84144","CDM","270","RC","","","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","84280","CDM","270","RC","","","facility","both","","","","670.69","335.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","84428","CDM","272","RC","C1729","HCPCS","facility","both","","","","137.04","68.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","8505","CDM","270","RC","","","facility","both","","","","5.06","2.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","85274","CDM","278","RC","C1713","HCPCS","facility","both","","","","1676.7","838.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","85275","CDM","278","RC","C1713","HCPCS","facility","both","","","","1676.7","838.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","853","CDM","270","RC","","","facility","both","","","","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","858","CDM","270","RC","","","facility","both","","","","21.76","10.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","8583","CDM","270","RC","","","facility","both","","","","2225.6","1112.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","862","CDM","270","RC","","","facility","both","","","","11.85","5.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86414","CDM","270","RC","","","facility","both","","","","23.24","11.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86417","CDM","270","RC","","","facility","both","","","","639.4","319.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86428","CDM","270","RC","","","facility","both","","","","371.45","185.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86458","CDM","278","RC","L8612","HCPCS","facility","both","","","","1820","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86494","CDM","270","RC","","","facility","both","","","","879.57","439.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86500","CDM","278","RC","C1713","HCPCS","facility","both","","","","677.56","338.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86502","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86601","CDM","278","RC","C1763","HCPCS","facility","both","","","","1495","747.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","8667","CDM","270","RC","","","facility","both","","","","29.64","14.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86769","CDM","278","RC","C1760","HCPCS","facility","both","","","","1035","517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86805","CDM","278","RC","C1713","HCPCS","facility","both","","","","1718.62","859.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86817","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86832","CDM","270","RC","","","facility","both","","","","571.61","285.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","86921","CDM","270","RC","","","facility","both","","","","588.8","294.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Draw Fee Venipuncture","87036415","CDM","300","RC","36415","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Capillary Blood Specimen","87036416","CDM","300","RC","36416","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drug Test Prsmv Dir Opt Obs","87080305","CDM","300","RC","80305","HCPCS","facility","both","","","","18","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urinalysis Auto W/Scope","87081001","CDM","300","RC","81001","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urinalysis Nonauto W/O Scope","87081002","CDM","300","RC","81002","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urinalysis Auto W/O Scope","87081003","CDM","300","RC","81003","HCPCS","facility","both","","","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urine Microscopic Only","87081015","CDM","300","RC","81015","HCPCS","facility","both","","","","44","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urine Pregnancy Test","87081025","CDM","300","RC","81025","HCPCS","facility","both","","","","285","142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stool-Blood Hemocult","87082270","CDM","300","RC","82270","HCPCS","facility","both","","","","46","23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occult Bld Feces 1-3 Tests","87082272","CDM","300","RC","82272","HCPCS","facility","both","","","","49","24.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Assay Test For Blood Fecal","87082274","CDM","300","RC","82274","HCPCS","facility","both","","","","212","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Calcium,Total","87082310","CDM","300","RC","82310","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chloride,Blood","87082435","CDM","300","RC","82435","HCPCS","facility","both","","","","138","69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Creatinine,Other Sources","87082570","CDM","300","RC","82570","HCPCS","facility","both","","","","208","104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Gas Mixed Wo O2 Sat","87082803","CDM","300","RC","82803","HCPCS","facility","both","","","","580","290","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose,Quant","87082947","CDM","300","RC","82947","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Tolerance Test(Gtt)","87082951","CDM","300","RC","82951","HCPCS","facility","both","","","","131","65.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Blood Test","87082962","CDM","300","RC","82962","HCPCS","facility","both","","","","36","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin,Glycated","87083036","CDM","300","RC","83036","HCPCS","facility","both","","","","219","109.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Potassium","87084132","CDM","300","RC","84132","HCPCS","facility","both","","","","126","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sodium,Serum","87084295","CDM","300","RC","84295","HCPCS","facility","both","","","","123","61.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bun","87084520","CDM","300","RC","84520","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hematocrit","87085014","CDM","300","RC","85014","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hgb","87085018","CDM","300","RC","85018","HCPCS","facility","both","","","","25","12.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prothrombin Time","87085610","CDM","300","RC","85610","HCPCS","facility","both","","","","184","92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mono Screen Routine","87086308","CDM","300","RC","86308","HCPCS","facility","both","","","","209","104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Histoplasmosis Skin Test","87086510","CDM","300","RC","86510","HCPCS","facility","both","","","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Test Tb Intradermal","87086580","CDM","300","RC","86580","HCPCS","facility","both","","","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Culture Of Specimen By Kit","87087084","CDM","300","RC","87084","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Koh Prep","87087220","CDM","300","RC","87220","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Assay W/Optic","87087804","CDM","300","RC","87804","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Strep A Assay W/Optic","87087880","CDM","300","RC","87880","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin","87090471","CDM","771","RC","90471","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaccine Inj Ea Addtl-Other","87090472","CDM","771","RC","90472","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Influenza Virus Vac","87090473","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remote Dx Retinal Imaging","87092227","CDM","761","RC","92227","HCPCS","facility","both","","","","162","81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pure Tone Audiometry,Air","87092552","CDM","940","RC","92552","HCPCS","facility","both","","","","276","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrocardiogram Tracing","87093005","CDM","940","RC","93005","HCPCS","facility","both","","","","453","226.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiovascular Stress Test","87093016","CDM","482","RC","93017","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiovascular Stress Test","87093017","CDM","482","RC","93017","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monitor Ecg","87093041","CDM","940","RC","93041","HCPCS","facility","both","","","","154","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecg Monit/Reprt Up To 48 Hrs","87093225","CDM","940","RC","93225","HCPCS","facility","both","","","","418","209","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecg Up To 48 Hrs Scan Anal Rpt","87093226","CDM","731","RC","93226","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remote 30 Day Ecg Tech Supp","87093229","CDM","761","RC","93229","HCPCS","facility","both","","","","390","195","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Ecg>48Hr<7D Recording","87093242","CDM","731","RC","93242","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Ecg>7D<15D Recording","87093246","CDM","731","RC","93246","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remote 30 Day Ecg Rev/Report","87093270","CDM","940","RC","93270","HCPCS","facility","both","","","","361","180.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inter Device Eval,Up To 90 Day","87093296","CDM","480","RC","93296","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ambulatory Bp Mntr W/Sw 24 Hr+ Recording Only","87093786","CDM","480","RC","93786","HCPCS","facility","both","","","","420","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Airway Inhal Trmt Sputum Ind","87094640","CDM","410","RC","94640","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"94664 Demon&Eval Pt Hhn/Ippb","87094664","CDM","410","RC","94664","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Pulse Oximetry Spot Check","87094760","CDM","460","RC","94760","HCPCS","facility","both","","","","179","89.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ear/Pulse Oximetry,02 Sat,Mult","87094761","CDM","460","RC","94761","HCPCS","facility","both","","","","688","344","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Or Application Test(S)","87095044","CDM","940","RC","95044","HCPCS","facility","both","","","","1178","589","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunotherapy One Injection","87095115","CDM","940","RC","95115","HCPCS","facility","both","","","","49","24.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunotherapy Injections","87095117","CDM","940","RC","95117","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cont Gluc Mntr Phys/Qhp Eqp","87095250","CDM","940","RC","95250","HCPCS","facility","both","","","","887","443.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl/Nrpsyc Tech 1St","87096138","CDM","918","RC","96138","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl/Nrpsyc Tst Tech Ea","87096139","CDM","918","RC","96139","HCPCS","facility","both","","","","39","19.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl/Nrpsyc Tst Auto Result","87096146","CDM","918","RC","96146","HCPCS","facility","both","","","","37","18.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","87096372","CDM","940","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thera/Prophy/Diag Inj;Iv Push","87096374","CDM","260","RC","96374","HCPCS","facility","both","","","","542","271","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chem Iv Push Inj,Ea Ad Seq","87096375","CDM","260","RC","96375","HCPCS","facility","both","","","","441","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultraviolet Light Therapy","87096900","CDM","940","RC","96900","HCPCS","facility","both","","","","274","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obtaining Screen Pap Smear","87099004","CDM","520","RC","Q0091","HCPCS","facility","both","","","","72","36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ko Adj Jnt Pos R Sup Pre Ots","87121833","CDM","274","RC","L1833","HCPCS","facility","both","","","","1657.04","828.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foot Plas Heel Stabi Pre Ots","87123170","CDM","274","RC","L3170","HCPCS","facility","both","","","","54.86","27.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","8716","CDM","270","RC","","","facility","both","","","","88.17","44.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87228","CDM","272","RC","C1757","HCPCS","facility","both","","","","174.8","87.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","8723","CDM","270","RC","","","facility","both","","","","934.26","467.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87269","CDM","272","RC","C1757","HCPCS","facility","both","","","","915.4","457.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87271","CDM","272","RC","C1757","HCPCS","facility","both","","","","630.84","315.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87272","CDM","272","RC","C1757","HCPCS","facility","both","","","","529","264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radiologic Examination Sacroiliac Jnts <3 Views","87272200","CDM","320","RC","72200","HCPCS","facility","both","","","","489","244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87273","CDM","272","RC","C1757","HCPCS","facility","both","","","","550.05","275.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87275","CDM","272","RC","C1757","HCPCS","facility","both","","","","529","264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87280","CDM","270","RC","","","facility","both","","","","78.66","39.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87282","CDM","272","RC","C2628","HCPCS","facility","both","","","","874","437","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fecal Blood Scrn Immunoassay","87297351","CDM","300","RC","G0328","HCPCS","facility","both","","","","178","89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lidocaine Hcl Epinephrine Injection .5%","87299661","CDM","278","RC","J3490","HCPCS","facility","both","","","","7.25","3.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ecg Monit/Reprt Up To 48 Hrs","87300295","CDM","731","RC","93226","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sutr/Staple Req Anes","87300297","CDM","761","RC","15851","HCPCS","facility","both","","","","5377","2688.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath For Specimen Collect Sgl","87309612","CDM","300","RC","P9612","HCPCS","facility","both","","","","28","14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/O Img Gdn Ea Addl","87310004","CDM","761","RC","10004","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Us Gdn 1St Les","87310005","CDM","761","RC","10005","HCPCS","facility","both","","","","1977","988.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Us Gdn Ea Addl","87310006","CDM","761","RC","10006","HCPCS","facility","both","","","","1977","988.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Fluor Gdn 1St Les","87310007","CDM","761","RC","10007","HCPCS","facility","both","","","","2177","1088.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/Ct Gdn 1St Les","87310009","CDM","761","RC","10009","HCPCS","facility","both","","","","2394","1197","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fine Needle Aspiration W/","87310021","CDM","761","RC","10021","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Dev Soft Tiss 1St Img","87310035","CDM","320","RC","10035","HCPCS","facility","both","","","","1999","999.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acne Surgery","87310040","CDM","761","RC","10040","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision & Drainage Abscess Simple/Single","87310060","CDM","761","RC","10060","HCPCS","facility","both","","","","1305","652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-I+D Abscess Complex Or Mu","87310061","CDM","761","RC","10061","HCPCS","facility","both","","","","1501","750.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10080 Pilonidal Cyst-Simple","87310080","CDM","761","RC","10080","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spec-Fb Removal Subcuta Tissue","87310120","CDM","761","RC","10120","HCPCS","facility","both","","","","1381","690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"10121 I&Fb Removal Subq-Comp","87310121","CDM","761","RC","10121","HCPCS","facility","both","","","","6803","3401.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ad-Hematoma,Seroma","87310140","CDM","761","RC","10140","HCPCS","facility","both","","","","4270","2135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punc Asp Abs,Hem,Bulla,Cyst","87310160","CDM","761","RC","10160","HCPCS","facility","both","","","","630","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision & Drainage Of Abscess","87310180","CDM","761","RC","10180","HCPCS","facility","both","","","","10236","5118","","","","","","","","","","","","","Gross Charge Type: Standard"
"11000 Debrd Inf Skin-10% Body","87311000","CDM","761","RC","11000","HCPCS","facility","both","","","","637","318.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11042 Debrd Skin&Subq 20Sqcm/<","87311042","CDM","761","RC","11042","HCPCS","facility","both","","","","1736","868","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia 20 Sq Cm/<","87311043","CDM","761","RC","11043","HCPCS","facility","both","","","","2599","1299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone 20 Sq Cm/<","87311044","CDM","761","RC","11044","HCPCS","facility","both","","","","5413","2706.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11045 Deb Subq Tissue Add-On","87311045","CDM","761","RC","11045","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia Add-On=<20 Sq","87311046","CDM","761","RC","11046","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone Add-On","87311047","CDM","761","RC","11047","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Bengn Hyperkerat Sngl","87311055","CDM","761","RC","11055","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Benign Hyperkerat 2-4","87311056","CDM","761","RC","11056","HCPCS","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pare/Cut Benign Hyperkerat>4","87311057","CDM","761","RC","11057","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Single Les","87311102","CDM","761","RC","11102","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangntl Bx Skin Ea Sep/Addl","87311103","CDM","761","RC","11103","HCPCS","facility","both","","","","714","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","87311104","CDM","761","RC","11104","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Sep/Addl","87311105","CDM","761","RC","11105","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Single Les","87311106","CDM","761","RC","11106","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Ea Sep/Addl","87311107","CDM","761","RC","11107","HCPCS","facility","both","","","","865","432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Skin Tags Up To 15","87311200","CDM","761","RC","11200","HCPCS","facility","both","","","","643","321.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Add Skin Tags 10+","87311201","CDM","761","RC","11201","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Trunk/Arm/Leg 0.5 Cm/<","87311300","CDM","761","RC","11300","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Trunk/Arm/Leg 0.6-1.0 Cm","87311301","CDM","761","RC","11301","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Trunk/Arm/Leg 1.1-2.0 Cm","87311302","CDM","761","RC","11302","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Trunk/Arm/Leg >2.0 Cm","87311303","CDM","761","RC","11303","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Scalp/Neck/Hands/Feet/Genitalia 0.5 Cm/<","87311305","CDM","761","RC","11305","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Scalp/Neck/Hands/Feet/Genitalia 0.6 -1.0 Cm","87311306","CDM","761","RC","11306","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Scalp/Neck/Hands/Feet/Genitalia 1.1-2.0 Cm","87311307","CDM","761","RC","11307","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Scalp/Neck/Hands/Feet/Genitalia >2.0 Cm","87311308","CDM","761","RC","11308","HCPCS","facility","both","","","","634","317","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Face/Ears/Eyelids/Nose/Lips/Mucosa 0.5 Cm/<","87311310","CDM","761","RC","11310","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Face/Ears/Eyelids/Nose/Lips/Mucosa 0.6-1.0 Cm","87311311","CDM","761","RC","11311","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Skin Lesion Face/Ears/Eyelids/Nose/Lips/Mucosa 1.1-2.0 Cm","87311312","CDM","761","RC","11312","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sp-Exc-Benign Les 0.5Cm Or<","87311400","CDM","761","RC","11400","HCPCS","facility","both","","","","2039","1019.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Tr-Ext B9+Marg 0.6-1 Cm","87311401","CDM","761","RC","11401","HCPCS","facility","both","","","","1646","823","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Tr-Ext B9+Marg 1.2-2 Cm","87311402","CDM","761","RC","11402","HCPCS","facility","both","","","","2299","1149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Tr-Ext B9+Marg 2.1-3 Cm","87311403","CDM","761","RC","11403","HCPCS","facility","both","","","","2665","1332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Skin Lesion","87311404","CDM","761","RC","11404","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Skin Lesion","87311406","CDM","761","RC","11406","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp B9+Marg 0.5<","87311420","CDM","761","RC","11420","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp B9+Marg 0.5-1","87311421","CDM","761","RC","11421","HCPCS","facility","both","","","","3433","1716.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp B9+Marg 1.1-2","87311422","CDM","761","RC","11422","HCPCS","facility","both","","","","3169","1584.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp B9+Marg 2.1-3","87311423","CDM","761","RC","11423","HCPCS","facility","both","","","","4687","2343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Skin Lesion","87311424","CDM","761","RC","11424","HCPCS","facility","both","","","","5630","2815","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Skin Lesion","87311426","CDM","761","RC","11426","HCPCS","facility","both","","","","6893","3446.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Face-Mm B9+Marg 0.5<Cm","87311440","CDM","761","RC","11440","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Face-Mm B9+Marg 0.6-1 Cm","87311441","CDM","761","RC","11441","HCPCS","facility","both","","","","2460","1230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Face-Mm B9+Marg 1.1-2 Cm","87311442","CDM","761","RC","11442","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 3.1-4 Cm","87311444","CDM","761","RC","11444","HCPCS","facility","both","","","","5326","2663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal,Sweat Gland Lesion","87311450","CDM","761","RC","11450","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hidrad Umbil; S/I Rep","87311470","CDM","761","RC","11470","HCPCS","facility","both","","","","9285","4642.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mlg+Marg 0.5<Cm","87311600","CDM","761","RC","11600","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Tr-Ext Mlg+Marg 0.6-1Cm","87311601","CDM","761","RC","11601","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Tr-Ext Mlg+Marg 1.1-2Cm","87311602","CDM","761","RC","11602","HCPCS","facility","both","","","","1968","984","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Tr-Ext Mlg+Marg 2.1-3Cm","87311603","CDM","761","RC","11603","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Skin Lesion","87311604","CDM","761","RC","11604","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Skin Lesion","87311606","CDM","761","RC","11606","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp Mlg-Marg 0.6-1","87311621","CDM","761","RC","11621","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp Mlg+Marg 1.1-2","87311622","CDM","761","RC","11622","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc H-F-Nk-Sp Mlg+Marg 2.1-3","87311623","CDM","761","RC","11623","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Skin Lesion","87311624","CDM","761","RC","11624","HCPCS","facility","both","","","","5372","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc H-F-Nk-Sp Mlg+Marg>4Cm","87311626","CDM","761","RC","11626","HCPCS","facility","both","","","","9285","4642.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Malig+Marg 0.5<","87311640","CDM","761","RC","11640","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Face-Mm Malig+Marg 0.6-1","87311641","CDM","761","RC","11641","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Face-Mm Malig+Marg 1.1-2","87311642","CDM","761","RC","11642","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Face-Mm Malig+Marg 2.1-3","87311643","CDM","761","RC","11643","HCPCS","facility","both","","","","4419","2209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm Malig+Marg 3.1-4","87311644","CDM","761","RC","11644","HCPCS","facility","both","","","","5023","2511.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Trim Nail(S)","87311719","CDM","761","RC","11719","HCPCS","facility","both","","","","217","108.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Nail Debrid 1-5 By Any Method","87311720","CDM","761","RC","11720","HCPCS","facility","both","","","","612","306","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Nail Debrid 6 Or>Any Method","87311721","CDM","761","RC","11721","HCPCS","facility","both","","","","204","102","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 11730 Avul Nail Plate Simp-1","87311730","CDM","761","RC","11730","HCPCS","facility","both","","","","327","163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Remove Nail Plate Add-On","87311732","CDM","761","RC","11732","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evac Subungual Hematoma","87311740","CDM","761","RC","11740","HCPCS","facility","both","","","","378","189","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 11750 Exc Nail&Matrx-Perm Rml","87311750","CDM","761","RC","11750","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Nail Bed","87311760","CDM","761","RC","11760","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"11765 Nail Fold Wedge Excision","87311765","CDM","761","RC","11765","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Pilonid Cyst;Smpl","87311770","CDM","761","RC","11770","HCPCS","facility","both","","","","6509","3254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Pilonid Cyst; Extens","87311771","CDM","761","RC","11771","HCPCS","facility","both","","","","9013","4506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Into Skin Lesions=<7","87311900","CDM","761","RC","11900","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Added Skin Lesions Injection>7","87311901","CDM","761","RC","11901","HCPCS","facility","both","","","","699","349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Contour Defects 5.1-10Cc","87311952","CDM","761","RC","11952","HCPCS","facility","both","","","","1976","988","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Contour Defects >10.0 Cc","87311954","CDM","761","RC","11954","HCPCS","facility","both","","","","1273","636.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Drug Delivery Implant","87311981","CDM","761","RC","11981","HCPCS","facility","both","","","","1838","919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Non-Biodegradable Drug Delivery Implant","87311982","CDM","761","RC","11982","HCPCS","facility","both","","","","1174","587","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl W/Rinsj Non-Biodegradable Drug Dlvr Implt","87311983","CDM","761","RC","11983","HCPCS","facility","both","","","","1351","675.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 12001 Simple Rep Trunk=<2.5Cm","87312001","CDM","761","RC","12001","HCPCS","facility","both","","","","923","461.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 12002 Simp Rep Trunk 2.5-7.5Cm","87312002","CDM","761","RC","12002","HCPCS","facility","both","","","","1551","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Intermediate S/A/T/E 2.5 Cm/<","87312031","CDM","761","RC","12031","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Intermediate S/A/T/E 2.6-7.5 Cm","87312032","CDM","761","RC","12032","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Intermediate S/A/T/E 7.6-12.5 Cm","87312034","CDM","761","RC","12034","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Intermediate S/A/T/E 12.6-20.0Cm","87312035","CDM","761","RC","12035","HCPCS","facility","both","","","","1250","625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 12041 Lay Clos Hnd/Ft=<2.5Cm","87312041","CDM","761","RC","12041","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12042 Lay Cls Hnd/Ft 2.5-7.5Cm","87312042","CDM","761","RC","12042","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 12044 Lay Cls Hnd/F 7.6-12.5Cm","87312044","CDM","761","RC","12044","HCPCS","facility","both","","","","811","405.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 12051 Layr Closr Face=<2.5Cm","87312051","CDM","761","RC","12051","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 12052 Layr Closr Face 2.6-5Cm","87312052","CDM","761","RC","12052","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"12053 Layr Clos Face 5.1-7.5Cm","87312053","CDM","761","RC","12053","HCPCS","facility","both","","","","518","259","","","","","","","","","","","","","Gross Charge Type: Standard"
"13101 Comp Rep Trunk 2.6-7.5Cm","87313101","CDM","761","RC","13101","HCPCS","facility","both","","","","2079","1039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13121 Comp Rep Ext/2.6-75.Cm","87313121","CDM","761","RC","13121","HCPCS","facility","both","","","","1478","739","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep F/G/H/F; 1-2.5Cm","87313131","CDM","761","RC","13131","HCPCS","facility","both","","","","1321","660.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13132 Comp Rep Face/2.6-7.5Cm","87313132","CDM","761","RC","13132","HCPCS","facility","both","","","","1523","761.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Rep Fac/Ea Add 5Cm","87313133","CDM","761","RC","13133","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"13152 Comp Rep Eyeld/2.6-7.5Cm","87313152","CDM","761","RC","13152","HCPCS","facility","both","","","","2331","1165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Late Closure Of Wound","87313160","CDM","761","RC","13160","HCPCS","facility","both","","","","6172","3086","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 14040 Adjacent Tiss Tran 10Sqc","87314040","CDM","761","RC","14040","HCPCS","facility","both","","","","3633","1816.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Wound Prep Trk/Arm/Leg 100Scm","87315002","CDM","761","RC","15002","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wound Prep F/N/Hf/G 100 Sq Cm/","87315004","CDM","761","RC","15004","HCPCS","facility","both","","","","2429","1214.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-App Skin Substi Graft 25 Sq","87315271","CDM","940","RC","15271","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Skn Subs-Face,Neck,Gen,Hnds 25","87315275","CDM","761","RC","15275","HCPCS","facility","both","","","","6203","3101.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Delay Flap;Trunk","87315600","CDM","761","RC","15600","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc C P Ulcer; W Flap","87315922","CDM","761","RC","15922","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc S P Ulcer W Skin Flap","87315934","CDM","761","RC","15934","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc S P Ulcer W Sf Ostectomy","87315935","CDM","761","RC","15935","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc I P Ulcer W Skin Flap W Os","87315945","CDM","761","RC","15945","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esc I P Ulcer W Ostect & Flap","87315946","CDM","761","RC","15946","HCPCS","facility","both","","","","10506","5253","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc T P Ulcer W Flap","87315952","CDM","761","RC","15952","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc T P Ulcer W Sf & Ostect","87315953","CDM","761","RC","15953","HCPCS","facility","both","","","","9437","4718.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc T P Ulcer; W Flap","87315956","CDM","761","RC","15956","HCPCS","facility","both","","","","5381","2690.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Burn Debridement Small","87316020","CDM","761","RC","16020","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burn Debridement Medium","87316025","CDM","761","RC","16025","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruct Premalg Lesion","87317000","CDM","761","RC","17000","HCPCS","facility","both","","","","290","145","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruct Premalg Les 2-14","87317003","CDM","761","RC","17003","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destroy Premlg Lesions 15+","87317004","CDM","761","RC","17004","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruct B9 Lesion 1-14","87317110","CDM","761","RC","17110","HCPCS","facility","both","","","","274","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruct Lesion 15 Or More","87317111","CDM","761","RC","17111","HCPCS","facility","both","","","","447","223.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Chemical Cautery,Tissue","87317250","CDM","761","RC","17250","HCPCS","facility","both","","","","476","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Of Skin Lesions","87317260","CDM","761","RC","17260","HCPCS","facility","both","","","","547","273.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317261","CDM","761","RC","17261","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317262","CDM","761","RC","17262","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317263","CDM","761","RC","17263","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317264","CDM","761","RC","17264","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317271","CDM","761","RC","17271","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317272","CDM","761","RC","17272","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317273","CDM","761","RC","17273","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317280","CDM","761","RC","17280","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317281","CDM","761","RC","17281","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317282","CDM","761","RC","17282","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Of Skin Lesions","87317283","CDM","761","RC","17283","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breast Puncture Aspir Cyst","87319000","CDM","761","RC","19000","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Mastotomy,Breast","87319020","CDM","490","RC","19020","HCPCS","facility","both","","","","4327","2163.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Biops,Brest W/Plcmnt Of Lcl","87319081","CDM","490","RC","19081","HCPCS","facility","both","","","","12312","6156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Biops,Brest W/Plcmnt Of Loc","87319083","CDM","761","RC","19083","HCPCS","facility","both","","","","6240","3120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Biops,Brest W/Plcmnt Of Lcl","87319084","CDM","490","RC","19084","HCPCS","facility","both","","","","10782","5391","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast Perc Needle Core,Sep","87319100","CDM","490","RC","19100","HCPCS","facility","both","","","","2131","1065.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast Open Incisional","87319101","CDM","761","RC","19101","HCPCS","facility","both","","","","10153","5076.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Breast Lesion","87319120","CDM","761","RC","19120","HCPCS","facility","both","","","","9792","4896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Place Po Breast Cath For Rad","87319296","CDM","761","RC","19296","HCPCS","facility","both","","","","27689","13844.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Muscle Percutaneous","87320206","CDM","490","RC","20206","HCPCS","facility","both","","","","1863","931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"20520 Rem Mscle/Tndn Fb Simpl","87320520","CDM","761","RC","20520","HCPCS","facility","both","","","","1642","821","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Muscle Foreign Body","87320525","CDM","761","RC","20525","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carpal Tunnel Injection","87320526","CDM","761","RC","20526","HCPCS","facility","both","","","","605","302.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Injec,Enzym,Palmr Fascial","87320527","CDM","761","RC","20527","HCPCS","facility","both","","","","1219","609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Sgl Tendon Sheath/Lig","87320550","CDM","761","RC","20550","HCPCS","facility","both","","","","735","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 20551 Injection Tendon Origin/","87320551","CDM","761","RC","20551","HCPCS","facility","both","","","","627","313.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proc-Inj Trig Pt 1-2 Muscles","87320552","CDM","761","RC","20552","HCPCS","facility","both","","","","1244","622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Inject Trigger Points =/>3","87320553","CDM","761","RC","20553","HCPCS","facility","both","","","","908","454","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Arthrocentesis-Sml Jnt W/O Us","87320600","CDM","761","RC","20600","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis Sml Jt Us Gd Lt","87320604","CDM","761","RC","20604","HCPCS","facility","both","","","","919","459.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis-Int Jnt W/O Us","87320605","CDM","761","RC","20605","HCPCS","facility","both","","","","843","421.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis-Int Jnt W/Us","87320606","CDM","761","RC","20606","HCPCS","facility","both","","","","1259","629.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Arthrocentesis-Maj Jnt W/O Us","87320610","CDM","761","RC","20610","HCPCS","facility","both","","","","1107","553.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis-Maj Jnt W/Us","87320611","CDM","761","RC","20611","HCPCS","facility","both","","","","1312","656","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Aspiration/Inj Ganglion Cyst","87320612","CDM","761","RC","20612","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Support Implant","87320670","CDM","761","RC","20670","HCPCS","facility","both","","","","6460","3230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Implant,Deep","87320680","CDM","761","RC","20680","HCPCS","facility","both","","","","8781","4390.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sc < 2 Cm","87321011","CDM","761","RC","21011","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sbq 2+ Cm","87321012","CDM","761","RC","21012","HCPCS","facility","both","","","","4100","2050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Soft Tissue,Neck Or Thrx","87321550","CDM","761","RC","21550","HCPCS","facility","both","","","","4085","2042.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Neck Les Sc 3+ Cm","87321552","CDM","761","RC","21552","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Lesion Neck/Chest","87321555","CDM","761","RC","21555","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Lesion Neck/Chest","87321556","CDM","761","RC","21556","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Back Les Sc <3 Cm","87321930","CDM","761","RC","21930","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Back Les Sc 3+ Cm","87321931","CDM","761","RC","21931","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Tum Deep < 5Cm","87321932","CDM","761","RC","21932","HCPCS","facility","both","","","","7828","3914","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Treat Spine Fracture","87322310","CDM","761","RC","22310","HCPCS","facility","both","","","","987","493.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abdl Tum Deep < 5 Cm","87322900","CDM","761","RC","22900","HCPCS","facility","both","","","","8627","4313.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Les Sc < 3 Cm","87322902","CDM","761","RC","22902","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Les Sc 3 Cm/>","87322903","CDM","761","RC","22903","HCPCS","facility","both","","","","9604","4802","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Shoulder Tissues","87323065","CDM","761","RC","23065","HCPCS","facility","both","","","","5092","2546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Shoulder Les Sc > 3 Cm","87323071","CDM","490","RC","23071","HCPCS","facility","both","","","","10752","5376","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Shoulder Lesion","87323075","CDM","761","RC","23075","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Shoulder Tum Deep < 5 Cm","87323076","CDM","490","RC","23076","HCPCS","facility","both","","","","9305","4652.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 23500 Clsd Rx Clv Fx No Manip","87323500","CDM","761","RC","23500","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Treat Shoulder Blade Fx","87323570","CDM","761","RC","23570","HCPCS","facility","both","","","","765","382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 23600 Cl Rx Dumer Fx No Manip","87323600","CDM","761","RC","23600","HCPCS","facility","both","","","","787","393.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Treat Humerus Fracture","87323620","CDM","761","RC","23620","HCPCS","facility","both","","","","765","382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Rx Sh Dsl-Man-No Anes","87323650","CDM","761","RC","23650","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis,Glenohumeral Joint","87323800","CDM","761","RC","23800","HCPCS","facility","both","","","","10969","5484.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 23931 I&D Up Arm/Bursa","87323931","CDM","761","RC","23931","HCPCS","facility","both","","","","8069","4034.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Arm/Elbow Les Sc 3+ Cm","87324071","CDM","761","RC","24071","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Arm/Elbow Lesion","87324075","CDM","761","RC","24075","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Arm/Elbow Lesion","87324076","CDM","761","RC","24076","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"24500 Cl Rx Hum Shft Fx No Man","87324500","CDM","761","RC","24500","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 24530 Cls Tx Supra/Trans Hum F","87324530","CDM","761","RC","24530","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"24560 Cls Tx Hum Epicond Fx Wo","87324560","CDM","761","RC","24560","HCPCS","facility","both","","","","515","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx C Humerus Fx Wo Manip","87324576","CDM","761","RC","24576","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 24650 Clsd Tx Rad Head/Neck Fx","87324650","CDM","761","RC","24650","HCPCS","facility","both","","","","750","375","","","","","","","","","","","","","Gross Charge Type: Standard"
"24670 Cl Rx Prox Uln No Man","87324670","CDM","761","RC","24670","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep I&D Absc - Farm/Wrist","87325028","CDM","761","RC","25028","HCPCS","facility","both","","","","10242","5121","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Forearm Les Sc>3 Cm","87325071","CDM","761","RC","25071","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Forearm Lesion","87325075","CDM","761","RC","25075","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Forearm Lesion.","87325076","CDM","761","RC","25076","HCPCS","facility","both","","","","4944","2472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25500 Clsd Tx Rad Shaft Fx Wo","87325500","CDM","761","RC","25500","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Fracture Of Radius","87325505","CDM","761","RC","25505","HCPCS","facility","both","","","","3102","1551","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25530 Clsd Rx Ulnar Fx No Mnip","87325530","CDM","761","RC","25530","HCPCS","facility","both","","","","752","376","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Rad&Ul Fx No Manip","87325560","CDM","761","RC","25560","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25600 Cl Rx Epih Spen No Mnip","87325600","CDM","761","RC","25600","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25605 Cl Rx Epih Spen W Mnip","87325605","CDM","761","RC","25605","HCPCS","facility","both","","","","2208","1104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25622 Cl Rx Scaphod Fx-No Mnip","87325622","CDM","761","RC","25622","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25630 Cl Rx Carp Fx-No Mnip Ea","87325630","CDM","761","RC","25630","HCPCS","facility","both","","","","689","344.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 25650 Clsd Rx Ulnar Styloid Fx","87325650","CDM","761","RC","25650","HCPCS","facility","both","","","","720","360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 26010 Smpl Drain Fngr Abscess","87326010","CDM","761","RC","26010","HCPCS","facility","both","","","","359","179.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Compl Drain Fing Abscess","87326011","CDM","761","RC","26011","HCPCS","facility","both","","","","2462","1231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dr Tendon Sheath 1 Dig And/Pal","87326020","CDM","490","RC","26020","HCPCS","facility","both","","","","10556","5278","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Hand Bone Lesion","87326034","CDM","761","RC","26034","HCPCS","facility","both","","","","8275","4137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Incise Finger Tendon Sheath","87326055","CDM","761","RC","26055","HCPCS","facility","both","","","","8275","4137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Explore/Treat Finger Joint.","87326080","CDM","761","RC","26080","HCPCS","facility","both","","","","8275","4137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Hand Les Sc< 1.5 Cm","87326115","CDM","761","RC","26115","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Hand Lesion.","87326116","CDM","761","RC","26116","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Tendon Sheath Lesion","87326160","CDM","761","RC","26160","HCPCS","facility","both","","","","8275","4137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Manip,Palmr Fascial Cord,Sngl","87326341","CDM","761","RC","26341","HCPCS","facility","both","","","","2372","1186","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Finger Tendon.","87326432","CDM","761","RC","26432","HCPCS","facility","both","","","","5274","2637","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 26600 Cl Rx Metacarp Fx No Man","87326600","CDM","761","RC","26600","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"26605 Cl Rx Metcrpl Fx W Manip","87326605","CDM","761","RC","26605","HCPCS","facility","both","","","","1198","599","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 26720 Cl Rx Fngr Fx-No Mnip Ea","87326720","CDM","761","RC","26720","HCPCS","facility","both","","","","561","280.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"26725 Cl Rx Finger Fx W Man Ea","87326725","CDM","761","RC","26725","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 26740 Cl Rx M-P/I/P Fx No Mnip","87326740","CDM","761","RC","26740","HCPCS","facility","both","","","","739","369.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 26750 Closed Rx Dstl Finger Fx","87326750","CDM","761","RC","26750","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 26770 Cl Rx Ip Dslo Hand W Man","87326770","CDM","761","RC","26770","HCPCS","facility","both","","","","424","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Iphal Jt Dislc W/Manj Req Anes","87326775","CDM","761","RC","26775","HCPCS","facility","both","","","","4759","2379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hip Pelvis Les Sc>3 Cm","87327043","CDM","761","RC","27043","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hip Pelvis Les Sc>3 Cm","87327047","CDM","761","RC","27047","HCPCS","facility","both","","","","8586","4293","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Hip/Pelvis Lesion.","87327048","CDM","761","RC","27048","HCPCS","facility","both","","","","7828","3914","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clsd Tx Pelvic Ring Fx","87327197","CDM","761","RC","27197","HCPCS","facility","both","","","","396","198","","","","","","","","","","","","","Gross Charge Type: Standard"
"27220 Clsd Tx Acetabulum Fx W/","87327220","CDM","761","RC","27220","HCPCS","facility","both","","","","355","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Fem Fx Prox End Nck W/O Manj","87327230","CDM","761","RC","27230","HCPCS","facility","both","","","","869","434.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Inter/Peri/Subtrochanteric Fem Fx W/O Manj","87327238","CDM","761","RC","27238","HCPCS","facility","both","","","","4479","2239.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Greater Trochanteric Fx W/O Manj","87327246","CDM","761","RC","27246","HCPCS","facility","both","","","","2659","1329.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Thigh Fx","87327267","CDM","761","RC","27267","HCPCS","facility","both","","","","9197","4598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Thigh Lesion","87327327","CDM","761","RC","27327","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Thigh/Knee Les Sc 3+Cm","87327337","CDM","761","RC","27337","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Femoral Shaft Fx Wo Mani","87327500","CDM","761","RC","27500","HCPCS","facility","both","","","","925","462.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treatment Of Thigh Fracture","87327501","CDM","761","RC","27501","HCPCS","facility","both","","","","687","343.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Sc/Tc Femur Fx W Manip","87327503","CDM","761","RC","27503","HCPCS","facility","both","","","","4606","2303","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx D Fem Fx Wo Manip","87327508","CDM","761","RC","27508","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 27520 Closed Rx Patellar Fx","87327520","CDM","761","RC","27520","HCPCS","facility","both","","","","760","380","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 27530 Cl Rx Tibia Fx-No Manip","87327530","CDM","761","RC","27530","HCPCS","facility","both","","","","760","380","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closed Tx Ic Sp Ortuberosity","87327538","CDM","761","RC","27538","HCPCS","facility","both","","","","802","401","","","","","","","","","","","","","Gross Charge Type: Standard"
"Superf Sft Tiss Bx Leg/Ankle","87327613","CDM","761","RC","27613","HCPCS","facility","both","","","","5092","2546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Leg/Ankle Tum<3Cm","87327618","CDM","761","RC","27618","HCPCS","facility","both","","","","8715","4357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Leg/Ankle Les Sc 3+Cm","87327632","CDM","761","RC","27632","HCPCS","facility","both","","","","11129","5564.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closed Treatment Of Tibial","87327750","CDM","490","RC","27750","HCPCS","facility","both","","","","891","445.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"27760 Clsd Tx Med Malleous Fx","87327760","CDM","761","RC","27760","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"27780 Cl Rx Fibular Fx No Mnip","87327780","CDM","761","RC","27780","HCPCS","facility","both","","","","528","264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 27786 Cl Rx Dstl Fib Fx-No Man","87327786","CDM","761","RC","27786","HCPCS","facility","both","","","","406","203","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 27808 Cl Rx Bimaleor Fx-No Man","87327808","CDM","761","RC","27808","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Trimall Ankle Fx; Wo Man","87327816","CDM","761","RC","27816","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Trimall Ankle Fx; W Mani","87327818","CDM","761","RC","27818","HCPCS","facility","both","","","","2505","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Exc Foot/Toe Tum Sc <1.5 Cm","87328043","CDM","761","RC","28043","HCPCS","facility","both","","","","6460","3230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Foot Joint Lining","87328070","CDM","761","RC","28070","HCPCS","facility","both","","","","7217","3608.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Cyst/Ganglion - Toes","87328092","CDM","761","RC","28092","HCPCS","facility","both","","","","5579","2789.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Phalanx Of Toe Tumor","87328175","CDM","761","RC","28175","HCPCS","facility","both","","","","6391","3195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 28190 Removal Subq Fb-Foot","87328190","CDM","761","RC","28190","HCPCS","facility","both","","","","2523","1261.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Incision Of Toe Tendon","87328232","CDM","761","RC","28232","HCPCS","facility","both","","","","4198","2099","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Incision Of Foot Tendon","87328234","CDM","761","RC","28234","HCPCS","facility","both","","","","3995","1997.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Release Of Foot Contracture","87328270","CDM","761","RC","28270","HCPCS","facility","both","","","","8393","4196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Hammertoe","87328285","CDM","761","RC","28285","HCPCS","facility","both","","","","10890","5445","","","","","","","","","","","","","Gross Charge Type: Standard"
"28400 Cl Rx Calcanl Fx-No Mnip","87328400","CDM","761","RC","28400","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Calcaneal Fx; W Manip","87328405","CDM","761","RC","28405","HCPCS","facility","both","","","","1132","566","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Talus Fx; Wo Manip","87328430","CDM","761","RC","28430","HCPCS","facility","both","","","","597","298.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Tarsal Bone Fx ; Wo Manipu","87328450","CDM","761","RC","28450","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 28470 Cl Rx Metarsal Fx-No Mnp","87328470","CDM","761","RC","28470","HCPCS","facility","both","","","","581","290.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"28490 Cl Rx Grt Toe Fx-No Mnip","87328490","CDM","761","RC","28490","HCPCS","facility","both","","","","528","264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Fx Gt Phalanx(S);W Manip","87328495","CDM","761","RC","28495","HCPCS","facility","both","","","","1155","577.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 28510 Cl Rx Phalanx Fx-No Mnip","87328510","CDM","761","RC","28510","HCPCS","facility","both","","","","642","321","","","","","","","","","","","","","Gross Charge Type: Standard"
"28515 Cl Rx Phalanx Fx W Manip","87328515","CDM","761","RC","28515","HCPCS","facility","both","","","","758","379","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Sesamoid Fracture","87328530","CDM","761","RC","28530","HCPCS","facility","both","","","","891","445.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Amputation Of Toe","87328820","CDM","761","RC","28820","HCPCS","facility","both","","","","8393","4196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Partial Amputation Of Toe","87328825","CDM","761","RC","28825","HCPCS","facility","both","","","","8393","4196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29065 Apply Long Arm Cast","87329065","CDM","761","RC","29065","HCPCS","facility","both","","","","790","395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29075 Apply Short Arm Cast","87329075","CDM","761","RC","29075","HCPCS","facility","both","","","","599","299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29085 Appl Cast Hand,Low Arm","87329085","CDM","761","RC","29085","HCPCS","facility","both","","","","382","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29105 Apply Long Arm Splint","87329105","CDM","761","RC","29105","HCPCS","facility","both","","","","978","489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - App Short Arm Splint,Sta","87329125","CDM","761","RC","29125","HCPCS","facility","both","","","","844","422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - App Finger Splint,Static","87329130","CDM","761","RC","29130","HCPCS","facility","both","","","","890","445","","","","","","","","","","","","","Gross Charge Type: Standard"
"29131 Appl Finger Splint","87329131","CDM","761","RC","29131","HCPCS","facility","both","","","","500","250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29200 Strapping Of Chest","87329200","CDM","761","RC","29200","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29260 Strapping-Elbow/Wrist","87329260","CDM","761","RC","29260","HCPCS","facility","both","","","","761","380.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29280 Strapping Hand Or Finger","87329280","CDM","761","RC","29280","HCPCS","facility","both","","","","951","475.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Of Long Leg Cast","87329345","CDM","761","RC","29345","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast-Appl Short Leg:Bel Kne-To","87329405","CDM","761","RC","29405","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Wlkr Sh Leg Cast","87329425","CDM","761","RC","29425","HCPCS","facility","both","","","","555","277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"29505 App Long Leg Splint","87329505","CDM","761","RC","29505","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29515 App Short Leg Splint","87329515","CDM","761","RC","29515","HCPCS","facility","both","","","","886","443","","","","","","","","","","","","","Gross Charge Type: Standard"
"Strapping Knee","87329530","CDM","761","RC","29530","HCPCS","facility","both","","","","770","385","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29540 Strapping-Ankle","87329540","CDM","761","RC","29540","HCPCS","facility","both","","","","734","367","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 29550 Strapping-Toes","87329550","CDM","761","RC","29550","HCPCS","facility","both","","","","751","375.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Appl Paste Boot","87329580","CDM","430","RC","29580","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Apply Multlay Comprs Lwr Leg","87329581","CDM","761","RC","29581","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Unna Boot","87329700","CDM","510","RC","29700","HCPCS","facility","both","","","","1046","523","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthroscopy Elbow; Lim Debrid","87329837","CDM","761","RC","29837","HCPCS","facility","both","","","","8446","4223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Intranasal","87330100","CDM","761","RC","30100","HCPCS","facility","both","","","","4884","2442","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Foreign Body Intranasal Office Procedure","87330300","CDM","761","RC","30300","HCPCS","facility","both","","","","262","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin","87330471","CDM","771","RC","90471","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablate Inf Turbinate Superf","87330801","CDM","761","RC","30801","HCPCS","facility","both","","","","3175","1587.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Control Nose Bleed-Smpl","87330901","CDM","761","RC","30901","HCPCS","facility","both","","","","938","469","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nasal Endoscopy Diagnostic Uni/Bi Spx","87331231","CDM","761","RC","31231","HCPCS","facility","both","","","","807","403.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nasal/Sinus Ndsc Surg W/Bx Polypect/Dbrdmt Spx","87331237","CDM","761","RC","31237","HCPCS","facility","both","","","","6855","3427.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngoscopy Flexible Diagnostic","87331575","CDM","761","RC","31575","HCPCS","facility","both","","","","628","314","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Samplng 1/2 Node","87331652","CDM","761","RC","31652","HCPCS","facility","both","","","","5927","2963.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Samplng 3/> Node","87331653","CDM","761","RC","31653","HCPCS","facility","both","","","","5927","2963.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Ivntj Perph Les","87331654","CDM","761","RC","31654","HCPCS","facility","both","","","","5927","2963.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Chest Tube","87332551","CDM","761","RC","32551","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Thoracentesis,Needle/Cath,Asp","87332554","CDM","761","RC","32554","HCPCS","facility","both","","","","2596","1298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temp Pacing Wire Proc-Dual Cha","87333211","CDM","481","RC","33211","HCPCS","facility","both","","","","10197","5098.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Echo,Transthracic,Realtm W/Img","87333906","CDM","483","RC","93306","HCPCS","facility","both","","","","3452","1726","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flex Sigm Cancer Screening","87335530","CDM","761","RC","G0104","HCPCS","facility","both","","","","2220","1110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Hormon Antineopl Sq/Sm","87336402","CDM","331","RC","96402","HCPCS","facility","both","","","","451","225.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Sclrsnt 1 Incmptnt Vein","87336470","CDM","761","RC","36470","HCPCS","facility","both","","","","1228","614","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endovenous Rf 1St Vein","87336475","CDM","761","RC","36475","HCPCS","facility","both","","","","8071","4035.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endovenous Rf Vein Add-On","87336476","CDM","761","RC","36476","HCPCS","facility","both","","","","4236","2118","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Nervous Sys","87336499","CDM","761","RC","64999","HCPCS","facility","both","","","","871","435.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Us Exam Of Head And Neck","87336536","CDM","320","RC","76536","HCPCS","facility","both","","","","1177","588.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Tnnld Cvc W/O Port/Pump","87336589","CDM","481","RC","36589","HCPCS","facility","both","","","","2532","1266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Rem Tnnld Cvc W/Port/Pump","87336590","CDM","481","RC","36590","HCPCS","facility","both","","","","5244","2622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Echo Exam Of Abdomen","87336705","CDM","320","RC","76705","HCPCS","facility","both","","","","1445","722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Echo Guide For Biopsy","87336942","CDM","320","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation,Leg Veins,Open","87337760","CDM","761","RC","37760","HCPCS","facility","both","","","","13231","6615.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stab Phleb Veins Xtr 10-20","87337765","CDM","761","RC","37765","HCPCS","facility","both","","","","11963","5981.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phleb Veins-Extrem 20+","87337766","CDM","761","RC","37766","HCPCS","facility","both","","","","11963","5981.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligate/Divide/Excise Vein","87337785","CDM","761","RC","37785","HCPCS","facility","both","","","","11963","5981.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Vasc Procedure","87337799","CDM","761","RC","37799","HCPCS","facility","both","","","","814","407","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy/Removal Of Lymph Node","87338500","CDM","761","RC","38500","HCPCS","facility","both","","","","12080","6040","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Biopsy Lymph Node/Needle","87338505","CDM","761","RC","38505","HCPCS","facility","both","","","","3650","1825","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Trim Nail(S)","87339127","CDM","761","RC","G0127","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Re-Assess Nutrition Ther; Ea15","87339168","CDM","942","RC","97803","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Foot Exam Pt Lops","87339245","CDM","761","RC","G0245","HCPCS","facility","both","","","","325","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Biopsy Of Lip","87340490","CDM","761","RC","40490","HCPCS","facility","both","","","","1722","861","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vestibule Mouth","87340808","CDM","761","RC","40808","HCPCS","facility","both","","","","1244","622","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Lesion Mucosa & Sbmcsl Vestibule Smpl Rpr","87340812","CDM","761","RC","40812","HCPCS","facility","both","","","","3779","1889.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision Of Tongue Fold","87341010","CDM","761","RC","41010","HCPCS","facility","both","","","","3823","1911.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Tongue Anterior Two-Thirds","87341100","CDM","761","RC","41100","HCPCS","facility","both","","","","1720","860","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Floor Of Mouth","87341108","CDM","761","RC","41108","HCPCS","facility","both","","","","5081","2540.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Palate Uvula","87342100","CDM","761","RC","42100","HCPCS","facility","both","","","","2353","1176.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Lesion Palate Uvula W/O Closure","87342104","CDM","761","RC","42104","HCPCS","facility","both","","","","7745","3872.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Stomach","87343999","CDM","761","RC","43999","HCPCS","facility","both","","","","2626","1313","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscopy Of Bowel Pouch","87344385","CDM","761","RC","44385","HCPCS","facility","both","","","","3452","1726","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proctosigmoidoscopy","87345300","CDM","761","RC","45300","HCPCS","facility","both","","","","2118","1059","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proctosigmoidscpy,Rigid W/Stnt","87345327","CDM","761","RC","45327","HCPCS","facility","both","","","","4991","2495.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Sigmoidoscopy","87345330","CDM","750","RC","45330","HCPCS","facility","both","","","","1930","965","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flexible Sigmoid For Biopsy","87345331","CDM","761","RC","45331","HCPCS","facility","both","","","","2118","1059","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy,Flex W/Stent","87345347","CDM","761","RC","45347","HCPCS","facility","both","","","","5366","2683","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Colonoscopy","87345378","CDM","761","RC","45378","HCPCS","facility","both","","","","2329","1164.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ad-Ishiore Perirectal","87346040","CDM","761","RC","46040","HCPCS","facility","both","","","","5597","2798.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ad-Perianal Superficial","87346050","CDM","490","RC","46050","HCPCS","facility","both","","","","3297","1648.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 46083 Ext Incis-Thrombosd Pile","87346083","CDM","761","RC","46083","HCPCS","facility","both","","","","794","397","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Anal Ext Tag/Papilla","87346220","CDM","761","RC","46220","HCPCS","facility","both","","","","7767","3883.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ligation Of Hemorrhoid(S)","87346221","CDM","761","RC","46221","HCPCS","facility","both","","","","2904","1452","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Anal Tabs","87346230","CDM","761","RC","46230","HCPCS","facility","both","","","","11732","5866","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Removal Of Hemorrhoid Clot","87346320","CDM","761","RC","46320","HCPCS","facility","both","","","","4198","2099","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 46600 Diagnostic Anoscopy","87346600","CDM","761","RC","46600","HCPCS","facility","both","","","","391","195.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Anoscopy And Biopsy","87346606","CDM","761","RC","46606","HCPCS","facility","both","","","","5857","2928.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Anoscopy & Biopsy","87346607","CDM","761","RC","46607","HCPCS","facility","both","","","","3173","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy;Control Bleeding","87346614","CDM","761","RC","46614","HCPCS","facility","both","","","","2146","1073","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy","87346615","CDM","761","RC","46615","HCPCS","facility","both","","","","5857","2928.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cryosurgery Anal Lesion(S)","87346916","CDM","761","RC","46916","HCPCS","facility","both","","","","729","364.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Anus Lesion,Excisn","87346922","CDM","761","RC","46922","HCPCS","facility","both","","","","7646","3823","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Internal Hemorrhoids","87346930","CDM","761","RC","46930","HCPCS","facility","both","","","","2610","1305","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Hrhc Tranal Dartlzj 2+","87346948","CDM","761","RC","46948","HCPCS","facility","both","","","","8693","4346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abd Paracentesis W/Imaging","87349083","CDM","761","RC","49083","HCPCS","facility","both","","","","3815","1907.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"51701 Non-Indwel Bladder Cath","87351701","CDM","761","RC","51701","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath(Foley","87351702","CDM","490","RC","51702","HCPCS","facility","both","","","","317","158.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Cystometrogram","87351725","CDM","761","RC","51725","HCPCS","facility","both","","","","867","433.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystometrogram W/Vp","87351728","CDM","761","RC","51728","HCPCS","facility","both","","","","2339","1169.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intraabdominal Pressure Test","87351797","CDM","761","RC","51797","HCPCS","facility","both","","","","760","380","","","","","","","","","","","","","Gross Charge Type: Standard"
"Measurment Post-Void Residual","87351798","CDM","490","RC","51798","HCPCS","facility","both","","","","362","181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Retrogr Ins Guide Wire","87352334","CDM","761","RC","52334","HCPCS","facility","both","","","","7909","3954.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Ureth Strict Sound;Male In","87353600","CDM","761","RC","53600","HCPCS","facility","both","","","","938","469","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate Urethra Stricture","87353601","CDM","761","RC","53601","HCPCS","facility","both","","","","484","242","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate Female Urethra, Initial","87353660","CDM","761","RC","53660","HCPCS","facility","both","","","","599","299.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Lesion(S) Penis Simple;","87354050","CDM","761","RC","54050","HCPCS","facility","both","","","","697","348.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Destruction Penis Lesion(S)","87354055","CDM","761","RC","54055","HCPCS","facility","both","","","","6498","3249","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cryosurgery Penis Lesion(S)","87354056","CDM","761","RC","54056","HCPCS","facility","both","","","","446","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Penis","87354100","CDM","761","RC","54100","HCPCS","facility","both","","","","4339","2169.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision W/Clamp/Oth Dev W/Block","87354150","CDM","761","RC","54150","HCPCS","facility","both","","","","3021","1510.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Penil Circumcis Adhes","87354162","CDM","761","RC","54162","HCPCS","facility","both","","","","7006","3503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foreskin Manipulation","87354450","CDM","761","RC","54450","HCPCS","facility","both","","","","1551","775.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punct Asp Hydrocele Tunica Vag","87355000","CDM","761","RC","55000","HCPCS","facility","both","","","","2263","1131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Of Scrotum Abscess","87355100","CDM","761","RC","55100","HCPCS","facility","both","","","","2995","1497.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Saturation Sampling","87355706","CDM","761","RC","55706","HCPCS","facility","both","","","","10325","5162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abscess Drainage Perineal","87356405","CDM","761","RC","56405","HCPCS","facility","both","","","","981","490.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Of Bartholins Gland Abscess","87356420","CDM","761","RC","56420","HCPCS","facility","both","","","","1832","916","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Vulva Lesions Sim","87356501","CDM","761","RC","56501","HCPCS","facility","both","","","","6479","3239.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vulva/Perineum 1 Lesion Spx","87356605","CDM","761","RC","56605","HCPCS","facility","both","","","","2061","1030.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vulva/Perineum Each Addl Lesion","87356606","CDM","761","RC","56606","HCPCS","facility","both","","","","2145","1072.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vaginal Mucosa Simple","87357100","CDM","761","RC","57100","HCPCS","facility","both","","","","1773","886.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Vaginal Septum","87357130","CDM","761","RC","57130","HCPCS","facility","both","","","","8568","4284","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fit&Insj Pessary/Oth Intravaginal Support Device","87357160","CDM","761","RC","57160","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Pervag Defect Vag","87357285","CDM","761","RC","57285","HCPCS","facility","both","","","","22038","11019","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Cervix Single/Mult/Excision Of Lesion Spx","87357500","CDM","761","RC","57500","HCPCS","facility","both","","","","3330","1665","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cautery Of Cervix; Electro/Thermal","87357510","CDM","761","RC","57510","HCPCS","facility","both","","","","9473","4736.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endometrial Bx W/Wo Endocervix Bx W/O Dilat Spx","87358100","CDM","761","RC","58100","HCPCS","facility","both","","","","974","487","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Done W/Colposcopy Add-On","87358110","CDM","761","RC","58110","HCPCS","facility","both","","","","611","305.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Intrauterine Device Iud","87358300","CDM","761","RC","58300","HCPCS","facility","both","","","","384","192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Intrauterine Device Iud","87358301","CDM","761","RC","58301","HCPCS","facility","both","","","","582","291","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Nonstress Test","87359025","CDM","761","RC","59025","HCPCS","facility","both","","","","856","428","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Thyroid Percutaneous","87360100","CDM","761","RC","60100","HCPCS","facility","both","","","","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Puncture","87362270","CDM","490","RC","62270","HCPCS","facility","both","","","","2970","1485","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Trigeminal Nerve","87364400","CDM","761","RC","64400","HCPCS","facility","both","","","","1198","599","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Greater Occipital Nrv","87364405","CDM","761","RC","64405","HCPCS","facility","both","","","","1164","582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Anesth; Intercostal Nerve","87364420","CDM","761","RC","64420","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - N Block Inj Intercost Mlt","87364421","CDM","761","RC","64421","HCPCS","facility","both","","","","3013","1506.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oth-Inj Iliongunial Nerve","87364425","CDM","761","RC","64425","HCPCS","facility","both","","","","2320","1160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Aa&/Strd Paracervical Nerve","87364435","CDM","761","RC","64435","HCPCS","facility","both","","","","783","391.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - N Block Other Peripheral","87364450","CDM","761","RC","64450","HCPCS","facility","both","","","","2314","1157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - N Block Inj Plantar Digit","87364455","CDM","761","RC","64455","HCPCS","facility","both","","","","1294","647","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pessary, Non Rubber,Any Type","87364562","CDM","761","RC","A4562","HCPCS","facility","both","","","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr W Neurolyt Trigem Nrv","87364600","CDM","761","RC","64600","HCPCS","facility","both","","","","3788","1894","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Saliv Glands","87364611","CDM","761","RC","64611","HCPCS","facility","both","","","","910","455","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenervation Face Sightctr","87364612","CDM","761","RC","64612","HCPCS","facility","both","","","","605","302.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Chemodenervatn Of Muscle(S","87364615","CDM","761","RC","64615","HCPCS","facility","both","","","","978","489","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Chemodenervation Of Muscl(S","87364616","CDM","761","RC","64616","HCPCS","facility","both","","","","879","439.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - N Block Inj Common Digit","87364632","CDM","761","RC","64632","HCPCS","facility","both","","","","1294","647","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Chemodenervation Of One Ext","87364642","CDM","761","RC","64642","HCPCS","facility","both","","","","2348","1174","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Chemodenervation Of One Ext","87364643","CDM","761","RC","64643","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Chemodenervation Of One Ext","87364644","CDM","761","RC","64644","HCPCS","facility","both","","","","2293","1146.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Chemodenrvaton Of One Extre","87364645","CDM","761","RC","64645","HCPCS","facility","both","","","","1104","552","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Trunk 1-5","87364646","CDM","761","RC","64646","HCPCS","facility","both","","","","2293","1146.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Ea Addtl Major Periph","87364859","CDM","761","RC","64859","HCPCS","facility","both","","","","3834","1917","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy External Ear","87369100","CDM","761","RC","69100","HCPCS","facility","both","","","","566","283","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 69200 Ext Audit Canal Fb Remov","87369200","CDM","761","RC","69200","HCPCS","facility","both","","","","585","292.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ca Screen;Pelvic/Breast Exam","87369202","CDM","770","RC","G0101","HCPCS","facility","both","","","","259","129.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clear Outer Ear Canal","87369205","CDM","761","RC","69205","HCPCS","facility","both","","","","11516","5758","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Remove Impacted Ear Wax Uni","87369209","CDM","761","RC","69209","HCPCS","facility","both","","","","221","110.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Unilateral Spec-Ear Irrigation","87369210","CDM","761","RC","69210","HCPCS","facility","both","","","","373","186.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Mastoidectomy Cavity Simple","87369220","CDM","761","RC","69220","HCPCS","facility","both","","","","492","246","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tympanostomy Local/Topical Anesthesia","87369433","CDM","761","RC","69433","HCPCS","facility","both","","","","1636","818","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Eye For Foreign Body","87370030","CDM","320","RC","70030","HCPCS","facility","both","","","","363","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Mandible Complete","87370110","CDM","320","RC","70110","HCPCS","facility","both","","","","822","411","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mastoids Less Than 3 Vw","87370120","CDM","320","RC","70120","HCPCS","facility","both","","","","280","140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Facial Bones Less Than 3 Vw","87370140","CDM","320","RC","70140","HCPCS","facility","both","","","","629","314.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Facial Bones Complete","87370150","CDM","320","RC","70150","HCPCS","facility","both","","","","1068","534","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Nasal Bones","87370160","CDM","320","RC","70160","HCPCS","facility","both","","","","596","298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Orbits Complete Min 4 Vw","87370200","CDM","320","RC","70200","HCPCS","facility","both","","","","1067","533.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Sinuses Less Than 3 Vw","87370210","CDM","320","RC","70210","HCPCS","facility","both","","","","953","476.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sinuses Complete","87370220","CDM","320","RC","70220","HCPCS","facility","both","","","","1607","803.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Skull Less Than 4 Vw","87370250","CDM","320","RC","70250","HCPCS","facility","both","","","","1058","529","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Skull Complete","87370260","CDM","320","RC","70260","HCPCS","facility","both","","","","1409","704.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Tmj Unilat Open & Closed","87370328","CDM","320","RC","70328","HCPCS","facility","both","","","","683","341.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Tmj Bilat Open & Closed","87370330","CDM","320","RC","70330","HCPCS","facility","both","","","","731","365.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Neck Soft Tissue","87370360","CDM","320","RC","70360","HCPCS","facility","both","","","","877","438.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Chest 1 View","87371045","CDM","324","RC","71045","HCPCS","facility","both","","","","468","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Chest 2 Views","87371046","CDM","324","RC","71046","HCPCS","facility","both","","","","563","281.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Chest 3 Views","87371047","CDM","324","RC","71047","HCPCS","facility","both","","","","813","406.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Chest 4+ Views","87371048","CDM","324","RC","71048","HCPCS","facility","both","","","","1016","508","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Rib Unilat 2 Vw","87371100","CDM","320","RC","71100","HCPCS","facility","both","","","","673","336.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Rib Unilat 2 Vw W/Pa Chest","87371101","CDM","320","RC","71101","HCPCS","facility","both","","","","893","446.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Rib Bilat Min 3 Vw","87371110","CDM","320","RC","71110","HCPCS","facility","both","","","","1225","612.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rib Bilat W/Pa Chest Min 4 Vw","87371111","CDM","320","RC","71111","HCPCS","facility","both","","","","1410","705","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Sternum","87371120","CDM","320","RC","71120","HCPCS","facility","both","","","","694","347","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Sternoclavicular Joints 3 Vw","87371130","CDM","320","RC","71130","HCPCS","facility","both","","","","799","399.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spine One View","87372020","CDM","320","RC","72020","HCPCS","facility","both","","","","562","281","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - C-Spine Two Or Three Views","87372040","CDM","320","RC","72040","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"C-Spine Min 4 Vw","87372050","CDM","320","RC","72050","HCPCS","facility","both","","","","888","444","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - C-Spine Compl W/Flex & Ext","87372052","CDM","320","RC","72052","HCPCS","facility","both","","","","1195","597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Thoracic Two Views","87372070","CDM","320","RC","72070","HCPCS","facility","both","","","","674","337","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Thoracic Three Views","87372072","CDM","320","RC","72072","HCPCS","facility","both","","","","721","360.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"T-Spine Min 4 Views","87372074","CDM","320","RC","72074","HCPCS","facility","both","","","","1177","588.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Thoracolumbar Two Views","87372080","CDM","320","RC","72080","HCPCS","facility","both","","","","960","480","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Entire Spi 2/3 Vw","87372082","CDM","320","RC","72082","HCPCS","facility","both","","","","339","169.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Entire Spi 4/5 Vw","87372083","CDM","320","RC","72083","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Entire Spi 6/> Vw","87372084","CDM","320","RC","72084","HCPCS","facility","both","","","","644","322","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Lumbar Two Or Three View","87372100","CDM","320","RC","72100","HCPCS","facility","both","","","","733","366.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Lumbar Minimum Four View","87372110","CDM","320","RC","72110","HCPCS","facility","both","","","","1056","528","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Lumbar Comp W/Bending","87372114","CDM","320","RC","72114","HCPCS","facility","both","","","","1559","779.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spine Lumbar Bending Only 4 V","87372120","CDM","320","RC","72120","HCPCS","facility","both","","","","1141","570.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Pelvis One Or Two Views","87372170","CDM","320","RC","72170","HCPCS","facility","both","","","","656","328","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Pelvis Complete Min 3 Vw","87372190","CDM","320","RC","72190","HCPCS","facility","both","","","","868","434","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Si Joints Greater Than 3 Vw","87372202","CDM","320","RC","72202","HCPCS","facility","both","","","","841","420.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Sacrum & Coccyx","87372220","CDM","320","RC","72220","HCPCS","facility","both","","","","839","419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Clavicle","87373000","CDM","320","RC","73000","HCPCS","facility","both","","","","593","296.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Scapula","87373010","CDM","320","RC","73010","HCPCS","facility","both","","","","776","388","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Shoulder One View","87373020","CDM","320","RC","73020","HCPCS","facility","both","","","","445","222.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Shoulder Two Views","87373030","CDM","320","RC","73030","HCPCS","facility","both","","","","638","319","","","","","","","","","","","","","Gross Charge Type: Standard"
"A-C Joints Bilat","87373050","CDM","320","RC","73050","HCPCS","facility","both","","","","617","308.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Humerus Min 2 Vw","87373060","CDM","320","RC","73060","HCPCS","facility","both","","","","674","337","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Elbow Two Views","87373070","CDM","320","RC","73070","HCPCS","facility","both","","","","537","268.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Elbow Min 3 Vw","87373080","CDM","320","RC","73080","HCPCS","facility","both","","","","902","451","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Forearm Two Views","87373090","CDM","320","RC","73090","HCPCS","facility","both","","","","659","329.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wrist Two Views","87373100","CDM","320","RC","73100","HCPCS","facility","both","","","","509","254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wrist Min 3 Vw","87373110","CDM","320","RC","73110","HCPCS","facility","both","","","","598","299","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Hand Two Views","87373120","CDM","320","RC","73120","HCPCS","facility","both","","","","488","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Hand Min 3 Vw","87373130","CDM","320","RC","73130","HCPCS","facility","both","","","","563","281.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fingers Min 2 Vw","87373140","CDM","320","RC","73140","HCPCS","facility","both","","","","404","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - X-Ray Exam Hip Uni 1 View","87373501","CDM","320","RC","73501","HCPCS","facility","both","","","","439","219.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - X-Ray Exam Hip Uni 2-3 Views","87373502","CDM","320","RC","73502","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - X-Ray Exam Hip Uni 4/> Views","87373503","CDM","320","RC","73503","HCPCS","facility","both","","","","681","340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - X-Ray Exam Hips Bi 2 Views","87373521","CDM","320","RC","73521","HCPCS","facility","both","","","","704","352","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - X-Ray Exam Hips Bi 3-4 Views","87373522","CDM","320","RC","73522","HCPCS","facility","both","","","","715","357.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Hips Bi 5/> Views","87373523","CDM","320","RC","73523","HCPCS","facility","both","","","","835","417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Of Femur 1","87373551","CDM","320","RC","73551","HCPCS","facility","both","","","","760","380","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - X-Ray Exam Of Femur 2/>","87373552","CDM","320","RC","73552","HCPCS","facility","both","","","","668","334","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Knee Ap & Lat","87373560","CDM","320","RC","73560","HCPCS","facility","both","","","","524","262","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Knee Ap/Lat/Obl Min 3 Vw","87373562","CDM","320","RC","73562","HCPCS","facility","both","","","","670","335","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Knee Ap/Lat/Obl W/Add Vw","87373564","CDM","320","RC","73564","HCPCS","facility","both","","","","869","434.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Knees Standing,Ap","87373565","CDM","320","RC","73565","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Tibia And Fibula Two Views","87373590","CDM","320","RC","73590","HCPCS","facility","both","","","","622","311","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ankle Two Views","87373600","CDM","320","RC","73600","HCPCS","facility","both","","","","538","269","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ankle Min 3 Vw","87373610","CDM","320","RC","73610","HCPCS","facility","both","","","","631","315.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Foot Two Views","87373620","CDM","320","RC","73620","HCPCS","facility","both","","","","592","296","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Foot Min 3 Vw","87373630","CDM","320","RC","73630","HCPCS","facility","both","","","","633","316.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Calcaneous Min 2 Vw","87373650","CDM","320","RC","73650","HCPCS","facility","both","","","","560","280","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Toes Min 2 Vw","87373660","CDM","320","RC","73660","HCPCS","facility","both","","","","502","251","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Abdomen 1 View","87374018","CDM","320","RC","74018","HCPCS","facility","both","","","","554","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Abdomen 2 Views","87374019","CDM","320","RC","74019","HCPCS","facility","both","","","","801","400.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radiologic Exam Abdomen 3+ Views","87374021","CDM","320","RC","74021","HCPCS","facility","both","","","","910","455","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Abdomen Flat/Upright W/Pacxr","87374022","CDM","320","RC","74022","HCPCS","facility","both","","","","989","494.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urography Retrograde With/Wo Kub","87374220","CDM","320","RC","74220","HCPCS","facility","both","","","","873","436.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Fetal Sngl/1St Gestation","87374712","CDM","614","RC","74712","HCPCS","facility","both","","","","1076","538","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Fetal Ea Addl Gestation","87374713","CDM","614","RC","74713","HCPCS","facility","both","","","","853","426.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"3D Rendering W/Interp & Postprocess Supervision","87376376","CDM","761","RC","76376","HCPCS","facility","both","","","","1402","701","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Thyroid/Soft Tissu","87376536","CDM","402","RC","76536","HCPCS","facility","both","","","","1177","588.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Chest B-Scan","87376604","CDM","402","RC","76604","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Breast Complete","87376641","CDM","402","RC","76641","HCPCS","facility","both","","","","1122","561","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Breast Limited","87376642","CDM","402","RC","76642","HCPCS","facility","both","","","","1096","548","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Abdomen","87376700","CDM","402","RC","76700","HCPCS","facility","both","","","","1737","868.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Abdomen Limited","87376705","CDM","402","RC","76705","HCPCS","facility","both","","","","1445","722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Retroperitoneal","87376770","CDM","402","RC","76770","HCPCS","facility","both","","","","1517","758.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Retro Limited","87376775","CDM","402","RC","76775","HCPCS","facility","both","","","","1118","559","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pregnant Uterus 14 Wk Transabdl 1/1St Gestation","87376801","CDM","402","RC","76801","HCPCS","facility","both","","","","960","480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus 14 Wk Transabdl Each Gestation","87376802","CDM","402","RC","76802","HCPCS","facility","both","","","","873","436.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus After 1St Trimest 1/1St Gestation","87376805","CDM","402","RC","76805","HCPCS","facility","both","","","","1209","604.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus > 1St Trimester Abdl Ea Gestation","87376810","CDM","402","RC","76810","HCPCS","facility","both","","","","1611","805.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus W/Detail Fetal Anat 1St Gestation","87376811","CDM","402","RC","76811","HCPCS","facility","both","","","","1328","664","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus Detail Fetal Anat Exam Ea Gestation","87376812","CDM","402","RC","76812","HCPCS","facility","both","","","","708","354","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Fetal Nuchal Translucency 1St Gestation","87376813","CDM","402","RC","76813","HCPCS","facility","both","","","","1044","522","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Fetal Nuchal Translucency Ea Addl Gestation","87376814","CDM","402","RC","76814","HCPCS","facility","both","","","","548","274","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pregnant Uterus Limited 1/> Fetuses","87376815","CDM","402","RC","76815","HCPCS","facility","both","","","","949","474.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus Real Time F/U Trnsabdl Per Fetus","87376816","CDM","402","RC","76816","HCPCS","facility","both","","","","378","189","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Preg Uterus Real Time W/Image Dcmtn Transvag","87376817","CDM","402","RC","76817","HCPCS","facility","both","","","","847","423.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Biophysical Profile Non-Stress Testing","87376818","CDM","402","RC","76818","HCPCS","facility","both","","","","851","425.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fetal Biophysical Profile W/O Non-Stress Testing","87376819","CDM","402","RC","76819","HCPCS","facility","both","","","","757","378.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doppler Velocimetry Fetal Umbilical Artery","87376820","CDM","761","RC","76820","HCPCS","facility","both","","","","834","417","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doppler Velocimetry Fetal Middle Cerebral Art","87376821","CDM","402","RC","76821","HCPCS","facility","both","","","","740","370","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo Fetal Cardiovasc W/Wo M-Mode Recording","87376825","CDM","483","RC","76825","HCPCS","facility","both","","","","2055","1027.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo Fetal Cardiovasc W/Wo M-Mode Repeat Std","87376826","CDM","483","RC","76826","HCPCS","facility","both","","","","638","319","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doppler Echo Fetal Spectral Display Complete","87376827","CDM","483","RC","76827","HCPCS","facility","both","","","","301","150.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doppler Echo Fetal Puls Spectral F/U/Repeat","87376828","CDM","483","RC","76828","HCPCS","facility","both","","","","301","150.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Transvaginal","87376830","CDM","402","RC","76830","HCPCS","facility","both","","","","1167","583.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Saline Infus Sonohysterography W/Color Doppler","87376831","CDM","761","RC","76831","HCPCS","facility","both","","","","1310","655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Pelvis Non-Ob","87376856","CDM","402","RC","76856","HCPCS","facility","both","","","","1474","737","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Pelvis Non-Ob Ltd","87376857","CDM","402","RC","76857","HCPCS","facility","both","","","","860","430","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Testicular","87376870","CDM","402","RC","76870","HCPCS","facility","both","","","","1417","708.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Transrectal","87376872","CDM","402","RC","76872","HCPCS","facility","both","","","","1324","662","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Extr Non-Vas,Comp","87376881","CDM","402","RC","76881","HCPCS","facility","both","","","","1568","784","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ultrasound Extr Non-Vasc,Ltd","87376882","CDM","402","RC","76882","HCPCS","facility","both","","","","613","306.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - U/S Guide Needle Placement","87376942","CDM","402","RC","76942","HCPCS","facility","both","","","","1655","827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Survey Limited","87377074","CDM","320","RC","77074","HCPCS","facility","both","","","","1524","762","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Bone Survey Complete","87377075","CDM","320","RC","77075","HCPCS","facility","both","","","","1794","897","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Bone Density Study-Central","87377080","CDM","320","RC","77080","HCPCS","facility","both","","","","1176","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Bone Density Study-Peripheral","87377081","CDM","320","RC","77081","HCPCS","facility","both","","","","663","331.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Myocardial Perfusn Imging","87378451","CDM","341","RC","78451","HCPCS","facility","both","","","","3386","1693","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Myocrdial Perfusion Imaging,T","87378452","CDM","341","RC","78452","HCPCS","facility","both","","","","6336","3168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cardiac Blood Pool Imaging,Gat","87378472","CDM","341","RC","78472","HCPCS","facility","both","","","","2696","1348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glycosylated Hb Home Device","87383037","CDM","300","RC","83037","HCPCS","facility","both","","","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov Coronavirus Ag Ia","87387426","CDM","300","RC","87426","HCPCS","facility","both","","","","35.33","17.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov & Inf Vir A&B Ag Ia","87387428","CDM","300","RC","87428","HCPCS","facility","both","","","","63.59","31.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rsv Assay W/Optic","87387807","CDM","300","RC","87807","HCPCS","facility","both","","","","129","64.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cytp Slides C/V Mnl Scr Under Phys","87388150","CDM","310","RC","88150","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diab Manage Trn Per Indv 30Min","87390108","CDM","942","RC","G0108","HCPCS","facility","both","","","","70","35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Initial Preventive Exam","87390402","CDM","520","RC","G0402","HCPCS","facility","both","","","","487","243.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Tracing For Initial Prev","87390404","CDM","761","RC","G0404","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ppps,Initial Visit","87390438","CDM","510","RC","G0438","HCPCS","facility","both","","","","953","476.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ppps,Subseq Visit","87390439","CDM","510","RC","G0439","HCPCS","facility","both","","","","639","319.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annual Depression Screen, 5 To 15 Mins","87390444","CDM","770","RC","G0444","HCPCS","facility","both","","","","51","25.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"High Inten Beh Couns Std 30M","87390445","CDM","510","RC","G0445","HCPCS","facility","both","","","","207","103.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Face To Face Obesity Counsl","87390447","CDM","510","RC","G0447","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"90471 Immunization Admin,1Vac","87390471","CDM","771","RC","90471","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Asses Care Plan Ccm Svc","87390506","CDM","510","RC","G0506","HCPCS","facility","both","","","","58","29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Interactive Complexity","87390785","CDM","761","RC","90785","HCPCS","facility","both","","","","76","38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Psytx Pt&/Family 30 Minutes","87390832","CDM","914","RC","90832","HCPCS","facility","both","","","","301","150.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Psychotherapy,45Min W/Pt,Fmly","87390834","CDM","914","RC","90834","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Psytx Pt&/Family 60 Minutes","87390837","CDM","914","RC","90837","HCPCS","facility","both","","","","439","219.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Family Psytx W/Pt 50 Min","87390847","CDM","900","RC","90847","HCPCS","facility","both","","","","459","229.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","87392083","CDM","510","RC","G0463","HCPCS","facility","both","","","","304","152","","","","","","","","","","","","","Gross Charge Type: Standard"
"Off Base Opioid Tx 70Min","87392086","CDM","510","RC","G2086","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Off Base Opioid Tx, 60 M","87392087","CDM","510","RC","G2087","HCPCS","facility","both","","","","335","167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Off Base Opioid Tx, Add 30","87392088","CDM","510","RC","G2088","HCPCS","facility","both","","","","168","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluorescein Angioscopy Interpretation & Report","87392230","CDM","761","RC","92230","HCPCS","facility","both","","","","1185","592.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caloric Vstblr Test W/Rec Bith","87392537","CDM","761","RC","92537","HCPCS","facility","both","","","","591","295.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caloric Vstblr Test W/Rec Mono","87392538","CDM","761","RC","92538","HCPCS","facility","both","","","","591","295.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Basic Vesticular Evaluation","87392540","CDM","940","RC","92540","HCPCS","facility","both","","","","650","325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Audiology-Screening","87392551","CDM","471","RC","92551","HCPCS","facility","both","","","","255","127.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pure Tone Audiometry Air & Bone","87392553","CDM","761","RC","92553","HCPCS","facility","both","","","","397","198.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Audiology-Basic","87392557","CDM","470","RC","92557","HCPCS","facility","both","","","","708","354","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tympanometry","87392567","CDM","471","RC","92567","HCPCS","facility","both","","","","93","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Select Picture Audiometry","87392583","CDM","470","RC","92583","HCPCS","facility","both","","","","293","146.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aep Neurodiagnostic Interpretation And Report","87392653","CDM","471","RC","92653","HCPCS","facility","both","","","","1833","916.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardioversion Elective Externl","87392960","CDM","481","RC","92960","HCPCS","facility","both","","","","2400","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pb Valvuloplasty; Pulmon Valve","87392990","CDM","480","RC","92990","HCPCS","facility","both","","","","19433","9716.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiovascular Stress Test","87393015","CDM","482","RC","93017","HCPCS","facility","both","","","","1502","751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Art Pressure Waveform Analys","87393050","CDM","921","RC","93050","HCPCS","facility","both","","","","110","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - 24 Hr Holter Monitor Scan Anly","87393226","CDM","731","RC","93226","HCPCS","facility","both","","","","601","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Ecg>48Hr<7D Recording","87393242","CDM","731","RC","93242","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Ecg>7D<15D Recording","87393246","CDM","731","RC","93246","HCPCS","facility","both","","","","589","294.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prgrmg Dev Eval Impltbl Sys","87393260","CDM","480","RC","93260","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interrogate Subq Defib","87393261","CDM","480","RC","93261","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Event Monitor & Analysis","87393271","CDM","730","RC","93271","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Program/Eval Sgl Pacer","87393279","CDM","480","RC","93279","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Program/Eval Dual Pacer","87393280","CDM","480","RC","93280","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Program/Eval Bi-V Pacer","87393281","CDM","481","RC","93281","HCPCS","facility","both","","","","778","389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Program/Eval Sgl Trnsvn Defb","87393282","CDM","480","RC","93282","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Program/Eval Dual Trnsvn Defb","87393283","CDM","480","RC","93283","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Program/Eval Bi-V Transvn Defb","87393284","CDM","481","RC","93284","HCPCS","facility","both","","","","467","233.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Prgrm Device Eval(In Prsn),Phy","87393285","CDM","480","RC","93285","HCPCS","facility","both","","","","448","224","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Interrogation Pacer","87393288","CDM","481","RC","93288","HCPCS","facility","both","","","","244","122","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Interrogation Transven Defib","87393289","CDM","480","RC","93289","HCPCS","facility","both","","","","477","238.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Inter Device Eval(In Prsn)","87393290","CDM","480","RC","93290","HCPCS","facility","both","","","","189","94.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Interrogation Loop Recorder","87393291","CDM","481","RC","93291","HCPCS","facility","both","","","","632","316","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Pm Phone R-Strip Device Eval","87393293","CDM","940","RC","93293","HCPCS","facility","both","","","","291","145.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Interrog Icpms <30 D Phys/Qhp","87393297","CDM","480","RC","93297","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Interrog Scrms <30 D Phys/Qhp","87393298","CDM","480","RC","93298","HCPCS","facility","both","","","","150","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tte W/Doppler Complete","87393306","CDM","483","RC","93306","HCPCS","facility","both","","","","3452","1726","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Echo,Trnsthoracic,Rltime W/Ima","87393307","CDM","480","RC","93307","HCPCS","facility","both","","","","1730","865","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Echo,Transthrcic W/Imge Doc 2D","87393308","CDM","760","RC","93308","HCPCS","facility","both","","","","1191","595.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doplr Echo,Pulsd Wave And/Or C","87393321","CDM","480","RC","93321","HCPCS","facility","both","","","","861","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Doppler Echocardiography Color","87393325","CDM","480","RC","93325","HCPCS","facility","both","","","","823","411.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Echo,Trnsthorac,Real-Time W/Im","87393513","CDM","940","RC","93351","HCPCS","facility","both","","","","1820","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Inject Congenital Card Cath","87393563","CDM","481","RC","93563","HCPCS","facility","both","","","","3938","1969","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Tilt Table Test","87393660","CDM","480","RC","93660","HCPCS","facility","both","","","","1509","754.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Carotid Duplex Bilat","87393880","CDM","921","RC","93880","HCPCS","facility","both","","","","1707","853.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Intraop Carotid Duplex","87393882","CDM","921","RC","93882","HCPCS","facility","both","","","","1070","535","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Digital Waveforms And Pressure","87393922","CDM","921","RC","93922","HCPCS","facility","both","","","","720","360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Lower Ext Art Without Exercise","87393923","CDM","920","RC","93923","HCPCS","facility","both","","","","1500","750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Lower Extremity Arterial With","87393924","CDM","921","RC","93924","HCPCS","facility","both","","","","1858","929","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Arterial Duplex Low Ext Bilat","87393925","CDM","921","RC","93925","HCPCS","facility","both","","","","2213","1106.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Arterial Duplx Low Ext Uni/Ltd","87393926","CDM","921","RC","93926","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Art Duplex Upp Ext Bilat","87393930","CDM","921","RC","93930","HCPCS","facility","both","","","","2209","1104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Upper Torso Duplex Unilateral","87393931","CDM","921","RC","93931","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Venous Duplex Low Ext Bilat","87393970","CDM","921","RC","93970","HCPCS","facility","both","","","","2164","1082","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Venous Duplex Low Ext Uni/Ltd","87393971","CDM","921","RC","93971","HCPCS","facility","both","","","","1476","738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Renal Artery/Vein Duplex Bilat","87393975","CDM","921","RC","93975","HCPCS","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Art/Ven Dplx,Abd/Plv/Scrot,Ltd","87393976","CDM","921","RC","93976","HCPCS","facility","both","","","","1807","903.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Abdominal Aorta Duplex","87393978","CDM","921","RC","93978","HCPCS","facility","both","","","","1399","699.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Intraop Thor Aorta Duplex","87393979","CDM","921","RC","93979","HCPCS","facility","both","","","","928","464","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dup-Scan Hemo Compl Bi Std","87393985","CDM","320","RC","93985","HCPCS","facility","both","","","","656","328","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dup-Scan Hemo Compl Uni Std","87393986","CDM","320","RC","93986","HCPCS","facility","both","","","","316","158","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Hemodialysis Access Scan","87393990","CDM","921","RC","93990","HCPCS","facility","both","","","","841","420.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spirometry Basic","87394010","CDM","460","RC","94010","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Spirometry W/Bronchodilators","87394060","CDM","460","RC","94060","HCPCS","facility","both","","","","950","475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vc,Total","87394150","CDM","460","RC","94150","HCPCS","facility","both","","","","356","178","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulmonary Stress Testing","87394618","CDM","460","RC","94618","HCPCS","facility","both","","","","696","348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Prostate Ca Screening;Dre","87394657","CDM","770","RC","G0102","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"O2 Uptake Exp Gas Analysis Rest Indirect Spx","87394690","CDM","460","RC","94690","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nitric Oxide Exp Gas Determina","87395012","CDM","460","RC","95012","HCPCS","facility","both","","","","292","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Emg-1 Extremity","87395860","CDM","922","RC","95860","HCPCS","facility","both","","","","616","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-2 Extremities","87395861","CDM","922","RC","95861","HCPCS","facility","both","","","","493","246.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg-Cranial Nerve Unilat","87395867","CDM","922","RC","95867","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg Limited Study 1 Ext","87395870","CDM","922","RC","95870","HCPCS","facility","both","","","","369","184.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Emg Jitter Blk Ea Muscl","87395872","CDM","922","RC","95872","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Nerv Destr Needle Emg","87395874","CDM","940","RC","95874","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Ndl Electrmygrphy,Extm,Lmtd","87395885","CDM","761","RC","95885","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Ndl Electrmygrphy,Extm,Cmpl","87395886","CDM","761","RC","95886","HCPCS","facility","both","","","","492","246","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Ndl Electrmygrphy,Non Extm","87395887","CDM","761","RC","95887","HCPCS","facility","both","","","","346","173","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Nerve Conduct Studies;1-2","87395907","CDM","922","RC","95907","HCPCS","facility","both","","","","584","292","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Nerve Conduct Studies;3-4","87395908","CDM","922","RC","95908","HCPCS","facility","both","","","","703","351.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Nerve Conduct Studies;5-6","87395909","CDM","922","RC","95909","HCPCS","facility","both","","","","838","419","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Nerve Conduct Studies;7-8","87395910","CDM","922","RC","95910","HCPCS","facility","both","","","","952","476","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Nerve Conduct Studies;9-10","87395911","CDM","922","RC","95911","HCPCS","facility","both","","","","1205","602.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Nerve Conduct Study;11-12","87395912","CDM","922","RC","95912","HCPCS","facility","both","","","","1444","722","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Nerve Cond Study;13 Or Mor","87395913","CDM","922","RC","95913","HCPCS","facility","both","","","","1731","865.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Autonomic Nerv Sys Fnc Test","87395922","CDM","922","RC","95922","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Fc-Autonmic Tsts/Sudomotr,>=1","87395923","CDM","922","RC","95923","HCPCS","facility","both","","","","765","382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Autonmic Tsts;W/At Lst 5 Min","87395924","CDM","740","RC","95924","HCPCS","facility","both","","","","377","188.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blink Reflex Test","87395933","CDM","920","RC","95933","HCPCS","facility","both","","","","503","251.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuromuscular Junction Testing","87395937","CDM","922","RC","95937","HCPCS","facility","both","","","","861","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Nx-Analysis W/O Reprogramming","87395970","CDM","920","RC","95970","HCPCS","facility","both","","","","652","326","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Smpl Cn Npgt Prgrmg","87395976","CDM","920","RC","95976","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Cplx Cn Npgt Prgrmg","87395977","CDM","920","RC","95977","HCPCS","facility","both","","","","529","264.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Brn Npgt Prgrmg 15 Min","87395983","CDM","920","RC","95983","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Brn Npgt Prgrmg Addl 15","87395984","CDM","920","RC","95984","HCPCS","facility","both","","","","220","110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Canalith Repositioning Proc","87395992","CDM","940","RC","95992","HCPCS","facility","both","","","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - St Neurobehavior Assessment","87396116","CDM","900","RC","96116","HCPCS","facility","both","","","","779","389.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nubhvl Xm Phy/Qhp Ea Addl Hr","87396121","CDM","918","RC","96121","HCPCS","facility","both","","","","384","192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brief Emotional/Behav Assmt","87396127","CDM","761","RC","96127","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl Tst Eval Phys/Qhp 1St","87396130","CDM","918","RC","96130","HCPCS","facility","both","","","","611","305.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl Tst Eval Phys/Qhp Ea","87396131","CDM","918","RC","96131","HCPCS","facility","both","","","","409","204.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrpsyc Tst Eval Phys/Qhp 1St","87396132","CDM","918","RC","96132","HCPCS","facility","both","","","","611","305.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrpsyc Tst Eval Phys/Qhp Ea","87396133","CDM","918","RC","96133","HCPCS","facility","both","","","","405","202.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl/Nrpsyc Tst Phy/Qhp 1St","87396136","CDM","918","RC","96136","HCPCS","facility","both","","","","147","73.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psycl/Nrpsyc Tst Phy/Qhp Ea","87396137","CDM","918","RC","96137","HCPCS","facility","both","","","","98","49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Assmt/Reassessment","87396156","CDM","761","RC","96156","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Hlth Bhv Ivntj Indiv 1St 30","87396158","CDM","761","RC","96158","HCPCS","facility","both","","","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Indiv Ea Addl15","87396159","CDM","761","RC","96159","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Grp 1St 30","87396164","CDM","761","RC","96164","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Grp Ea Addl 15","87396165","CDM","915","RC","96165","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Fam 1St 30 Min","87396167","CDM","916","RC","96167","HCPCS","facility","both","","","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Fam Ea Addl 15","87396168","CDM","916","RC","96168","HCPCS","facility","both","","","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iv Inf,Hydra;Int To 1 Hr","87396360","CDM","260","RC","96360","HCPCS","facility","both","","","","672","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iv Inf,Hydra;Ea Add Hour","87396361","CDM","260","RC","96361","HCPCS","facility","both","","","","371","185.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Chemo Injection Sq/Im","87396372","CDM","260","RC","96372","HCPCS","facility","both","","","","187","93.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Inj Sq/Im(Non-Horm Anti)","87396401","CDM","331","RC","96401","HCPCS","facility","both","","","","567","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Intralesional Up To 7","87396405","CDM","280","RC","96405","HCPCS","facility","both","","","","197","98.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Irrigaj Implntd Venous Access Drug Delivery Syst","87396523","CDM","761","RC","96523","HCPCS","facility","both","","","","170","85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trichogram","87396902","CDM","940","RC","96902","HCPCS","facility","both","","","","120","60","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Uvb Therapy","87396910","CDM","940","RC","96910","HCPCS","facility","both","","","","274","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Massge Therapy Ea 15 Mins","87397124","CDM","761","RC","97124","HCPCS","facility","both","","","","158","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Visit Debrd Selec-1St 20Sqcm/<","87397597","CDM","510","RC","97597","HCPCS","facility","both","","","","676","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Vist-Debir Selec-Eaadtl 20Sqcm","87397598","CDM","510","RC","97598","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit-Debride Nonselect","87397602","CDM","510","RC","97602","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Npwt Non-Disposable </=50Sqcm","87397605","CDM","510","RC","97605","HCPCS","facility","both","","","","748","374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Npwt Non-Disposable >50Sqcm","87397606","CDM","510","RC","97606","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wnd Tx <=50 Sq Cm","87397607","CDM","761","RC","97607","HCPCS","facility","both","","","","1368","684","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt Initial 15 Min","87397802","CDM","942","RC","97802","HCPCS","facility","both","","","","52","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupunct W/O Stimul 15 Min","87397810","CDM","940","RC","97810","HCPCS","facility","both","","","","183","91.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt One To Two Body Regions","87398925","CDM","940","RC","98925","HCPCS","facility","both","","","","148","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt Three To Four Body Regions","87398926","CDM","940","RC","98926","HCPCS","facility","both","","","","148","74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteopathic Manipulation 5-6","87398927","CDM","530","RC","98927","HCPCS","facility","both","","","","112","56","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","87399024","CDM","510","RC","G0463","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Hepatitis B Vaccine","87399056","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine","87399057","CDM","771","RC","G0009","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coll & Interp Data Ea 30 Days","87399091","CDM","761","RC","99091","HCPCS","facility","both","","","","181","90.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office/Outpatient New Moderate Mdm 45 Minutes","87399204","CDM","510","RC","G0463","HCPCS","facility","both","","","","456","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office O/P Min Prob Lev 1","87399211","CDM","510","RC","G0463","HCPCS","facility","both","","","","344","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Sf 10-19 Min Lv2","87399212","CDM","510","RC","G0463","HCPCS","facility","both","","","","379","189.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Low 20-29 Min L3","87399213","CDM","510","RC","G0463","HCPCS","facility","both","","","","416","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"F/U Office Op Mod 30-39 Min L4","87399214","CDM","510","RC","G0463","HCPCS","facility","both","","","","456","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Follow Up Visit Level 5","87399215","CDM","510","RC","G0463","HCPCS","facility","both","","","","502","251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lops;Follow Up","87399246","CDM","761","RC","G0246","HCPCS","facility","both","","","","365","182.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lops;Treatment","87399247","CDM","761","RC","G0247","HCPCS","facility","both","","","","306","153","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Service W/O Contact","87399358","CDM","761","RC","99358","HCPCS","facility","both","","","","266","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Subs Interv 15-30Mn","87399408","CDM","940","RC","G0396","HCPCS","facility","both","","","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Clincl Staff Svc","87399415","CDM","510","RC","99415","HCPCS","facility","both","","","","47","23.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Clincl Staff Svc Add","87399416","CDM","510","RC","99416","HCPCS","facility","both","","","","8","4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chrnc Care Mgmt Svc Ea Addl","87399439","CDM","510","RC","99439","HCPCS","facility","both","","","","182","91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cplx Chrnc Care 1St 60 Min","87399487","CDM","510","RC","99487","HCPCS","facility","both","","","","206","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmplx Chron Care Addl 30 Min","87399489","CDM","510","RC","99489","HCPCS","facility","both","","","","103","51.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chron Care Mgmt Srvc 20 Min","87399490","CDM","510","RC","99490","HCPCS","facility","both","","","","182","91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan First 30 Min","87399497","CDM","761","RC","99497","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Addl 30 Min","87399498","CDM","761","RC","99498","HCPCS","facility","both","","","","215","107.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ko Elastic With Joints","87401810","CDM","274","RC","L1810","HCPCS","facility","both","","","","202.86","101.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ko Elastic W/Joints Pre Ots","87401812","CDM","274","RC","L1812","HCPCS","facility","both","","","","112.82","56.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ko W Condyl Pad & Jnts","87401820","CDM","274","RC","L1820","HCPCS","facility","both","","","","251.51","125.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ko Adj Jnt Rigid Support","87401832","CDM","274","RC","L1832","HCPCS","facility","both","","","","1213.02","606.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Premold Long/Metatars Removble","87403060","CDM","274","RC","L3060","HCPCS","facility","both","","","","89.01","44.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgical,Orthowedge Shoe/Boot","87403260","CDM","274","RC","L3260","HCPCS","facility","both","","","","41.4","20.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Heel New Rubber Standard","87403460","CDM","274","RC","L3460","HCPCS","facility","both","","","","41.4","20.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orthopedic Half Sole","87403530","CDM","274","RC","L3530","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"So Vest Canvas/Web Pre Ots","87403675","CDM","274","RC","L3675","HCPCS","facility","both","","","","189.41","94.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Splint,Thumb Spica","87403999","CDM","274","RC","L3999","HCPCS","facility","both","","","","20.7","10.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Airsport","87404190","CDM","274","RC","L1906","HCPCS","facility","both","","","","256.68","128.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Afo Plastic Molded W/Ankle J","87404197","CDM","274","RC","L1970","HCPCS","facility","both","","","","1466.6","733.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Non-Pneum Walk Boot Prefab","87404386","CDM","274","RC","L4386","HCPCS","facility","both","","","","67.28","33.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Knee Orthosis,Adj Knee Joints","87404389","CDM","274","RC","L1832","HCPCS","facility","both","","","","1886.81","943.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Afo Ankle Gauntlet","87404392","CDM","274","RC","L1902","HCPCS","facility","both","","","","251.51","125.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Eo Withjoint,Prefabricated","87404398","CDM","274","RC","L3760","HCPCS","facility","both","","","","1268.91","634.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Walking Boot,Pneumatic","87404399","CDM","274","RC","L4360","HCPCS","facility","both","","","","823.86","411.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Static Afo","87404400","CDM","274","RC","L4396","HCPCS","facility","both","","","","471.96","235.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Digit","87408450","CDM","270","RC","S8450","HCPCS","facility","both","","","","119.03","59.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Premold Metatars Foot Arch Sup","87443050","CDM","274","RC","L3050","HCPCS","facility","both","","","","53.82","26.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","87444","CDM","270","RC","","","facility","both","","","","202.4","101.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Theraskin Per 1 Sq Cm","87444121","CDM","278","RC","Q4121","HCPCS","facility","both","","","","101.43","50.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grafix Prime Per Sq Cm","87444133","CDM","278","RC","Q4133","HCPCS","facility","both","","","","211.14","105.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epifix Per Sq Cm","87444186","CDM","278","RC","Q4186","HCPCS","facility","both","","","","410.9","205.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puraply Per Sqcm","87444195","CDM","278","RC","Q4195","HCPCS","facility","both","","","","180.09","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puraply Am 1 Sq Cm","87444196","CDM","278","RC","Q4196","HCPCS","facility","both","","","","326.03","163.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Knee Support: Elastic (Sm-Xlg)","87444467","CDM","290","RC","A4467","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Belt Strap Sleev Grmnt Cover","87464674","CDM","290","RC","A4467","HCPCS","facility","both","","","","16","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Metacarp Fx Orthosis Pre Cst","87493917","CDM","274","RC","L3917","HCPCS","facility","both","","","","108.68","54.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast,Fiberglass-Long Arm","87497523","CDM","270","RC","Q4006","HCPCS","facility","both","","","","67.28","33.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cast,Fiberglass-Forearm","87497525","CDM","270","RC","Q4010","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cast Sup Ln Arm Splint Fbrg","87497527","CDM","270","RC","Q4018","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast,Plaster-Forearm Static","87497528","CDM","270","RC","Q4021","HCPCS","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cast,Fiberglass-Forearm Static","87497529","CDM","270","RC","Q4022","HCPCS","facility","both","","","","30.02","15.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast,Fiberglass-Long Leg","87497533","CDM","270","RC","Q4030","HCPCS","facility","both","","","","102.47","51.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cast,Fiberglass Short Leg","87497537","CDM","270","RC","Q4038","HCPCS","facility","both","","","","90.05","45.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Sup Gauntlet Fiberglass","87497540","CDM","270","RC","Q4014","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Sup Sht Leg Splnt Fbrgl","87497544","CDM","270","RC","Q4046","HCPCS","facility","both","","","","42.44","21.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast,Short Arm,Peds","87497555","CDM","270","RC","Q4012","HCPCS","facility","both","","","","92.12","46.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Hepatitis B Vaccine","87499056","CDM","771","RC","G0010","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine","87499057","CDM","771","RC","G0009","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Sterile Gauze<= 16 Sq In","87499083","CDM","623","RC","A6216","HCPCS","facility","both","","","","64.17","32.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Finger Orthosis,Non Torsion","87499365","CDM","270","RC","","","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Aerochamber","87499502","CDM","270","RC","A4627","HCPCS","facility","both","","","","40.37","20.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ankle Splint","87499518","CDM","274","RC","L1906","HCPCS","facility","both","","","","106.61","53.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ankle Support","87499522","CDM","274","RC","L2999","HCPCS","facility","both","","","","67.28","33.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Sling-Arm(All)-For Home Use","87499524","CDM","274","RC","A4565","HCPCS","facility","both","","","","41.4","20.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Post Op Shoe/Boot","87499533","CDM","274","RC","L3260","HCPCS","facility","both","","","","41.4","20.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cerv Flexible Non-Adjustable","87499540","CDM","274","RC","L0120","HCPCS","facility","both","","","","61.07","30.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Slings","87499544","CDM","274","RC","A4565","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Shoulder Immobolizer","87499555","CDM","274","RC","L3670","HCPCS","facility","both","","","","19.67","9.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ear Wicks","87499560","CDM","270","RC","","","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Elbow Brace,Elastic","87499564","CDM","274","RC","L3999","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Splint-Finger","87499577","CDM","270","RC","Q4049","HCPCS","facility","both","","","","16.56","8.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Immobiilzer-Knee","87499591","CDM","274","RC","L1830","HCPCS","facility","both","","","","119.03","59.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Jelco Catheter 20 Guage","87499596","CDM","270","RC","","","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Jelco Catheter 22 Gauge","87499597","CDM","270","RC","","","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Cannula-Nasal","87499607","CDM","270","RC","A4615","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hand-Held Pefr Meter","87499622","CDM","270","RC","A4614","HCPCS","facility","both","","","","52.79","26.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ring Removal","87499650","CDM","270","RC","","","facility","both","","","","15.53","7.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Shlder Fig 8 Abduct Restrain","87499660","CDM","274","RC","L3650","HCPCS","facility","both","","","","27.95","13.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Splint-Wrist Any Type","87499695","CDM","270","RC","Q4051","HCPCS","facility","both","","","","57.96","28.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wrist Splint,Control Lock-Up","87499696","CDM","274","RC","L3908","HCPCS","facility","both","","","","125.24","62.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wrist Cock-Up Non-Molded","87499697","CDM","274","RC","L3908","HCPCS","facility","both","","","","125.24","62.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sterile 4X4'S Per Pk","87499705","CDM","270","RC","","","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Iv Tubing #10","87499745","CDM","270","RC","","","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Unna Boot Materials","87499770","CDM","270","RC","","","facility","both","","","","77.63","38.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ace Bandage,3 Inches","87499970","CDM","270","RC","A6449","HCPCS","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ace Bandage-2 Inches","87499971","CDM","270","RC","A6448","HCPCS","facility","both","","","","11.39","5.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ace Bandage-6Inches","87499972","CDM","270","RC","A6450","HCPCS","facility","both","","","","13.46","6.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Ace Bandage-4 Inches","87499973","CDM","270","RC","A6449","HCPCS","facility","both","","","","21.74","10.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint,Finger","87499977","CDM","274","RC","A4570","HCPCS","facility","both","","","","68.31","34.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prefab Afo W Ankle Jnt","87661971","CDM","274","RC","L1971","HCPCS","facility","both","","","","550.62","275.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indwelling Catheter Latex","87664338","CDM","270","RC","A4338","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Straight Tip Urine Catheter","87664351","CDM","270","RC","A4351","HCPCS","facility","both","","","","17.6","8.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urinary Leg Or Abdomen Bag","87664358","CDM","270","RC","A4358","HCPCS","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Hip Uni 2-3 Views","87773502","CDM","320","RC","73502","HCPCS","facility","both","","","","501","250.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Exam Hip Uni 4/> Views","87773503","CDM","320","RC","73503","HCPCS","facility","both","","","","681","340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Abdl Aorta Screen Aaa","87773706","CDM","402","RC","76706","HCPCS","facility","both","","","","1383","691.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator,Meatal","87899070","CDM","270","RC","","","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged Office/Outpatient E/M Svc Ea 15 Min","87902212","CDM","761","RC","G2212","HCPCS","facility","both","","","","49","24.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrist Cock-Up Non-Molded","87903908","CDM","274","RC","L3908","HCPCS","facility","both","","","","25.88","12.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Thumb Guard Spic Splint","87903923","CDM","274","RC","L3923","HCPCS","facility","both","","","","127.31","63.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sns With 80 Ml Bottle","87909970","CDM","270","RC","99070","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wrist Cock-Up Non-Molded","87913908","CDM","274","RC","L3908","HCPCS","facility","both","","","","23.81","11.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sutures/Staples Not Requiring Anesthesia","87915853","CDM","761","RC","15853","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suction Lipectomy Lwr Extrem","87915879","CDM","761","RC","15879","HCPCS","facility","both","","","","11322","5661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record","87920666","CDM","761","RC","G2066","HCPCS","facility","both","","","","130","65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proced Forearm/Wrist","87925999","CDM","761","RC","25999","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Hands/Fingers","87926989","CDM","761","RC","26989","HCPCS","facility","both","","","","299","149.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Pleural Cath","87932550","CDM","761","RC","32550","HCPCS","facility","both","","","","7105","3552.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","87932555","CDM","761","RC","32555","HCPCS","facility","both","","","","4726","2363","","","","","","","","","","","","","Gross Charge Type: Standard"
"Metacarp Fx Orthosis Pre Ots","87933918","CDM","274","RC","L3918","HCPCS","facility","both","","","","98.33","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hfo W/Joints","87939239","CDM","274","RC","L3923","HCPCS","facility","both","","","","127.31","63.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fc-Inj,Solesta Gel,1Ml Syr","87939490","CDM","274","RC","L8605","HCPCS","facility","both","","","","1702.58","851.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Long Thumb Spica,Lt/Rt","87939807","CDM","274","RC","L3807","HCPCS","facility","both","","","","303.26","151.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Boxers Fracture Brace,Lt/Rt","87939907","CDM","274","RC","L3807","HCPCS","facility","both","","","","303.26","151.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Short Arm Fracture Brace,Lt/Rt","87939982","CDM","274","RC","L3982","HCPCS","facility","both","","","","465.75","232.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deroyal Air/Gel Ankle Stirrup","87949350","CDM","274","RC","L4350","HCPCS","facility","both","","","","27.95","13.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo & Rmvl Of Iud Abd Cavit","87949392","CDM","761","RC","49329","HCPCS","facility","both","","","","8747","4373.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Spinal Cord Lesion","87962281","CDM","761","RC","62281","HCPCS","facility","both","","","","2674","1337","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antegrade Urography Radiological Supvj & Interpj","87974425","CDM","761","RC","74425","HCPCS","facility","both","","","","1036","518","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abscess Drainage Under X-Ray","87975989","CDM","320","RC","75989","HCPCS","facility","both","","","","4239","2119.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Exam K Transpl W/Doppler","87976776","CDM","402","RC","76776","HCPCS","facility","both","","","","1191","595.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow Imaging Limited Area","87978102","CDM","761","RC","78102","HCPCS","facility","both","","","","1622","811","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow Imaging Whole Body","87978104","CDM","761","RC","78104","HCPCS","facility","both","","","","2331","1165.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulmonary Ventilation & Perfusion Imaging","87978582","CDM","761","RC","78582","HCPCS","facility","both","","","","2830","1415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Quant Differential Pulm Perfusion W/Wo Imaging","87978597","CDM","761","RC","78597","HCPCS","facility","both","","","","2536","1268","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kidney Img Morphology Vascular Flow 1 W/O Rx","87978707","CDM","761","RC","78707","HCPCS","facility","both","","","","2063","1031.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kidney Img Morphology Vascular Flow Multiple","87978709","CDM","761","RC","78709","HCPCS","facility","both","","","","2063","1031.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"N-Autom Urine Dip W Micro","87981000","CDM","300","RC","81000","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Upper Ext Fx Orthosis Rad/Ul","87983982","CDM","274","RC","L3982","HCPCS","facility","both","","","","342.59","171.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Assay W/Optic","87987804","CDM","300","RC","87804","HCPCS","facility","both","","","","298","149","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Cardiovascular Service/Procedure","87989379","CDM","480","RC","93799","HCPCS","facility","both","","","","386","193","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adm Of Soc Dtr Assess 5-15 M","87990136","CDM","761","RC","G0136","HCPCS","facility","both","","","","74","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Rou Ecg W/12 Leads;Trac Only","87990404","CDM","761","RC","G0404","HCPCS","facility","both","","","","151","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Pelvic Ring Fracture Uni/Bil","87990413","CDM","761","RC","G0413","HCPCS","facility","both","","","","9198","4599","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annual Alcohol Screen 5 To 15 Mins","87990442","CDM","510","RC","G0442","HCPCS","facility","both","","","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imm Admn Sarscov2 Vaccine Single Dose","87990480","CDM","771","RC","90480","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insj Wcs Lv Compl Sys","87990515","CDM","481","RC","0515T","HCPCS","facility","both","","","","89417","44708.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insj Wcs Lv Eltrd Only","87990516","CDM","481","RC","0516T","HCPCS","facility","both","","","","30099","15049.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Vacc 3Mcg/0.3Ml Tris-Sucrose Im Use (Pfizer)","87991318","CDM","771","RC","91318","HCPCS","facility","both","","","","68.63","34.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Vacc 10Mcg/0.3Ml Tris-Sucrose Im Use (Pfizer)","87991319","CDM","771","RC","91319","HCPCS","facility","both","","","","92.17","46.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Vacc 30Mcg/0.3Ml Tris-Sucrose Im Use (Pfizer)","87991320","CDM","771","RC","91320","HCPCS","facility","both","","","","137.66","68.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Vaccine 25 Mcg/0.25 Ml For Im Use (Moderna)","87991321","CDM","771","RC","91321","HCPCS","facility","both","","","","153.22","76.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Vaccine 50 Mcg/0.5 Ml For Im Use (Moderna)","87991322","CDM","771","RC","91322","HCPCS","facility","both","","","","153.22","76.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg Unlisted Procedure Pelvis/Hip","87992729","CDM","761","RC","27299","HCPCS","facility","both","","","","792","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percutaneous Transluminal Coronary Lithotripsy","87992972","CDM","481","RC","92972","HCPCS","facility","both","","","","231","115.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eo, Adj Lock Joint Prefab Ot","87993761","CDM","274","RC","L3761","HCPCS","facility","both","","","","497.84","248.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrist Cock-Up Non-Molded","87993908","CDM","274","RC","L3908","HCPCS","facility","both","","","","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wrist Cock-Up Non-Molded","87993999","CDM","274","RC","L3999","HCPCS","facility","both","","","","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apligraf Per 1 Sq Cm","87994101","CDM","278","RC","Q4101","HCPCS","facility","both","","","","166.64","83.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oasis Tri-Layer Wound Matrix","87994124","CDM","278","RC","Q4124","HCPCS","facility","both","","","","37.26","18.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kerecis Omega3, Per Sq Cm","87994158","CDM","278","RC","Q4158","HCPCS","facility","both","","","","292.91","146.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nushield 1 Square Cm","87994160","CDM","278","RC","Q4160","HCPCS","facility","both","","","","214.25","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Non-Pneum Walk Boot Pre Ots","87994387","CDM","274","RC","L4387","HCPCS","facility","both","","","","241.16","120.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Eval Low Complex 15 Mins","87997169","CDM","420","RC","97169","HCPCS","facility","both","","","","432","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Eval Mod Complex 30 Mins","87997170","CDM","420","RC","97170","HCPCS","facility","both","","","","526","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Eval High Complex 45 Mins","87997171","CDM","420","RC","97171","HCPCS","facility","both","","","","578","289","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athletic Training Re-Eval Est Plan Care 20 Mins","87997172","CDM","420","RC","97172","HCPCS","facility","both","","","","246","123","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Sandal,Open Toe","87999069","CDM","270","RC","","","facility","both","","","","17.6","8.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Splint,Finger(Stax)","87999070","CDM","270","RC","","","facility","both","","","","14.49","7.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Wet Mounts/W Preparations","87999111","CDM","300","RC","Q0111","HCPCS","facility","both","","","","62","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Koh Preparations(Q0112)","87999112","CDM","300","RC","Q0112","HCPCS","facility","both","","","","40","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt Ea 15 M After 2Nd Refrl","87999170","CDM","942","RC","G0270","HCPCS","facility","both","","","","101","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Skin Tissue Procedure","87999179","CDM","761","RC","17999","HCPCS","facility","both","","","","1360","680","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Mepilex Lite,2.4X3.4;Each","87999236","CDM","270","RC","A6209","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mepilex,4X4;Each","87999239","CDM","270","RC","A6209","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Mepilex Border,4X4;Each","87999241","CDM","272","RC","A6212","HCPCS","facility","both","","","","16.56","8.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pneuma/Vac Walk Boot Pre Ots","87999361","CDM","274","RC","L4361","HCPCS","facility","both","","","","347.76","173.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Admin Flu Virus Vac","87999471","CDM","771","RC","G0008","HCPCS","facility","both","","","","96","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Technetium Tc-99M Sestamibi","87999500","CDM","343","RC","A9500","HCPCS","facility","both","","","","735","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rp:Tc-99 Pyp Per Dose","87999538","CDM","343","RC","A9538","HCPCS","facility","both","","","","127","63.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chg - Deroyal Wrist & Forearm Splnt","87999907","CDM","270","RC","","","facility","both","","","","12.42","6.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88011","CDM","270","RC","","","facility","both","","","","605.59","302.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88609","CDM","270","RC","","","facility","both","","","","18.02","9.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88611","CDM","270","RC","A6197","HCPCS","facility","both","","","","72.13","36.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88612","CDM","270","RC","A6198","HCPCS","facility","both","","","","98.61","49.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88613","CDM","270","RC","A6199","HCPCS","facility","both","","","","36.73","18.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88656","CDM","270","RC","","","facility","both","","","","966.28","483.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88696","CDM","270","RC","","","facility","both","","","","501.75","250.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88697","CDM","270","RC","","","facility","both","","","","27.51","13.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88704","CDM","272","RC","C1769","HCPCS","facility","both","","","","136.16","68.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88705","CDM","272","RC","C1769","HCPCS","facility","both","","","","191.69","95.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88706","CDM","272","RC","C1769","HCPCS","facility","both","","","","212.18","106.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88707","CDM","272","RC","C1769","HCPCS","facility","both","","","","136.16","68.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88708","CDM","272","RC","C1769","HCPCS","facility","both","","","","198.6","99.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88709","CDM","272","RC","C1769","HCPCS","facility","both","","","","220.06","110.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88714","CDM","272","RC","C1769","HCPCS","facility","both","","","","137.94","68.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88717","CDM","272","RC","C1887","HCPCS","facility","both","","","","247.25","123.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88728","CDM","272","RC","C1769","HCPCS","facility","both","","","","150.42","75.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88737","CDM","272","RC","C1769","HCPCS","facility","both","","","","207.69","103.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88739","CDM","272","RC","C1769","HCPCS","facility","both","","","","214.82","107.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88740","CDM","272","RC","C1769","HCPCS","facility","both","","","","224.62","112.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88745","CDM","272","RC","C1769","HCPCS","facility","both","","","","240.83","120.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88746","CDM","272","RC","C1769","HCPCS","facility","both","","","","246.22","123.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88774","CDM","272","RC","C1893","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88796","CDM","272","RC","C1893","HCPCS","facility","both","","","","42.78","21.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88799","CDM","272","RC","C1893","HCPCS","facility","both","","","","43.47","21.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88850","CDM","272","RC","C1887","HCPCS","facility","both","","","","238.24","119.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88864","CDM","272","RC","C1769","HCPCS","facility","both","","","","30.47","15.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88889","CDM","272","RC","C1887","HCPCS","facility","both","","","","235","117.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","889","CDM","270","RC","","","facility","both","","","","26.17","13.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88908","CDM","272","RC","C1758","HCPCS","facility","both","","","","155.16","77.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88909","CDM","272","RC","C1729","HCPCS","facility","both","","","","43.38","21.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88913","CDM","272","RC","C1769","HCPCS","facility","both","","","","114.68","57.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88914","CDM","272","RC","C1769","HCPCS","facility","both","","","","114.68","57.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88915","CDM","272","RC","C1769","HCPCS","facility","both","","","","114.68","57.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88916","CDM","272","RC","C1769","HCPCS","facility","both","","","","114.68","57.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88928","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88930","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88931","CDM","278","RC","C2625","HCPCS","facility","both","","","","395.6","197.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88935","CDM","272","RC","C1726","HCPCS","facility","both","","","","999.63","499.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88936","CDM","278","RC","C1726","HCPCS","facility","both","","","","999.63","499.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88938","CDM","272","RC","C1726","HCPCS","facility","both","","","","999.63","499.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88941","CDM","272","RC","C1887","HCPCS","facility","both","","","","414","207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88957","CDM","270","RC","","","facility","both","","","","651.23","325.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88958","CDM","270","RC","","","facility","both","","","","809.92","404.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","88959","CDM","270","RC","","","facility","both","","","","936.67","468.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","89124","CDM","270","RC","","","facility","both","","","","304.98","152.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","89145","CDM","270","RC","","","facility","both","","","","385.71","192.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90184","CDM","278","RC","C1713","HCPCS","facility","both","","","","553.2","276.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90286","CDM","278","RC","C1713","HCPCS","facility","both","","","","1019.13","509.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90288","CDM","278","RC","C1713","HCPCS","facility","both","","","","1019.13","509.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90801","CDM","278","RC","C1713","HCPCS","facility","both","","","","427.85","213.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90802","CDM","278","RC","C1713","HCPCS","facility","both","","","","460.16","230.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90803","CDM","278","RC","C1713","HCPCS","facility","both","","","","498.69","249.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90804","CDM","278","RC","C1713","HCPCS","facility","both","","","","448.31","224.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90805","CDM","278","RC","C1713","HCPCS","facility","both","","","","427.85","213.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90825","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90830","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90882","CDM","278","RC","C1713","HCPCS","facility","both","","","","760.66","380.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90884","CDM","278","RC","C1713","HCPCS","facility","both","","","","666.08","333.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90885","CDM","278","RC","C1713","HCPCS","facility","both","","","","984.91","492.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90886","CDM","278","RC","C1713","HCPCS","facility","both","","","","672.16","336.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90888","CDM","278","RC","C1713","HCPCS","facility","both","","","","681.6","340.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90890","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90892","CDM","278","RC","C1713","HCPCS","facility","both","","","","697.26","348.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90894","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90896","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90900","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90904","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90908","CDM","278","RC","C1713","HCPCS","facility","both","","","","760.66","380.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","90912","CDM","278","RC","C1713","HCPCS","facility","both","","","","632.82","316.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","91267","CDM","278","RC","C1776","HCPCS","facility","both","","","","1599.78","799.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","91298","CDM","270","RC","","","facility","both","","","","84.77","42.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","91445","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","91447","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-Cut Slide","91700135","CDM","310","RC","88323","HCPCS","facility","both","","","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-Travel Histo","91700990","CDM","310","RC","88399","HCPCS","facility","both","","","","20","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-Slide/Block Retrieval","91700991","CDM","310","RC","88399","HCPCS","facility","both","","","","67","33.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-Admin","91700993","CDM","310","RC","88399","HCPCS","facility","both","","","","67","33.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-Ihc Technical","91702340","CDM","300","RC","88399","HCPCS","facility","both","","","","67","33.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-H&E","91709786","CDM","310","RC","88305","HCPCS","facility","both","","","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","91747","CDM","270","RC","","","facility","both","","","","1227.29","613.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chgl Research Study-Cytology Technical","92000253","CDM","310","RC","88399","HCPCS","facility","both","","","","67","33.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","92070","CDM","270","RC","","","facility","both","","","","1215.78","607.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","92410","CDM","278","RC","C1713","HCPCS","facility","both","","","","1415.7","707.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","9299","CDM","270","RC","","","facility","both","","","","133.08","66.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93269","CDM","272","RC","C1887","HCPCS","facility","both","","","","434.7","217.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93314","CDM","278","RC","C1874","HCPCS","facility","both","","","","4645.5","2322.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93315","CDM","278","RC","C1874","HCPCS","facility","both","","","","4835.5","2417.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93376","CDM","278","RC","C1789","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93497","CDM","270","RC","","","facility","both","","","","994.75","497.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93689","CDM","278","RC","C1713","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93696","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","93699","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94196","CDM","270","RC","","","facility","both","","","","53.82","26.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94507","CDM","278","RC","C1713","HCPCS","facility","both","","","","1733.94","866.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94511","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94512","CDM","278","RC","C1713","HCPCS","facility","both","","","","745.2","372.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94523","CDM","278","RC","C1713","HCPCS","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94554","CDM","272","RC","C1769","HCPCS","facility","both","","","","844.23","422.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94563","CDM","278","RC","C1713","HCPCS","facility","both","","","","2125.2","1062.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94568","CDM","270","RC","","","facility","both","","","","749.8","374.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94569","CDM","270","RC","","","facility","both","","","","726.8","363.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94579","CDM","270","RC","","","facility","both","","","","130.69","65.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94718","CDM","270","RC","C2626","HCPCS","facility","both","","","","818.15","409.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94721","CDM","270","RC","","","facility","both","","","","87.4","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94722","CDM","270","RC","","","facility","both","","","","109.25","54.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94784","CDM","270","RC","","","facility","both","","","","7.59","3.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","94817","CDM","270","RC","","","facility","both","","","","96.6","48.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95079","CDM","270","RC","","","facility","both","","","","19.99","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95080","CDM","270","RC","","","facility","both","","","","30.53","15.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95157","CDM","278","RC","C1713","HCPCS","facility","both","","","","483","241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95238","CDM","270","RC","","","facility","both","","","","1576.83","788.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95348","CDM","270","RC","","","facility","both","","","","239.62","119.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95690","CDM","270","RC","","","facility","both","","","","204.97","102.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95710","CDM","270","RC","","","facility","both","","","","196.47","98.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","958","CDM","270","RC","","","facility","both","","","","6.97","3.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95903","CDM","272","RC","C1769","HCPCS","facility","both","","","","248.99","124.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95920","CDM","270","RC","","","facility","both","","","","5001.79","2500.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95921","CDM","270","RC","","","facility","both","","","","26.85","13.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95922","CDM","270","RC","","","facility","both","","","","5.83","2.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95923","CDM","270","RC","","","facility","both","","","","8.14","4.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95926","CDM","270","RC","","","facility","both","","","","5.66","2.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95927","CDM","270","RC","","","facility","both","","","","5.42","2.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95928","CDM","270","RC","","","facility","both","","","","24.58","12.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95929","CDM","270","RC","","","facility","both","","","","5.52","2.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95930","CDM","270","RC","","","facility","both","","","","33.76","16.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95931","CDM","270","RC","","","facility","both","","","","33.51","16.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95932","CDM","270","RC","","","facility","both","","","","39.18","19.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95941","CDM","270","RC","","","facility","both","","","","209.07","104.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95943","CDM","270","RC","","","facility","both","","","","662.33","331.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95946","CDM","270","RC","","","facility","both","","","","237.17","118.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95950","CDM","270","RC","","","facility","both","","","","261.27","130.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95951","CDM","270","RC","","","facility","both","","","","309.06","154.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95952","CDM","270","RC","","","facility","both","","","","331.65","165.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95954","CDM","270","RC","","","facility","both","","","","397.27","198.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95955","CDM","270","RC","","","facility","both","","","","502.32","251.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95956","CDM","270","RC","","","facility","both","","","","261.63","130.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95957","CDM","270","RC","","","facility","both","","","","126.01","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95958","CDM","270","RC","","","facility","both","","","","488.34","244.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95959","CDM","270","RC","","","facility","both","","","","369.21","184.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95962","CDM","270","RC","","","facility","both","","","","129.03","64.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95968","CDM","270","RC","","","facility","both","","","","114.62","57.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95969","CDM","270","RC","","","facility","both","","","","114.62","57.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95983","CDM","270","RC","","","facility","both","","","","1950.4","975.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95991","CDM","270","RC","","","facility","both","","","","26.52","13.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95993","CDM","270","RC","","","facility","both","","","","53.16","26.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95995","CDM","270","RC","","","facility","both","","","","8.21","4.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95998","CDM","270","RC","","","facility","both","","","","20.36","10.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","95999","CDM","270","RC","","","facility","both","","","","15.13","7.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96039","CDM","270","RC","","","facility","both","","","","318.87","159.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96043","CDM","270","RC","","","facility","both","","","","366.39","183.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96044","CDM","270","RC","","","facility","both","","","","425.18","212.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96072","CDM","272","RC","C1893","HCPCS","facility","both","","","","218.72","109.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96087","CDM","270","RC","","","facility","both","","","","378.35","189.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96270","CDM","270","RC","","","facility","both","","","","297.07","148.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96279","CDM","278","RC","C1817","HCPCS","facility","both","","","","38.76","19.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96293","CDM","270","RC","","","facility","both","","","","323.38","161.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96322","CDM","270","RC","","","facility","both","","","","187.72","93.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96324","CDM","270","RC","","","facility","both","","","","40.48","20.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96377","CDM","278","RC","C1788","HCPCS","facility","both","","","","1051.57","525.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96379","CDM","270","RC","","","facility","both","","","","166.06","83.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96384","CDM","270","RC","","","facility","both","","","","504.74","252.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96387","CDM","270","RC","","","facility","both","","","","60.74","30.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96390","CDM","270","RC","","","facility","both","","","","135.7","67.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96432","CDM","270","RC","","","facility","both","","","","2264.86","1132.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96500","CDM","270","RC","","","facility","both","","","","245.1","122.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96501","CDM","270","RC","","","facility","both","","","","145.9","72.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96502","CDM","270","RC","","","facility","both","","","","180.08","90.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96517","CDM","270","RC","","","facility","both","","","","106.57","53.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96523","CDM","272","RC","C1769","HCPCS","facility","both","","","","91.94","45.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96665","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96684","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96693","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96717","CDM","278","RC","C1713","HCPCS","facility","both","","","","1840","920","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96813","CDM","270","RC","","","facility","both","","","","1378","689","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96818","CDM","270","RC","","","facility","both","","","","12.46","6.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96833","CDM","270","RC","","","facility","both","","","","1590.45","795.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96837","CDM","270","RC","","","facility","both","","","","61.45","30.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96842","CDM","272","RC","C1751","HCPCS","facility","both","","","","227.85","113.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96843","CDM","270","RC","","","facility","both","","","","37.63","18.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96844","CDM","270","RC","","","facility","both","","","","118","59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96846","CDM","270","RC","","","facility","both","","","","90.8","45.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96870","CDM","270","RC","","","facility","both","","","","76.54","38.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96871","CDM","270","RC","","","facility","both","","","","260.54","130.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96875","CDM","272","RC","C1787","HCPCS","facility","both","","","","2261","1130.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96876","CDM","270","RC","","","facility","both","","","","368","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96889","CDM","270","RC","","","facility","both","","","","44.9","22.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96893","CDM","270","RC","","","facility","both","","","","30.84","15.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96894","CDM","270","RC","","","facility","both","","","","14.24","7.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96903","CDM","270","RC","","","facility","both","","","","28.06","14.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96904","CDM","272","RC","C1729","HCPCS","facility","both","","","","84.17","42.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96912","CDM","270","RC","","","facility","both","","","","5.24","2.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96920","CDM","270","RC","","","facility","both","","","","111.47","55.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96921","CDM","270","RC","","","facility","both","","","","65.85","32.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96922","CDM","270","RC","","","facility","both","","","","57.24","28.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96925","CDM","270","RC","","","facility","both","","","","3.58","1.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","96933","CDM","270","RC","","","facility","both","","","","180.03","90.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97240","CDM","270","RC","","","facility","both","","","","27.72","13.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97284","CDM","272","RC","A6203","HCPCS","facility","both","","","","4.78","2.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97285","CDM","272","RC","A6203","HCPCS","facility","both","","","","6.36","3.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97286","CDM","272","RC","A6203","HCPCS","facility","both","","","","3.2","1.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97289","CDM","270","RC","","","facility","both","","","","12.04","6.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97310","CDM","270","RC","","","facility","both","","","","970.6","485.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97331","CDM","278","RC","C1765","HCPCS","facility","both","","","","2095.78","1047.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97379","CDM","270","RC","","","facility","both","","","","199.1","99.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97401","CDM","270","RC","","","facility","both","","","","96.69","48.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97449","CDM","270","RC","","","facility","both","","","","28.06","14.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97510","CDM","270","RC","L0174","HCPCS","facility","both","","","","217.12","108.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97520","CDM","270","RC","","","facility","both","","","","57.24","28.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97616","CDM","272","RC","C1773","HCPCS","facility","both","","","","1233.62","616.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97624","CDM","270","RC","","","facility","both","","","","175.17","87.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","9783","CDM","278","RC","C1713","HCPCS","facility","both","","","","365.33","182.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","9791","CDM","278","RC","C1713","HCPCS","facility","both","","","","312.43","156.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97975","CDM","270","RC","","","facility","both","","","","296.61","148.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97978","CDM","270","RC","","","facility","both","","","","296.61","148.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","97998","CDM","270","RC","","","facility","both","","","","889.33","444.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98101","CDM","270","RC","","","facility","both","","","","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98104","CDM","272","RC","C1769","HCPCS","facility","both","","","","1392.19","696.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98107","CDM","270","RC","","","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98253","CDM","278","RC","C1768","HCPCS","facility","both","","","","2005.11","1002.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98254","CDM","278","RC","C1768","HCPCS","facility","both","","","","2333.2","1166.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98760","CDM","270","RC","","","facility","both","","","","1006.76","503.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98785","CDM","270","RC","","","facility","both","","","","825.93","412.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","9880","CDM","278","RC","C1713","HCPCS","facility","both","","","","114.5","57.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","98817","CDM","270","RC","A6208","HCPCS","facility","both","","","","6.73","3.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","9882","CDM","278","RC","C1713","HCPCS","facility","both","","","","67.3","33.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","9884","CDM","278","RC","C1713","HCPCS","facility","both","","","","161.69","80.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","99271","CDM","270","RC","","","facility","both","","","","595.26","297.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","99409","CDM","270","RC","","","facility","both","","","","302.13","151.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","99412","CDM","270","RC","","","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","99413","CDM","270","RC","","","facility","both","","","","243.8","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","99674","CDM","270","RC","","","facility","both","","","","736","368","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","A4100_0278","CDM","278","RC","A4100","HCPCS","facility","both","","","","8242.41","4121.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","A6210_0272","CDM","272","RC","A6210","HCPCS","facility","both","","","","66.79","33.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1713_0272","CDM","272","RC","C1713","HCPCS","facility","both","","","","606.36","303.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1713_0278","CDM","278","RC","C1713","HCPCS","facility","both","","","","334.12","167.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1725_0272","CDM","272","RC","C1725","HCPCS","facility","both","","","","751.82","375.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1729_0272","CDM","272","RC","C1729","HCPCS","facility","both","","","","101.28","50.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1729_0278","CDM","278","RC","C1729","HCPCS","facility","both","","","","295.92","147.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1751_0278","CDM","278","RC","C1751","HCPCS","facility","both","","","","1164.03","582.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1757_0272","CDM","272","RC","C1757","HCPCS","facility","both","","","","547.4","273.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1758_0272","CDM","272","RC","C1758","HCPCS","facility","both","","","","152.26","76.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1765_0278","CDM","278","RC","C1765","HCPCS","facility","both","","","","1557.24","778.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1767_0278","CDM","278","RC","C1767","HCPCS","facility","both","","","","1150","575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1769_0272","CDM","272","RC","C1769","HCPCS","facility","both","","","","498.81","249.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1769_0278","CDM","278","RC","C1769","HCPCS","facility","both","","","","606.45","303.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1776_0278","CDM","278","RC","C1776","HCPCS","facility","both","","","","7357.13","3678.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1822_0272","CDM","272","RC","C1822","HCPCS","facility","both","","","","1900","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1822_0278","CDM","278","RC","C1822","HCPCS","facility","both","","","","1900","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1887_0272","CDM","272","RC","C1887","HCPCS","facility","both","","","","1003.86","501.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1894_0272","CDM","272","RC","C1894","HCPCS","facility","both","","","","85.37","42.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1894_0278","CDM","278","RC","C1894","HCPCS","facility","both","","","","245.33","122.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C1897_0278","CDM","278","RC","C1897","HCPCS","facility","both","","","","6555","3277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C2618_0278","CDM","278","RC","C2618","HCPCS","facility","both","","","","2005.6","1002.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","C2625_0272","CDM","272","RC","C2625","HCPCS","facility","both","","","","41.4","20.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hb Cdsm Evicore","HBG1001","CDM","G1001","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Medcurrent","HBG1002","CDM","G1002","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Medicalis","HBG1003","CDM","G1003","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Ndsc","HBG1004","CDM","G1004","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Nia","HBG1005","CDM","G1005","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Test Approp","HBG1006","CDM","G1006","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Aim","HBG1007","CDM","G1007","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Cranberry Pk","HBG1008","CDM","G1008","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Sage Health","HBG1009","CDM","G1009","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Stanson","HBG1010","CDM","G1010","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Qualified Nos","HBG1011","CDM","G1011","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Agilemd's Clinical Decision Support Mechanism","HBG1012","CDM","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Evidencecare's Imaging Advisor","HBG1013","CDM","G1013","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Inveniqa's Semantic Answers In Medicine","HBG1014","CDM","G1014","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Reliant Medical Group Cdsm","HBG1015","CDM","G1015","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Speed Of Care Cdsm","HBG1016","CDM","G1016","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Healthhelp's Clinical Decision Support Mechanism","HBG1017","CDM","G1017","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Infinx Cdsm","HBG1018","CDM","H1018","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Hb Cdsm Logicnets Auc Solution","HBG1019","CDM","G1019","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: HB CDSM G CODE .01 [124]"
"Noncdm Charge Record Medical Supplies","ITM00000107","CDM","278","RC","C1776","HCPCS","facility","both","","","","5301","2650.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000113","CDM","278","RC","C1776","HCPCS","facility","both","","","","2340","1170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000117","CDM","278","RC","C1783","HCPCS","facility","both","","","","2945","1472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000210","CDM","270","RC","","","facility","both","","","","3.96","1.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000247","CDM","278","RC","C1713","HCPCS","facility","both","","","","1357","678.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000269","CDM","270","RC","","","facility","both","","","","1490.6","745.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000326","CDM","270","RC","C1760","HCPCS","facility","both","","","","3515","1757.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000404","CDM","278","RC","C1776","HCPCS","facility","both","","","","13402.13","6701.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000408","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000423","CDM","278","RC","C1776","HCPCS","facility","both","","","","4796.55","2398.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000440","CDM","278","RC","C1776","HCPCS","facility","both","","","","1380","690","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000670","CDM","278","RC","C1769","HCPCS","facility","both","","","","1219","609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000672","CDM","272","RC","C1769","HCPCS","facility","both","","","","1219","609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000673","CDM","272","RC","C1769","HCPCS","facility","both","","","","1219","609.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000743","CDM","270","RC","","","facility","both","","","","14535","7267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000748","CDM","270","RC","Q4114","HCPCS","facility","both","","","","2660","1330","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000926","CDM","270","RC","","","facility","both","","","","537.47","268.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000938","CDM","270","RC","","","facility","both","","","","1443.26","721.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000947","CDM","270","RC","","","facility","both","","","","1443.26","721.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000949","CDM","270","RC","","","facility","both","","","","1681.16","840.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00000965","CDM","270","RC","","","facility","both","","","","2208","1104","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001053","CDM","278","RC","C1776","HCPCS","facility","both","","","","4370","2185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001142","CDM","270","RC","","","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001143","CDM","270","RC","C1713","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001332","CDM","278","RC","C1776","HCPCS","facility","both","","","","4573.21","2286.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001346","CDM","278","RC","C1776","HCPCS","facility","both","","","","2433.1","1216.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001415","CDM","270","RC","C1713","HCPCS","facility","both","","","","3610","1805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001416","CDM","278","RC","C1713","HCPCS","facility","both","","","","3610","1805","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001466","CDM","278","RC","C1713","HCPCS","facility","both","","","","1690","845","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001505","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001508","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001522","CDM","278","RC","C1713","HCPCS","facility","both","","","","1288","644","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001569","CDM","278","RC","C1713","HCPCS","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001589","CDM","278","RC","C1713","HCPCS","facility","both","","","","2028","1014","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001609","CDM","278","RC","C1713","HCPCS","facility","both","","","","1380","690","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001618","CDM","278","RC","C1713","HCPCS","facility","both","","","","7220","3610","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001652","CDM","278","RC","C1713","HCPCS","facility","both","","","","460","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001664","CDM","278","RC","C1713","HCPCS","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001726","CDM","278","RC","C1713","HCPCS","facility","both","","","","2464.8","1232.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001727","CDM","278","RC","C1713","HCPCS","facility","both","","","","2508","1254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001728","CDM","278","RC","C1713","HCPCS","facility","both","","","","3648","1824","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001729","CDM","278","RC","C1713","HCPCS","facility","both","","","","6004","3002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001782","CDM","270","RC","","","facility","both","","","","3752.5","1876.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001879","CDM","278","RC","C1713","HCPCS","facility","both","","","","4560","2280","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001880","CDM","278","RC","C1713","HCPCS","facility","both","","","","2280","1140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001926","CDM","278","RC","C1713","HCPCS","facility","both","","","","584.43","292.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001977","CDM","278","RC","C1776","HCPCS","facility","both","","","","7410","3705","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001979","CDM","278","RC","C1776","HCPCS","facility","both","","","","1380","690","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00001999","CDM","270","RC","","","facility","both","","","","699.2","349.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002010","CDM","270","RC","","","facility","both","","","","423.2","211.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002022","CDM","272","RC","C1894","HCPCS","facility","both","","","","1308.74","654.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002087","CDM","278","RC","C1713","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002116","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002130","CDM","272","RC","C2628","HCPCS","facility","both","","","","3239.5","1619.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002154","CDM","270","RC","","","facility","both","","","","10370.2","5185.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002159","CDM","270","RC","","","facility","both","","","","10370.2","5185.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002161","CDM","270","RC","","","facility","both","","","","10370.2","5185.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002170","CDM","278","RC","C1776","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002185","CDM","270","RC","","","facility","both","","","","560.96","280.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002186","CDM","270","RC","","","facility","both","","","","560.96","280.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002187","CDM","270","RC","","","facility","both","","","","92","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002189","CDM","270","RC","","","facility","both","","","","1242","621","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002202","CDM","270","RC","","","facility","both","","","","2757.89","1378.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002203","CDM","278","RC","C1767","HCPCS","facility","both","","","","20234.22","10117.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002204","CDM","270","RC","C1787","HCPCS","facility","both","","","","3230","1615","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002205","CDM","278","RC","C1778","HCPCS","facility","both","","","","6593.33","3296.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002216","CDM","278","RC","C1713","HCPCS","facility","both","","","","1932","966","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002288","CDM","278","RC","C1776","HCPCS","facility","both","","","","1326","663","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002294","CDM","270","RC","","","facility","both","","","","40.65","20.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002316","CDM","270","RC","","","facility","both","","","","136.23","68.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002341","CDM","278","RC","A2008","HCPCS","facility","both","","","","138.54","69.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002657","CDM","270","RC","","","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002658","CDM","270","RC","","","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002659","CDM","270","RC","","","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002660","CDM","270","RC","","","facility","both","","","","2275","1137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002667","CDM","270","RC","","","facility","both","","","","488.38","244.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002669","CDM","270","RC","","","facility","both","","","","544.59","272.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002680","CDM","270","RC","","","facility","both","","","","524.03","262.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002701","CDM","270","RC","","","facility","both","","","","700.95","350.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002708","CDM","270","RC","","","facility","both","","","","613.09","306.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002715","CDM","270","RC","","","facility","both","","","","671.55","335.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002726","CDM","270","RC","","","facility","both","","","","441.83","220.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002732","CDM","270","RC","","","facility","both","","","","585.72","292.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002734","CDM","270","RC","","","facility","both","","","","585.72","292.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002743","CDM","270","RC","","","facility","both","","","","613.09","306.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002757","CDM","270","RC","","","facility","both","","","","863.14","431.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002759","CDM","270","RC","","","facility","both","","","","595.98","297.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002760","CDM","270","RC","","","facility","both","","","","667.92","333.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002774","CDM","270","RC","","","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002782","CDM","270","RC","","","facility","both","","","","1265","632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002787","CDM","270","RC","","","facility","both","","","","585.72","292.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002816","CDM","278","RC","C1713","HCPCS","facility","both","","","","602.98","301.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002818","CDM","278","RC","C1713","HCPCS","facility","both","","","","9120","4560","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002820","CDM","278","RC","C1713","HCPCS","facility","both","","","","9120","4560","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002840","CDM","278","RC","C1713","HCPCS","facility","both","","","","3040","1520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002842","CDM","278","RC","C1713","HCPCS","facility","both","","","","3040","1520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002843","CDM","278","RC","C1713","HCPCS","facility","both","","","","3040","1520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002851","CDM","278","RC","C1713","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002852","CDM","278","RC","C1713","HCPCS","facility","both","","","","115","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002862","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002863","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002864","CDM","278","RC","C1713","HCPCS","facility","both","","","","345","172.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002882","CDM","278","RC","C1713","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002883","CDM","278","RC","C1713","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002884","CDM","278","RC","C1713","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002890","CDM","278","RC","C1713","HCPCS","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002893","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002900","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002901","CDM","270","RC","","","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002983","CDM","278","RC","C1776","HCPCS","facility","both","","","","4796.55","2398.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00002987","CDM","278","RC","C1776","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003003","CDM","270","RC","","","facility","both","","","","1300","650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003012","CDM","272","RC","C1887","HCPCS","facility","both","","","","2346.5","1173.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003013","CDM","272","RC","C1887","HCPCS","facility","both","","","","2346.5","1173.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003030","CDM","272","RC","C1769","HCPCS","facility","both","","","","1702.27","851.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003031","CDM","272","RC","C1769","HCPCS","facility","both","","","","1779.65","889.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003033","CDM","272","RC","C1769","HCPCS","facility","both","","","","1779.65","889.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003058","CDM","278","RC","C1713","HCPCS","facility","both","","","","690","345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003296","CDM","270","RC","C1760","HCPCS","facility","both","","","","1035","517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003303","CDM","272","RC","C1725","HCPCS","facility","both","","","","6555","3277.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003341","CDM","270","RC","","","facility","both","","","","125.76","62.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003361","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003380","CDM","278","RC","C1713","HCPCS","facility","both","","","","920","460","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003510","CDM","270","RC","","","facility","both","","","","139.4","69.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003528","CDM","278","RC","C1776","HCPCS","facility","both","","","","20768.9","10384.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003530","CDM","270","RC","","","facility","both","","","","135.78","67.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003578","CDM","278","RC","B4087","HCPCS","facility","both","","","","147.98","73.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003641","CDM","278","RC","C1713","HCPCS","facility","both","","","","1430","715","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003794","CDM","278","RC","C1776","HCPCS","facility","both","","","","1872","936","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00003913","CDM","270","RC","","","facility","both","","","","73.74","36.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004023","CDM","278","RC","C1713","HCPCS","facility","both","","","","1950","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004185","CDM","278","RC","C1713","HCPCS","facility","both","","","","3040","1520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004321","CDM","278","RC","C1762","HCPCS","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004322","CDM","270","RC","","","facility","both","","","","5472","2736","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004482","CDM","270","RC","","","facility","both","","","","632.87","316.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004487","CDM","270","RC","","","facility","both","","","","114.1","57.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004498","CDM","270","RC","","","facility","both","","","","1817","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004510","CDM","270","RC","","","facility","both","","","","271.4","135.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004589","CDM","278","RC","C1713","HCPCS","facility","both","","","","1560","780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004633","CDM","272","RC","C1725","HCPCS","facility","both","","","","3325","1662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004853","CDM","270","RC","","","facility","both","","","","1909.7","954.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004854","CDM","270","RC","","","facility","both","","","","1883","941.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004856","CDM","270","RC","","","facility","both","","","","2358.2","1179.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004870","CDM","270","RC","","","facility","both","","","","483","241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004896","CDM","270","RC","","","facility","both","","","","18050","9025","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004899","CDM","270","RC","","","facility","both","","","","18335","9167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004906","CDM","270","RC","","","facility","both","","","","71.47","35.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004907","CDM","270","RC","","","facility","both","","","","116.36","58.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00004916","CDM","278","RC","Q4158","HCPCS","facility","both","","","","97.26","48.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005132","CDM","278","RC","Q4158","HCPCS","facility","both","","","","108.95","54.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005136","CDM","278","RC","Q4158","HCPCS","facility","both","","","","72.11","36.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005138","CDM","278","RC","Q4158","HCPCS","facility","both","","","","84.56","42.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005349","CDM","278","RC","A4100","HCPCS","facility","both","","","","53.18","26.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005432","CDM","278","RC","C1776","HCPCS","facility","both","","","","11352.5","5676.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005478","CDM","278","RC","C1713","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005613","CDM","278","RC","C1776","HCPCS","facility","both","","","","2069.1","1034.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005636","CDM","272","RC","C1726","HCPCS","facility","both","","","","999.62","499.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005673","CDM","270","RC","","","facility","both","","","","2087.8","1043.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005714","CDM","278","RC","C1713","HCPCS","facility","both","","","","864.8","432.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005715","CDM","278","RC","C1713","HCPCS","facility","both","","","","864.8","432.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005735","CDM","278","RC","C1713","HCPCS","facility","both","","","","588.8","294.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005739","CDM","278","RC","C1713","HCPCS","facility","both","","","","616.4","308.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005827","CDM","278","RC","C1713","HCPCS","facility","both","","","","2178.8","1089.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005833","CDM","278","RC","C1713","HCPCS","facility","both","","","","441.6","220.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00005918","CDM","270","RC","","","facility","both","","","","800.4","400.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00006081","CDM","278","RC","C1768","HCPCS","facility","both","","","","1921.74","960.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00007247","CDM","278","RC","C1874","HCPCS","facility","both","","","","5967.9","2983.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00007540","CDM","276","RC","V2632","HCPCS","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00007542","CDM","276","RC","V2632","HCPCS","facility","both","","","","200","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical Supplies","ITM00008238","CDM","278","RC","C1713","HCPCS","facility","both","","","","230","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","720","","","","","","","fee schedule","720","864",""
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","720","","","","","","","fee schedule","720","864",""
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","720","","","","","","","fee schedule","720","864",""
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","864","","","","","","","fee schedule","720","864",""
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","864","","","","","","","fee schedule","720","864",""
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","754.2","","","","","","","fee schedule","720","864","APC"
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","741.6","","","","","","","fee schedule","720","864","APC"
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","734.4","","","","","","","fee schedule","720","864","APC"
"Rbc dna hea 35 ag 11 bld grp","0001U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","756","","","","","","","fee schedule","720","864","APC"
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.4","","","","","","","fee schedule","503.4","528.57",""
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","503.4","","","","","","","fee schedule","503.4","528.57",""
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","503.4","","","","","","","fee schedule","503.4","528.57",""
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","527.31","","","","","","","fee schedule","503.4","528.57","APC"
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","518.5","","","","","","","fee schedule","503.4","528.57","APC"
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","513.47","","","","","","","fee schedule","503.4","528.57","APC"
"Liver dis 10 assays w/ash","0002M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","528.57","","","","","","","fee schedule","503.4","528.57","APC"
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25","","","","","","","fee schedule","25","30",""
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25","","","","","","","fee schedule","25","30",""
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25","","","","","","","fee schedule","25","30",""
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30","","","","","","","fee schedule","25","30",""
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30","","","","","","","fee schedule","25","30",""
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.19","","","","","","","fee schedule","25","30","APC"
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.75","","","","","","","fee schedule","25","30","APC"
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.5","","","","","","","fee schedule","25","30","APC"
"Onc clrct 3 ur metab alg plp","0002U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.25","","","","","","","fee schedule","25","30","APC"
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.4","","","","","","","fee schedule","503.4","528.57",""
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","503.4","","","","","","","fee schedule","503.4","528.57",""
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","503.4","","","","","","","fee schedule","503.4","528.57",""
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","527.31","","","","","","","fee schedule","503.4","528.57","APC"
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","518.5","","","","","","","fee schedule","503.4","528.57","APC"
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","513.47","","","","","","","fee schedule","503.4","528.57","APC"
"Liver dis 10 assays w/nash","0003M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","528.57","","","","","","","fee schedule","503.4","528.57","APC"
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","950","","","","","","","fee schedule","950","1140",""
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","950","","","","","","","fee schedule","950","1140",""
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","950","","","","","","","fee schedule","950","1140",""
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1140","","","","","","","fee schedule","950","1140",""
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1140","","","","","","","fee schedule","950","1140",""
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","995.13","","","","","","","fee schedule","950","1140","APC"
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","978.5","","","","","","","fee schedule","950","1140","APC"
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","969","","","","","","","fee schedule","950","1140","APC"
"Onc ovar 5 prtn ser alg scor","0003U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","997.5","","","","","","","fee schedule","950","1140","APC"
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79","","","","","","","fee schedule","79","82.95",""
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","79","","","","","","","fee schedule","79","82.95",""
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","79","","","","","","","fee schedule","79","82.95",""
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.75","","","","","","","fee schedule","79","82.95","APC"
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.37","","","","","","","fee schedule","79","82.95","APC"
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.58","","","","","","","fee schedule","79","82.95","APC"
"Scoliosis dna alys","0004M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.95","","","","","","","fee schedule","79","82.95","APC"
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onco prst8 3 gene ur alg","0005U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150","","","","","","","fee schedule","150","157.5",""
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","150","","","","","","","fee schedule","150","157.5",""
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150","","","","","","","fee schedule","150","157.5",""
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.13","","","","","","","fee schedule","150","157.5","APC"
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.5","","","","","","","fee schedule","150","157.5","APC"
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153","","","","","","","fee schedule","150","157.5","APC"
"Onc hep gene risk classifier","0006M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.5","","","","","","","fee schedule","150","157.5","APC"
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375","","","","","","","fee schedule","375","393.75",""
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375","","","","","","","fee schedule","375","393.75",""
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375","","","","","","","fee schedule","375","393.75",""
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","392.81","","","","","","","fee schedule","375","393.75","APC"
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.25","","","","","","","fee schedule","375","393.75","APC"
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.5","","","","","","","fee schedule","375","393.75","APC"
"Onc gastro 51 gene nomogram","0007M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","393.75","","","","","","","fee schedule","375","393.75","APC"
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","114.43","","","","","","","fee schedule","114.43","137.32",""
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.43","","","","","","","fee schedule","114.43","137.32",""
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.43","","","","","","","fee schedule","114.43","137.32",""
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","137.32","","","","","","","fee schedule","114.43","137.32",""
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","137.32","","","","","","","fee schedule","114.43","137.32",""
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.87","","","","","","","fee schedule","114.43","137.32","APC"
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.86","","","","","","","fee schedule","114.43","137.32","APC"
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.72","","","","","","","fee schedule","114.43","137.32","APC"
"Rx test prsmv ur w/def conf","0007U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.15","","","","","","","fee schedule","114.43","137.32","APC"
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","597.91","","","","","","","fee schedule","597.91","717.49",""
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","597.91","","","","","","","fee schedule","597.91","717.49",""
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","597.91","","","","","","","fee schedule","597.91","717.49",""
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","717.49","","","","","","","fee schedule","597.91","717.49",""
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","717.49","","","","","","","fee schedule","597.91","717.49",""
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","597.91","717.49","APC"
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","597.91","717.49","APC"
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","597.91","717.49","APC"
"Hpylori detcj abx rstnc dna","0008U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","597.91","717.49","APC"
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","107","","","","","","","fee schedule","107","128.4",""
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","107","","","","","","","fee schedule","107","128.4",""
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","107","","","","","","","fee schedule","107","128.4",""
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","128.4","","","","","","","fee schedule","107","128.4",""
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","128.4","","","","","","","fee schedule","107","128.4",""
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","112.08","","","","","","","fee schedule","107","128.4","APC"
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","110.21","","","","","","","fee schedule","107","128.4","APC"
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","109.14","","","","","","","fee schedule","107","128.4","APC"
"Onc brst ca erbb2 amp/nonamp","0009U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","112.35","","","","","","","fee schedule","107","128.4","APC"
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","427.26","","","","","","","fee schedule","427.26","512.71",""
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","427.26","","","","","","","fee schedule","427.26","512.71",""
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","427.26","","","","","","","fee schedule","427.26","512.71",""
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","512.71","","","","","","","fee schedule","427.26","512.71",""
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","512.71","","","","","","","fee schedule","427.26","512.71",""
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","447.55","","","","","","","fee schedule","427.26","512.71","APC"
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","440.08","","","","","","","fee schedule","427.26","512.71","APC"
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","435.81","","","","","","","fee schedule","427.26","512.71","APC"
"Nfct ds strn typ whl gen seq","0010U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","448.62","","","","","","","fee schedule","427.26","512.71","APC"
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 ca mrna 12 gen alg","0011M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","114.43","","","","","","","fee schedule","114.43","137.32",""
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.43","","","","","","","fee schedule","114.43","137.32",""
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.43","","","","","","","fee schedule","114.43","137.32",""
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","137.32","","","","","","","fee schedule","114.43","137.32",""
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","137.32","","","","","","","fee schedule","114.43","137.32",""
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.87","","","","","","","fee schedule","114.43","137.32","APC"
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.86","","","","","","","fee schedule","114.43","137.32","APC"
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.72","","","","","","","fee schedule","114.43","137.32","APC"
"Rx mntr lc-ms/ms oral fluid","0011U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.15","","","","","","","fee schedule","114.43","137.32","APC"
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen rsk urthl ca","0012M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc mrna 5 gen recr urthl ca","0013M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1305.37","","","","","","","fee schedule","1305.37","1566.44",""
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1305.37","","","","","","","fee schedule","1305.37","1566.44",""
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1305.37","","","","","","","fee schedule","1305.37","1566.44",""
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1566.44","","","","","","","fee schedule","1305.37","1566.44",""
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1566.44","","","","","","","fee schedule","1305.37","1566.44",""
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1367.38","","","","","","","fee schedule","1305.37","1566.44","APC"
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1344.53","","","","","","","fee schedule","1305.37","1566.44","APC"
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1331.48","","","","","","","fee schedule","1305.37","1566.44","APC"
"Adrnl cortcl tum bchm asy 25","0015M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1370.64","","","","","","","fee schedule","1305.37","1566.44","APC"
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3489.63","","","","","","","fee schedule","3489.63","4187.56",""
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3489.63","","","","","","","fee schedule","3489.63","4187.56",""
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3489.63","","","","","","","fee schedule","3489.63","4187.56",""
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4187.56","","","","","","","fee schedule","3489.63","4187.56",""
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4187.56","","","","","","","fee schedule","3489.63","4187.56",""
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3655.39","","","","","","","fee schedule","3489.63","4187.56","APC"
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3594.32","","","","","","","fee schedule","3489.63","4187.56","APC"
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3559.42","","","","","","","fee schedule","3489.63","4187.56","APC"
"Onc bladder mrna 209 gen alg","0016M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3664.11","","","","","","","fee schedule","3489.63","4187.56","APC"
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","163.96","","","","","","","fee schedule","163.96","242.9",""
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","163.96","","","","","","","fee schedule","163.96","242.9",""
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","163.96","","","","","","","fee schedule","163.96","242.9",""
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","242.9","","","","","","","fee schedule","163.96","242.9",""
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","242.9","","","","","","","fee schedule","163.96","242.9",""
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","171.75","","","","","","","fee schedule","163.96","242.9","APC"
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","168.88","","","","","","","fee schedule","163.96","242.9","APC"
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","167.24","","","","","","","fee schedule","163.96","242.9","APC"
"Onc hmtlmf neo rna bcr/abl1","0016U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","172.16","","","","","","","fee schedule","163.96","242.9","APC"
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2510.21","","","","","","","fee schedule","2510.21","3012.25",""
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2510.21","","","","","","","fee schedule","2510.21","3012.25",""
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2510.21","","","","","","","fee schedule","2510.21","3012.25",""
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3012.25","","","","","","","fee schedule","2510.21","3012.25",""
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3012.25","","","","","","","fee schedule","2510.21","3012.25",""
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2629.44","","","","","","","fee schedule","2510.21","3012.25","APC"
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2585.52","","","","","","","fee schedule","2510.21","3012.25","APC"
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2560.41","","","","","","","fee schedule","2510.21","3012.25","APC"
"Onc dlbcl mrna 20 genes alg","0017M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2635.72","","","","","","","fee schedule","2510.21","3012.25","APC"
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.66","","","","","","","fee schedule","91.66","135.8",""
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","91.66","","","","","","","fee schedule","91.66","135.8",""
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","91.66","","","","","","","fee schedule","91.66","135.8",""
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","135.8","","","","","","","fee schedule","91.66","135.8",""
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","135.8","","","","","","","fee schedule","91.66","135.8",""
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","96.01","","","","","","","fee schedule","91.66","135.8","APC"
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.41","","","","","","","fee schedule","91.66","135.8","APC"
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.49","","","","","","","fee schedule","91.66","135.8","APC"
"Onc hmtlmf neo jak2 mut dna","0017U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.24","","","","","","","fee schedule","91.66","135.8","APC"
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","640.73","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","640.73","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","640.73","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","768.88","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","768.88","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","671.16","","","","","","","fee schedule","640.73","768.88","APC"
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","659.95","","","","","","","fee schedule","640.73","768.88","APC"
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","653.54","","","","","","","fee schedule","640.73","768.88","APC"
"Trnsplj rnl meas cd154+cll","0018M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","672.77","","","","","","","fee schedule","640.73","768.88","APC"
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3002.09","","","","","","","fee schedule","3002.09","3602.51",""
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3002.09","","","","","","","fee schedule","3002.09","3602.51",""
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3002.09","","","","","","","fee schedule","3002.09","3602.51",""
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3602.51","","","","","","","fee schedule","3002.09","3602.51",""
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3602.51","","","","","","","fee schedule","3002.09","3602.51",""
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3144.69","","","","","","","fee schedule","3002.09","3602.51","APC"
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3092.15","","","","","","","fee schedule","3002.09","3602.51","APC"
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3062.13","","","","","","","fee schedule","3002.09","3602.51","APC"
"Onc thyr 10 microrna seq alg","0018U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3152.19","","","","","","","fee schedule","3002.09","3602.51","APC"
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","712.4","","","","","","","fee schedule","712.4","748.02",""
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","712.4","","","","","","","fee schedule","712.4","748.02",""
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","712.4","","","","","","","fee schedule","712.4","748.02",""
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","746.24","","","","","","","fee schedule","712.4","748.02","APC"
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","733.77","","","","","","","fee schedule","712.4","748.02","APC"
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","726.65","","","","","","","fee schedule","712.4","748.02","APC"
"Cv ds plasma alys prtn bmrk","0019M","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","748.02","","","","","","","fee schedule","712.4","748.02","APC"
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3675","","","","","","","fee schedule","3675","4410",""
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3675","","","","","","","fee schedule","3675","4410",""
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3675","","","","","","","fee schedule","3675","4410",""
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4410","","","","","","","fee schedule","3675","4410",""
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4410","","","","","","","fee schedule","3675","4410",""
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3849.56","","","","","","","fee schedule","3675","4410","APC"
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3785.25","","","","","","","fee schedule","3675","4410","APC"
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3748.5","","","","","","","fee schedule","3675","4410","APC"
"Onc rna tiss predict alg","0019U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3858.75","","","","","","","fee schedule","3675","4410","APC"
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 detcj 8 autoantb","0021U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1950","","","","","","","fee schedule","1950","2340",""
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1950","","","","","","","fee schedule","1950","2340",""
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1950","","","","","","","fee schedule","1950","2340",""
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2340","","","","","","","fee schedule","1950","2340",""
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2340","","","","","","","fee schedule","1950","2340",""
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2042.63","","","","","","","fee schedule","1950","2340","APC"
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2008.5","","","","","","","fee schedule","1950","2340","APC"
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1989","","","","","","","fee schedule","1950","2340","APC"
"Trgt gen seq dna&rna 23 gene","0022U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2047.5","","","","","","","fee schedule","1950","2340","APC"
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","248.51","","","","","","","fee schedule","248.51","298.21",""
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","248.51","","","","","","","fee schedule","248.51","298.21",""
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.51","","","","","","","fee schedule","248.51","298.21",""
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","298.21","","","","","","","fee schedule","248.51","298.21",""
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","298.21","","","","","","","fee schedule","248.51","298.21",""
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","260.31","","","","","","","fee schedule","248.51","298.21","APC"
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","255.97","","","","","","","fee schedule","248.51","298.21","APC"
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","253.48","","","","","","","fee schedule","248.51","298.21","APC"
"Onc aml dna detcj/nondetcj","0023U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","260.94","","","","","","","fee schedule","248.51","298.21","APC"
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.19","","","","","","","fee schedule","34.19","42.07",""
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.19","","","","","","","fee schedule","34.19","42.07",""
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.19","","","","","","","fee schedule","34.19","42.07",""
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.07","","","","","","","fee schedule","34.19","42.07",""
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.07","","","","","","","fee schedule","34.19","42.07",""
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.81","","","","","","","fee schedule","34.19","42.07","APC"
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.22","","","","","","","fee schedule","34.19","42.07","APC"
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.87","","","","","","","fee schedule","34.19","42.07","APC"
"Glyca nuc mr spectrsc quan","0024U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.9","","","","","","","fee schedule","34.19","42.07","APC"
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","114.43","","","","","","","fee schedule","114.36","120.15",""
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.43","","","","","","","fee schedule","114.36","120.15",""
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.43","","","","","","","fee schedule","114.36","120.15",""
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","114.36","","","","","","","fee schedule","114.36","120.15",""
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","114.36","","","","","","","fee schedule","114.36","120.15",""
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.87","","","","","","","fee schedule","114.36","120.15","APC"
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.86","","","","","","","fee schedule","114.36","120.15","APC"
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.72","","","","","","","fee schedule","114.36","120.15","APC"
"Tenofovir liq chrom ur quan","0025U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.15","","","","","","","fee schedule","114.36","120.15","APC"
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3600","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3600","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3600","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4320","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4320","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3771","","","","","","","fee schedule","3600","4320","APC"
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3708","","","","","","","fee schedule","3600","4320","APC"
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3672","","","","","","","fee schedule","3600","4320","APC"
"Onc thyr dna&mrna 112 genes","0026U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3780","","","","","","","fee schedule","3600","4320","APC"
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","121.91","","","","","","","fee schedule","121.91","180.62",""
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","121.91","","","","","","","fee schedule","121.91","180.62",""
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","121.91","","","","","","","fee schedule","121.91","180.62",""
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","180.62","","","","","","","fee schedule","121.91","180.62",""
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","180.62","","","","","","","fee schedule","121.91","180.62",""
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","127.7","","","","","","","fee schedule","121.91","180.62","APC"
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.57","","","","","","","fee schedule","121.91","180.62","APC"
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.35","","","","","","","fee schedule","121.91","180.62","APC"
"Jak2 gene trgt seq alys","0027U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.01","","","","","","","fee schedule","121.91","180.62","APC"
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","890.72","","","","","","","fee schedule","742.27","890.72",""
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","890.72","","","","","","","fee schedule","742.27","890.72",""
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","777.53","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","764.54","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","757.12","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab advrs trgt seq alys","0029U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","779.38","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","134.13","","","","","","","fee schedule","134.13","160.96",""
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","134.13","","","","","","","fee schedule","134.13","160.96",""
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","134.13","","","","","","","fee schedule","134.13","160.96",""
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","160.96","","","","","","","fee schedule","134.13","160.96",""
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","160.96","","","","","","","fee schedule","134.13","160.96",""
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","140.5","","","","","","","fee schedule","134.13","160.96","APC"
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","138.15","","","","","","","fee schedule","134.13","160.96","APC"
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","136.81","","","","","","","fee schedule","134.13","160.96","APC"
"Rx metab warf trgt seq alys","0030U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","140.84","","","","","","","fee schedule","134.13","160.96","APC"
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp1a2 gene","0031U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Comt gene","0032U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Htr2a htr2c genes","0033U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","349.62","","","","","","","fee schedule","349.62","419.54",""
"Htr2a htr2c genes","0033U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","349.62","","","","","","","fee schedule","349.62","419.54",""
"Htr2a htr2c genes","0033U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","349.62","","","","","","","fee schedule","349.62","419.54",""
"Htr2a htr2c genes","0033U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","419.54","","","","","","","fee schedule","349.62","419.54",""
"Htr2a htr2c genes","0033U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","419.54","","","","","","","fee schedule","349.62","419.54",""
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","466.17","","","","","","","fee schedule","466.17","559.4",""
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","466.17","","","","","","","fee schedule","466.17","559.4",""
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","466.17","","","","","","","fee schedule","466.17","559.4",""
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","559.4","","","","","","","fee schedule","466.17","559.4",""
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","559.4","","","","","","","fee schedule","466.17","559.4",""
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","488.31","","","","","","","fee schedule","466.17","559.4","APC"
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","480.16","","","","","","","fee schedule","466.17","559.4","APC"
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","475.49","","","","","","","fee schedule","466.17","559.4","APC"
"Tpmt nudt15 genes","0034U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","489.48","","","","","","","fee schedule","466.17","559.4","APC"
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","540.99","","","","","","","fee schedule","540.99","649.19",""
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","540.99","","","","","","","fee schedule","540.99","649.19",""
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","540.99","","","","","","","fee schedule","540.99","649.19",""
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","649.19","","","","","","","fee schedule","540.99","649.19",""
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","649.19","","","","","","","fee schedule","540.99","649.19",""
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","566.69","","","","","","","fee schedule","540.99","649.19","APC"
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","557.22","","","","","","","fee schedule","540.99","649.19","APC"
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","551.81","","","","","","","fee schedule","540.99","649.19","APC"
"Neuro csf prion prtn qual","0035U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","568.04","","","","","","","fee schedule","540.99","649.19","APC"
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4780","","","","","","","fee schedule","4780","5736",""
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4780","","","","","","","fee schedule","4780","5736",""
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4780","","","","","","","fee schedule","4780","5736",""
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5736","","","","","","","fee schedule","4780","5736",""
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5736","","","","","","","fee schedule","4780","5736",""
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5007.05","","","","","","","fee schedule","4780","5736","APC"
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4923.4","","","","","","","fee schedule","4780","5736","APC"
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4875.6","","","","","","","fee schedule","4780","5736","APC"
"Xome tum & nml spec seq alys","0036U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5019","","","","","","","fee schedule","4780","5736","APC"
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3500","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3500","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3500","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4200","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4200","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3666.25","","","","","","","fee schedule","3500","4200","APC"
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3605","","","","","","","fee schedule","3500","4200","APC"
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3570","","","","","","","fee schedule","3500","4200","APC"
"Trgt gen seq dna 324 genes","0037U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3675","","","","","","","fee schedule","3500","4200","APC"
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.6","","","","","","","fee schedule","29.6","39.47",""
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.6","","","","","","","fee schedule","29.6","39.47",""
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.6","","","","","","","fee schedule","29.6","39.47",""
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.47","","","","","","","fee schedule","29.6","39.47",""
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.47","","","","","","","fee schedule","29.6","39.47",""
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.01","","","","","","","fee schedule","29.6","39.47","APC"
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.49","","","","","","","fee schedule","29.6","39.47","APC"
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.19","","","","","","","fee schedule","29.6","39.47","APC"
"Vitamin d srm microsamp quan","0038U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.08","","","","","","","fee schedule","29.6","39.47","APC"
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.74","","","","","","","fee schedule","13.74","18.32",""
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.74","","","","","","","fee schedule","13.74","18.32",""
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.74","","","","","","","fee schedule","13.74","18.32",""
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.32","","","","","","","fee schedule","13.74","18.32",""
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.32","","","","","","","fee schedule","13.74","18.32",""
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.39","","","","","","","fee schedule","13.74","18.32","APC"
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.15","","","","","","","fee schedule","13.74","18.32","APC"
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.01","","","","","","","fee schedule","13.74","18.32","APC"
"Dna antb 2strand hi avidity","0039U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.43","","","","","","","fee schedule","13.74","18.32","APC"
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","409.9","","","","","","","fee schedule","409.9","546.54",""
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","409.9","","","","","","","fee schedule","409.9","546.54",""
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","409.9","","","","","","","fee schedule","409.9","546.54",""
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","546.54","","","","","","","fee schedule","409.9","546.54",""
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","546.54","","","","","","","fee schedule","409.9","546.54",""
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","429.37","","","","","","","fee schedule","409.9","546.54","APC"
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","422.2","","","","","","","fee schedule","409.9","546.54","APC"
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","418.1","","","","","","","fee schedule","409.9","546.54","APC"
"Bcr/abl1 gene major bp quan","0040U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","430.4","","","","","","","fee schedule","409.9","546.54","APC"
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.21","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.21","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.21","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.65","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.65","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.03","","","","","","","fee schedule","17.21","20.65","APC"
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.73","","","","","","","fee schedule","17.21","20.65","APC"
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.55","","","","","","","fee schedule","17.21","20.65","APC"
"B brgdrferi antb 5 prtn igm","0041U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.07","","","","","","","fee schedule","17.21","20.65","APC"
"Ct perfusion w/contrast cbf","0042T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1635","","","","","","","fee schedule","1635","1682",""
"Ct perfusion w/contrast cbf","0042T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1682","","","","","","","fee schedule","1635","1682",""
"Ct perfusion w/contrast cbf","0042T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1642","","","","","","","fee schedule","1635","1682",""
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.21","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.21","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.21","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.65","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.65","","","","","","","fee schedule","17.21","20.65",""
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.03","","","","","","","fee schedule","17.21","20.65","APC"
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.73","","","","","","","fee schedule","17.21","20.65","APC"
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.55","","","","","","","fee schedule","17.21","20.65","APC"
"B brgdrferi antb 12 prtn igg","0042U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.07","","","","","","","fee schedule","17.21","20.65","APC"
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.86","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.86","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.86","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.83","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.83","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.57","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.31","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.16","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igm","0043U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.6","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.86","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.86","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.86","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.83","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.83","","","","","","","fee schedule","14.86","17.83",""
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.57","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.31","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.16","","","","","","","fee schedule","14.86","17.83","APC"
"Tbrf b grp antb 4 prtn igg","0044U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.6","","","","","","","fee schedule","14.86","17.83","APC"
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst dux carc is 12 gene","0045U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","407.43","","","","","","","fee schedule","198.61","427.8",""
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","407.43","","","","","","","fee schedule","198.61","427.8",""
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","407.43","","","","","","","fee schedule","198.61","427.8",""
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","198.61","","","","","","","fee schedule","198.61","427.8",""
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","198.61","","","","","","","fee schedule","198.61","427.8",""
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","426.78","","","","","","","fee schedule","198.61","427.8","APC"
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","419.65","","","","","","","fee schedule","198.61","427.8","APC"
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","415.58","","","","","","","fee schedule","198.61","427.8","APC"
"Flt3 gene itd variants quan","0046U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","427.8","","","","","","","fee schedule","198.61","427.8","APC"
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prst8 mrna 17 gene alg","0047U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld org neo dna 468 gene","0048U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","407.43","","","","","","","fee schedule","295.82","427.8",""
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","407.43","","","","","","","fee schedule","295.82","427.8",""
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","407.43","","","","","","","fee schedule","295.82","427.8",""
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","295.82","","","","","","","fee schedule","295.82","427.8",""
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","295.82","","","","","","","fee schedule","295.82","427.8",""
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","426.78","","","","","","","fee schedule","295.82","427.8","APC"
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","419.65","","","","","","","fee schedule","295.82","427.8","APC"
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","415.58","","","","","","","fee schedule","295.82","427.8","APC"
"Npm1 gene analysis quan","0049U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","427.8","","","","","","","fee schedule","295.82","427.8","APC"
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2916.6","","","","","","","fee schedule","2916.6","3499.92",""
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2916.6","","","","","","","fee schedule","2916.6","3499.92",""
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2916.6","","","","","","","fee schedule","2916.6","3499.92",""
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3499.92","","","","","","","fee schedule","2916.6","3499.92",""
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499.92","","","","","","","fee schedule","2916.6","3499.92",""
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3055.14","","","","","","","fee schedule","2916.6","3499.92","APC"
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3004.1","","","","","","","fee schedule","2916.6","3499.92","APC"
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2974.93","","","","","","","fee schedule","2916.6","3499.92","APC"
"Trgt gen seq dna 194 genes","0050U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3062.43","","","","","","","fee schedule","2916.6","3499.92","APC"
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.76","259.27",""
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.76","259.27",""
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.76","259.27",""
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","246.76","","","","","","","fee schedule","246.76","259.27",""
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","246.76","","","","","","","fee schedule","246.76","259.27",""
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.76","259.27","APC"
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.76","259.27","APC"
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.76","259.27","APC"
"Rx mntr lc-ms/ms ur 31 pnl","0051U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.76","259.27","APC"
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.86","","","","","","","fee schedule","33.86","40.63",""
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.86","","","","","","","fee schedule","33.86","40.63",""
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","33.86","","","","","","","fee schedule","33.86","40.63",""
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","40.63","","","","","","","fee schedule","33.86","40.63",""
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","40.63","","","","","","","fee schedule","33.86","40.63",""
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.47","","","","","","","fee schedule","33.86","40.63","APC"
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.88","","","","","","","fee schedule","33.86","40.63","APC"
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.54","","","","","","","fee schedule","33.86","40.63","APC"
"Lpoprtn bld w/5 maj classes","0052U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.55","","","","","","","fee schedule","33.86","40.63","APC"
"Bone srgry cmptr fluor image","0054T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Bone srgry cmptr fluor image","0054T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","198.74","","","","","","","fee schedule","198.62","208.68",""
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.74","","","","","","","fee schedule","198.62","208.68",""
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.74","","","","","","","fee schedule","198.62","208.68",""
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","198.62","","","","","","","fee schedule","198.62","208.68",""
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","198.62","","","","","","","fee schedule","198.62","208.68",""
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","208.18","","","","","","","fee schedule","198.62","208.68","APC"
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","204.7","","","","","","","fee schedule","198.62","208.68","APC"
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","202.71","","","","","","","fee schedule","198.62","208.68","APC"
"Rx mntr 14+ drugs & sbsts","0054U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","208.68","","","","","","","fee schedule","198.62","208.68","APC"
"Bone srgry cmptr ct/mri imag","0055T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Bone srgry cmptr ct/mri imag","0055T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3240","","","","","","","fee schedule","3240","3888",""
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3240","","","","","","","fee schedule","3240","3888",""
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3240","","","","","","","fee schedule","3240","3888",""
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3888","","","","","","","fee schedule","3240","3888",""
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3888","","","","","","","fee schedule","3240","3888",""
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3393.9","","","","","","","fee schedule","3240","3888","APC"
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3337.2","","","","","","","fee schedule","3240","3888","APC"
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3304.8","","","","","","","fee schedule","3240","3888","APC"
"Card hrt trnspl 96 dna seq","0055U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3402","","","","","","","fee schedule","3240","3888","APC"
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","322.96","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","322.96","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","322.96","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","430.62","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","430.62","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","338.3","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","332.65","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","329.42","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm quan","0058U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","339.11","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","322.96","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","322.96","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","322.96","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","430.62","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","430.62","","","","","","","fee schedule","322.96","430.62",""
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","338.3","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","332.65","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","329.42","","","","","","","fee schedule","322.96","430.62","APC"
"Onc merkel cll carc srm +/-","0059U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","339.11","","","","","","","fee schedule","322.96","430.62","APC"
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","910.86",""
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","910.86",""
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","910.86",""
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","910.86","","","","","","","fee schedule","759.05","910.86",""
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","910.86","","","","","","","fee schedule","759.05","910.86",""
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","759.05","910.86","APC"
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","759.05","910.86","APC"
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","759.05","910.86","APC"
"Twn zyg gen seq alys chrms2","0060U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","759.05","910.86","APC"
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.1","","","","","","","fee schedule","25.1","33.42",""
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.1","","","","","","","fee schedule","25.1","33.42",""
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.1","","","","","","","fee schedule","25.1","33.42",""
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.42","","","","","","","fee schedule","25.1","33.42",""
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.42","","","","","","","fee schedule","25.1","33.42",""
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.29","","","","","","","fee schedule","25.1","33.42","APC"
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.85","","","","","","","fee schedule","25.1","33.42","APC"
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.6","","","","","","","fee schedule","25.1","33.42","APC"
"Tc meas 5 bmrk sfdi m-s alys","0061U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.36","","","","","","","fee schedule","25.1","33.42","APC"
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","380.72","","","","","","","fee schedule","380.72","456.86",""
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","380.72","","","","","","","fee schedule","380.72","456.86",""
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","380.72","","","","","","","fee schedule","380.72","456.86",""
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","456.86","","","","","","","fee schedule","380.72","456.86",""
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","456.86","","","","","","","fee schedule","380.72","456.86",""
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","398.8","","","","","","","fee schedule","380.72","456.86","APC"
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","392.14","","","","","","","fee schedule","380.72","456.86","APC"
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","388.33","","","","","","","fee schedule","380.72","456.86","APC"
"Ai sle igg&igm alys 80 bmrk","0062U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","399.76","","","","","","","fee schedule","380.72","456.86","APC"
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","900",""
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","900",""
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","900",""
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","900","","","","","","","fee schedule","750","900",""
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","900","","","","","","","fee schedule","750","900",""
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","900","APC"
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","900","APC"
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","900","APC"
"Neuro autism 32 amines alg","0063U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","900","APC"
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.33","","","","","","","fee schedule","31.33","37.6",""
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.33","","","","","","","fee schedule","31.33","37.6",""
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","31.33","","","","","","","fee schedule","31.33","37.6",""
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.6","","","","","","","fee schedule","31.33","37.6",""
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.6","","","","","","","fee schedule","31.33","37.6",""
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.82","","","","","","","fee schedule","31.33","37.6","APC"
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.27","","","","","","","fee schedule","31.33","37.6","APC"
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.96","","","","","","","fee schedule","31.33","37.6","APC"
"Antb tp total&rpr ia qual","0064U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.9","","","","","","","fee schedule","31.33","37.6","APC"
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.09","","","","","","","fee schedule","18.09","21.71",""
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.09","","","","","","","fee schedule","18.09","21.71",""
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.09","","","","","","","fee schedule","18.09","21.71",""
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.71","","","","","","","fee schedule","18.09","21.71",""
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.71","","","","","","","fee schedule","18.09","21.71",""
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.09","21.71","APC"
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.63","","","","","","","fee schedule","18.09","21.71","APC"
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.45","","","","","","","fee schedule","18.09","21.71","APC"
"Syfls tst nontreponemal antb","0065U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.99","","","","","","","fee schedule","18.09","21.71","APC"
"Pamg-1 ia cervico-vag fluid","0066U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.29","","","","","","","fee schedule","15.29","15.29",""
"Pamg-1 ia cervico-vag fluid","0066U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.29","","","","","","","fee schedule","15.29","15.29",""
"Pamg-1 ia cervico-vag fluid","0066U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.29","","","","","","","fee schedule","15.29","15.29",""
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1897","","","","","","","fee schedule","1897","2276.4",""
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1897","","","","","","","fee schedule","1897","2276.4",""
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1897","","","","","","","fee schedule","1897","2276.4",""
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2276.4","","","","","","","fee schedule","1897","2276.4",""
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2276.4","","","","","","","fee schedule","1897","2276.4",""
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1987.11","","","","","","","fee schedule","1897","2276.4","APC"
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1953.91","","","","","","","fee schedule","1897","2276.4","APC"
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1934.94","","","","","","","fee schedule","1897","2276.4","APC"
"Onc brst imhchem prfl 4 bmrk","0067U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1991.85","","","","","","","fee schedule","1897","2276.4","APC"
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.16",""
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.16","","","","","","","fee schedule","142.63","171.16",""
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.16","","","","","","","fee schedule","142.63","171.16",""
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","171.16","APC"
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","171.16","APC"
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","171.16","APC"
"Candida species pnl amp prb","0068U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","171.16","APC"
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","380","","","","","","","fee schedule","380","456",""
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","380","","","","","","","fee schedule","380","456",""
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","380","","","","","","","fee schedule","380","456",""
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","456","","","","","","","fee schedule","380","456",""
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","456","","","","","","","fee schedule","380","456",""
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","398.05","","","","","","","fee schedule","380","456","APC"
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","391.4","","","","","","","fee schedule","380","456","APC"
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","387.6","","","","","","","fee schedule","380","456","APC"
"Onc clrct microrna mir-31-3p","0069U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","399","","","","","","","fee schedule","380","456","APC"
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","676.37","","","","","","","fee schedule","676.37","811.64",""
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","676.37","","","","","","","fee schedule","676.37","811.64",""
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","676.37","","","","","","","fee schedule","676.37","811.64",""
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","811.64","","","","","","","fee schedule","676.37","811.64",""
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","811.64","","","","","","","fee schedule","676.37","811.64",""
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","708.5","","","","","","","fee schedule","676.37","811.64","APC"
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","696.66","","","","","","","fee schedule","676.37","811.64","APC"
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","689.9","","","","","","","fee schedule","676.37","811.64","APC"
"Cyp2d6 gen com&slct rar vrnt","0070U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","710.19","","","","","","","fee schedule","676.37","811.64","APC"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3221.58","14111",""
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Us leiomyomata ablate <200","0071T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","600","","","","","","","fee schedule","361.62","630",""
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","600","","","","","","","fee schedule","361.62","630",""
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","600","","","","","","","fee schedule","361.62","630",""
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","361.62","630",""
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","361.62","630",""
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","628.5","","","","","","","fee schedule","361.62","630","APC"
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","618","","","","","","","fee schedule","361.62","630","APC"
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","612","","","","","","","fee schedule","361.62","630","APC"
"Cyp2d6 full gene sequence","0071U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","630","","","","","","","fee schedule","361.62","630","APC"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3221.58","14111",""
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Us leiomyomata ablate >200","0072T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","472.33","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","464.44","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","459.93","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d6-2d7 hybrid","0072U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","473.46","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","472.33","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","464.44","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","459.93","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 gen cyp2d7-2d6 hybrid","0073U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","473.46","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","472.33","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","464.44","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","459.93","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 nonduplicated gene","0074U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","473.46","","","","","","","fee schedule","450.91","541.09","APC"
"Perq Stent/Chest Vert Art","0075T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq Stent/Chest Vert Art","0075T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","472.33","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","464.44","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","459.93","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 5' gene dup/mlt","0075U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","473.46","","","","","","","fee schedule","450.91","541.09","APC"
"S&I Stent/Chest Vert Art","0076T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"S&I Stent/Chest Vert Art","0076T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.09","","","","","","","fee schedule","450.91","541.09",""
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","472.33","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","464.44","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","459.93","","","","","","","fee schedule","450.91","541.09","APC"
"Cyp2d6 3' gene dup/mlt","0076U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","473.46","","","","","","","fee schedule","450.91","541.09","APC"
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.43","","","","","","","fee schedule","43.43","52.12",""
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.43","","","","","","","fee schedule","43.43","52.12",""
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.43","","","","","","","fee schedule","43.43","52.12",""
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","52.12","","","","","","","fee schedule","43.43","52.12",""
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","52.12","","","","","","","fee schedule","43.43","52.12",""
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45.49","","","","","","","fee schedule","43.43","52.12","APC"
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.73","","","","","","","fee schedule","43.43","52.12","APC"
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.3","","","","","","","fee schedule","43.43","52.12","APC"
"Ig paraprotein qual bld/ur","0077U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45.6","","","","","","","fee schedule","43.43","52.12","APC"
"Pain mgt opi use gnotyp pnl","0078U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.09",""
"Pain mgt opi use gnotyp pnl","0078U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Pain mgt opi use gnotyp pnl","0078U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.09",""
"Pain mgt opi use gnotyp pnl","0078U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.09","","","","","","","fee schedule","450.91","541.09",""
"Pain mgt opi use gnotyp pnl","0078U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.09","","","","","","","fee schedule","450.91","541.09",""
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3520","","","","","","","fee schedule","3520","4224",""
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3520","","","","","","","fee schedule","3520","4224",""
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3520","","","","","","","fee schedule","3520","4224",""
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4224","","","","","","","fee schedule","3520","4224",""
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4224","","","","","","","fee schedule","3520","4224",""
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3687.2","","","","","","","fee schedule","3520","4224","APC"
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3625.6","","","","","","","fee schedule","3520","4224","APC"
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3590.4","","","","","","","fee schedule","3520","4224","APC"
"Onc lng 5 clin rsk factr alg","0080U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3696","","","","","","","fee schedule","3520","4224","APC"
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","296.3",""
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","296.3",""
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","296.3",""
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","296.3","","","","","","","fee schedule","246.92","296.3",""
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","296.3","","","","","","","fee schedule","246.92","296.3",""
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","296.3","APC"
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","296.3","APC"
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","296.3","APC"
"Rx test def 90+ rx/sbsts ur","0082U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","296.3","APC"
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","167.35","","","","","","","fee schedule","167.35","200.82",""
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","167.35","","","","","","","fee schedule","167.35","200.82",""
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","167.35","","","","","","","fee schedule","167.35","200.82",""
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","200.82","","","","","","","fee schedule","167.35","200.82",""
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","200.82","","","","","","","fee schedule","167.35","200.82",""
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","175.3","","","","","","","fee schedule","167.35","200.82","APC"
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","172.37","","","","","","","fee schedule","167.35","200.82","APC"
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","170.7","","","","","","","fee schedule","167.35","200.82","APC"
"Onc rspse chemo cntrst tomog","0083U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","175.72","","","","","","","fee schedule","167.35","200.82","APC"
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","720","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","720","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","720","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","864","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","864","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","754.2","","","","","","","fee schedule","720","864","APC"
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","741.6","","","","","","","fee schedule","720","864","APC"
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","734.4","","","","","","","fee schedule","720","864","APC"
"Rbc dna gnotyp 10 bld groups","0084U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","756","","","","","","","fee schedule","720","864","APC"
"Breath Test Heart Reject","0085T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","200","","","","","","","fee schedule","200","240",""
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","200","","","","","","","fee schedule","200","240",""
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","200","","","","","","","fee schedule","200","240",""
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","240","","","","","","","fee schedule","200","240",""
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","240","","","","","","","fee schedule","200","240",""
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","209.5","","","","","","","fee schedule","200","240","APC"
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","206","","","","","","","fee schedule","200","240","APC"
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","204","","","","","","","fee schedule","200","240","APC"
"Nfct ds bact&fng org id 6+","0086U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","210","","","","","","","fee schedule","200","240","APC"
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3309.49","","","","","","","fee schedule","3159.42","3791.3","APC"
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3254.2","","","","","","","fee schedule","3159.42","3791.3","APC"
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3222.61","","","","","","","fee schedule","3159.42","3791.3","APC"
"Crd hrt trnspl mrna 1283 gen","0087U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3317.39","","","","","","","fee schedule","3159.42","3791.3","APC"
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3309.49","","","","","","","fee schedule","3159.42","3791.3","APC"
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3254.2","","","","","","","fee schedule","3159.42","3791.3","APC"
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3222.61","","","","","","","fee schedule","3159.42","3791.3","APC"
"Trnsplj kdn algrft rej 1494","0088U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3317.39","","","","","","","fee schedule","3159.42","3791.3","APC"
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc mlnma prame & linc00518","0089U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1950","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1950","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1950","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2340","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2340","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2042.63","","","","","","","fee schedule","1950","2340","APC"
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2008.5","","","","","","","fee schedule","1950","2340","APC"
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1989","","","","","","","fee schedule","1950","2340","APC"
"Onc cutan mlnma mrna 23 gene","0090U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2047.5","","","","","","","fee schedule","1950","2340","APC"
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2488","","","","","","","fee schedule","2488","2985.6",""
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2488","","","","","","","fee schedule","2488","2985.6",""
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2488","","","","","","","fee schedule","2488","2985.6",""
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2985.6","","","","","","","fee schedule","2488","2985.6",""
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2985.6","","","","","","","fee schedule","2488","2985.6",""
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2606.18","","","","","","","fee schedule","2488","2985.6","APC"
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2562.64","","","","","","","fee schedule","2488","2985.6","APC"
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2537.76","","","","","","","fee schedule","2488","2985.6","APC"
"Onc lng 3 prtn bmrk plsm alg","0092U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2612.4","","","","","","","fee schedule","2488","2985.6","APC"
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.14","","","","","","","fee schedule","62.14","74.57",""
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.14","","","","","","","fee schedule","62.14","74.57",""
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62.14","","","","","","","fee schedule","62.14","74.57",""
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","74.57","","","","","","","fee schedule","62.14","74.57",""
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","74.57","","","","","","","fee schedule","62.14","74.57",""
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.09","","","","","","","fee schedule","62.14","74.57","APC"
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64","","","","","","","fee schedule","62.14","74.57","APC"
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.38","","","","","","","fee schedule","62.14","74.57","APC"
"Rx mntr 65 com drugs urine","0093U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.25","","","","","","","fee schedule","62.14","74.57","APC"
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7582.2","","","","","","","fee schedule","7582.2","9098.64",""
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7582.2","","","","","","","fee schedule","7582.2","9098.64",""
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7582.2","","","","","","","fee schedule","7582.2","9098.64",""
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9098.64","","","","","","","fee schedule","7582.2","9098.64",""
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9098.64","","","","","","","fee schedule","7582.2","9098.64",""
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7942.35","","","","","","","fee schedule","7582.2","9098.64","APC"
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7809.67","","","","","","","fee schedule","7582.2","9098.64","APC"
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7733.84","","","","","","","fee schedule","7582.2","9098.64","APC"
"Genome rapid sequence alys","0094U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7961.31","","","","","","","fee schedule","7582.2","9098.64","APC"
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","771.98","","","","","","","fee schedule","771.98","926.38",""
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","771.98","","","","","","","fee schedule","771.98","926.38",""
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","771.98","","","","","","","fee schedule","771.98","926.38",""
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","926.38","","","","","","","fee schedule","771.98","926.38",""
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","926.38","","","","","","","fee schedule","771.98","926.38",""
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","808.65","","","","","","","fee schedule","771.98","926.38","APC"
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","795.14","","","","","","","fee schedule","771.98","926.38","APC"
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","787.42","","","","","","","fee schedule","771.98","926.38","APC"
"Inflm ee elisa alys alg","0095U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","810.58","","","","","","","fee schedule","771.98","926.38","APC"
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","42.11",""
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","35.09","42.11",""
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","35.09","42.11",""
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","42.11","APC"
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","42.11","APC"
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","42.11","APC"
"Hpv hi risk types male urine","0096U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","42.11","APC"
"Implant Corneal Ring","0099T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Prosth Retina Receive&Gen","0100T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","13700","60970",""
"Prosth Retina Receive&Gen","0100T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","60970",""
"Prosth Retina Receive&Gen","0100T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","13700","60970",""
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","245.48","19040",""
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","245.48","19040",""
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","245.48","19040",""
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","19040","APC 277.30"
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","19040","APC 296.56"
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","19040","APC 308.91"
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","19040","APC"
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","19040","APC"
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","19040","APC"
"Extracorp shockwv tx hi enrg","0101T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","19040","APC"
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1743.95","","","","","","","fee schedule","1403.76","1831.15",""
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1743.95","","","","","","","fee schedule","1403.76","1831.15",""
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1743.95","","","","","","","fee schedule","1403.76","1831.15",""
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1403.76","","","","","","","fee schedule","1403.76","1831.15",""
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1403.76","","","","","","","fee schedule","1403.76","1831.15",""
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1826.79","","","","","","","fee schedule","1403.76","1831.15","APC"
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1796.27","","","","","","","fee schedule","1403.76","1831.15","APC"
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1778.83","","","","","","","fee schedule","1403.76","1831.15","APC"
"Hered colon ca do 15 genes","0101U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1831.15","","","","","","","fee schedule","1403.76","1831.15","APC"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","19040",""
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Extracorp shockwv tx anesth","0102T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1341.58","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1341.58","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered brst ca rltd do 17 gen","0102U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1743.95","","","","","","","fee schedule","1341.58","1831.15",""
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1743.95","","","","","","","fee schedule","1341.58","1831.15",""
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1743.95","","","","","","","fee schedule","1341.58","1831.15",""
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1341.58","","","","","","","fee schedule","1341.58","1831.15",""
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1341.58","","","","","","","fee schedule","1341.58","1831.15",""
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1826.79","","","","","","","fee schedule","1341.58","1831.15","APC"
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1796.27","","","","","","","fee schedule","1341.58","1831.15","APC"
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1778.83","","","","","","","fee schedule","1341.58","1831.15","APC"
"Hered ova ca pnl 24 genes","0103U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1831.15","","","","","","","fee schedule","1341.58","1831.15","APC"
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","950","","","","","","","fee schedule","950","1140",""
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","950","","","","","","","fee schedule","950","1140",""
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","950","","","","","","","fee schedule","950","1140",""
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1140","","","","","","","fee schedule","950","1140",""
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1140","","","","","","","fee schedule","950","1140",""
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","995.13","","","","","","","fee schedule","950","1140","APC"
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","978.5","","","","","","","fee schedule","950","1140","APC"
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","969","","","","","","","fee schedule","950","1140","APC"
"Neph ckd mult eclia tum nec","0105U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","997.5","","","","","","","fee schedule","950","1140","APC"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Touch Quant Sensory Test","0106T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","874.49","","","","","","","fee schedule","874.49","1049.39",""
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","874.49","","","","","","","fee schedule","874.49","1049.39",""
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","874.49","","","","","","","fee schedule","874.49","1049.39",""
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1049.39","","","","","","","fee schedule","874.49","1049.39",""
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1049.39","","","","","","","fee schedule","874.49","1049.39",""
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","916.03","","","","","","","fee schedule","874.49","1049.39","APC"
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","900.72","","","","","","","fee schedule","874.49","1049.39","APC"
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","891.98","","","","","","","fee schedule","874.49","1049.39","APC"
"Gstr emptg 7 timed brth spec","0106U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","918.21","","","","","","","fee schedule","874.49","1049.39","APC"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Vibrate Quant Sensory Test","0107T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16","","","","","","","fee schedule","16","19.2",""
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16","","","","","","","fee schedule","16","19.2",""
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16","","","","","","","fee schedule","16","19.2",""
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.2","","","","","","","fee schedule","16","19.2",""
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.2","","","","","","","fee schedule","16","19.2",""
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.76","","","","","","","fee schedule","16","19.2","APC"
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.48","","","","","","","fee schedule","16","19.2","APC"
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.32","","","","","","","fee schedule","16","19.2","APC"
"C diff tox ag detcj ia stool","0107U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.8","","","","","","","fee schedule","16","19.2","APC"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Cool Quant Sensory Test","0108T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4950","","","","","","","fee schedule","3015.9","5197.5",""
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4950","","","","","","","fee schedule","3015.9","5197.5",""
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4950","","","","","","","fee schedule","3015.9","5197.5",""
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3015.9","","","","","","","fee schedule","3015.9","5197.5",""
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3015.9","","","","","","","fee schedule","3015.9","5197.5",""
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5185.13","","","","","","","fee schedule","3015.9","5197.5","APC"
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5098.5","","","","","","","fee schedule","3015.9","5197.5","APC"
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5049","","","","","","","fee schedule","3015.9","5197.5","APC"
"Gi barrett esoph 9 prtn bmrk","0108U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5197.5","","","","","","","fee schedule","3015.9","5197.5","APC"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Heat Quant Sensory Test","0109T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.16",""
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.16","","","","","","","fee schedule","142.63","171.16",""
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.16","","","","","","","fee schedule","142.63","171.16",""
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","171.16","APC"
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","171.16","APC"
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","171.16","APC"
"Id aspergillus dna 4 species","0109U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","171.16","APC"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Nos Quant Sensory Test","0110T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","32.53",""
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.53","","","","","","","fee schedule","27.11","32.53",""
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.53","","","","","","","fee schedule","27.11","32.53",""
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","32.53","APC"
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","32.53","APC"
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","32.53","APC"
"Rx mntr 1+oral onc rx&sbsts","0110U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","32.53","APC"
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","682.29","","","","","","","fee schedule","682.29","818.75",""
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","682.29","","","","","","","fee schedule","682.29","818.75",""
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","682.29","","","","","","","fee schedule","682.29","818.75",""
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","818.75","","","","","","","fee schedule","682.29","818.75",""
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","818.75","","","","","","","fee schedule","682.29","818.75",""
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","714.7","","","","","","","fee schedule","682.29","818.75","APC"
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","702.76","","","","","","","fee schedule","682.29","818.75","APC"
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","695.94","","","","","","","fee schedule","682.29","818.75","APC"
"Onc colon ca kras&nras alys","0111U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","716.4","","","","","","","fee schedule","682.29","818.75","APC"
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","356.13","","","","","","","fee schedule","356.13","427.36",""
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","356.13","","","","","","","fee schedule","356.13","427.36",""
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","356.13","","","","","","","fee schedule","356.13","427.36",""
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","427.36","","","","","","","fee schedule","356.13","427.36",""
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","427.36","","","","","","","fee schedule","356.13","427.36",""
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","373.05","","","","","","","fee schedule","356.13","427.36","APC"
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","366.81","","","","","","","fee schedule","356.13","427.36","APC"
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","363.25","","","","","","","fee schedule","356.13","427.36","APC"
"Iadi 16s&18s rrna genes","0112U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","373.94","","","","","","","fee schedule","356.13","427.36","APC"
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 pca3&tmprss2-erg","0113U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1938.01","","","","","","","fee schedule","1938.01","2325.61",""
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1938.01","","","","","","","fee schedule","1938.01","2325.61",""
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1938.01","","","","","","","fee schedule","1938.01","2325.61",""
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2325.61","","","","","","","fee schedule","1938.01","2325.61",""
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2325.61","","","","","","","fee schedule","1938.01","2325.61",""
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2030.07","","","","","","","fee schedule","1938.01","2325.61","APC"
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1996.15","","","","","","","fee schedule","1938.01","2325.61","APC"
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1976.77","","","","","","","fee schedule","1938.01","2325.61","APC"
"Gi barretts esoph vim&ccna1","0114U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2034.91","","","","","","","fee schedule","1938.01","2325.61","APC"
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","275.35","","","","","","","fee schedule","275.35","330.42",""
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","275.35","","","","","","","fee schedule","275.35","330.42",""
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","275.35","","","","","","","fee schedule","275.35","330.42",""
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","330.42","","","","","","","fee schedule","275.35","330.42",""
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","330.42","","","","","","","fee schedule","275.35","330.42",""
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","288.43","","","","","","","fee schedule","275.35","330.42","APC"
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.61","","","","","","","fee schedule","275.35","330.42","APC"
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.86","","","","","","","fee schedule","275.35","330.42","APC"
"Respir iadna 18 viral&2 bact","0115U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","289.12","","","","","","","fee schedule","275.35","330.42","APC"
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","296.3",""
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","296.3",""
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","296.3",""
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","296.3","","","","","","","fee schedule","246.92","296.3",""
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","296.3","","","","","","","fee schedule","246.92","296.3",""
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","296.3","APC"
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","296.3","APC"
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","296.3","APC"
"Rx mntr nzm ia 35+oral flu","0116U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","296.3","APC"
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","840.65","","","","","","","fee schedule","840.65","1008.78",""
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","840.65","","","","","","","fee schedule","840.65","1008.78",""
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","840.65","","","","","","","fee schedule","840.65","1008.78",""
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1008.78","","","","","","","fee schedule","840.65","1008.78",""
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1008.78","","","","","","","fee schedule","840.65","1008.78",""
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","880.58","","","","","","","fee schedule","840.65","1008.78","APC"
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","865.87","","","","","","","fee schedule","840.65","1008.78","APC"
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","857.46","","","","","","","fee schedule","840.65","1008.78","APC"
"Pain mgmt 11 endogenous anal","0117U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","882.68","","","","","","","fee schedule","840.65","1008.78","APC"
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2753.25","","","","","","","fee schedule","2753.25","3303.9",""
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2753.25","","","","","","","fee schedule","2753.25","3303.9",""
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2753.25","","","","","","","fee schedule","2753.25","3303.9",""
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3303.9","","","","","","","fee schedule","2753.25","3303.9",""
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3303.9","","","","","","","fee schedule","2753.25","3303.9",""
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2884.03","","","","","","","fee schedule","2753.25","3303.9","APC"
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2835.85","","","","","","","fee schedule","2753.25","3303.9","APC"
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2808.32","","","","","","","fee schedule","2753.25","3303.9","APC"
"Trnsplj don-drv cll-fr dna","0118U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2890.91","","","","","","","fee schedule","2753.25","3303.9","APC"
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","83.76","","","","","","","fee schedule","83.76","100.51",""
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","83.76","","","","","","","fee schedule","83.76","100.51",""
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","83.76","","","","","","","fee schedule","83.76","100.51",""
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","100.51","","","","","","","fee schedule","83.76","100.51",""
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","100.51","","","","","","","fee schedule","83.76","100.51",""
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","87.74","","","","","","","fee schedule","83.76","100.51","APC"
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","86.27","","","","","","","fee schedule","83.76","100.51","APC"
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","85.44","","","","","","","fee schedule","83.76","100.51","APC"
"Crd ceramides liq chrom plsm","0119U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","87.95","","","","","","","fee schedule","83.76","100.51","APC"
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2510.21","","","","","","","fee schedule","2510.21","3346.94",""
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2510.21","","","","","","","fee schedule","2510.21","3346.94",""
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2510.21","","","","","","","fee schedule","2510.21","3346.94",""
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3346.94","","","","","","","fee schedule","2510.21","3346.94",""
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3346.94","","","","","","","fee schedule","2510.21","3346.94",""
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2629.44","","","","","","","fee schedule","2510.21","3346.94","APC"
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2585.52","","","","","","","fee schedule","2510.21","3346.94","APC"
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2560.41","","","","","","","fee schedule","2510.21","3346.94","APC"
"Onc b cll lymphm mrna 58 gen","0120U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2635.72","","","","","","","fee schedule","2510.21","3346.94","APC"
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","509.2","","","","","","","fee schedule","509.2","611.04",""
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","509.2","","","","","","","fee schedule","509.2","611.04",""
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","509.2","","","","","","","fee schedule","509.2","611.04",""
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","611.04","","","","","","","fee schedule","509.2","611.04",""
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","611.04","","","","","","","fee schedule","509.2","611.04",""
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","533.39","","","","","","","fee schedule","509.2","611.04","APC"
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","524.48","","","","","","","fee schedule","509.2","611.04","APC"
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","519.38","","","","","","","fee schedule","509.2","611.04","APC"
"Sc dis vcam-1 whole blood","0121U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","534.66","","","","","","","fee schedule","509.2","611.04","APC"
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","526.23","","","","","","","fee schedule","526.23","631.48",""
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","526.23","","","","","","","fee schedule","526.23","631.48",""
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","526.23","","","","","","","fee schedule","526.23","631.48",""
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","631.48","","","","","","","fee schedule","526.23","631.48",""
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","631.48","","","","","","","fee schedule","526.23","631.48",""
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.23","","","","","","","fee schedule","526.23","631.48","APC"
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542.02","","","","","","","fee schedule","526.23","631.48","APC"
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.75","","","","","","","fee schedule","526.23","631.48","APC"
"Sc dis p-selectin whl blood","0122U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.54","","","","","","","fee schedule","526.23","631.48","APC"
"Scleral Fistulization","0123T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","10181",""
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","357.63","","","","","","","fee schedule","357.63","429.16",""
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","357.63","","","","","","","fee schedule","357.63","429.16",""
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","357.63","","","","","","","fee schedule","357.63","429.16",""
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","429.16","","","","","","","fee schedule","357.63","429.16",""
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","429.16","","","","","","","fee schedule","357.63","429.16",""
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","374.62","","","","","","","fee schedule","357.63","429.16","APC"
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","368.36","","","","","","","fee schedule","357.63","429.16","APC"
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","364.78","","","","","","","fee schedule","357.63","429.16","APC"
"Mchnl fragility rbc prflg","0123U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","375.51","","","","","","","fee schedule","357.63","429.16","APC"
"Conjunctival Drug Placement","0124T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Chd Risk Imt Study","0126T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1341.58","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1341.58","","","","","","","fee schedule","1303.95","1369.15",""
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered brst ca rltd do panel","0129U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","701.88",""
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","701.88",""
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","701.88",""
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","701.88","","","","","","","fee schedule","584.9","701.88",""
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","701.88","","","","","","","fee schedule","584.9","701.88",""
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","701.88","APC"
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","701.88","APC"
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","701.88","APC"
"Hered colon ca do mrna pnl","0130U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","701.88","APC"
"Hered brst ca rltd do pnl 13","0131U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","710","","","","","","","fee schedule","710","852",""
"Hered brst ca rltd do pnl 13","0131U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","710","","","","","","","fee schedule","710","852",""
"Hered brst ca rltd do pnl 13","0131U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","710","","","","","","","fee schedule","710","852",""
"Hered brst ca rltd do pnl 13","0131U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","852","","","","","","","fee schedule","710","852",""
"Hered brst ca rltd do pnl 13","0131U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","852","","","","","","","fee schedule","710","852",""
"Hered ova ca rltd do pnl 17","0132U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","741.64","","","","","","","fee schedule","741.64","889.97",""
"Hered ova ca rltd do pnl 17","0132U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","741.64","","","","","","","fee schedule","741.64","889.97",""
"Hered ova ca rltd do pnl 17","0132U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","741.64","","","","","","","fee schedule","741.64","889.97",""
"Hered ova ca rltd do pnl 17","0132U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","889.97","","","","","","","fee schedule","741.64","889.97",""
"Hered ova ca rltd do pnl 17","0132U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","889.97","","","","","","","fee schedule","741.64","889.97",""
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","690.29","","","","","","","fee schedule","690.29","828.35",""
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","690.29","","","","","","","fee schedule","690.29","828.35",""
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","690.29","","","","","","","fee schedule","690.29","828.35",""
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","828.35","","","","","","","fee schedule","690.29","828.35",""
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","828.35","","","","","","","fee schedule","690.29","828.35",""
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.08","","","","","","","fee schedule","690.29","828.35","APC"
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711","","","","","","","fee schedule","690.29","828.35","APC"
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.1","","","","","","","fee schedule","690.29","828.35","APC"
"Hered prst8 ca rltd do 11","0133U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","724.8","","","","","","","fee schedule","690.29","828.35","APC"
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","748.39","","","","","","","fee schedule","748.39","898.07",""
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","748.39","","","","","","","fee schedule","748.39","898.07",""
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","748.39","","","","","","","fee schedule","748.39","898.07",""
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","898.07","","","","","","","fee schedule","748.39","898.07",""
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","898.07","","","","","","","fee schedule","748.39","898.07",""
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","783.94","","","","","","","fee schedule","748.39","898.07","APC"
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","770.84","","","","","","","fee schedule","748.39","898.07","APC"
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","763.36","","","","","","","fee schedule","748.39","898.07","APC"
"Hered pan ca mrna pnl 18 gen","0134U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","785.81","","","","","","","fee schedule","748.39","898.07","APC"
"Hered gyn ca mrna pnl 12 gen","0135U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","700.56","","","","","","","fee schedule","700.56","840.67",""
"Hered gyn ca mrna pnl 12 gen","0135U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","700.56","","","","","","","fee schedule","700.56","840.67",""
"Hered gyn ca mrna pnl 12 gen","0135U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","700.56","","","","","","","fee schedule","700.56","840.67",""
"Hered gyn ca mrna pnl 12 gen","0135U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","840.67","","","","","","","fee schedule","700.56","840.67",""
"Hered gyn ca mrna pnl 12 gen","0135U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","840.67","","","","","","","fee schedule","700.56","840.67",""
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","407.43","","","","","","","fee schedule","407.43","488.92",""
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","407.43","","","","","","","fee schedule","407.43","488.92",""
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","407.43","","","","","","","fee schedule","407.43","488.92",""
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","488.92","","","","","","","fee schedule","407.43","488.92",""
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","488.92","","","","","","","fee schedule","407.43","488.92",""
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","426.78","","","","","","","fee schedule","407.43","488.92","APC"
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","419.65","","","","","","","fee schedule","407.43","488.92","APC"
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","415.58","","","","","","","fee schedule","407.43","488.92","APC"
"Atm mrna seq alys","0136U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","427.8","","","","","","","fee schedule","407.43","488.92","APC"
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Palb2 mrna seq alys","0137U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","468.33","","","","","","","fee schedule","468.33","562",""
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","468.33","","","","","","","fee schedule","468.33","562",""
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","468.33","","","","","","","fee schedule","468.33","562",""
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","562","","","","","","","fee schedule","468.33","562",""
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","562","","","","","","","fee schedule","468.33","562",""
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","490.58","","","","","","","fee schedule","468.33","562","APC"
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","482.38","","","","","","","fee schedule","468.33","562","APC"
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","477.7","","","","","","","fee schedule","468.33","562","APC"
"Brca1 brca2 mrna seq alys","0138U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","491.75","","","","","","","fee schedule","468.33","562","APC"
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","188.1","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","188.1","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","164.2","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","161.45","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.88","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds fungi dna 15 trgt","0140U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","164.59","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","188.1","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","188.1","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","164.2","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","161.45","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.88","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram pos","0141U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","164.59","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","156.75","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","188.1","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","188.1","","","","","","","fee schedule","156.75","188.1",""
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","164.2","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","161.45","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.88","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct ds bact&fng gram neg","0142U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","164.59","","","","","","","fee schedule","156.75","188.1","APC"
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2126.2","","","","","","","fee schedule","2126.2","2551.44",""
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2126.2","","","","","","","fee schedule","2126.2","2551.44",""
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2126.2","","","","","","","fee schedule","2126.2","2551.44",""
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2551.44","","","","","","","fee schedule","2126.2","2551.44",""
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2551.44","","","","","","","fee schedule","2126.2","2551.44",""
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2227.19","","","","","","","fee schedule","2126.2","2551.44","APC"
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2189.99","","","","","","","fee schedule","2126.2","2551.44","APC"
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2168.72","","","","","","","fee schedule","2126.2","2551.44","APC"
"Nfct bct fng prst dna >1000","0152U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2232.51","","","","","","","fee schedule","2126.2","2551.44","APC"
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3309.49","","","","","","","fee schedule","3159.42","3791.3","APC"
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3254.2","","","","","","","fee schedule","3159.42","3791.3","APC"
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3222.61","","","","","","","fee schedule","3159.42","3791.3","APC"
"Onc breast mrna 101 genes","0153U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3317.39","","","","","","","fee schedule","3159.42","3791.3","APC"
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","482.14","","","","","","","fee schedule","248.77","506.25",""
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","482.14","","","","","","","fee schedule","248.77","506.25",""
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","482.14","","","","","","","fee schedule","248.77","506.25",""
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","248.77","","","","","","","fee schedule","248.77","506.25",""
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","248.77","","","","","","","fee schedule","248.77","506.25",""
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","505.04","","","","","","","fee schedule","248.77","506.25","APC"
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","496.6","","","","","","","fee schedule","248.77","506.25","APC"
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","491.78","","","","","","","fee schedule","248.77","506.25","APC"
"Fgfr3 gene analysis","0154U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","506.25","","","","","","","fee schedule","248.77","506.25","APC"
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Pik3ca gene analysis","0155U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1740","","","","","","","fee schedule","1740","2088",""
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1740","","","","","","","fee schedule","1740","2088",""
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1740","","","","","","","fee schedule","1740","2088",""
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2088","","","","","","","fee schedule","1740","2088",""
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2088","","","","","","","fee schedule","1740","2088",""
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1822.65","","","","","","","fee schedule","1740","2088","APC"
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1792.2","","","","","","","fee schedule","1740","2088","APC"
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1774.8","","","","","","","fee schedule","1740","2088","APC"
"Copy number sequence alys","0156U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1827","","","","","","","fee schedule","1740","2088","APC"
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Apc mrna seq alys","0157U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Mlh1 mrna seq alys","0158U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Msh2 mrna seq alys","0159U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Msh6 mrna seq alys","0160U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Pms2 mrna seq alys","0161U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","486.54","","","","","","","fee schedule","486.54","583.85",""
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","486.54","","","","","","","fee schedule","486.54","583.85",""
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","486.54","","","","","","","fee schedule","486.54","583.85",""
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","583.85","","","","","","","fee schedule","486.54","583.85",""
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","583.85","","","","","","","fee schedule","486.54","583.85",""
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","509.65","","","","","","","fee schedule","486.54","583.85","APC"
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","501.14","","","","","","","fee schedule","486.54","583.85","APC"
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","496.27","","","","","","","fee schedule","486.54","583.85","APC"
"Hered colon ca trgt mrna pnl","0162U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","510.87","","","","","","","fee schedule","486.54","583.85","APC"
"Onc clrct scr 3 prtn alg","0163U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","390.75","","","","","","","fee schedule","390.75","468.9",""
"Onc clrct scr 3 prtn alg","0163U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Onc clrct scr 3 prtn alg","0163U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Onc clrct scr 3 prtn alg","0163U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","468.9","","","","","","","fee schedule","390.75","468.9",""
"Onc clrct scr 3 prtn alg","0163U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","468.9","","","","","","","fee schedule","390.75","468.9",""
"Remove Lumb Artif Disc Addl","0164T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Remove Lumb Artif Disc Addl","0164T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","112.02","","","","","","","fee schedule","112.02","134.42",""
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","112.02","","","","","","","fee schedule","112.02","134.42",""
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","112.02","","","","","","","fee schedule","112.02","134.42",""
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","134.42","","","","","","","fee schedule","112.02","134.42",""
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","134.42","","","","","","","fee schedule","112.02","134.42",""
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","117.34","","","","","","","fee schedule","112.02","134.42","APC"
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","115.38","","","","","","","fee schedule","112.02","134.42","APC"
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","114.26","","","","","","","fee schedule","112.02","134.42","APC"
"Gi ibs ia anti-cdtb&vinculin","0164U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","117.62","","","","","","","fee schedule","112.02","134.42","APC"
"Revise Lumb Artif Disc Addl","0165T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Revise Lumb Artif Disc Addl","0165T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","463.76","","","","","","","fee schedule","463.76","556.51",""
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","463.76","","","","","","","fee schedule","463.76","556.51",""
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","463.76","","","","","","","fee schedule","463.76","556.51",""
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","556.51","","","","","","","fee schedule","463.76","556.51",""
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","556.51","","","","","","","fee schedule","463.76","556.51",""
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","485.79","","","","","","","fee schedule","463.76","556.51","APC"
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","477.67","","","","","","","fee schedule","463.76","556.51","APC"
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","473.04","","","","","","","fee schedule","463.76","556.51","APC"
"Peanut allg spec asmt 64 epi","0165U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","486.95","","","","","","","fee schedule","463.76","556.51","APC"
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.4","","","","","","","fee schedule","503.4","604.08",""
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","503.4","","","","","","","fee schedule","503.4","604.08",""
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","503.4","","","","","","","fee schedule","503.4","604.08",""
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","604.08","","","","","","","fee schedule","503.4","604.08",""
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","604.08","","","","","","","fee schedule","503.4","604.08",""
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","527.31","","","","","","","fee schedule","503.4","604.08","APC"
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","518.5","","","","","","","fee schedule","503.4","604.08","APC"
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","513.47","","","","","","","fee schedule","503.4","604.08","APC"
"Liver ds 10 biochem asy srm","0166U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","528.57","","","","","","","fee schedule","503.4","604.08","APC"
"Chornc gonadotropin hcg ia","0167U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.02","","","","","","","fee schedule","9.02","9.02",""
"Chornc gonadotropin hcg ia","0167U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.02","","","","","","","fee schedule","9.02","9.02",""
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","466.17","","","","","","","fee schedule","466.17","559.4",""
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","466.17","","","","","","","fee schedule","466.17","559.4",""
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","466.17","","","","","","","fee schedule","466.17","559.4",""
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","559.4","","","","","","","fee schedule","466.17","559.4",""
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","559.4","","","","","","","fee schedule","466.17","559.4",""
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","488.31","","","","","","","fee schedule","466.17","559.4","APC"
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","480.16","","","","","","","fee schedule","466.17","559.4","APC"
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","475.49","","","","","","","fee schedule","466.17","559.4","APC"
"Nudt15&tpmt gene com vrnt","0169U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","489.48","","","","","","","fee schedule","466.17","559.4","APC"
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1950","","","","","","","fee schedule","1950","2106",""
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1950","","","","","","","fee schedule","1950","2106",""
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1950","","","","","","","fee schedule","1950","2106",""
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2106","","","","","","","fee schedule","1950","2106",""
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2106","","","","","","","fee schedule","1950","2106",""
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2042.63","","","","","","","fee schedule","1950","2106","APC"
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2008.5","","","","","","","fee schedule","1950","2106","APC"
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1989","","","","","","","fee schedule","1950","2106","APC"
"Neuro asd rna next gen seq","0170U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2047.5","","","","","","","fee schedule","1950","2106","APC"
"Lumbar spine proces distract","0171T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1519.06","","","","","","","fee schedule","1519.06","1822.87",""
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1519.06","","","","","","","fee schedule","1519.06","1822.87",""
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1519.06","","","","","","","fee schedule","1519.06","1822.87",""
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1822.87","","","","","","","fee schedule","1519.06","1822.87",""
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1822.87","","","","","","","fee schedule","1519.06","1822.87",""
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.22","","","","","","","fee schedule","1519.06","1822.87","APC"
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1564.63","","","","","","","fee schedule","1519.06","1822.87","APC"
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.44","","","","","","","fee schedule","1519.06","1822.87","APC"
"Trgt gen seq alys pnl dna 23","0171U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.01","","","","","","","fee schedule","1519.06","1822.87","APC"
"Lumbar spine process addl","0172T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3030","","","","","","","fee schedule","3030","3636",""
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3030","","","","","","","fee schedule","3030","3636",""
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3030","","","","","","","fee schedule","3030","3636",""
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3636","","","","","","","fee schedule","3030","3636",""
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3636","","","","","","","fee schedule","3030","3636",""
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3173.92","","","","","","","fee schedule","3030","3636","APC"
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3120.9","","","","","","","fee schedule","3030","3636","APC"
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3090.6","","","","","","","fee schedule","3030","3636","APC"
"Onc sld tum alys brca1 brca2","0172U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3181.5","","","","","","","fee schedule","3030","3636","APC"
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","466.17","","","","","","","fee schedule","466.17","559.4",""
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","466.17","","","","","","","fee schedule","466.17","559.4",""
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","466.17","","","","","","","fee schedule","466.17","559.4",""
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","559.4","","","","","","","fee schedule","466.17","559.4",""
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","559.4","","","","","","","fee schedule","466.17","559.4",""
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","488.31","","","","","","","fee schedule","466.17","559.4","APC"
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","480.16","","","","","","","fee schedule","466.17","559.4","APC"
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","475.49","","","","","","","fee schedule","466.17","559.4","APC"
"Psyc gen alys panel 14 genes","0173U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","489.48","","","","","","","fee schedule","466.17","559.4","APC"
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1305.37","","","","","","","fee schedule","1305.37","1566.44",""
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1305.37","","","","","","","fee schedule","1305.37","1566.44",""
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1305.37","","","","","","","fee schedule","1305.37","1566.44",""
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1566.44","","","","","","","fee schedule","1305.37","1566.44",""
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1566.44","","","","","","","fee schedule","1305.37","1566.44",""
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1367.38","","","","","","","fee schedule","1305.37","1566.44","APC"
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1344.53","","","","","","","fee schedule","1305.37","1566.44","APC"
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1331.48","","","","","","","fee schedule","1305.37","1566.44","APC"
"Onc solid tumor 30 prtn trgt","0174U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1370.64","","","","","","","fee schedule","1305.37","1566.44","APC"
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc gen alys panel 15 genes","0175U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.19","","","","","","","fee schedule","64.19","77.03",""
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.19","","","","","","","fee schedule","64.19","77.03",""
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.19","","","","","","","fee schedule","64.19","77.03",""
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","77.03","","","","","","","fee schedule","64.19","77.03",""
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","77.03","","","","","","","fee schedule","64.19","77.03",""
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.24","","","","","","","fee schedule","64.19","77.03","APC"
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.12","","","","","","","fee schedule","64.19","77.03","APC"
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.47","","","","","","","fee schedule","64.19","77.03","APC"
"Cdtb&vinculin igg antb ia","0176U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.4","","","","","","","fee schedule","64.19","77.03","APC"
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","295.82",""
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","295.82",""
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","295.82",""
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","295.82","","","","","","","fee schedule","274.83","295.82",""
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","295.82","","","","","","","fee schedule","274.83","295.82",""
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","295.82","APC"
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","295.82","APC"
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","295.82","APC"
"Onc brst ca dna pik3ca 11","0177U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","295.82","APC"
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","459.86","","","","","","","fee schedule","459.86","551.83",""
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","459.86","","","","","","","fee schedule","459.86","551.83",""
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.86","","","","","","","fee schedule","459.86","551.83",""
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","551.83","","","","","","","fee schedule","459.86","551.83",""
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","551.83","","","","","","","fee schedule","459.86","551.83",""
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","481.7","","","","","","","fee schedule","459.86","551.83","APC"
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","473.66","","","","","","","fee schedule","459.86","551.83","APC"
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","469.06","","","","","","","fee schedule","459.86","551.83","APC"
"Peanut allg asmt epi clin rx","0178U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","482.85","","","","","","","fee schedule","459.86","551.83","APC"
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1943.21","","","","","","","fee schedule","1943.21","2331.85",""
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1943.21","","","","","","","fee schedule","1943.21","2331.85",""
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1943.21","","","","","","","fee schedule","1943.21","2331.85",""
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2331.85","","","","","","","fee schedule","1943.21","2331.85",""
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2331.85","","","","","","","fee schedule","1943.21","2331.85",""
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2035.51","","","","","","","fee schedule","1943.21","2331.85","APC"
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2001.51","","","","","","","fee schedule","1943.21","2331.85","APC"
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1982.07","","","","","","","fee schedule","1943.21","2331.85","APC"
"Onc nonsm cll lng ca alys 23","0179U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2040.37","","","","","","","fee schedule","1943.21","2331.85","APC"
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Abo gnotyp abo 7 exons","0180U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Corneal hysteresis","0181T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Co gnotyp aqp1 exon 1","0181U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Crom gnotyp cd55 exons 1-10","0182U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Di gnotyp slc4a1 exon 19","0183U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6041.75","20959.15",""
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6041.75","20959.15",""
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"Exc rectal tumor endoscopic","0184T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Do gnotyp art4 exon 2","0184U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Fut1 gnotyp fut1 exon 4","0185U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Suprachoroidal drug delivery","0186T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Fut2 gnotyp fut2 exon 2","0186U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Fy gnotyp ackr1 exons 1-2","0187U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Ge gnotyp gypc exons 1-4","0188U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Gypa gnotyp ntrns 1 5 exon 2","0189U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Place intraoc radiation src","0190T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Gypb gnotyp ntrns 1 5 seux 3","0190U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Insert ant segment drain int","0191T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"In gnotyp cd44 exons 2 3 6","0191U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Insert ant seg aqueous drainage devis; ext apprch","0192T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Jk gnotyp slc14a1 exon 9","0192U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Jr gnotyp abcg2 exons 2-26","0193U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Kel gnotyp kel exon 8","0194U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375.25","","","","","","","fee schedule","375.25","450.3",""
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375.25","","","","","","","fee schedule","375.25","450.3",""
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375.25","","","","","","","fee schedule","375.25","450.3",""
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","450.3","","","","","","","fee schedule","375.25","450.3",""
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","450.3","","","","","","","fee schedule","375.25","450.3",""
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","393.07","","","","","","","fee schedule","375.25","450.3","APC"
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.51","","","","","","","fee schedule","375.25","450.3","APC"
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.76","","","","","","","fee schedule","375.25","450.3","APC"
"Klf1 targeted sequencing","0195U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","394.01","","","","","","","fee schedule","375.25","450.3","APC"
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Lu gnotyp bcam exon 3","0196U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Lw gnotyp icam4 exon 1","0197U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ocular blood flow measure","0198T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Rhd&rhce gntyp rhd1-10&rhce5","0198U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Sc gnotyp ermap exons 4 12","0199U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Perq sacral augmt unilat inj","0200T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Xk gnotyp xk exons 1-3","0200U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","25051.33",""
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Perq sacral augmt bilat inj","0201T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Yt gnotyp ache exon 2","0201U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Post vert arthrplst 1 lumbar","0202T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds 22 trgt sars-cov-2","0202U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","500.14","APC"
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Ai ibd mrna xprsn prfl 17","0203U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc thyr mrna xprsn alys 593","0204U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","3503.52","3503.52",""
"Onc thyr mrna xprsn alys 593","0204U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","3503.52","3503.52",""
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47","","","","","","","fee schedule","47","56.4",""
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47","","","","","","","fee schedule","47","56.4",""
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47","","","","","","","fee schedule","47","56.4",""
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","56.4","","","","","","","fee schedule","47","56.4",""
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","56.4","","","","","","","fee schedule","47","56.4",""
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.23","","","","","","","fee schedule","47","56.4","APC"
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.41","","","","","","","fee schedule","47","56.4","APC"
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.94","","","","","","","fee schedule","47","56.4","APC"
"Oph amd alys 3 gene variants","0205U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.35","","","","","","","fee schedule","47","56.4","APC"
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2215.4","","","","","","","fee schedule","2215.4","2658.48",""
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2215.4","","","","","","","fee schedule","2215.4","2658.48",""
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2215.4","","","","","","","fee schedule","2215.4","2658.48",""
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2658.48","","","","","","","fee schedule","2215.4","2658.48",""
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2658.48","","","","","","","fee schedule","2215.4","2658.48",""
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2320.63","","","","","","","fee schedule","2215.4","2658.48","APC"
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2281.86","","","","","","","fee schedule","2215.4","2658.48","APC"
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2259.71","","","","","","","fee schedule","2215.4","2658.48","APC"
"Neuro alzheimer cell aggregj","0206U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2326.17","","","","","","","fee schedule","2215.4","2658.48","APC"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","2633",""
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","2633",""
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","2633","APC 277.30"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","2633","APC 296.56"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","2633","APC 308.91"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","2633","APC"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","2633","APC"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","2633","APC"
"Clear eyelid gland w/heat","0207T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","2633","APC"
"Neuro alzheimer quan imaging","0207U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","511.2","","","","","","","fee schedule","511.2","613.44",""
"Neuro alzheimer quan imaging","0207U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","511.2","","","","","","","fee schedule","511.2","613.44",""
"Neuro alzheimer quan imaging","0207U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","511.2","","","","","","","fee schedule","511.2","613.44",""
"Neuro alzheimer quan imaging","0207U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","613.44","","","","","","","fee schedule","511.2","613.44",""
"Neuro alzheimer quan imaging","0207U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","613.44","","","","","","","fee schedule","511.2","613.44",""
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air only","0208T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Audiometry air & bone","0209T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","787.15","","","","","","","fee schedule","787.15","944.58",""
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","787.15","","","","","","","fee schedule","787.15","944.58",""
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","787.15","","","","","","","fee schedule","787.15","944.58",""
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","944.58","","","","","","","fee schedule","787.15","944.58",""
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","944.58","","","","","","","fee schedule","787.15","944.58",""
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","824.54","","","","","","","fee schedule","787.15","944.58","APC"
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","810.76","","","","","","","fee schedule","787.15","944.58","APC"
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","802.89","","","","","","","fee schedule","787.15","944.58","APC"
"Cytog const alys interrog","0209U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","826.51","","","","","","","fee schedule","787.15","944.58","APC"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Speech audiometry threshold","0210T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.63","","","","","","","fee schedule","18.63","22.36",""
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.63","","","","","","","fee schedule","18.63","22.36",""
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.63","","","","","","","fee schedule","18.63","22.36",""
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.36","","","","","","","fee schedule","18.63","22.36",""
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.36","","","","","","","fee schedule","18.63","22.36",""
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.51","","","","","","","fee schedule","18.63","22.36","APC"
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.19","","","","","","","fee schedule","18.63","22.36","APC"
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19","","","","","","","fee schedule","18.63","22.36","APC"
"Syphilis tst antb ia quan","0210U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.56","","","","","","","fee schedule","18.63","22.36","APC"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Speech audiom thresh & recog","0211T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8455","","","","","","","fee schedule","4410","8877.75",""
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8455","","","","","","","fee schedule","4410","8877.75",""
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8455","","","","","","","fee schedule","4410","8877.75",""
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4410","","","","","","","fee schedule","4410","8877.75",""
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4410","","","","","","","fee schedule","4410","8877.75",""
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8856.61","","","","","","","fee schedule","4410","8877.75","APC"
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8708.65","","","","","","","fee schedule","4410","8877.75","APC"
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8624.1","","","","","","","fee schedule","4410","8877.75","APC"
"Onc pan-tum dna&rna gnrj seq","0211U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8877.75","","","","","","","fee schedule","4410","8877.75","APC"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Compre audiometry evaluation","0212T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5475.2","","","","","","","fee schedule","5475.2","6570.24",""
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5475.2","","","","","","","fee schedule","5475.2","6570.24",""
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5475.2","","","","","","","fee schedule","5475.2","6570.24",""
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6570.24","","","","","","","fee schedule","5475.2","6570.24",""
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6570.24","","","","","","","fee schedule","5475.2","6570.24",""
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5735.27","","","","","","","fee schedule","5475.2","6570.24","APC"
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5639.46","","","","","","","fee schedule","5475.2","6570.24","APC"
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5584.7","","","","","","","fee schedule","5475.2","6570.24","APC"
"Rare ds gen dna alys proband","0212U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5748.96","","","","","","","fee schedule","5475.2","6570.24","APC"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Njx paravert w/us cer/thor","0213T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2709.95","","","","","","","fee schedule","2709.95","3251.94",""
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2709.95","","","","","","","fee schedule","2709.95","3251.94",""
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2709.95","","","","","","","fee schedule","2709.95","3251.94",""
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3251.94","","","","","","","fee schedule","2709.95","3251.94",""
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3251.94","","","","","","","fee schedule","2709.95","3251.94",""
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2838.67","","","","","","","fee schedule","2709.95","3251.94","APC"
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2791.25","","","","","","","fee schedule","2709.95","3251.94","APC"
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2764.15","","","","","","","fee schedule","2709.95","3251.94","APC"
"Rare ds gen dna alys ea comp","0213U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2845.45","","","","","","","fee schedule","2709.95","3251.94","APC"
"Njx paravert w/us cer/thor","0214T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us cer/thor","0214T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us cer/thor","0214T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5224.6","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5224.6","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5224.6","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6269.52","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6269.52","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5472.77","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5381.34","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5329.09","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds xom dna alys proband","0214U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5485.83","","","","","","","fee schedule","5224.6","6269.52","APC"
"Njx paravert w/us cer/thor","0215T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us cer/thor","0215T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us cer/thor","0215T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2574.65","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2574.65","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2574.65","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3089.58","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3089.58","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2696.95","","","","","","","fee schedule","2574.65","3089.58","APC"
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2651.89","","","","","","","fee schedule","2574.65","3089.58","APC"
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2626.14","","","","","","","fee schedule","2574.65","3089.58","APC"
"Rare ds xom dna alys ea comp","0215U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2703.38","","","","","","","fee schedule","2574.65","3089.58","APC"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Njx paravert w/us lumb/sac","0216T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1537.02","","","","","","","fee schedule","1537.02","1844.42",""
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1537.02","","","","","","","fee schedule","1537.02","1844.42",""
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1537.02","","","","","","","fee schedule","1537.02","1844.42",""
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1844.42","","","","","","","fee schedule","1537.02","1844.42",""
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1844.42","","","","","","","fee schedule","1537.02","1844.42",""
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1610.03","","","","","","","fee schedule","1537.02","1844.42","APC"
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1583.13","","","","","","","fee schedule","1537.02","1844.42","APC"
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1567.76","","","","","","","fee schedule","1537.02","1844.42","APC"
"Neuro inh ataxia dna 12 com","0216U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1613.87","","","","","","","fee schedule","1537.02","1844.42","APC"
"Njx paravert w/us lumb/sac","0217T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us lumb/sac","0217T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us lumb/sac","0217T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2198.35","","","","","","","fee schedule","2198.35","2638.02",""
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2198.35","","","","","","","fee schedule","2198.35","2638.02",""
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2198.35","","","","","","","fee schedule","2198.35","2638.02",""
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2638.02","","","","","","","fee schedule","2198.35","2638.02",""
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2638.02","","","","","","","fee schedule","2198.35","2638.02",""
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2302.77","","","","","","","fee schedule","2198.35","2638.02","APC"
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2264.3","","","","","","","fee schedule","2198.35","2638.02","APC"
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2242.32","","","","","","","fee schedule","2198.35","2638.02","APC"
"Neuro inh ataxia dna 51 gene","0217U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2308.27","","","","","","","fee schedule","2198.35","2638.02","APC"
"Njx paravert w/us lumb/sac","0218T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us lumb/sac","0218T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Njx paravert w/us lumb/sac","0218T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2279","","","","","","","fee schedule","2279","2734.8",""
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2279","","","","","","","fee schedule","2279","2734.8",""
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2279","","","","","","","fee schedule","2279","2734.8",""
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2734.8","","","","","","","fee schedule","2279","2734.8",""
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2734.8","","","","","","","fee schedule","2279","2734.8",""
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2387.25","","","","","","","fee schedule","2279","2734.8","APC"
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2347.37","","","","","","","fee schedule","2279","2734.8","APC"
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2324.58","","","","","","","fee schedule","2279","2734.8","APC"
"Neuro musc dys dmd seq alys","0218U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2392.95","","","","","","","fee schedule","2279","2734.8","APC"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Plmt post facet implt cerv","0219T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","725","","","","","","","fee schedule","725","870",""
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725","","","","","","","fee schedule","725","870",""
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","725","","","","","","","fee schedule","725","870",""
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","870","","","","","","","fee schedule","725","870",""
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","870","","","","","","","fee schedule","725","870",""
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","759.44","","","","","","","fee schedule","725","870","APC"
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","746.75","","","","","","","fee schedule","725","870","APC"
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","739.5","","","","","","","fee schedule","725","870","APC"
"Nfct agt hiv gnrj seq alys","0219U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","761.25","","","","","","","fee schedule","725","870","APC"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Plmt post facet implt thor","0220T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.8","","","","","","","fee schedule","706.25","847.5","APC"
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.44","","","","","","","fee schedule","706.25","847.5","APC"
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.38","","","","","","","fee schedule","706.25","847.5","APC"
"Onc brst ca ai assmt 12 feat","0220U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.56","","","","","","","fee schedule","706.25","847.5","APC"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","25051.33",""
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Plmt post facet implt lumb","0221T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Abo gnotyp next gnrj seq abo","0221U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Plmt post facet implt addl","0222T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Plmt post facet implt addl","0222T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Plmt post facet implt addl","0222T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Rhd&rhce gntyp next gnrj seq","0222U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.12","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.12","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","500.12","APC"
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","500.12","APC"
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","500.12","APC"
"Nfct ds 22 trgt sars-cov-2","0223U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","500.12","APC"
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.43","","","","","","","fee schedule","50.56","54",""
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.43","","","","","","","fee schedule","50.56","54",""
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.43","","","","","","","fee schedule","50.56","54",""
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.56","","","","","","","fee schedule","50.56","54",""
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.56","","","","","","","fee schedule","50.56","54",""
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.87","","","","","","","fee schedule","50.56","54","APC"
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.97","","","","","","","fee schedule","50.56","54","APC"
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.46","","","","","","","fee schedule","50.56","54","APC"
"Antibody sars-cov-2 titer(s)","0224U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54","","","","","","","fee schedule","50.56","54","APC"
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.12","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.12","","","","","","","fee schedule","416.78","500.12",""
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","500.12","APC"
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","500.12","APC"
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","500.12","APC"
"Nfct ds dna&rna 21 sarscov2","0225U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","500.12","APC"
"Anosc high resol dx +-coll","0226T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.28","","","","","","","fee schedule","42.28","50.56",""
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.28","","","","","","","fee schedule","42.28","50.56",""
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.28","","","","","","","fee schedule","42.28","50.56",""
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.56","","","","","","","fee schedule","42.28","50.56",""
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.56","","","","","","","fee schedule","42.28","50.56",""
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.29","","","","","","","fee schedule","42.28","50.56","APC"
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.55","","","","","","","fee schedule","42.28","50.56","APC"
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.13","","","","","","","fee schedule","42.28","50.56","APC"
"Svnt sarscov2 elisa plsm srm","0226U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.39","","","","","","","fee schedule","42.28","50.56","APC"
"Anosc high resol dx w/bx","0227T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.14","","","","","","","fee schedule","62.14","74.57",""
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.14","","","","","","","fee schedule","62.14","74.57",""
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62.14","","","","","","","fee schedule","62.14","74.57",""
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","74.57","","","","","","","fee schedule","62.14","74.57",""
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","74.57","","","","","","","fee schedule","62.14","74.57",""
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.09","","","","","","","fee schedule","62.14","74.57","APC"
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64","","","","","","","fee schedule","62.14","74.57","APC"
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.38","","","","","","","fee schedule","62.14","74.57","APC"
"Rx asy prsmv 30+rx/metablt","0227U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.25","","","","","","","fee schedule","62.14","74.57","APC"
"Njx tfrml eprl w/us cer/thor","0228T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","173.03","","","","","","","fee schedule","173.03","207.64",""
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","173.03","","","","","","","fee schedule","173.03","207.64",""
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.03","","","","","","","fee schedule","173.03","207.64",""
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","207.64","","","","","","","fee schedule","173.03","207.64",""
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","207.64","","","","","","","fee schedule","173.03","207.64",""
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","181.25","","","","","","","fee schedule","173.03","207.64","APC"
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","178.22","","","","","","","fee schedule","173.03","207.64","APC"
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","176.49","","","","","","","fee schedule","173.03","207.64","APC"
"Onc prst8 ma molec prfl alg","0228U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","181.68","","","","","","","fee schedule","173.03","207.64","APC"
"Njx tfrml eprl w/us cer/thor","0229T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","384","","","","","","","fee schedule","230.4","403.2",""
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","384","","","","","","","fee schedule","230.4","403.2",""
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","384","","","","","","","fee schedule","230.4","403.2",""
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","230.4","","","","","","","fee schedule","230.4","403.2",""
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","230.4","","","","","","","fee schedule","230.4","403.2",""
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","402.24","","","","","","","fee schedule","230.4","403.2","APC"
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","395.52","","","","","","","fee schedule","230.4","403.2","APC"
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","391.68","","","","","","","fee schedule","230.4","403.2","APC"
"Bcat1 promoter mthyltn alys","0229U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","403.2","","","","","","","fee schedule","230.4","403.2","APC"
"Njx tfrml eprl w/us lumb/sac","0230T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Ar full sequence analysis","0230U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Njx tfrml eprl w/us lumb/sac","0231T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1015.52","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1015.52","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","886.47","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","871.66","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","863.2","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a full gene analysis","0231U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","888.58","","","","","","","fee schedule","846.27","1015.52","APC"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Njx platelet plasma","0232T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb full gene analysis","0232U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene analysis","0233U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc renal art","0234T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","527.87","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","527.87","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","527.87","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","633.44","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","633.44","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","552.94","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","543.71","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","538.43","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 full gene analysis","0234U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","554.26","","","","","","","fee schedule","527.87","633.44","APC"
"Trluml perip athrc visceral","0235T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Trluml perip athrc visceral","0235T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","600","","","","","","","fee schedule","600","720",""
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","600","","","","","","","fee schedule","600","720",""
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","600","","","","","","","fee schedule","600","720",""
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","720","","","","","","","fee schedule","600","720",""
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","720","","","","","","","fee schedule","600","720",""
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","628.5","","","","","","","fee schedule","600","720","APC"
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","618","","","","","","","fee schedule","600","720","APC"
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","612","","","","","","","fee schedule","600","720","APC"
"Pten full gene analysis","0235U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","630","","","","","","","fee schedule","600","720","APC"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc abd aorta","0236T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","602.7","","","","","","","fee schedule","602.7","723.24",""
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","602.7","","","","","","","fee schedule","602.7","723.24",""
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","602.7","","","","","","","fee schedule","602.7","723.24",""
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","723.24","","","","","","","fee schedule","602.7","723.24",""
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","723.24","","","","","","","fee schedule","602.7","723.24",""
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","631.33","","","","","","","fee schedule","602.7","723.24","APC"
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","620.78","","","","","","","fee schedule","602.7","723.24","APC"
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","614.75","","","","","","","fee schedule","602.7","723.24","APC"
"Smn1&smn2 full gene analysis","0236U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","632.84","","","","","","","fee schedule","602.7","723.24","APC"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Trluml perip athrc brchiocph","0237T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","701.88",""
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","701.88",""
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","701.88",""
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","701.88","","","","","","","fee schedule","584.9","701.88",""
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","701.88","","","","","","","fee schedule","584.9","701.88",""
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","701.88","APC"
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","701.88","APC"
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","701.88","APC"
"Car ion chnlpthy gen seq pnl","0237U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","701.88","APC"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Trluml perip athrc iliac art","0238T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","701.88",""
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","701.88",""
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","701.88",""
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","701.88","","","","","","","fee schedule","584.9","701.88",""
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","701.88","","","","","","","fee schedule","584.9","701.88",""
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","701.88","APC"
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","701.88","APC"
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","701.88","APC"
"Onc lnch syn gen dna seq aly","0238U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","701.88","APC"
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3500","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3500","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3500","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4200","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4200","","","","","","","fee schedule","3500","4200",""
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3666.25","","","","","","","fee schedule","3500","4200","APC"
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3605","","","","","","","fee schedule","3500","4200","APC"
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3570","","","","","","","fee schedule","3500","4200","APC"
"Trgt gen seq alys pnl 311+","0239U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3675","","","","","","","fee schedule","3500","4200","APC"
"Nfct ds vir resp rna 3 trgt","0240U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 3 trgt","0240U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 3 trgt","0240U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 3 trgt","0240U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.12","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 3 trgt","0240U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.12","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 4 trgt","0241U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 4 trgt","0241U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 4 trgt","0241U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 4 trgt","0241U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.12","","","","","","","fee schedule","142.63","171.12",""
"Nfct ds vir resp rna 4 trgt","0241U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.12","","","","","","","fee schedule","142.63","171.12",""
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5237.5","","","","","","","fee schedule","5000","6000","APC"
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5150","","","","","","","fee schedule","5000","6000","APC"
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5100","","","","","","","fee schedule","5000","6000","APC"
"Trgt gen seq alys pnl 55-74","0242U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5250","","","","","","","fee schedule","5000","6000","APC"
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.41","","","","","","","fee schedule","64.41","77.29",""
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.41","","","","","","","fee schedule","64.41","77.29",""
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.41","","","","","","","fee schedule","64.41","77.29",""
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","77.29","","","","","","","fee schedule","64.41","77.29",""
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","77.29","","","","","","","fee schedule","64.41","77.29",""
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.47","","","","","","","fee schedule","64.41","77.29","APC"
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.34","","","","","","","fee schedule","64.41","77.29","APC"
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.7","","","","","","","fee schedule","64.41","77.29","APC"
"Ob pe biochem assay pgf alg","0243U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.63","","","","","","","fee schedule","64.41","77.29","APC"
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3500","","","","","","","fee schedule","3500","4200",""
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3500","","","","","","","fee schedule","3500","4200",""
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3500","","","","","","","fee schedule","3500","4200",""
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4200","","","","","","","fee schedule","3500","4200",""
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4200","","","","","","","fee schedule","3500","4200",""
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3666.25","","","","","","","fee schedule","3500","4200","APC"
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3605","","","","","","","fee schedule","3500","4200","APC"
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3570","","","","","","","fee schedule","3500","4200","APC"
"Onc solid orgn dna 257 genes","0244U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3675","","","","","","","fee schedule","3500","4200","APC"
"Opn tx rib fx 1-2 ribs","0245T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1266.07","","","","","","","fee schedule","1266.07","1519.28",""
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1266.07","","","","","","","fee schedule","1266.07","1519.28",""
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1266.07","","","","","","","fee schedule","1266.07","1519.28",""
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1519.28","","","","","","","fee schedule","1266.07","1519.28",""
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1519.28","","","","","","","fee schedule","1266.07","1519.28",""
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1326.21","","","","","","","fee schedule","1266.07","1519.28","APC"
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1304.05","","","","","","","fee schedule","1266.07","1519.28","APC"
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1291.39","","","","","","","fee schedule","1266.07","1519.28","APC"
"Onc thyr mut alys 10 gen&37","0245U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1329.37","","","","","","","fee schedule","1266.07","1519.28","APC"
"Opn tx rib fx 3-4 ribs","0246T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","720","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","720","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","720","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","864","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","864","","","","","","","fee schedule","720","864",""
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","754.2","","","","","","","fee schedule","720","864","APC"
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","741.6","","","","","","","fee schedule","720","864","APC"
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","734.4","","","","","","","fee schedule","720","864","APC"
"Rbc dna gnotyp 16 bld groups","0246U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","756","","","","","","","fee schedule","720","864","APC"
"Opn tx rib fx 5-6 ribs","0247T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","900",""
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","900",""
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","900",""
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","900","","","","","","","fee schedule","750","900",""
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","900","","","","","","","fee schedule","750","900",""
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","900","APC"
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","900","APC"
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","900","APC"
"Ob prtrm brth ibp4 shbg meas","0247U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","900","APC"
"Opn tx rib fx 7+ ribs","0248T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3033.86","","","","","","","fee schedule","3033.86","3640.63",""
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3033.86","","","","","","","fee schedule","3033.86","3640.63",""
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3033.86","","","","","","","fee schedule","3033.86","3640.63",""
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3640.63","","","","","","","fee schedule","3033.86","3640.63",""
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3640.63","","","","","","","fee schedule","3033.86","3640.63",""
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3177.97","","","","","","","fee schedule","3033.86","3640.63","APC"
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3124.88","","","","","","","fee schedule","3033.86","3640.63","APC"
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3094.54","","","","","","","fee schedule","3033.86","3640.63","APC"
"Onc brn sphrd cll 12 rx pnl","0248U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3185.55","","","","","","","fee schedule","3033.86","3640.63","APC"
"Ligation hemorrhoid w/us","0249T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2219.13","","","","","","","fee schedule","2219.13","2662.96",""
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2219.13","","","","","","","fee schedule","2219.13","2662.96",""
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2219.13","","","","","","","fee schedule","2219.13","2662.96",""
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2662.96","","","","","","","fee schedule","2219.13","2662.96",""
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2662.96","","","","","","","fee schedule","2219.13","2662.96",""
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2324.54","","","","","","","fee schedule","2219.13","2662.96","APC"
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2285.7","","","","","","","fee schedule","2219.13","2662.96","APC"
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2263.51","","","","","","","fee schedule","2219.13","2662.96","APC"
"Onc brst alys 32 phsprtn alg","0249U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2330.09","","","","","","","fee schedule","2219.13","2662.96","APC"
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld org neo dna 505 gene","0250U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.72","","","","","","","fee schedule","17.27","20.72",""
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.72","","","","","","","fee schedule","17.27","20.72",""
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","20.72","APC"
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","20.72","APC"
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","20.72","APC"
"Hepcidin-25 elisa serum/plsm","0251U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","20.72","APC"
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","910.86",""
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","910.86",""
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","910.86",""
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","910.86","","","","","","","fee schedule","759.05","910.86",""
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","910.86","","","","","","","fee schedule","759.05","910.86",""
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","759.05","910.86","APC"
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","759.05","910.86","APC"
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","759.05","910.86","APC"
"Ftl aneuploidy str alys dna","0252U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","759.05","910.86","APC"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4113.58","23971",""
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Insert aqueous drain device","0253T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3159.42","","","","","","","fee schedule","3159.42","3791.3",""
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3791.3","","","","","","","fee schedule","3159.42","3791.3",""
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3309.49","","","","","","","fee schedule","3159.42","3791.3","APC"
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3254.2","","","","","","","fee schedule","3159.42","3791.3","APC"
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3222.61","","","","","","","fee schedule","3159.42","3791.3","APC"
"Rprdtve med rna gen prfl 238","0253U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3317.39","","","","","","","fee schedule","3159.42","3791.3","APC"
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","910.86",""
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","910.86",""
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","910.86",""
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","910.86","","","","","","","fee schedule","759.05","910.86",""
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","910.86","","","","","","","fee schedule","759.05","910.86",""
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","759.05","910.86","APC"
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","759.05","910.86","APC"
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","759.05","910.86","APC"
"Reprdtve med alys 24 chrmsm","0254U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","759.05","910.86","APC"
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.6","","","","","","","fee schedule","31.6","37.92",""
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.6","","","","","","","fee schedule","31.6","37.92",""
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","31.6","","","","","","","fee schedule","31.6","37.92",""
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.92","","","","","","","fee schedule","31.6","37.92",""
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.92","","","","","","","fee schedule","31.6","37.92",""
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.1","","","","","","","fee schedule","31.6","37.92","APC"
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.55","","","","","","","fee schedule","31.6","37.92","APC"
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.23","","","","","","","fee schedule","31.6","37.92","APC"
"Andrology infertility assmt","0255U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.18","","","","","","","fee schedule","31.6","37.92","APC"
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","159.95","","","","","","","fee schedule","159.95","191.94",""
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","159.95","","","","","","","fee schedule","159.95","191.94",""
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","159.95","","","","","","","fee schedule","159.95","191.94",""
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","191.94","","","","","","","fee schedule","159.95","191.94",""
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","191.94","","","","","","","fee schedule","159.95","191.94",""
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","167.55","","","","","","","fee schedule","159.95","191.94","APC"
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","164.75","","","","","","","fee schedule","159.95","191.94","APC"
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","163.15","","","","","","","fee schedule","159.95","191.94","APC"
"Tma/tmao prfl ms/ms ur alg","0256U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","167.95","","","","","","","fee schedule","159.95","191.94","APC"
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","712.47","","","","","","","fee schedule","712.47","854.96",""
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","712.47","","","","","","","fee schedule","712.47","854.96",""
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","712.47","","","","","","","fee schedule","712.47","854.96",""
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","854.96","","","","","","","fee schedule","712.47","854.96",""
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","854.96","","","","","","","fee schedule","712.47","854.96",""
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","746.31","","","","","","","fee schedule","712.47","854.96","APC"
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","733.84","","","","","","","fee schedule","712.47","854.96","APC"
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","726.72","","","","","","","fee schedule","712.47","854.96","APC"
"Vlcad leuk nzm actv whl bld","0257U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","748.09","","","","","","","fee schedule","712.47","854.96","APC"
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3675","","","","","","","fee schedule","3675","4410",""
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3675","","","","","","","fee schedule","3675","4410",""
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3675","","","","","","","fee schedule","3675","4410",""
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4410","","","","","","","fee schedule","3675","4410",""
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4410","","","","","","","fee schedule","3675","4410",""
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3849.56","","","","","","","fee schedule","3675","4410","APC"
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3785.25","","","","","","","fee schedule","3675","4410","APC"
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3748.5","","","","","","","fee schedule","3675","4410","APC"
"Ai psor mrna 50-100 gen alg","0258U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3858.75","","","","","","","fee schedule","3675","4410","APC"
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","52.71","","","","","","","fee schedule","52.71","63.25",""
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","52.71","","","","","","","fee schedule","52.71","63.25",""
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","52.71","","","","","","","fee schedule","52.71","63.25",""
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","63.25","","","","","","","fee schedule","52.71","63.25",""
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","63.25","","","","","","","fee schedule","52.71","63.25",""
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","55.21","","","","","","","fee schedule","52.71","63.25","APC"
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","54.29","","","","","","","fee schedule","52.71","63.25","APC"
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","53.76","","","","","","","fee schedule","52.71","63.25","APC"
"Neph ckd nuc mrs meas gfr","0259U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55.35","","","","","","","fee schedule","52.71","63.25","APC"
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1516.24","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1516.24","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.55","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.44","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.8","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rare ds id opt genome mapg","0260U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.71","","","","","","","fee schedule","1263.53","1516.24","APC"
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2513.25","","","","","","","fee schedule","2513.25","3015.9",""
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2513.25","","","","","","","fee schedule","2513.25","3015.9",""
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2513.25","","","","","","","fee schedule","2513.25","3015.9",""
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3015.9","","","","","","","fee schedule","2513.25","3015.9",""
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3015.9","","","","","","","fee schedule","2513.25","3015.9",""
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2632.63","","","","","","","fee schedule","2513.25","3015.9","APC"
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2588.65","","","","","","","fee schedule","2513.25","3015.9","APC"
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2563.52","","","","","","","fee schedule","2513.25","3015.9","APC"
"Onc clrct ca img alys w/ai","0261U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2638.91","","","","","","","fee schedule","2513.25","3015.9","APC"
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3200","","","","","","","fee schedule","3200","3840",""
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3200","","","","","","","fee schedule","3200","3840",""
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3200","","","","","","","fee schedule","3200","3840",""
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3840","","","","","","","fee schedule","3200","3840",""
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3840","","","","","","","fee schedule","3200","3840",""
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3352","","","","","","","fee schedule","3200","3840","APC"
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3296","","","","","","","fee schedule","3200","3840","APC"
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3264","","","","","","","fee schedule","3200","3840","APC"
"Onc sld tum rt-pcr 7 gen","0262U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3360","","","","","","","fee schedule","3200","3840","APC"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther cmpl","0263T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","900",""
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","900",""
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","900",""
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","900","","","","","","","fee schedule","750","900",""
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","900","","","","","","","fee schedule","750","900",""
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","900","APC"
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","900","APC"
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","900","APC"
"Neuro asd meas 16 c metblt","0263U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","900","APC"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther xcl hrvst","0264T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1516.24","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1516.24","","","","","","","fee schedule","1263.53","1516.24",""
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.55","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.44","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.8","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rare ds id opt genome mapg","0264U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.71","","","","","","","fee schedule","1263.53","1516.24","APC"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Im b1 mrw cel ther hrvst onl","0265T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5475.8","","","","","","","fee schedule","5475.8","6570.96",""
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5475.8","","","","","","","fee schedule","5475.8","6570.96",""
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5475.8","","","","","","","fee schedule","5475.8","6570.96",""
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6570.96","","","","","","","fee schedule","5475.8","6570.96",""
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6570.96","","","","","","","fee schedule","5475.8","6570.96",""
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5735.9","","","","","","","fee schedule","5475.8","6570.96","APC"
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5640.07","","","","","","","fee schedule","5475.8","6570.96","APC"
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5585.32","","","","","","","fee schedule","5475.8","6570.96","APC"
"Rar do whl gn&mtcdrl dna als","0265U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5749.59","","","","","","","fee schedule","5475.8","6570.96","APC"
"Implt/rpl crtd sns dev total","0266T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","45861","50815",""
"Implt/rpl crtd sns dev total","0266T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","45861","50815",""
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3200","","","","","","","fee schedule","3200","3840",""
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3200","","","","","","","fee schedule","3200","3840",""
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3200","","","","","","","fee schedule","3200","3840",""
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3840","","","","","","","fee schedule","3200","3840",""
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3840","","","","","","","fee schedule","3200","3840",""
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3352","","","","","","","fee schedule","3200","3840","APC"
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3296","","","","","","","fee schedule","3200","3840","APC"
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3264","","","","","","","fee schedule","3200","3840","APC"
"Unxpl cnst hrtbl do gn xprsn","0266U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3360","","","","","","","fee schedule","3200","3840","APC"
"Implt/rpl crtd sns dev lead","0267T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Implt/rpl crtd sns dev lead","0267T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6739.33","","","","","","","fee schedule","6739.33","8087.2",""
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6739.33","","","","","","","fee schedule","6739.33","8087.2",""
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6739.33","","","","","","","fee schedule","6739.33","8087.2",""
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8087.2","","","","","","","fee schedule","6739.33","8087.2",""
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8087.2","","","","","","","fee schedule","6739.33","8087.2",""
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7059.45","","","","","","","fee schedule","6739.33","8087.2","APC"
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6941.51","","","","","","","fee schedule","6739.33","8087.2","APC"
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6874.12","","","","","","","fee schedule","6739.33","8087.2","APC"
"Rare do id opt gen mapg&seq","0267U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7076.3","","","","","","","fee schedule","6739.33","8087.2","APC"
"Implt/rpl crtd sns dev gen","0268T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","45861","50815",""
"Implt/rpl crtd sns dev gen","0268T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","45861","50815",""
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem ahus gen seq alys 15 gen","0268U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Rev/remvl crtd sns dev total","0269T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rev/remvl crtd sns dev total","0269T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem aut dm cgen trmbctpna 14","0269U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Rev/remvl crtd sns dev lead","0270T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Rev/remvl crtd sns dev lead","0270T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem cgen coagj do 20 genes","0270U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Rev/remvl crtd sns dev gen","0271T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Rev/remvl crtd sns dev gen","0271T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem cgen neutropenia 23 gen","0271U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem genetic bld do 51 genes","0272U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen hyprfibrnlysis 8 gen","0273U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Perq lamot/lam crv/thrc","0274T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen pltlt do 43 genes","0274U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Perq lamot/lam lumbar","0275T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq lamot/lam lumbar","0275T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq lamot/lam lumbar","0275T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.37","","","","","","","fee schedule","18.37","22.04",""
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.37","","","","","","","fee schedule","18.37","22.04",""
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.37","","","","","","","fee schedule","18.37","22.04",""
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.04","","","","","","","fee schedule","18.37","22.04",""
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.04","","","","","","","fee schedule","18.37","22.04",""
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.24","","","","","","","fee schedule","18.37","22.04","APC"
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.92","","","","","","","fee schedule","18.37","22.04","APC"
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.74","","","","","","","fee schedule","18.37","22.04","APC"
"Hem heprn nduc trmbctpna srm","0275U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.29","","","","","","","fee schedule","18.37","22.04","APC"
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2564.87","","","","","","","fee schedule","2448.56","2938.27","APC"
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2522.02","","","","","","","fee schedule","2448.56","2938.27","APC"
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2497.53","","","","","","","fee schedule","2448.56","2938.27","APC"
"Hem inh thrombocytopenia 23","0276U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2570.99","","","","","","","fee schedule","2448.56","2938.27","APC"
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen pltlt funcj do 31","0277U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","2633",""
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","2633",""
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","2633","APC 277.30"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","2633","APC 296.56"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","2633","APC 308.91"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","2633","APC"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","2633","APC"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","2633","APC"
"Tempr","0278T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","2633","APC"
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.17","","","","","","","fee schedule","608.17","729.8",""
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","729.8","","","","","","","fee schedule","608.17","729.8",""
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.06","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","626.42","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","620.33","","","","","","","fee schedule","608.17","729.8","APC"
"Hem gen thrombosis 12 genes","0278U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","638.58","","","","","","","fee schedule","608.17","729.8","APC"
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","13.84",""
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","13.84",""
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","13.84",""
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.84","","","","","","","fee schedule","11.53","13.84",""
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.84","","","","","","","fee schedule","11.53","13.84",""
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","13.84","APC"
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","13.84","APC"
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","13.84","APC"
"Hem vw factor&clgn iii bndg","0279U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","13.84","APC"
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.72","","","","","","","fee schedule","17.27","20.72",""
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.72","","","","","","","fee schedule","17.27","20.72",""
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","20.72","APC"
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","20.72","APC"
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","20.72","APC"
"Hem vw factor&clgn iv bndg","0280U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","20.72","APC"
"Hem vwd propeptide ag lvl","0281U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hem vwd propeptide ag lvl","0281U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hem vwd propeptide ag lvl","0281U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Hem vwd propeptide ag lvl","0281U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.72","","","","","","","fee schedule","17.27","20.72",""
"Hem vwd propeptide ag lvl","0281U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.72","","","","","","","fee schedule","17.27","20.72",""
"Hem vwd propeptide ag lvl","0281U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","20.72","APC"
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"Onc rsps radj cll fr dna tox","0285U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","443.31","","","","","","","fee schedule","443.31","531.97",""
"Onc rsps radj cll fr dna tox","0285U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","443.31","","","","","","","fee schedule","443.31","531.97",""
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"Onc rsps radj cll fr dna tox","0285U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","531.97","","","","","","","fee schedule","443.31","531.97",""
"Onc rsps radj cll fr dna tox","0285U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","464.37","","","","","","","fee schedule","443.31","531.97","APC"
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"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","134.13","","","","","","","fee schedule","134.13","160.96",""
"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","134.13","","","","","","","fee schedule","134.13","160.96",""
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"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","160.96","","","","","","","fee schedule","134.13","160.96",""
"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","160.96","","","","","","","fee schedule","134.13","160.96",""
"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","140.5","","","","","","","fee schedule","134.13","160.96","APC"
"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","138.15","","","","","","","fee schedule","134.13","160.96","APC"
"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","136.81","","","","","","","fee schedule","134.13","160.96","APC"
"Cep72 nudt15&tpmt gene alys","0286U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","140.84","","","","","","","fee schedule","134.13","160.96","APC"
"Onc thyr dna&mrna 112 genes","0287U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3600","","","","","","","fee schedule","3600","4320",""
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"Onc thyr dna&mrna 112 genes","0287U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4320","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0287U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4320","","","","","","","fee schedule","3600","4320",""
"Onc thyr dna&mrna 112 genes","0287U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3771","","","","","","","fee schedule","3600","4320","APC"
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"Onc lung mrna quan pcr 11&3","0288U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
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"Psyc suicidal idea mrna 54","0293U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
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"Onc orl&/orop ca 20 mlc feat","0296U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2042.63","","","","","","","fee schedule","1950","2106","APC"
"Onc orl&/orop ca 20 mlc feat","0296U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2008.5","","","","","","","fee schedule","1950","2106","APC"
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"Ext ecg scan w/report","0297T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","646","","","","","","","fee schedule","646","664",""
"Ext ecg scan w/report","0297T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","664","","","","","","","fee schedule","646","664",""
"Ext ecg scan w/report","0297T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","648","","","","","","","fee schedule","646","664",""
"Onc pan tum whl gen seq dna","0297U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
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"Onc pan tum whl gen seq dna","0297U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc pan tum whl gen seq dna","0297U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl gen seq dna","0297U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl gen seq dna","0297U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl gen seq dna","0297U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
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"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc pan tum whl trns seq rna","0298U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"Esw wound healing init wound","0299T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1863.22","","","","","","","fee schedule","1863.22","2235.86",""
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"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2235.86","","","","","","","fee schedule","1863.22","2235.86",""
"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2235.86","","","","","","","fee schedule","1863.22","2235.86",""
"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1951.72","","","","","","","fee schedule","1863.22","2235.86","APC"
"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1919.12","","","","","","","fee schedule","1863.22","2235.86","APC"
"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1900.48","","","","","","","fee schedule","1863.22","2235.86","APC"
"Onc pan tum whl gen opt mapg","0299U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1956.38","","","","","","","fee schedule","1863.22","2235.86","APC"
"Esw wound healing addl wound","0300T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc pan tum whl gen seq&opt","0300U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4183.13","","","","","","","fee schedule","4183.13","5019.76",""
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"Onc pan tum whl gen seq&opt","0300U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4381.83","","","","","","","fee schedule","4183.13","5019.76","APC"
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"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","262.72","","","","","","","fee schedule","262.72","315.26",""
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","262.72","","","","","","","fee schedule","262.72","315.26",""
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","262.72","","","","","","","fee schedule","262.72","315.26",""
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","315.26","","","","","","","fee schedule","262.72","315.26",""
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","315.26","","","","","","","fee schedule","262.72","315.26",""
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.2","","","","","","","fee schedule","262.72","315.26","APC"
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","270.6","","","","","","","fee schedule","262.72","315.26","APC"
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","267.97","","","","","","","fee schedule","262.72","315.26","APC"
"Iadna bartonella ddpcr","0301U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","275.86","","","","","","","fee schedule","262.72","315.26","APC"
"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","361.37","","","","","","","fee schedule","361.37","433.64",""
"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","361.37","","","","","","","fee schedule","361.37","433.64",""
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"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","433.64","","","","","","","fee schedule","361.37","433.64",""
"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","433.64","","","","","","","fee schedule","361.37","433.64",""
"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","378.54","","","","","","","fee schedule","361.37","433.64","APC"
"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","372.21","","","","","","","fee schedule","361.37","433.64","APC"
"Iadna brtnla ddpcr flwg liq","0302U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","368.6","","","","","","","fee schedule","361.37","433.64","APC"
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"Hem rbc fnclty&dfrm shr strs","0305U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","795.1","","","","","","","fee schedule","662.58","795.1",""
"Hem rbc fnclty&dfrm shr strs","0305U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","795.1","","","","","","","fee schedule","662.58","795.1",""
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"Onc mrd nxt-gnrj alys 1st","0306U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4654.14","","","","","","","fee schedule","3878.45","4654.14",""
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"Onc mrd nxt-gnrj alys 1st","0306U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3994.8","","","","","","","fee schedule","3878.45","4654.14","APC"
"Onc mrd nxt-gnrj alys 1st","0306U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3956.02","","","","","","","fee schedule","3878.45","4654.14","APC"
"Onc mrd nxt-gnrj alys 1st","0306U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4072.37","","","","","","","fee schedule","3878.45","4654.14","APC"
"Rmvl icar ischm mntrng dvce","0307T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","794.49","","","","","","","fee schedule","794.49","953.39",""
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","794.49","","","","","","","fee schedule","794.49","953.39",""
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","794.49","","","","","","","fee schedule","794.49","953.39",""
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","953.39","","","","","","","fee schedule","794.49","953.39",""
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","953.39","","","","","","","fee schedule","794.49","953.39",""
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","832.23","","","","","","","fee schedule","794.49","953.39","APC"
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","818.32","","","","","","","fee schedule","794.49","953.39","APC"
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","810.38","","","","","","","fee schedule","794.49","953.39","APC"
"Onc mrd nxt-gnrj alys sbsq","0307U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","834.21","","","","","","","fee schedule","794.49","953.39","APC"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","13700","56829.3",""
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","56829.3",""
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","13700","56829.3",""
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51014.1","","","","","","","fee schedule","13700","56829.3","APC 277.30"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","54557.31","","","","","","","fee schedule","13700","56829.3","APC 296.56"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","56829.3","","","","","","","fee schedule","13700","56829.3","APC 308.91"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16823.46","","","","","","","fee schedule","13700","56829.3","APC"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16542.4","","","","","","","fee schedule","13700","56829.3","APC"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16381.79","","","","","","","fee schedule","13700","56829.3","APC"
"Insj ocular telescope prosth","0308T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16863.61","","","","","","","fee schedule","13700","56829.3","APC"
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","390.75","","","","","","","fee schedule","390.75","468.9",""
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","468.9","","","","","","","fee schedule","390.75","468.9",""
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","468.9","","","","","","","fee schedule","390.75","468.9",""
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.31","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.47","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.56","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cad alys 3 prtn plsm alg","0308U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.29","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","390.75","","","","","","","fee schedule","390.75","468.9",""
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","468.9","","","","","","","fee schedule","390.75","468.9",""
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","468.9","","","","","","","fee schedule","390.75","468.9",""
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.31","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.47","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.56","","","","","","","fee schedule","390.75","468.9","APC"
"Crd cv ds aly 4 prtn plm alg","0309U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.29","","","","","","","fee schedule","390.75","468.9","APC"
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","390.75","","","","","","","fee schedule","390.75","468.9",""
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","468.9","","","","","","","fee schedule","390.75","468.9",""
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","468.9","","","","","","","fee schedule","390.75","468.9",""
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.31","","","","","","","fee schedule","390.75","468.9","APC"
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.47","","","","","","","fee schedule","390.75","468.9","APC"
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.56","","","","","","","fee schedule","390.75","468.9","APC"
"Ped vsclts kd alys 3 bmrks","0310U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.29","","","","","","","fee schedule","390.75","468.9","APC"
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.08","","","","","","","fee schedule","8.08","9.7",""
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.08","","","","","","","fee schedule","8.08","9.7",""
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.08","","","","","","","fee schedule","8.08","9.7",""
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.7","","","","","","","fee schedule","8.08","9.7",""
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.7","","","","","","","fee schedule","8.08","9.7",""
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.46","","","","","","","fee schedule","8.08","9.7","APC"
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.32","","","","","","","fee schedule","8.08","9.7","APC"
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.24","","","","","","","fee schedule","8.08","9.7","APC"
"Nfct ds bct quan antmcrb sc","0311U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.48","","","","","","","fee schedule","8.08","9.7","APC"
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","840.65","","","","","","","fee schedule","840.65","1008.78",""
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","840.65","","","","","","","fee schedule","840.65","1008.78",""
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","840.65","","","","","","","fee schedule","840.65","1008.78",""
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1008.78","","","","","","","fee schedule","840.65","1008.78",""
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1008.78","","","","","","","fee schedule","840.65","1008.78",""
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","880.58","","","","","","","fee schedule","840.65","1008.78","APC"
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","865.87","","","","","","","fee schedule","840.65","1008.78","APC"
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","857.46","","","","","","","fee schedule","840.65","1008.78","APC"
"Ai ds sle alys 8 igg autoant","0312U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","882.68","","","","","","","fee schedule","840.65","1008.78","APC"
"Laps rmvl nstim array vagus","0313T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3600","","","","","","","fee schedule","3600","4320",""
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3600","","","","","","","fee schedule","3600","4320",""
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3600","","","","","","","fee schedule","3600","4320",""
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4320","","","","","","","fee schedule","3600","4320",""
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4320","","","","","","","fee schedule","3600","4320",""
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3771","","","","","","","fee schedule","3600","4320","APC"
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3708","","","","","","","fee schedule","3600","4320","APC"
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3672","","","","","","","fee schedule","3600","4320","APC"
"Onc pncrs dna&mrna seq 74","0313U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3780","","","","","","","fee schedule","3600","4320","APC"
"Laps rmvl vgl arry&pls gen","0314T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1950","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1950","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1950","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2340","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2340","","","","","","","fee schedule","1950","2340",""
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2042.63","","","","","","","fee schedule","1950","2340","APC"
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2008.5","","","","","","","fee schedule","1950","2340","APC"
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1989","","","","","","","fee schedule","1950","2340","APC"
"Onc cutan mlnma mrna 35 gene","0314U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2047.5","","","","","","","fee schedule","1950","2340","APC"
"Rmvl vagus nerve pls gen","0315T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8500","","","","","","","fee schedule","8500","10200",""
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8500","","","","","","","fee schedule","8500","10200",""
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8500","","","","","","","fee schedule","8500","10200",""
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10200","","","","","","","fee schedule","8500","10200",""
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10200","","","","","","","fee schedule","8500","10200",""
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8903.75","","","","","","","fee schedule","8500","10200","APC"
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8755","","","","","","","fee schedule","8500","10200","APC"
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8670","","","","","","","fee schedule","8500","10200","APC"
"Onc cutan sq cll ca mrna 40","0315U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8925","","","","","","","fee schedule","8500","10200","APC"
"Replc vagus nerve pls gen","0316T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.66","","","","","","","fee schedule","18.66","22.39",""
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.66","","","","","","","fee schedule","18.66","22.39",""
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.66","","","","","","","fee schedule","18.66","22.39",""
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.39","","","","","","","fee schedule","18.66","22.39",""
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.39","","","","","","","fee schedule","18.66","22.39",""
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.55","","","","","","","fee schedule","18.66","22.39","APC"
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.22","","","","","","","fee schedule","18.66","22.39","APC"
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.03","","","","","","","fee schedule","18.66","22.39","APC"
"B brgdrferi lyme ds ospa evl","0316U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.59","","","","","","","fee schedule","18.66","22.39","APC"
"Elec alys vagus nrv pls gen","0317T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2030","","","","","","","fee schedule","2030","2436",""
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2030","","","","","","","fee schedule","2030","2436",""
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2030","","","","","","","fee schedule","2030","2436",""
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2436","","","","","","","fee schedule","2030","2436",""
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2436","","","","","","","fee schedule","2030","2436",""
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2126.43","","","","","","","fee schedule","2030","2436","APC"
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2090.9","","","","","","","fee schedule","2030","2436","APC"
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2070.6","","","","","","","fee schedule","2030","2436","APC"
"Onc lung ca 4-prb fish assay","0317U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2131.5","","","","","","","fee schedule","2030","2436","APC"
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1770.48","","","","","","","fee schedule","1770.48","2124.58",""
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1770.48","","","","","","","fee schedule","1770.48","2124.58",""
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1770.48","","","","","","","fee schedule","1770.48","2124.58",""
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2124.58","","","","","","","fee schedule","1770.48","2124.58",""
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2124.58","","","","","","","fee schedule","1770.48","2124.58",""
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1854.58","","","","","","","fee schedule","1770.48","2124.58","APC"
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1823.59","","","","","","","fee schedule","1770.48","2124.58","APC"
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1805.89","","","","","","","fee schedule","1770.48","2124.58","APC"
"Ped whl gen mthyltn alys 50+","0318U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1859","","","","","","","fee schedule","1770.48","2124.58","APC"
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2650","","","","","","","fee schedule","2650","3180",""
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2650","","","","","","","fee schedule","2650","3180",""
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2650","","","","","","","fee schedule","2650","3180",""
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3180","","","","","","","fee schedule","2650","3180",""
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3180","","","","","","","fee schedule","2650","3180",""
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2775.88","","","","","","","fee schedule","2650","3180","APC"
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2729.5","","","","","","","fee schedule","2650","3180","APC"
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2703","","","","","","","fee schedule","2650","3180","APC"
"Neph rna pretrnspl perph bld","0319U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2782.5","","","","","","","fee schedule","2650","3180","APC"
"Insert subq defib electrode","0320T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2650","","","","","","","fee schedule","2650","3180",""
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2650","","","","","","","fee schedule","2650","3180",""
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2650","","","","","","","fee schedule","2650","3180",""
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3180","","","","","","","fee schedule","2650","3180",""
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3180","","","","","","","fee schedule","2650","3180",""
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2775.88","","","","","","","fee schedule","2650","3180","APC"
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2729.5","","","","","","","fee schedule","2650","3180","APC"
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2703","","","","","","","fee schedule","2650","3180","APC"
"Neph rna psttrnspl perph bld","0320U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2782.5","","","","","","","fee schedule","2650","3180","APC"
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","634.84","","","","","","","fee schedule","634.84","761.81",""
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","634.84","","","","","","","fee schedule","634.84","761.81",""
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","634.84","","","","","","","fee schedule","634.84","761.81",""
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","761.81","","","","","","","fee schedule","634.84","761.81",""
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","761.81","","","","","","","fee schedule","634.84","761.81",""
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","664.99","","","","","","","fee schedule","634.84","761.81","APC"
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","653.89","","","","","","","fee schedule","634.84","761.81","APC"
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","647.54","","","","","","","fee schedule","634.84","761.81","APC"
"Iadna gu pthgn 20bct&fng org","0321U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","666.58","","","","","","","fee schedule","634.84","761.81","APC"
"Rmvl subq defib pls gen","0322T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","900",""
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","900",""
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","900",""
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","900","","","","","","","fee schedule","750","900",""
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","900","","","","","","","fee schedule","750","900",""
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","900","APC"
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","900","APC"
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","900","APC"
"Neuro asd meas 14 acyl carn","0322U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","900","APC"
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2126.2","","","","","","","fee schedule","2126.2","2551.44",""
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2126.2","","","","","","","fee schedule","2126.2","2551.44",""
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2126.2","","","","","","","fee schedule","2126.2","2551.44",""
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2551.44","","","","","","","fee schedule","2126.2","2551.44",""
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2551.44","","","","","","","fee schedule","2126.2","2551.44",""
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2227.19","","","","","","","fee schedule","2126.2","2551.44","APC"
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2189.99","","","","","","","fee schedule","2126.2","2551.44","APC"
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2168.72","","","","","","","fee schedule","2126.2","2551.44","APC"
"Iadna cns pthgn next gen seq","0323U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2232.51","","","","","","","fee schedule","2126.2","2551.44","APC"
"Rmvl subq defib electrode","0324T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Repos subq defib eltrd &/gen","0325T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6000","","","","","","","fee schedule","5000","6000",""
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5237.5","","","","","","","fee schedule","5000","6000","APC"
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5150","","","","","","","fee schedule","5000","6000","APC"
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5100","","","","","","","fee schedule","5000","6000","APC"
"Trgt gen seq alys pnl 83+","0326U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5250","","","","","","","fee schedule","5000","6000","APC"
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","795","","","","","","","fee schedule","795","954",""
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","795","","","","","","","fee schedule","795","954",""
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","795","","","","","","","fee schedule","795","954",""
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","954","","","","","","","fee schedule","795","954",""
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","954","","","","","","","fee schedule","795","954",""
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","832.76","","","","","","","fee schedule","795","954","APC"
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","818.85","","","","","","","fee schedule","795","954","APC"
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","810.9","","","","","","","fee schedule","795","954","APC"
"Ftl aneuploidy trsmy dna seq","0327U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","834.75","","","","","","","fee schedule","795","954","APC"
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","114.43","","","","","","","fee schedule","114.43","137.32",""
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.43","","","","","","","fee schedule","114.43","137.32",""
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.43","","","","","","","fee schedule","114.43","137.32",""
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","137.32","","","","","","","fee schedule","114.43","137.32",""
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","137.32","","","","","","","fee schedule","114.43","137.32",""
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.87","","","","","","","fee schedule","114.43","137.32","APC"
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.86","","","","","","","fee schedule","114.43","137.32","APC"
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.72","","","","","","","fee schedule","114.43","137.32","APC"
"Drug assay 120+ rx&metablt","0328U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.15","","","","","","","fee schedule","114.43","137.32","APC"
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3437.98","","","","","","","fee schedule","3437.98","4125.58",""
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3437.98","","","","","","","fee schedule","3437.98","4125.58",""
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3437.98","","","","","","","fee schedule","3437.98","4125.58",""
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4125.58","","","","","","","fee schedule","3437.98","4125.58",""
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4125.58","","","","","","","fee schedule","3437.98","4125.58",""
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3601.28","","","","","","","fee schedule","3437.98","4125.58","APC"
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3541.12","","","","","","","fee schedule","3437.98","4125.58","APC"
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3506.74","","","","","","","fee schedule","3437.98","4125.58","APC"
"Onc neo xome&trns seq alys","0329U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3609.88","","","","","","","fee schedule","3437.98","4125.58","APC"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Tear film img uni/bi w/i&r","0330T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","500.14","APC"
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","500.14","APC"
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","500.14","APC"
"Iadna vag pthgn panel 27 org","0330U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","500.14","APC"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart symp image plnr","0331T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1863.22","","","","","","","fee schedule","1863.22","2235.86",""
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1863.22","","","","","","","fee schedule","1863.22","2235.86",""
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1863.22","","","","","","","fee schedule","1863.22","2235.86",""
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2235.86","","","","","","","fee schedule","1863.22","2235.86",""
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2235.86","","","","","","","fee schedule","1863.22","2235.86",""
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1951.72","","","","","","","fee schedule","1863.22","2235.86","APC"
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1919.12","","","","","","","fee schedule","1863.22","2235.86","APC"
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1900.48","","","","","","","fee schedule","1863.22","2235.86","APC"
"Onc hl neo opt gen mapping","0331U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1956.38","","","","","","","fee schedule","1863.22","2235.86","APC"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart symp image plnr spect","0332T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1142.06","","","","","","","fee schedule","1142.06","1370.47",""
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1142.06","","","","","","","fee schedule","1142.06","1370.47",""
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1142.06","","","","","","","fee schedule","1142.06","1370.47",""
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1370.47","","","","","","","fee schedule","1142.06","1370.47",""
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1370.47","","","","","","","fee schedule","1142.06","1370.47",""
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1196.31","","","","","","","fee schedule","1142.06","1370.47","APC"
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1176.32","","","","","","","fee schedule","1142.06","1370.47","APC"
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1164.9","","","","","","","fee schedule","1142.06","1370.47","APC"
"Onc pan tum gen prflg 8 dna","0332U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1199.16","","","","","","","fee schedule","1142.06","1370.47","APC"
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","662.32","","","","","","","fee schedule","662.32","794.78",""
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","662.32","","","","","","","fee schedule","662.32","794.78",""
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","662.32","","","","","","","fee schedule","662.32","794.78",""
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","794.78","","","","","","","fee schedule","662.32","794.78",""
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","794.78","","","","","","","fee schedule","662.32","794.78",""
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","693.78","","","","","","","fee schedule","662.32","794.78","APC"
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","682.19","","","","","","","fee schedule","662.32","794.78","APC"
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","675.57","","","","","","","fee schedule","662.32","794.78","APC"
"Onc lvr surveilanc hcc cfdna","0333U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","695.44","","","","","","","fee schedule","662.32","794.78","APC"
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3500","","","","","","","fee schedule","3500","3675",""
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3500","","","","","","","fee schedule","3500","3675",""
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3500","","","","","","","fee schedule","3500","3675",""
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","3500","3675",""
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","3500","3675",""
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3666.25","","","","","","","fee schedule","3500","3675","APC"
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3605","","","","","","","fee schedule","3500","3675","APC"
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3570","","","","","","","fee schedule","3500","3675","APC"
"Onc sld orgn tgsa dna 84/+","0334U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3675","","","","","","","fee schedule","3500","3675","APC"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","7221.37","25051.33",""
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","7221.37","25051.33",""
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Extraosseous joint stblztion","0335T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5224.6","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5224.6","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5224.6","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6269.52","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6269.52","","","","","","","fee schedule","5224.6","6269.52",""
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5472.77","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5381.34","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5329.09","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds whl gen seq fetal","0335U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5485.83","","","","","","","fee schedule","5224.6","6269.52","APC"
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2574.65","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2574.65","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2574.65","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3089.58","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3089.58","","","","","","","fee schedule","2574.65","3089.58",""
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2696.95","","","","","","","fee schedule","2574.65","3089.58","APC"
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2651.89","","","","","","","fee schedule","2574.65","3089.58","APC"
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2626.14","","","","","","","fee schedule","2574.65","3089.58","APC"
"Rare ds whl gen seq bld/slv","0336U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2703.38","","","","","","","fee schedule","2574.65","3089.58","APC"
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2435","","","","","","","fee schedule","2435","2922",""
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2435","","","","","","","fee schedule","2435","2922",""
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2435","","","","","","","fee schedule","2435","2922",""
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2922","","","","","","","fee schedule","2435","2922",""
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2922","","","","","","","fee schedule","2435","2922",""
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2550.66","","","","","","","fee schedule","2435","2922","APC"
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2508.05","","","","","","","fee schedule","2435","2922","APC"
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2483.7","","","","","","","fee schedule","2435","2922","APC"
"Onc plsm cell do&myeloma id","0337U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2556.75","","","","","","","fee schedule","2435","2922","APC"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5664.24","19649.53",""
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5664.24","19649.53",""
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","19649.53","APC 277.30"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","19649.53","APC 296.56"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","19649.53","APC 308.91"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","19649.53","APC"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","19649.53","APC"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","19649.53","APC"
"Trnscth renal symp denrv unl","0338T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","19649.53","APC"
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2435","","","","","","","fee schedule","2435","2922",""
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2435","","","","","","","fee schedule","2435","2922",""
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2435","","","","","","","fee schedule","2435","2922",""
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2922","","","","","","","fee schedule","2435","2922",""
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2922","","","","","","","fee schedule","2435","2922",""
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2550.66","","","","","","","fee schedule","2435","2922","APC"
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2508.05","","","","","","","fee schedule","2435","2922","APC"
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2483.7","","","","","","","fee schedule","2435","2922","APC"
"Onc sld tum crcg tum cl slct","0338U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2556.75","","","","","","","fee schedule","2435","2922","APC"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5664.24","19649.53",""
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5664.24","19649.53",""
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","19649.53","APC 277.30"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","19649.53","APC 296.56"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","19649.53","APC 308.91"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","19649.53","APC"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","19649.53","APC"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","19649.53","APC"
"Trnscth renal symp denrv bil","0339T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","19649.53","APC"
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 mrna hoxc6 & dlx1","0339U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","4704",""
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","4704",""
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","4704",""
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4704","","","","","","","fee schedule","2919.6","4704",""
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4704","","","","","","","fee schedule","2919.6","4704",""
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3760.53","","","","","","","fee schedule","2919.6","4704","APC"
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3697.7","","","","","","","fee schedule","2919.6","4704","APC"
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3661.8","","","","","","","fee schedule","2919.6","4704","APC"
"Onc pan ca alys mrd plasma","0340U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3769.5","","","","","","","fee schedule","2919.6","4704","APC"
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1900.2","","","","","","","fee schedule","1900.2","2280.24",""
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1900.2","","","","","","","fee schedule","1900.2","2280.24",""
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1900.2","","","","","","","fee schedule","1900.2","2280.24",""
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2280.24","","","","","","","fee schedule","1900.2","2280.24",""
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2280.24","","","","","","","fee schedule","1900.2","2280.24",""
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1990.46","","","","","","","fee schedule","1900.2","2280.24","APC"
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1957.21","","","","","","","fee schedule","1900.2","2280.24","APC"
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1938.2","","","","","","","fee schedule","1900.2","2280.24","APC"
"Ftl aneup dna seq cmpr alys","0341U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1995.21","","","","","","","fee schedule","1900.2","2280.24","APC"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Thxp apheresis w/hdl delip","0342T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Onc pncrtc ca mult ia eclia","0342U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","897","","","","","","","fee schedule","897","1076.4",""
"Onc pncrtc ca mult ia eclia","0342U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","897","","","","","","","fee schedule","897","1076.4",""
"Onc pncrtc ca mult ia eclia","0342U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","897","","","","","","","fee schedule","897","1076.4",""
"Onc pncrtc ca mult ia eclia","0342U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc pncrtc ca mult ia eclia","0342U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 xom aly 442 sncrna","0343U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","792.17","","","","","","","fee schedule","792.17","950.6",""
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","792.17","","","","","","","fee schedule","792.17","950.6",""
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","792.17","","","","","","","fee schedule","792.17","950.6",""
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","950.6","","","","","","","fee schedule","792.17","950.6",""
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","950.6","","","","","","","fee schedule","792.17","950.6",""
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","829.8","","","","","","","fee schedule","792.17","950.6","APC"
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","815.94","","","","","","","fee schedule","792.17","950.6","APC"
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","808.01","","","","","","","fee schedule","792.17","950.6","APC"
"Hep nafld semiq evl 28 lipid","0344U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","831.78","","","","","","","fee schedule","792.17","950.6","APC"
"Transcath mtral vlve repair","0345T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Transcath mtral vlve repair","0345T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc genom alys pnl 15 gen","0345U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"Beta amyl a?40&a?42 lc-ms/ms","0346U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","111.91","","","","","","","fee schedule","111.91","111.91",""
"Beta amyl a?40&a?42 lc-ms/ms","0346U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","111.91","","","","","","","fee schedule","111.91","111.91",""
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","2633",""
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","2633",""
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","2633","APC 277.30"
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","2633","APC 296.56"
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","2633","APC 308.91"
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","2633","APC"
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","2633","APC"
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","2633","APC"
"Ins bone device for rsa","0347T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","2633","APC"
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab/pcx dna 16 gen alys","0347U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"RSA spine exam","0348T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","890.72","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","890.72","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","777.53","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","764.54","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","757.12","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab/pcx dna 25 gen alys","0348U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","779.38","","","","","","","fee schedule","742.27","890.72","APC"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"RSA upper extr exam","0349T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","742.27","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","890.72","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","890.72","","","","","","","fee schedule","742.27","890.72",""
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","777.53","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","764.54","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","757.12","","","","","","","fee schedule","742.27","890.72","APC"
"Rx metab/pcx dna 27gen rx ia","0349U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","779.38","","","","","","","fee schedule","742.27","890.72","APC"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"RSA lower extr exam","0350T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab/pcx dna 27 gen alys","0350U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.5","","","","","","","fee schedule","260.5","312.6",""
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.5","","","","","","","fee schedule","260.5","312.6",""
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.5","","","","","","","fee schedule","260.5","312.6",""
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","312.6","","","","","","","fee schedule","260.5","312.6",""
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","312.6","","","","","","","fee schedule","260.5","312.6",""
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","260.5","312.6","APC"
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","260.5","312.6","APC"
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","260.5","312.6","APC"
"Nfct ds bct/viral trail ip10","0351U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","260.5","312.6","APC"
"Nfct ds bv&vaginitis amp prb","0352U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.16","","","","","","","fee schedule","171.16","171.16",""
"Nfct ds bv&vaginitis amp prb","0352U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.16","","","","","","","fee schedule","171.16","171.16",""
"Iadna chlmyd&gonorr amp prb","0353U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","84.22","","","","","","","fee schedule","84.22","84.22",""
"Iadna chlmyd&gonorr amp prb","0353U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","84.22","","","","","","","fee schedule","84.22","84.22",""
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Apol1 risk variants","0355U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1800","","","","","","","fee schedule","1800","2160",""
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1800","","","","","","","fee schedule","1800","2160",""
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1800","","","","","","","fee schedule","1800","2160",""
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2160","","","","","","","fee schedule","1800","2160",""
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2160","","","","","","","fee schedule","1800","2160",""
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1885.5","","","","","","","fee schedule","1800","2160","APC"
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1854","","","","","","","fee schedule","1800","2160","APC"
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1836","","","","","","","fee schedule","1800","2160","APC"
"Onc orop 17 dna ddpcr alg","0356U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1890","","","","","","","fee schedule","1800","2160","APC"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"BIA whole body","0358T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.5","","","","","","","fee schedule","260.5","312.6",""
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.5","","","","","","","fee schedule","260.5","312.6",""
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.5","","","","","","","fee schedule","260.5","312.6",""
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","312.6","","","","","","","fee schedule","260.5","312.6",""
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","312.6","","","","","","","fee schedule","260.5","312.6",""
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","260.5","312.6","APC"
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","260.5","312.6","APC"
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","260.5","312.6","APC"
"Neuro alys b-amyl 1-42&1-40","0358U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","260.5","312.6","APC"
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 ca alys all psa","0359U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","782.93","","","","","","","fee schedule","782.93","1008.78",""
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","782.93","","","","","","","fee schedule","782.93","1008.78",""
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","782.93","","","","","","","fee schedule","782.93","1008.78",""
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1008.78","","","","","","","fee schedule","782.93","1008.78",""
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1008.78","","","","","","","fee schedule","782.93","1008.78",""
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","880.58","","","","","","","fee schedule","782.93","1008.78","APC"
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","865.87","","","","","","","fee schedule","782.93","1008.78","APC"
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","857.46","","","","","","","fee schedule","782.93","1008.78","APC"
"Onc lung elisa 7 autoant alg","0360U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","882.68","","","","","","","fee schedule","782.93","1008.78","APC"
"Neurflmnt lt chn dig ia quan","0361U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.23","","","","","","","fee schedule","116.23","116.23",""
"Neurflmnt lt chn dig ia quan","0361U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","116.23","","","","","","","fee schedule","116.23","116.23",""
"Neurflmnt lt chn dig ia quan","0361U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","116.23","","","","","","","fee schedule","116.23","116.23",""
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Expose behav assessment","0362T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3600","","","","","","","fee schedule","3600","4320",""
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3600","","","","","","","fee schedule","3600","4320",""
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3600","","","","","","","fee schedule","3600","4320",""
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4320","","","","","","","fee schedule","3600","4320",""
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4320","","","","","","","fee schedule","3600","4320",""
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3771","","","","","","","fee schedule","3600","4320","APC"
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3708","","","","","","","fee schedule","3600","4320","APC"
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3672","","","","","","","fee schedule","3600","4320","APC"
"Onc pap thyr ca rna 82&10","0362U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3780","","","","","","","fee schedule","3600","4320","APC"
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc urthl mrna 5 gen alg","0363U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2007.25","","","","","","","fee schedule","2007.25","2107.61",""
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2007.25","","","","","","","fee schedule","2007.25","2107.61",""
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2007.25","","","","","","","fee schedule","2007.25","2107.61",""
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2102.59","","","","","","","fee schedule","2007.25","2107.61","APC"
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2067.47","","","","","","","fee schedule","2007.25","2107.61","APC"
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2047.4","","","","","","","fee schedule","2007.25","2107.61","APC"
"Onc hl neo gen seq alys alg","0364U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2107.61","","","","","","","fee schedule","2007.25","2107.61","APC"
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","897","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","897","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","897","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.61","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.91","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.94","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb bldr ca","0365U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.85","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","897","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","897","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","897","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.61","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.91","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.94","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 prb recr bldr ca","0366U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.85","","","","","","","fee schedule","897","1076.4","APC"
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","902.18","","","","","","","fee schedule","902.18","1082.62",""
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","902.18","","","","","","","fee schedule","902.18","1082.62",""
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","902.18","","","","","","","fee schedule","902.18","1082.62",""
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1082.62","","","","","","","fee schedule","902.18","1082.62",""
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1082.62","","","","","","","fee schedule","902.18","1082.62",""
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","945.03","","","","","","","fee schedule","902.18","1082.62","APC"
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","929.25","","","","","","","fee schedule","902.18","1082.62","APC"
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","920.22","","","","","","","fee schedule","902.18","1082.62","APC"
"Onc bldr 10 flwg trurl rescj","0367U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","947.29","","","","","","","fee schedule","902.18","1082.62","APC"
"Onc clrct ca mut&mthyltn mrk","0368U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","416.78",""
"Onc clrct ca mut&mthyltn mrk","0368U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","416.78",""
"Onc clrct ca mut&mthyltn mrk","0368U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","416.78",""
"Iadna gi pthgn 31 org&21 arg","0369U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gi pthgn 31 org&21 arg","0369U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gi pthgn 31 org&21 arg","0369U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gi pthgn 31 org&21 arg","0369U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna gi pthgn 31 org&21 arg","0369U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna surg wnd pthgn 34&21","0370U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna surg wnd pthgn 34&21","0370U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna surg wnd pthgn 34&21","0370U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna surg wnd pthgn 34&21","0370U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna surg wnd pthgn 34&21","0370U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","500.14","APC"
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","500.14","APC"
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","500.14","APC"
"Iadna gu pthgn semiq dna16&1","0371U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","500.14","APC"
"Nfct ds gu pthgn arg detcj","0372U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","500.14","APC"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Exposure behavior treatment","0373T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Iadna rsp tr nfct 17 8 13&16","0373U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna rsp tr nfct 17 8 13&16","0373U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna rsp tr nfct 17 8 13&16","0373U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna rsp tr nfct 17 8 13&16","0373U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna rsp tr nfct 17 8 13&16","0373U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn 21 org&21arg","0374U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn 21 org&21arg","0374U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn 21 org&21arg","0374U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn 21 org&21arg","0374U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","416.78","500.14",""
"Iadna gu pthgn 21 org&21arg","0374U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","416.78","500.14",""
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","897","","","","","","","fee schedule","897","1076.4",""
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","897","","","","","","","fee schedule","897","1076.4",""
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","897","","","","","","","fee schedule","897","1076.4",""
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.61","","","","","","","fee schedule","897","1076.4","APC"
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.91","","","","","","","fee schedule","897","1076.4","APC"
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.94","","","","","","","fee schedule","897","1076.4","APC"
"Onc ovrn bchm asy 7 prtn alg","0375U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.85","","","","","","","fee schedule","897","1076.4","APC"
"Insert ant segment drain int","0376T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.8","","","","","","","fee schedule","706.25","847.5","APC"
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.44","","","","","","","fee schedule","706.25","847.5","APC"
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.38","","","","","","","fee schedule","706.25","847.5","APC"
"Onc prst8 ca img alys 128","0376U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.56","","","","","","","fee schedule","706.25","847.5","APC"
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.58","","","","","","","fee schedule","47.58","57.1",""
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.58","","","","","","","fee schedule","47.58","57.1",""
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.58","","","","","","","fee schedule","47.58","57.1",""
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","57.1","","","","","","","fee schedule","47.58","57.1",""
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","57.1","","","","","","","fee schedule","47.58","57.1",""
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.84","","","","","","","fee schedule","47.58","57.1","APC"
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49.01","","","","","","","fee schedule","47.58","57.1","APC"
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.53","","","","","","","fee schedule","47.58","57.1","APC"
"Cv ds quan advsrm/plsm lprtn","0377U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.96","","","","","","","fee schedule","47.58","57.1","APC"
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Rfc1 repeat xpnsj vrnt alys","0378U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Vis field assmnt tech suppt","0379T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3288.51","","","","","","","fee schedule","3288.51","3452.94",""
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3288.51","","","","","","","fee schedule","3288.51","3452.94",""
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3288.51","","","","","","","fee schedule","3288.51","3452.94",""
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3444.71","","","","","","","fee schedule","3288.51","3452.94","APC"
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3387.17","","","","","","","fee schedule","3288.51","3452.94","APC"
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3354.28","","","","","","","fee schedule","3288.51","3452.94","APC"
"Tgsap sl or neo dna523&rna55","0379U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3452.94","","","","","","","fee schedule","3288.51","3452.94","APC"
"Rx metb advrs trgt sq aly 20","0380U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","500.14","","","","","","","fee schedule","500.14","500.14",""
"Rx metb advrs trgt sq aly 20","0380U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","500.14","","","","","","","fee schedule","500.14","500.14",""
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44.12","","","","","","","fee schedule","44.12","46.33",""
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.12","","","","","","","fee schedule","44.12","46.33",""
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44.12","","","","","","","fee schedule","44.12","46.33",""
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.22","","","","","","","fee schedule","44.12","46.33","APC"
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.44","","","","","","","fee schedule","44.12","46.33","APC"
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45","","","","","","","fee schedule","44.12","46.33","APC"
"Maple syrup ur ds mntr quan","0381U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.33","","","","","","","fee schedule","44.12","46.33","APC"
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.64","","","","","","","fee schedule","51.64","54.22",""
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.64","","","","","","","fee schedule","51.64","54.22",""
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.64","","","","","","","fee schedule","51.64","54.22",""
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.09","","","","","","","fee schedule","51.64","54.22","APC"
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.19","","","","","","","fee schedule","51.64","54.22","APC"
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.67","","","","","","","fee schedule","51.64","54.22","APC"
"Hyprphenylalninmia mntr quan","0382U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.22","","","","","","","fee schedule","51.64","54.22","APC"
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","52.05","","","","","","","fee schedule","52.05","54.65",""
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","52.05","","","","","","","fee schedule","52.05","54.65",""
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","52.05","","","","","","","fee schedule","52.05","54.65",""
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.52","","","","","","","fee schedule","52.05","54.65","APC"
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.61","","","","","","","fee schedule","52.05","54.65","APC"
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","53.09","","","","","","","fee schedule","52.05","54.65","APC"
"Tyrosinemia typ i mntr quan","0383U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.65","","","","","","","fee schedule","52.05","54.65","APC"
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","900",""
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","900",""
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","900",""
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","900","","","","","","","fee schedule","750","900",""
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","900","","","","","","","fee schedule","750","900",""
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","900","APC"
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","900","APC"
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","900","APC"
"Neph ckd rsk hi stg kdn ds","0384U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","900","APC"
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","390.75","","","","","","","fee schedule","390.75","468.9",""
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","468.9","","","","","","","fee schedule","390.75","468.9",""
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","468.9","","","","","","","fee schedule","390.75","468.9",""
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.31","","","","","","","fee schedule","390.75","468.9","APC"
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.47","","","","","","","fee schedule","390.75","468.9","APC"
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.56","","","","","","","fee schedule","390.75","468.9","APC"
"Neph ckd alg rsk dbtc kdn ds","0385U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.29","","","","","","","fee schedule","390.75","468.9","APC"
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","948.5","","","","","","","fee schedule","948.5","1138.2",""
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","948.5","","","","","","","fee schedule","948.5","1138.2",""
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","948.5","","","","","","","fee schedule","948.5","1138.2",""
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1138.2","","","","","","","fee schedule","948.5","1138.2",""
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1138.2","","","","","","","fee schedule","948.5","1138.2",""
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","993.55","","","","","","","fee schedule","948.5","1138.2","APC"
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","976.96","","","","","","","fee schedule","948.5","1138.2","APC"
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","967.47","","","","","","","fee schedule","948.5","1138.2","APC"
"Onc mlnma ambra1&amlo","0387U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","995.92","","","","","","","fee schedule","948.5","1138.2","APC"
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3500","","","","","","","fee schedule","3500","3675",""
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3500","","","","","","","fee schedule","3500","3675",""
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3500","","","","","","","fee schedule","3500","3675",""
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3666.25","","","","","","","fee schedule","3500","3675","APC"
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3605","","","","","","","fee schedule","3500","3675","APC"
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3570","","","","","","","fee schedule","3500","3675","APC"
"Onc nonsm cll lng ca 37 gen","0388U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3675","","","","","","","fee schedule","3500","3675","APC"
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.2","","","","","","","fee schedule","70.2","73.71",""
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.2","","","","","","","fee schedule","70.2","73.71",""
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.2","","","","","","","fee schedule","70.2","73.71",""
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.53","","","","","","","fee schedule","70.2","73.71","APC"
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.31","","","","","","","fee schedule","70.2","73.71","APC"
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.6","","","","","","","fee schedule","70.2","73.71","APC"
"Ped fbrl kd ifi27&mcemp1 rna","0389U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.71","","","","","","","fee schedule","70.2","73.71","APC"
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.41","","","","","","","fee schedule","64.41","77.29",""
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.41","","","","","","","fee schedule","64.41","77.29",""
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.41","","","","","","","fee schedule","64.41","77.29",""
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","77.29","","","","","","","fee schedule","64.41","77.29",""
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","77.29","","","","","","","fee schedule","64.41","77.29",""
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.47","","","","","","","fee schedule","64.41","77.29","APC"
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.34","","","","","","","fee schedule","64.41","77.29","APC"
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.7","","","","","","","fee schedule","64.41","77.29","APC"
"Ob pe kdr eng&rbp4 ia alg","0390U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.63","","","","","","","fee schedule","64.41","77.29","APC"
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3600","","","","","","","fee schedule","3600","4320",""
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3600","","","","","","","fee schedule","3600","4320",""
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3600","","","","","","","fee schedule","3600","4320",""
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4320","","","","","","","fee schedule","3600","4320",""
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4320","","","","","","","fee schedule","3600","4320",""
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3771","","","","","","","fee schedule","3600","4320","APC"
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3708","","","","","","","fee schedule","3600","4320","APC"
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3672","","","","","","","fee schedule","3600","4320","APC"
"Onc sld tum dna&rna 437 gen","0391U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3780","","","","","","","fee schedule","3600","4320","APC"
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rx metab genrx ia 16 genes","0392U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","540.99","","","","","","","fee schedule","540.99","649.19",""
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","540.99","","","","","","","fee schedule","540.99","649.19",""
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","540.99","","","","","","","fee schedule","540.99","649.19",""
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","649.19","","","","","","","fee schedule","540.99","649.19",""
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","649.19","","","","","","","fee schedule","540.99","649.19",""
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","566.69","","","","","","","fee schedule","540.99","649.19","APC"
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","557.22","","","","","","","fee schedule","540.99","649.19","APC"
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","551.81","","","","","","","fee schedule","540.99","649.19","APC"
"Neu prksn msfl ?-syncln prtn","0393U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","568.04","","","","","","","fee schedule","540.99","649.19","APC"
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","198.74","","","","","","","fee schedule","198.74","238.49",""
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.74","","","","","","","fee schedule","198.74","238.49",""
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.74","","","","","","","fee schedule","198.74","238.49",""
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","238.49","","","","","","","fee schedule","198.74","238.49",""
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","238.49","","","","","","","fee schedule","198.74","238.49",""
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","208.18","","","","","","","fee schedule","198.74","238.49","APC"
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","204.7","","","","","","","fee schedule","198.74","238.49","APC"
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","202.71","","","","","","","fee schedule","198.74","238.49","APC"
"Pfas 16 pfas compnd lc ms/ms","0394U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","208.68","","","","","","","fee schedule","198.74","238.49","APC"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","2404.51","APC 277.30"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","2404.51","APC 296.56"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","2404.51","APC 308.91"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr elctr ntrst/ntrcv brchtx","0395T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","2404.51","APC"
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","797.45","","","","","","","fee schedule","797.45","837.32",""
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","797.45","","","","","","","fee schedule","797.45","837.32",""
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","797.45","","","","","","","fee schedule","797.45","837.32",""
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","835.33","","","","","","","fee schedule","797.45","837.32","APC"
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","821.37","","","","","","","fee schedule","797.45","837.32","APC"
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","813.4","","","","","","","fee schedule","797.45","837.32","APC"
"Onc lng multiomics plsm alg","0395U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","837.32","","","","","","","fee schedule","797.45","837.32","APC"
"Ercp w/optical endomicroscpy","0397T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Ercp w/optical endomicroscpy","0397T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1755","","","","","","","fee schedule","1755","1842.75",""
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1755","","","","","","","fee schedule","1755","1842.75",""
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1755","","","","","","","fee schedule","1755","1842.75",""
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1838.36","","","","","","","fee schedule","1755","1842.75","APC"
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1807.65","","","","","","","fee schedule","1755","1842.75","APC"
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1790.1","","","","","","","fee schedule","1755","1842.75","APC"
"Gi baret esph dna mthyln aly","0398U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1842.75","","","","","","","fee schedule","1755","1842.75","APC"
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","300","","","","","","","fee schedule","300","315",""
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","300","","","","","","","fee schedule","300","315",""
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300","","","","","","","fee schedule","300","315",""
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","314.25","","","","","","","fee schedule","300","315","APC"
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","309","","","","","","","fee schedule","300","315","APC"
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","306","","","","","","","fee schedule","300","315","APC"
"Neuro cere folate defncy srm","0399U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","315","","","","","","","fee schedule","300","315","APC"
"Ob xpnd car scr 145 genes","0400U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1456.88","","","","","","","fee schedule","1456.88","1456.88",""
"Ob xpnd car scr 145 genes","0400U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1456.88","","","","","","","fee schedule","1456.88","1456.88",""
"Ob xpnd car scr 145 genes","0400U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1456.88","","","","","","","fee schedule","1456.88","1456.88",""
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","489.68","","","","","","","fee schedule","489.68","514.16",""
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","489.68","","","","","","","fee schedule","489.68","514.16",""
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","489.68","","","","","","","fee schedule","489.68","514.16",""
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","512.94","","","","","","","fee schedule","489.68","514.16","APC"
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","504.37","","","","","","","fee schedule","489.68","514.16","APC"
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","499.47","","","","","","","fee schedule","489.68","514.16","APC"
"Crd c hrt ds 9 gen 12 vrnts","0401U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","514.16","","","","","","","fee schedule","489.68","514.16","APC"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Collagen crosslinking cornea","0402T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.16",""
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.16","","","","","","","fee schedule","142.63","171.16",""
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.16","","","","","","","fee schedule","142.63","171.16",""
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct agt sti mult amp prb tq","0402U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","171.16","APC"
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc prst8 mrna 18 gen dre ur","0403U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","322.96","","","","","","","fee schedule","322.96","387.55",""
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","322.96","","","","","","","fee schedule","322.96","387.55",""
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","322.96","","","","","","","fee schedule","322.96","387.55",""
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","387.55","","","","","","","fee schedule","322.96","387.55",""
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","387.55","","","","","","","fee schedule","322.96","387.55",""
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","338.3","","","","","","","fee schedule","322.96","387.55","APC"
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","332.65","","","","","","","fee schedule","322.96","387.55","APC"
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","329.42","","","","","","","fee schedule","322.96","387.55","APC"
"Onc brst semiq meas thym kn","0404U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","339.11","","","","","","","fee schedule","322.96","387.55","APC"
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1770.48","","","","","","","fee schedule","1770.48","2124.58",""
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1770.48","","","","","","","fee schedule","1770.48","2124.58",""
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1770.48","","","","","","","fee schedule","1770.48","2124.58",""
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2124.58","","","","","","","fee schedule","1770.48","2124.58",""
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2124.58","","","","","","","fee schedule","1770.48","2124.58",""
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1854.58","","","","","","","fee schedule","1770.48","2124.58","APC"
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1823.59","","","","","","","fee schedule","1770.48","2124.58","APC"
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1805.89","","","","","","","fee schedule","1770.48","2124.58","APC"
"Onc pncrtc 59 mthltn blk mrk","0405U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1859","","","","","","","fee schedule","1770.48","2124.58","APC"
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","912",""
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","912",""
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","912",""
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","912","","","","","","","fee schedule","760","912",""
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","912","","","","","","","fee schedule","760","912",""
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","912","APC"
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","912","APC"
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","912","APC"
"Onc lung flow cytmtry 5 mrk","0406U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","912","APC"
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","950","","","","","","","fee schedule","950","1140",""
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","950","","","","","","","fee schedule","950","1140",""
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","950","","","","","","","fee schedule","950","1140",""
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1140","","","","","","","fee schedule","950","1140",""
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1140","","","","","","","fee schedule","950","1140",""
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","995.13","","","","","","","fee schedule","950","1140","APC"
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","978.5","","","","","","","fee schedule","950","1140","APC"
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","969","","","","","","","fee schedule","950","1140","APC"
"Neph dbtc ckd mult eclia alg","0407U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","997.5","","","","","","","fee schedule","950","1140","APC"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","31238.15","108366.8",""
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","31238.15","108366.8",""
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","31238.15","108366.8","APC 277.30"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","31238.15","108366.8","APC 296.56"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","31238.15","108366.8","APC 308.91"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj/rplc cardiac modulj sys","0408T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","31238.15","108366.8","APC"
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.13","","","","","","","fee schedule","14.13","14.84",""
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.13","","","","","","","fee schedule","14.13","14.84",""
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.13","","","","","","","fee schedule","14.13","14.84",""
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.8","","","","","","","fee schedule","14.13","14.84","APC"
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.55","","","","","","","fee schedule","14.13","14.84","APC"
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.41","","","","","","","fee schedule","14.13","14.84","APC"
"Iaad blk ac wv bsnsr sarscv2","0408U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.84","","","","","","","fee schedule","14.13","14.84","APC"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","22136.77","76793.64",""
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","22136.77","76793.64",""
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","22136.77","76793.64","APC 277.30"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","22136.77","76793.64","APC 296.56"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","22136.77","76793.64","APC 308.91"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj/rplc car modulj pls gn","0409T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","22136.77","76793.64","APC"
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Onc sld tum dna 80 & rna 36","0409U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplc car modulj atr elt","0410T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160","","","","","","","fee schedule","1160","1392",""
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1160","","","","","","","fee schedule","1160","1392",""
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1160","","","","","","","fee schedule","1160","1392",""
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1392","","","","","","","fee schedule","1160","1392",""
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1392","","","","","","","fee schedule","1160","1392",""
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1215.1","","","","","","","fee schedule","1160","1392","APC"
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1194.8","","","","","","","fee schedule","1160","1392","APC"
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1183.2","","","","","","","fee schedule","1160","1392","APC"
"Onc pncrtc dna whl gn seq 5-","0410U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1218","","","","","","","fee schedule","1160","1392","APC"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplc car modulj vnt elt","0411T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Psyc genom alys pnl 15 gen","0411U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl cardiac modulj pls gen","0412T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","787.5",""
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","787.5",""
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","787.5",""
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","787.5","APC"
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","787.5","APC"
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","787.5","APC"
"Beta amyloid a?42/40 imprcip","0412U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","787.5","APC"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl car modulj tranvns elt","0413T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1263.53","","","","","","","fee schedule","1263.53","1516.24",""
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1516.24","","","","","","","fee schedule","1263.53","1516.24",""
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1516.24","","","","","","","fee schedule","1263.53","1516.24",""
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.55","","","","","","","fee schedule","1263.53","1516.24","APC"
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.44","","","","","","","fee schedule","1263.53","1516.24","APC"
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.8","","","","","","","fee schedule","1263.53","1516.24","APC"
"Onc hl neo opt gen mapg dna","0413U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.71","","","","","","","fee schedule","1263.53","1516.24","APC"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","22136.77","76793.64",""
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","22136.77","76793.64",""
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","22136.77","76793.64","APC 277.30"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","22136.77","76793.64","APC 296.56"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","22136.77","76793.64","APC 308.91"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rmvl & rpl car modulj pls gn","0414T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","22136.77","76793.64","APC"
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.8","","","","","","","fee schedule","706.25","847.5","APC"
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.44","","","","","","","fee schedule","706.25","847.5","APC"
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.38","","","","","","","fee schedule","706.25","847.5","APC"
"Onc lng aug alg aly whl sld8","0414U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.56","","","","","","","fee schedule","706.25","847.5","APC"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Repos car modulj tranvns elt","0415T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","390.75","","","","","","","fee schedule","390.75","468.9",""
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","390.75","","","","","","","fee schedule","390.75","468.9",""
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","468.9","","","","","","","fee schedule","390.75","468.9",""
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","468.9","","","","","","","fee schedule","390.75","468.9",""
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.31","","","","","","","fee schedule","390.75","468.9","APC"
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.47","","","","","","","fee schedule","390.75","468.9","APC"
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.56","","","","","","","fee schedule","390.75","468.9","APC"
"Cv ds acs bld alg 5 yr score","0415U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.29","","","","","","","fee schedule","390.75","468.9","APC"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Reloc skin pocket pls gen","0416T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval cardiac modulj","0417T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2842.53","","","","","","","fee schedule","2842.53","2984.66",""
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2842.53","","","","","","","fee schedule","2842.53","2984.66",""
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2842.53","","","","","","","fee schedule","2842.53","2984.66",""
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2977.55","","","","","","","fee schedule","2842.53","2984.66","APC"
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2927.81","","","","","","","fee schedule","2842.53","2984.66","APC"
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2899.38","","","","","","","fee schedule","2842.53","2984.66","APC"
"Rare ds alys 335 nuc genes","0417U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2984.66","","","","","","","fee schedule","2842.53","2984.66","APC"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interro eval cardiac modulj","0418T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","706.25","","","","","","","fee schedule","706.25","847.5",""
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","847.5","","","","","","","fee schedule","706.25","847.5",""
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.8","","","","","","","fee schedule","706.25","847.5","APC"
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.44","","","","","","","fee schedule","706.25","847.5","APC"
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.38","","","","","","","fee schedule","706.25","847.5","APC"
"Onc brst aug alg aly whl sl8","0418U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.56","","","","","","","fee schedule","706.25","847.5","APC"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","2633",""
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","2633",""
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","2633","APC 277.30"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","2633","APC 296.56"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","2633","APC 308.91"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","2633","APC"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","2633","APC"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","2633","APC"
"Dstrj neurofibroma xtnsv","0419T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","2633","APC"
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1336.09","","","","","","","fee schedule","1336.09","1603.31",""
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1603.31","","","","","","","fee schedule","1336.09","1603.31",""
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1399.55","","","","","","","fee schedule","1336.09","1603.31","APC"
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1376.17","","","","","","","fee schedule","1336.09","1603.31","APC"
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1362.81","","","","","","","fee schedule","1336.09","1603.31","APC"
"Nrpsyc gen seq vrnt aly 13","0419U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1402.89","","","","","","","fee schedule","1336.09","1603.31","APC"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","2633",""
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","2633",""
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","2633","APC 277.30"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","2633","APC 296.56"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","2633","APC 308.91"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","2633","APC"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","2633","APC"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","2633","APC"
"Dstrj neurofibroma xtnsv","0420T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","2633","APC"
"Onc urthl mrna xprsn 6 snp","0420U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1391.42","","","","","","","fee schedule","1354.89","1394.74","APC"
"Onc urthl mrna xprsn 6 snp","0420U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1368.17","","","","","","","fee schedule","1354.89","1394.74","APC"
"Onc urthl mrna xprsn 6 snp","0420U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1354.89","","","","","","","fee schedule","1354.89","1394.74","APC"
"Onc urthl mrna xprsn 6 snp","0420U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1394.74","","","","","","","fee schedule","1354.89","1394.74","APC"
"Waterjet prostate abltj cmpl","0421T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","21639","23971",""
"Waterjet prostate abltj cmpl","0421T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","21639","23971",""
"Onc clrct scr sgl amp 8 rna","0421U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","508.87","","","","","","","fee schedule","508.87","508.87",""
"Onc clrct scr sgl amp 8 rna","0421U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","508.87","","","","","","","fee schedule","508.87","508.87",""
"Onc clrct scr sgl amp 8 rna","0421U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","508.87","","","","","","","fee schedule","508.87","508.87",""
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Tactile breast img uni/bi","0422T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Onc pan solid tum alys dna","0422U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2035.51","","","","","","","fee schedule","1982.07","2040.37","APC"
"Onc pan solid tum alys dna","0422U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2001.51","","","","","","","fee schedule","1982.07","2040.37","APC"
"Onc pan solid tum alys dna","0422U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1982.07","","","","","","","fee schedule","1982.07","2040.37","APC"
"Onc pan solid tum alys dna","0422U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2040.37","","","","","","","fee schedule","1982.07","2040.37","APC"
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Psyc genomic alys pnl 26 gen","0423U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","798",""
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","798",""
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","798",""
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","798","APC"
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","798","APC"
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","798","APC"
"Onc prst8 xom alys 53 sncrna","0424U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","798","APC"
"Genom rpd seq alys ea cmprtr","0425U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4288.87","","","","","","","fee schedule","4176.28","4299.11","APC"
"Genom rpd seq alys ea cmprtr","0425U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4217.22","","","","","","","fee schedule","4176.28","4299.11","APC"
"Genom rpd seq alys ea cmprtr","0425U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4176.28","","","","","","","fee schedule","4176.28","4299.11","APC"
"Genom rpd seq alys ea cmprtr","0425U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4299.11","","","","","","","fee schedule","4176.28","4299.11","APC"
"Genome ultra-rapid seq alys","0426U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7942.35","","","","","","","fee schedule","7733.84","7961.31","APC"
"Genome ultra-rapid seq alys","0426U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7809.67","","","","","","","fee schedule","7733.84","7961.31","APC"
"Genome ultra-rapid seq alys","0426U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7733.84","","","","","","","fee schedule","7733.84","7961.31","APC"
"Genome ultra-rapid seq alys","0426U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7961.31","","","","","","","fee schedule","7733.84","7961.31","APC"
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.48","","","","","","","fee schedule","4.48","4.7",""
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.48","","","","","","","fee schedule","4.48","4.7",""
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.48","","","","","","","fee schedule","4.48","4.7",""
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.69","","","","","","","fee schedule","4.48","4.7","APC"
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.61","","","","","","","fee schedule","4.48","4.7","APC"
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.57","","","","","","","fee schedule","4.48","4.7","APC"
"Monocyte dstrbj wdth whl bld","0427U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.7","","","","","","","fee schedule","4.48","4.7","APC"
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","36.84",""
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","36.84",""
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","36.84",""
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv orop swab 14 hi-risk typ","0429U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","36.84","APC"
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","61.54","","","","","","","fee schedule","61.54","64.62",""
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.54","","","","","","","fee schedule","61.54","64.62",""
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.54","","","","","","","fee schedule","61.54","64.62",""
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.46","","","","","","","fee schedule","61.54","64.62","APC"
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.39","","","","","","","fee schedule","61.54","64.62","APC"
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.77","","","","","","","fee schedule","61.54","64.62","APC"
"Gi malabs aat calpro pncrtc","0430U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.62","","","","","","","fee schedule","61.54","64.62","APC"
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.57","","","","","","","fee schedule","36.57","38.4",""
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.57","","","","","","","fee schedule","36.57","38.4",""
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.57","","","","","","","fee schedule","36.57","38.4",""
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.31","","","","","","","fee schedule","36.57","38.4","APC"
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.67","","","","","","","fee schedule","36.57","38.4","APC"
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.3","","","","","","","fee schedule","36.57","38.4","APC"
"Gly rcptr alpha1 igg srm/csf","0431U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.4","","","","","","","fee schedule","36.57","38.4","APC"
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.57","","","","","","","fee schedule","36.57","38.4",""
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.57","","","","","","","fee schedule","36.57","38.4",""
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.57","","","","","","","fee schedule","36.57","38.4",""
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.31","","","","","","","fee schedule","36.57","38.4","APC"
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.67","","","","","","","fee schedule","36.57","38.4","APC"
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.3","","","","","","","fee schedule","36.57","38.4","APC"
"Klhl11 antb sr/csf asy qual","0432U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.4","","","","","","","fee schedule","36.57","38.4","APC"
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","798",""
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","798",""
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","798",""
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","798","APC"
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","798","APC"
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","798","APC"
"Onc prst8 5 dna reg mrk pcr","0433U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","798","APC"
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab advrs vrnt alys 25","0434U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3033.86","","","","","","","fee schedule","3033.86","3185.55",""
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3033.86","","","","","","","fee schedule","3033.86","3185.55",""
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3033.86","","","","","","","fee schedule","3033.86","3185.55",""
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3177.97","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3124.88","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3094.54","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc chemo rx cytox csc 14 rx","0435U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3185.55","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc lng plsm alys 388 prtn","0436U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1575.69","","","","","","","fee schedule","1534.32","1579.45","APC"
"Onc lng plsm alys 388 prtn","0436U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1549.37","","","","","","","fee schedule","1534.32","1579.45","APC"
"Onc lng plsm alys 388 prtn","0436U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1534.32","","","","","","","fee schedule","1534.32","1579.45","APC"
"Onc lng plsm alys 388 prtn","0436U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1579.45","","","","","","","fee schedule","1534.32","1579.45","APC"
"Impltj synth rnfcmt abdl wal","0437T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Impltj synth rnfcmt abdl wal","0437T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","798",""
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","798",""
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","798",""
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","798","APC"
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","798","APC"
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","798","APC"
"Psyc anxiety do mrna 15 bmrk","0437U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","798","APC"
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab advrs vrnt alys 33","0438U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Crd chd dna alys 5 snp 3 dna","0439U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","894.56","","","","","","","fee schedule","871.08","896.7","APC"
"Crd chd dna alys 5 snp 3 dna","0439U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","879.62","","","","","","","fee schedule","871.08","896.7","APC"
"Crd chd dna alys 5 snp 3 dna","0439U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","871.08","","","","","","","fee schedule","871.08","896.7","APC"
"Crd chd dna alys 5 snp 3 dna","0439U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","896.7","","","","","","","fee schedule","871.08","896.7","APC"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","1943.35","23971",""
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","1943.35","23971",""
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","23971","APC 277.30"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","23971","APC 296.56"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","23971","APC 308.91"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","23971","APC"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","23971","APC"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","23971","APC"
"Abltj perc uxtr/perph nrv","0440T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","23971","APC"
"Crd chd dna alys 10 snp 6dna","0440U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","894.56","","","","","","","fee schedule","871.08","896.7","APC"
"Crd chd dna alys 10 snp 6dna","0440U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","879.62","","","","","","","fee schedule","871.08","896.7","APC"
"Crd chd dna alys 10 snp 6dna","0440U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","871.08","","","","","","","fee schedule","871.08","896.7","APC"
"Crd chd dna alys 10 snp 6dna","0440U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","896.7","","","","","","","fee schedule","871.08","896.7","APC"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","1943.35","23971",""
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","1943.35","23971",""
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","23971","APC 277.30"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","23971","APC 296.56"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","23971","APC 308.91"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","23971","APC"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","23971","APC"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","23971","APC"
"Abltj perc lxtr/perph nrv","0441T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","23971","APC"
"Nfct ds bct fngl/viral semiq","0441U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","465.17","","","","","","","fee schedule","452.96","466.28","APC"
"Nfct ds bct fngl/viral semiq","0441U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","457.4","","","","","","","fee schedule","452.96","466.28","APC"
"Nfct ds bct fngl/viral semiq","0441U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","452.96","","","","","","","fee schedule","452.96","466.28","APC"
"Nfct ds bct fngl/viral semiq","0441U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","466.28","","","","","","","fee schedule","452.96","466.28","APC"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","8733.71","30297.71",""
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","8733.71","30297.71",""
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","8733.71","30297.71","APC 277.30"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","8733.71","30297.71","APC 296.56"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","8733.71","30297.71","APC 308.91"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","8733.71","30297.71","APC"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","8733.71","30297.71","APC"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","8733.71","30297.71","APC"
"Abltj perc plex/trncl nrv","0442T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","8733.71","30297.71","APC"
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.38","","","","","","","fee schedule","41.38","43.45",""
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.38","","","","","","","fee schedule","41.38","43.45",""
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.38","","","","","","","fee schedule","41.38","43.45",""
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.35","","","","","","","fee schedule","41.38","43.45","APC"
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.62","","","","","","","fee schedule","41.38","43.45","APC"
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.21","","","","","","","fee schedule","41.38","43.45","APC"
"Nfct ds respir nfctj mxa&crp","0442U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.45","","","","","","","fee schedule","41.38","43.45","APC"
"R-t spctrl alys prst8 tiss","0443T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"R-t spctrl alys prst8 tiss","0443T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Neurflmnt lt chn ultrsens ia","0443U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","121.75","","","","","","","fee schedule","118.55","122.04","APC"
"Neurflmnt lt chn ultrsens ia","0443U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","119.72","","","","","","","fee schedule","118.55","122.04","APC"
"Neurflmnt lt chn ultrsens ia","0443U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","118.55","","","","","","","fee schedule","118.55","122.04","APC"
"Neurflmnt lt chn ultrsens ia","0443U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","122.04","","","","","","","fee schedule","118.55","122.04","APC"
"1st plmt drug elut oc ins","0444T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"1st plmt drug elut oc ins","0444T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3065.58",""
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3065.58",""
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3065.58",""
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3065.58","APC"
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3065.58","APC"
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3065.58","APC"
"Onc sld orgn neo tgsap 361","0444U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3065.58","APC"
"Sbsqt plmt drug elut oc ins","0445T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Sbsqt plmt drug elut oc ins","0445T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.5","","","","","","","fee schedule","260.5","273.52",""
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.5","","","","","","","fee schedule","260.5","273.52",""
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.5","","","","","","","fee schedule","260.5","273.52",""
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ptau181 eclia csf","0445U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","260.5","273.52","APC"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","14363.31",""
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","14363.31",""
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12893.55","","","","","","","fee schedule","2375","14363.31","APC 277.30"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13789.07","","","","","","","fee schedule","2375","14363.31","APC 296.56"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14363.31","","","","","","","fee schedule","2375","14363.31","APC 308.91"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4252.04","","","","","","","fee schedule","2375","14363.31","APC"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4181","","","","","","","fee schedule","2375","14363.31","APC"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4140.41","","","","","","","fee schedule","2375","14363.31","APC"
"Insj impltbl glucose sensor","0446T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4262.19","","","","","","","fee schedule","2375","14363.31","APC"
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","840.65","","","","","","","fee schedule","840.65","882.68",""
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","840.65","","","","","","","fee schedule","840.65","882.68",""
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","840.65","","","","","","","fee schedule","840.65","882.68",""
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","880.58","","","","","","","fee schedule","840.65","882.68","APC"
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","865.87","","","","","","","fee schedule","840.65","882.68","APC"
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","857.46","","","","","","","fee schedule","840.65","882.68","APC"
"Ai ds sle alys 10 cytokine","0446U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","882.68","","","","","","","fee schedule","840.65","882.68","APC"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","2633",""
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","2633",""
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","2633","APC 277.30"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","2633","APC 296.56"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","2633","APC 308.91"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl impltbl glucose sensor","0447T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","2633","APC"
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","840.65","","","","","","","fee schedule","840.65","882.68",""
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","840.65","","","","","","","fee schedule","840.65","882.68",""
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","840.65","","","","","","","fee schedule","840.65","882.68",""
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","880.58","","","","","","","fee schedule","840.65","882.68","APC"
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","865.87","","","","","","","fee schedule","840.65","882.68","APC"
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","857.46","","","","","","","fee schedule","840.65","882.68","APC"
"Ai ds sle alys 11 cytokine","0447U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","882.68","","","","","","","fee schedule","840.65","882.68","APC"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","14363.31",""
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","14363.31",""
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12893.55","","","","","","","fee schedule","2375","14363.31","APC 277.30"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13789.07","","","","","","","fee schedule","2375","14363.31","APC 296.56"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14363.31","","","","","","","fee schedule","2375","14363.31","APC 308.91"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4252.04","","","","","","","fee schedule","2375","14363.31","APC"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4181","","","","","","","fee schedule","2375","14363.31","APC"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4140.41","","","","","","","fee schedule","2375","14363.31","APC"
"Remvl insj impltbl gluc sens","0448T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4262.19","","","","","","","fee schedule","2375","14363.31","APC"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Insj aqueous drain dev 1st","0449T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Car scr sev inh cond 5 genes","0449U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1824.88","","","","","","","fee schedule","1824.88","1824.88",""
"Car scr sev inh cond 5 genes","0449U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1824.88","","","","","","","fee schedule","1824.88","1824.88",""
"Car scr sev inh cond 5 genes","0449U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1824.88","","","","","","","fee schedule","1824.88","1824.88",""
"Insj aqueous drain dev each","0450T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Insj aqueous drain dev each","0450T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Onc mm lc-ms/ms monoc p-prtn","0450U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.43","","","","","","","fee schedule","43.43","43.43",""
"Onc mm lc-ms/ms monoc p-prtn","0450U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.43","","","","","","","fee schedule","43.43","43.43",""
"Onc mm lc-ms/ms monoc p-prtn","0450U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.43","","","","","","","fee schedule","43.43","43.43",""
"Onc mm lc-ms/ms pep ion quan","0451U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.43","","","","","","","fee schedule","43.43","43.43",""
"Onc mm lc-ms/ms pep ion quan","0451U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.43","","","","","","","fee schedule","43.43","43.43",""
"Onc mm lc-ms/ms pep ion quan","0451U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.43","","","","","","","fee schedule","43.43","43.43",""
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","192","","","","","","","fee schedule","192","201.6",""
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","192","","","","","","","fee schedule","192","201.6",""
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","192","","","","","","","fee schedule","192","201.6",""
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.12","","","","","","","fee schedule","192","201.6","APC"
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","197.76","","","","","","","fee schedule","192","201.6","APC"
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","195.84","","","","","","","fee schedule","192","201.6","APC"
"Onc bldr mthyl penk lte-qmsp","0452U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.6","","","","","","","fee schedule","192","201.6","APC"
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","192","","","","","","","fee schedule","192","201.6",""
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","192","","","","","","","fee schedule","192","201.6",""
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","192","","","","","","","fee schedule","192","201.6",""
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.12","","","","","","","fee schedule","192","201.6","APC"
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","197.76","","","","","","","fee schedule","192","201.6","APC"
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","195.84","","","","","","","fee schedule","192","201.6","APC"
"Onc clrct ca cfdna qpcr asy","0453U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.6","","","","","","","fee schedule","192","201.6","APC"
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1263.53","","","","","","","fee schedule","1263.53","1326.71",""
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1263.53","","","","","","","fee schedule","1263.53","1326.71",""
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1263.53","","","","","","","fee schedule","1263.53","1326.71",""
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.55","","","","","","","fee schedule","1263.53","1326.71","APC"
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.44","","","","","","","fee schedule","1263.53","1326.71","APC"
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.8","","","","","","","fee schedule","1263.53","1326.71","APC"
"U rare ds id opt genome mapg","0454U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.71","","","","","","","fee schedule","1263.53","1326.71","APC"
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","149.76",""
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","149.76",""
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","149.76",""
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","149.76","APC"
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","149.76","APC"
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","149.76","APC"
"Nfct agt sti mult amp prb ur","0455U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","149.76","APC"
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","198.74","","","","","","","fee schedule","198.74","208.68",""
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.74","","","","","","","fee schedule","198.74","208.68",""
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.74","","","","","","","fee schedule","198.74","208.68",""
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","208.18","","","","","","","fee schedule","198.74","208.68","APC"
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","204.7","","","","","","","fee schedule","198.74","208.68","APC"
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","202.71","","","","","","","fee schedule","198.74","208.68","APC"
"Pfas 9 cmpnd lcms/ms pls/sr","0457U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","208.68","","","","","","","fee schedule","198.74","208.68","APC"
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.5","","","","","","","fee schedule","260.5","273.52",""
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.5","","","","","","","fee schedule","260.5","273.52",""
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.5","","","","","","","fee schedule","260.5","273.52",""
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","260.5","273.52","APC"
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","260.5","273.52","APC"
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","260.5","273.52","APC"
"Onc brst ca s100 a8&a9 elisa","0458U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.5","","","","","","","fee schedule","260.5","273.52",""
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.5","","","","","","","fee schedule","260.5","273.52",""
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.5","","","","","","","fee schedule","260.5","273.52",""
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","260.5","273.52","APC"
"Abeta42 & ttau eclia csf","0459U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","260.5","273.52","APC"
"Onc whl bld/bucc rtpcr 24gen","0460U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","960.64","","","","","","","fee schedule","935.42","962.93","APC"
"Onc whl bld/bucc rtpcr 24gen","0460U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","944.59","","","","","","","fee schedule","935.42","962.93","APC"
"Onc whl bld/bucc rtpcr 24gen","0460U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","935.42","","","","","","","fee schedule","935.42","962.93","APC"
"Onc whl bld/bucc rtpcr 24gen","0460U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","962.93","","","","","","","fee schedule","935.42","962.93","APC"
"Onc rxgenom alys rtpcr 24gen","0461U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","960.64","","","","","","","fee schedule","935.42","962.93","APC"
"Onc rxgenom alys rtpcr 24gen","0461U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","944.59","","","","","","","fee schedule","935.42","962.93","APC"
"Onc rxgenom alys rtpcr 24gen","0461U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","935.42","","","","","","","fee schedule","935.42","962.93","APC"
"Onc rxgenom alys rtpcr 24gen","0461U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","962.93","","","","","","","fee schedule","935.42","962.93","APC"
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","18.13",""
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","18.13",""
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","18.13",""
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","18.13","APC"
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","18.13","APC"
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","18.13","APC"
"Melatonin lvl tst slp std7/9","0462U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","18.13","APC"
"Onc crvx mrna genxprsn 14bmk","0463U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","775.2","798","APC"
"Onc crvx mrna genxprsn 14bmk","0463U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","775.2","798","APC"
"Onc crvx mrna genxprsn 14bmk","0463U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","775.2","798","APC"
"Onc crvx mrna genxprsn 14bmk","0463U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","775.2","798","APC"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Visual ep test for glaucoma","0464T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","591.92","","","","","","","fee schedule","591.92","621.52",""
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","591.92","","","","","","","fee schedule","591.92","621.52",""
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","591.92","","","","","","","fee schedule","591.92","621.52",""
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","620.04","","","","","","","fee schedule","591.92","621.52","APC"
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","609.68","","","","","","","fee schedule","591.92","621.52","APC"
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","603.76","","","","","","","fee schedule","591.92","621.52","APC"
"Onc clrct scr qrtsa dna mrk","0464U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","621.52","","","","","","","fee schedule","591.92","621.52","APC"
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1938.01","","","","","","","fee schedule","1938.01","2034.91",""
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1938.01","","","","","","","fee schedule","1938.01","2034.91",""
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1938.01","","","","","","","fee schedule","1938.01","2034.91",""
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2030.07","","","","","","","fee schedule","1938.01","2034.91","APC"
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1996.15","","","","","","","fee schedule","1938.01","2034.91","APC"
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1976.77","","","","","","","fee schedule","1938.01","2034.91","APC"
"Onc urthl carc dna qmsp 2gen","0465U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2034.91","","","","","","","fee schedule","1938.01","2034.91","APC"
"Crd cad dna gwas 564856 snp","0466U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","361.84","","","","","","","fee schedule","352.34","362.7","APC"
"Crd cad dna gwas 564856 snp","0466U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","355.79","","","","","","","fee schedule","352.34","362.7","APC"
"Crd cad dna gwas 564856 snp","0466U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","352.34","","","","","","","fee schedule","352.34","362.7","APC"
"Crd cad dna gwas 564856 snp","0466U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","362.7","","","","","","","fee schedule","352.34","362.7","APC"
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1519.06","","","","","","","fee schedule","1519.06","1595.01",""
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1519.06","","","","","","","fee schedule","1519.06","1595.01",""
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1519.06","","","","","","","fee schedule","1519.06","1595.01",""
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.22","","","","","","","fee schedule","1519.06","1595.01","APC"
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1564.63","","","","","","","fee schedule","1519.06","1595.01","APC"
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.44","","","","","","","fee schedule","1519.06","1595.01","APC"
"Onc bldr dna ngs 60gen&aneup","0467U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.01","","","","","","","fee schedule","1519.06","1595.01","APC"
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","251.7","","","","","","","fee schedule","251.7","264.29",""
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","251.7","","","","","","","fee schedule","251.7","264.29",""
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","251.7","","","","","","","fee schedule","251.7","264.29",""
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","263.66","","","","","","","fee schedule","251.7","264.29","APC"
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","259.25","","","","","","","fee schedule","251.7","264.29","APC"
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","256.73","","","","","","","fee schedule","251.7","264.29","APC"
"Hep nash mir34a5p ?2m ykl40","0468U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","264.29","","","","","","","fee schedule","251.7","264.29","APC"
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1197.94","","","","","","","fee schedule","1197.94","1257.84",""
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1197.94","","","","","","","fee schedule","1197.94","1257.84",""
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1197.94","","","","","","","fee schedule","1197.94","1257.84",""
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1254.84","","","","","","","fee schedule","1197.94","1257.84","APC"
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1233.88","","","","","","","fee schedule","1197.94","1257.84","APC"
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1221.9","","","","","","","fee schedule","1197.94","1257.84","APC"
"Rare ds whl gen seq ftl samp","0469U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1257.84","","","","","","","fee schedule","1197.94","1257.84","APC"
"Onc orop detcj mrd 8 dna hpv","0470U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","609.87","627.81","APC"
"Onc orop detcj mrd 8 dna hpv","0470U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","609.87","627.81","APC"
"Onc orop detcj mrd 8 dna hpv","0470U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","609.87","627.81","APC"
"Onc orop detcj mrd 8 dna hpv","0470U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","609.87","627.81","APC"
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","798",""
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","798",""
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","798",""
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","798","APC"
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","798","APC"
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","798","APC"
"Onc clrc ca 35 vrn kras&nras","0471U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","798","APC"
"Ca vi psp&sp1 antb sj?gren","0472U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.23","","","","","","","fee schedule","28.46","29.3","APC"
"Ca vi psp&sp1 antb sj?gren","0472U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.74","","","","","","","fee schedule","28.46","29.3","APC"
"Ca vi psp&sp1 antb sj?gren","0472U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.46","","","","","","","fee schedule","28.46","29.3","APC"
"Ca vi psp&sp1 antb sj?gren","0472U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.3","","","","","","","fee schedule","28.46","29.3","APC"
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4500","","","","","","","fee schedule","4500","4725",""
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4500","","","","","","","fee schedule","4500","4725",""
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4500","","","","","","","fee schedule","4500","4725",""
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4713.75","","","","","","","fee schedule","4500","4725","APC"
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4635","","","","","","","fee schedule","4500","4725","APC"
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4590","","","","","","","fee schedule","4500","4725","APC"
"Onc sld tum bld/slv 648 gene","0473U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4725","","","","","","","fee schedule","4500","4725","APC"
"Insj aqueous drg dev io rsvr","0474T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Insj aqueous drg dev io rsvr","0474T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Insj aqueous drg dev io rsvr","0474T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered pan ca gsap 88gene ngs","0474U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","1303.95","1369.15",""
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","1303.95","1369.15","APC"
"Hered prst8 ca gsap 23 genes","0475U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","1303.95","1369.15","APC"
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psyc 14gen&cyp2d6","0476U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab psy 14&cyp2d6 gn-rx","0477U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Onc nsclc dna&rna dpcr 9 gen","0478U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","579.26","","","","","","","fee schedule","564.05","580.64","APC"
"Onc nsclc dna&rna dpcr 9 gen","0478U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","569.58","","","","","","","fee schedule","564.05","580.64","APC"
"Onc nsclc dna&rna dpcr 9 gen","0478U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","564.05","","","","","","","fee schedule","564.05","580.64","APC"
"Onc nsclc dna&rna dpcr 9 gen","0478U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","580.64","","","","","","","fee schedule","564.05","580.64","APC"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","735.52","5220",""
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","735.52","5220",""
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Fxjl abl lsr 1st 100 sq cm","0479T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","18.13",""
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","18.13",""
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","18.13",""
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","18.13","APC"
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","18.13","APC"
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","18.13","APC"
"Tau phosphorylated ptau217","0479U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","18.13","APC"
"Fxjl abl lsr ea addl 100sqcm","0480T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fxjl abl lsr ea addl 100sqcm","0480T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fxjl abl lsr ea addl 100sqcm","0480T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2126.2","","","","","","","fee schedule","2126.2","2232.51",""
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2126.2","","","","","","","fee schedule","2126.2","2232.51",""
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2126.2","","","","","","","fee schedule","2126.2","2232.51",""
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2227.19","","","","","","","fee schedule","2126.2","2232.51","APC"
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2189.99","","","","","","","fee schedule","2126.2","2232.51","APC"
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2168.72","","","","","","","fee schedule","2126.2","2232.51","APC"
"Nfct ds csf metag ngs alys","0480U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2232.51","","","","","","","fee schedule","2126.2","2232.51","APC"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Njx autol wbc concentrate","0481T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","674.24","","","","","","","fee schedule","674.24","707.95",""
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","674.24","","","","","","","fee schedule","674.24","707.95",""
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","674.24","","","","","","","fee schedule","674.24","707.95",""
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","706.27","","","","","","","fee schedule","674.24","707.95","APC"
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","694.47","","","","","","","fee schedule","674.24","707.95","APC"
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","687.72","","","","","","","fee schedule","674.24","707.95","APC"
"Idh1 idh2&tert promoter ngs","0481U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","707.95","","","","","","","fee schedule","674.24","707.95","APC"
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","128.82","","","","","","","fee schedule","128.82","135.26",""
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","128.82","","","","","","","fee schedule","128.82","135.26",""
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.82","","","","","","","fee schedule","128.82","135.26",""
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","134.94","","","","","","","fee schedule","128.82","135.26","APC"
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.68","","","","","","","fee schedule","128.82","135.26","APC"
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.4","","","","","","","fee schedule","128.82","135.26","APC"
"Ob pe biochem asy sfit1&pigf","0482U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.26","","","","","","","fee schedule","128.82","135.26","APC"
"Tmvi percutaneous approach","0483T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tmvi percutaneous approach","0483T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tmvi percutaneous approach","0483T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Nfct ds ng gyra s91f pt mut","0483U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.79","36.84","APC"
"Nfct ds ng gyra s91f pt mut","0483U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.79","36.84","APC"
"Nfct ds ng gyra s91f pt mut","0483U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.79","36.84","APC"
"Nfct ds ng gyra s91f pt mut","0483U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.79","36.84","APC"
"Tmvi transthoracic exposure","0484T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tmvi transthoracic exposure","0484T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tmvi transthoracic exposure","0484T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Nfct ds mgen 23s rrna pt mut","0484U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.79","36.84","APC"
"Nfct ds mgen 23s rrna pt mut","0484U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.79","36.84","APC"
"Nfct ds mgen 23s rrna pt mut","0484U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.79","36.84","APC"
"Nfct ds mgen 23s rrna pt mut","0484U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.79","36.84","APC"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Oct mid ear i&r unilateral","0485T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Onc sol tum cfdna&rna ngs gm","0485U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3822.83","","","","","","","fee schedule","3722.47","3831.95","APC"
"Onc sol tum cfdna&rna ngs gm","0485U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3758.96","","","","","","","fee schedule","3722.47","3831.95","APC"
"Onc sol tum cfdna&rna ngs gm","0485U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3722.47","","","","","","","fee schedule","3722.47","3831.95","APC"
"Onc sol tum cfdna&rna ngs gm","0485U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3831.95","","","","","","","fee schedule","3722.47","3831.95","APC"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Oct mid ear i&r bilateral","0486T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Onc pan sol tum ngs cfctdna","0486U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1722.35","","","","","","","fee schedule","1677.14","1726.46","APC"
"Onc pan sol tum ngs cfctdna","0486U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1693.58","","","","","","","fee schedule","1677.14","1726.46","APC"
"Onc pan sol tum ngs cfctdna","0486U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1677.14","","","","","","","fee schedule","1677.14","1726.46","APC"
"Onc pan sol tum ngs cfctdna","0486U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1726.46","","","","","","","fee schedule","1677.14","1726.46","APC"
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3065.58",""
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3065.58",""
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3065.58",""
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3065.58","APC"
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3065.58","APC"
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3065.58","APC"
"Onc sol tum cfcdna tgsap 84","0487U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3065.58","APC"
"Ob fetal ag nipt cfdna alys","0488U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","759.05",""
"Ob fetal ag nipt cfdna alys","0488U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","759.05",""
"Ob fetal ag nipt cfdna alys","0488U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","759.05",""
"Regn cell tx scldr hands","0489T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Regn cell tx scldr hands","0489T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Regn cell tx scldr hands","0489T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Regn cell tx scldr h mlt inj","0490T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Regn cell tx scldr h mlt inj","0490T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Regn cell tx scldr h mlt inj","0490T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2550.66","","","","","","","fee schedule","2435","2556.75","APC"
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2508.05","","","","","","","fee schedule","2435","2556.75","APC"
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2483.7","","","","","","","fee schedule","2435","2556.75","APC"
"Onc cutan/uveal mlnma cd146","0490U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2556.75","","","","","","","fee schedule","2435","2556.75","APC"
"Abl lsr opn wnd 1st 20 sqcm","0491T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2550.66","","","","","","","fee schedule","2435","2556.75","APC"
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2508.05","","","","","","","fee schedule","2435","2556.75","APC"
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2483.7","","","","","","","fee schedule","2435","2556.75","APC"
"Onc sol tum ctc slct er prtn","0491U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2556.75","","","","","","","fee schedule","2435","2556.75","APC"
"Abl lsr opn wnd addl 20 sqcm","0492T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2435","","","","","","","fee schedule","2435","2556.75",""
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2550.66","","","","","","","fee schedule","2435","2556.75","APC"
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2508.05","","","","","","","fee schedule","2435","2556.75","APC"
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2483.7","","","","","","","fee schedule","2435","2556.75","APC"
"Onc sol tum ctc slctn pd-l1","0492U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2556.75","","","","","","","fee schedule","2435","2556.75","APC"
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2753.25","","","","","","","fee schedule","2753.25","2890.91",""
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2753.25","","","","","","","fee schedule","2753.25","2890.91",""
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2753.25","","","","","","","fee schedule","2753.25","2890.91",""
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2884.03","","","","","","","fee schedule","2753.25","2890.91","APC"
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2835.85","","","","","","","fee schedule","2753.25","2890.91","APC"
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2808.32","","","","","","","fee schedule","2753.25","2890.91","APC"
"Trnspl med quan dd-cfdna ngs","0493U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2890.91","","","","","","","fee schedule","2753.25","2890.91","APC"
"Prep & cannulj cdvr don lung","0494T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep & cannulj cdvr don lung","0494T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep & cannulj cdvr don lung","0494T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","797",""
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","797",""
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","797",""
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","759.05","797","APC"
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","759.05","797","APC"
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","759.05","797","APC"
"Rbc ag ftl rhd gene alys ngs","0494U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","759.05","797","APC"
"Mntr cdvr don lng 1st 2 hrs","0495T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Mntr cdvr don lng 1st 2 hrs","0495T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","760","798",""
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","760","798",""
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","760","798",""
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","760","798","APC"
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","760","798","APC"
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","760","798","APC"
"Onc prst8 alys crcg plsm prt","0495U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","760","798","APC"
"Mntr cdvr don lng ea addl hr","0496T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Mntr cdvr don lng ea addl hr","0496T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Onc clrct cfdna 8/7 genes","0496U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","508.94","","","","","","","fee schedule","495.58","510.15","APC"
"Onc clrct cfdna 8/7 genes","0496U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","500.44","","","","","","","fee schedule","495.58","510.15","APC"
"Onc clrct cfdna 8/7 genes","0496U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","495.58","","","","","","","fee schedule","495.58","510.15","APC"
"Onc clrct cfdna 8/7 genes","0496U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","510.15","","","","","","","fee schedule","495.58","510.15","APC"
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4066.65",""
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4066.65",""
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4066.65",""
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4066.65","APC"
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4066.65","APC"
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4066.65","APC"
"Onc prst8 mrna rt-pcr 6 gene","0497U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4066.65","APC"
"Onc clrct ngs mut detc 43gen","0498U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1409.21","","","","","","","fee schedule","1372.22","1412.58","APC"
"Onc clrct ngs mut detc 43gen","0498U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1385.67","","","","","","","fee schedule","1372.22","1412.58","APC"
"Onc clrct ngs mut detc 43gen","0498U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1372.22","","","","","","","fee schedule","1372.22","1412.58","APC"
"Onc clrct ngs mut detc 43gen","0498U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1412.58","","","","","","","fee schedule","1372.22","1412.58","APC"
"Cysto f/urtl strix/stenosis","0499T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","597.91","","","","","","","fee schedule","597.91","627.81",""
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","597.91","","","","","","","fee schedule","597.91","627.81",""
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","597.91","","","","","","","fee schedule","597.91","627.81",""
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","597.91","627.81","APC"
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","597.91","627.81","APC"
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","597.91","627.81","APC"
"Onc clrct&lng dna ngs 8gene","0499U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","597.91","627.81","APC"
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.4","","","","","","","fee schedule","175.4","184.17",""
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","175.4","","","","","","","fee schedule","175.4","184.17",""
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.4","","","","","","","fee schedule","175.4","184.17",""
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.73","","","","","","","fee schedule","175.4","184.17","APC"
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.66","","","","","","","fee schedule","175.4","184.17","APC"
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.91","","","","","","","fee schedule","175.4","184.17","APC"
"Autoinflam ds vexas synd dna","0500U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.17","","","","","","","fee schedule","175.4","184.17","APC"
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","36.84",""
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","36.84",""
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","36.84",""
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv e6/e7 mrk hi-rsk typ crv","0502U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","36.84","APC"
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","750","","","","","","","fee schedule","750","787.5",""
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750","","","","","","","fee schedule","750","787.5",""
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","750","","","","","","","fee schedule","750","787.5",""
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","785.63","","","","","","","fee schedule","750","787.5","APC"
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","772.5","","","","","","","fee schedule","750","787.5","APC"
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","765","","","","","","","fee schedule","750","787.5","APC"
"Neuro alz ds ?amyl&tau prtn","0503U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","787.5","","","","","","","fee schedule","750","787.5","APC"
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Nfct ds uti id 17 path orgs","0504U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Ev fempop artl revsc","0505T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","679.77","","","","","","","fee schedule","679.77","713.76",""
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","679.77","","","","","","","fee schedule","679.77","713.76",""
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","679.77","","","","","","","fee schedule","679.77","713.76",""
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.06","","","","","","","fee schedule","679.77","713.76","APC"
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.16","","","","","","","fee schedule","679.77","713.76","APC"
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.37","","","","","","","fee schedule","679.77","713.76","APC"
"Nfct ds vag infctj id 32orgs","0505U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.76","","","","","","","fee schedule","679.77","713.76","APC"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Mac pgmt opt dns meas hfp","0506T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1938.01","","","","","","","fee schedule","1938.01","2034.91",""
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1938.01","","","","","","","fee schedule","1938.01","2034.91",""
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1938.01","","","","","","","fee schedule","1938.01","2034.91",""
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2030.07","","","","","","","fee schedule","1938.01","2034.91","APC"
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1996.15","","","","","","","fee schedule","1938.01","2034.91","APC"
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1976.77","","","","","","","fee schedule","1938.01","2034.91","APC"
"Gi barretts esophgl cell 89","0506U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2034.91","","","","","","","fee schedule","1938.01","2034.91","APC"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Near ifr 2img mibmn glnd i&r","0507T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160","","","","","","","fee schedule","1160","1218",""
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1160","","","","","","","fee schedule","1160","1218",""
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1160","","","","","","","fee schedule","1160","1218",""
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1215.1","","","","","","","fee schedule","1160","1218","APC"
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1194.8","","","","","","","fee schedule","1160","1218","APC"
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1183.2","","","","","","","fee schedule","1160","1218","APC"
"Onc ovr dna whole gen w/5hmc","0507U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1218","","","","","","","fee schedule","1160","1218","APC"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Pattern erg w/i&r","0509T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl sinus tarsi implant","0510T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Onc pncrtc ca alg alys 16gen","0510U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","496.42","","","","","","","fee schedule","483.39","497.61","APC"
"Onc pncrtc ca alg alys 16gen","0510U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","488.13","","","","","","","fee schedule","483.39","497.61","APC"
"Onc pncrtc ca alg alys 16gen","0510U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","483.39","","","","","","","fee schedule","483.39","497.61","APC"
"Onc pncrtc ca alg alys 16gen","0510U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","497.61","","","","","","","fee schedule","483.39","497.61","APC"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","7221.37","25051.33",""
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","7221.37","25051.33",""
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Rmvl&rinsj sinus tarsi implt","0511T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3033.86","","","","","","","fee schedule","3033.86","3185.55",""
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3033.86","","","","","","","fee schedule","3033.86","3185.55",""
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3033.86","","","","","","","fee schedule","3033.86","3185.55",""
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3177.97","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3124.88","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3094.54","","","","","","","fee schedule","3033.86","3185.55","APC"
"Onc sol tum 3dmicroenvir 36+","0511U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3185.55","","","","","","","fee schedule","3033.86","3185.55","APC"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Esw integ wnd hlg 1st wnd","0512T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","706.25","","","","","","","fee schedule","706.25","741.56",""
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","706.25","","","","","","","fee schedule","706.25","741.56",""
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","706.25","","","","","","","fee schedule","706.25","741.56",""
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.8","","","","","","","fee schedule","706.25","741.56","APC"
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.44","","","","","","","fee schedule","706.25","741.56","APC"
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.38","","","","","","","fee schedule","706.25","741.56","APC"
"Onc prst8 alys dgtz img msi","0512U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.56","","","","","","","fee schedule","706.25","741.56","APC"
"Esw integ wnd hlg ea addl","0513T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Esw integ wnd hlg ea addl","0513T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Esw integ wnd hlg ea addl","0513T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","706.25","","","","","","","fee schedule","706.25","741.56",""
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","706.25","","","","","","","fee schedule","706.25","741.56",""
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","706.25","","","","","","","fee schedule","706.25","741.56",""
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.8","","","","","","","fee schedule","706.25","741.56","APC"
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.44","","","","","","","fee schedule","706.25","741.56","APC"
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.38","","","","","","","fee schedule","706.25","741.56","APC"
"Onc prst8 alg alys msi&hrd","0513U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.56","","","","","","","fee schedule","706.25","741.56","APC"
"Intraop vis axis id pt fixj","0514T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","40.5",""
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","40.5",""
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","40.5",""
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","40.5","APC"
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","40.5","APC"
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","40.5","APC"
"Gi ibd ia quan deter adl lvl","0514U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","40.5","APC"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","22136.77","76793.64",""
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","22136.77","76793.64",""
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","22136.77","76793.64","APC 277.30"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","22136.77","76793.64","APC 296.56"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","22136.77","76793.64","APC 308.91"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj wcs lv compl sys","0515T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","22136.77","76793.64","APC"
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","40.5",""
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","40.5",""
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","40.5",""
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","40.5","APC"
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","40.5","APC"
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","40.5","APC"
"Gi ibd ia quan deter ifx lvl","0515U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","40.5","APC"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","10401.81","36084.43",""
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","10401.81","36084.43",""
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","10401.81","36084.43","APC 277.30"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","10401.81","36084.43","APC 296.56"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","10401.81","36084.43","APC 308.91"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","10401.81","36084.43","APC"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","10401.81","36084.43","APC"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","10401.81","36084.43","APC"
"Insj wcs lv eltrd only","0516T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","10401.81","36084.43","APC"
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","437.62",""
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","437.62","APC"
"Rx metab rxgenomic gnotyp 40","0516U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","437.62","APC"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","10401.81","36084.43",""
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","10401.81","36084.43",""
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","10401.81","36084.43","APC 277.30"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","10401.81","36084.43","APC 296.56"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","10401.81","36084.43","APC 308.91"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","10401.81","36084.43","APC"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","10401.81","36084.43","APC"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","10401.81","36084.43","APC"
"Insj wcs lv pg compnt","0517T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","10401.81","36084.43","APC"
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 80+ psyactiv rx","0517U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","259.27","APC"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl pg compnt wcs","0518T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 90+ pn&mtl hlth","0518U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","259.27","APC"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","36084.43",""
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36084.43",""
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","36084.43",""
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","36084.43","APC 277.30"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","36084.43","APC 296.56"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","36084.43","APC 308.91"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","36084.43","APC"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","36084.43","APC"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","36084.43","APC"
"Rmvl & rplcmt pg compnt wcs","0519T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","36084.43","APC"
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr meds p/d/a 110+","0519U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","259.27","APC"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","10401.81","60970",""
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","10401.81","60970",""
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","10401.81","60970","APC 277.30"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","10401.81","60970","APC 296.56"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","10401.81","60970","APC 308.91"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","10401.81","60970","APC"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","10401.81","60970","APC"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","10401.81","60970","APC"
"Rmvl&rplcmt pg wcs new eltrd","0520T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","10401.81","60970","APC"
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","259.27","APC"
"Ther rx mntr 200+ rx/sbsts","0520U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","259.27","APC"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Interrog dev eval wcs ip","0521T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Rf iga&igm ccp antb sr-a ia","0521U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.26","","","","","","","fee schedule","52.84","54.39","APC"
"Rf iga&igm ccp antb sr-a ia","0521U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.35","","","","","","","fee schedule","52.84","54.39","APC"
"Rf iga&igm ccp antb sr-a ia","0521U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.84","","","","","","","fee schedule","52.84","54.39","APC"
"Rf iga&igm ccp antb sr-a ia","0521U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.39","","","","","","","fee schedule","52.84","54.39","APC"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval wcs ip","0522T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Ca vi psp&sp1 antb cl semiql","0522U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","265.71","273.52","APC"
"Ca vi psp&sp1 antb cl semiql","0522U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","265.71","273.52","APC"
"Ca vi psp&sp1 antb cl semiql","0522U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","265.71","273.52","APC"
"Ca vi psp&sp1 antb cl semiql","0522U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","265.71","273.52","APC"
"Ntrapx c ffr w/3d funcjl map","0523T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Ntrapx c ffr w/3d funcjl map","0523T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Onc soltum dna ngs snv 22gen","0523U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1416.31","","","","","","","fee schedule","1379.13","1419.69","APC"
"Onc soltum dna ngs snv 22gen","0523U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1392.65","","","","","","","fee schedule","1379.13","1419.69","APC"
"Onc soltum dna ngs snv 22gen","0523U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1379.13","","","","","","","fee schedule","1379.13","1419.69","APC"
"Onc soltum dna ngs snv 22gen","0523U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1419.69","","","","","","","fee schedule","1379.13","1419.69","APC"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ev cath dir chem abltj w/img","0524T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ob pe sflt-1/plgf ia srm/pls","0524U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","134.94","","","","","","","fee schedule","131.4","135.26","APC"
"Ob pe sflt-1/plgf ia srm/pls","0524U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.68","","","","","","","fee schedule","131.4","135.26","APC"
"Ob pe sflt-1/plgf ia srm/pls","0524U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.4","","","","","","","fee schedule","131.4","135.26","APC"
"Ob pe sflt-1/plgf ia srm/pls","0524U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.26","","","","","","","fee schedule","131.4","135.26","APC"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Insj/rplcmt compl iims","0525T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Onc sphrd cell cul 11-rx pnl","0525U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3177.97","","","","","","","fee schedule","3094.54","3185.55","APC"
"Onc sphrd cell cul 11-rx pnl","0525U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3124.88","","","","","","","fee schedule","3094.54","3185.55","APC"
"Onc sphrd cell cul 11-rx pnl","0525U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3094.54","","","","","","","fee schedule","3094.54","3185.55","APC"
"Onc sphrd cell cul 11-rx pnl","0525U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3185.55","","","","","","","fee schedule","3094.54","3185.55","APC"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims eltrd only","0526T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insj/rplcmt iims implt mntr","0527T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Hsv 1&2 vzv amp prb tq pthgn","0527U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","145.48","149.76","APC"
"Hsv 1&2 vzv amp prb tq pthgn","0527U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","145.48","149.76","APC"
"Hsv 1&2 vzv amp prb tq pthgn","0527U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","145.48","149.76","APC"
"Hsv 1&2 vzv amp prb tq pthgn","0527U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","145.48","149.76","APC"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval iims ip","0528T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Lrt iad 18bct/8vir&7arg rna","0528U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","664.99","","","","","","","fee schedule","647.54","666.58","APC"
"Lrt iad 18bct/8vir&7arg rna","0528U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","653.89","","","","","","","fee schedule","647.54","666.58","APC"
"Lrt iad 18bct/8vir&7arg rna","0528U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","647.54","","","","","","","fee schedule","647.54","666.58","APC"
"Lrt iad 18bct/8vir&7arg rna","0528U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","666.58","","","","","","","fee schedule","647.54","666.58","APC"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval iims ip","0529T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Removal complete iims","0530T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Onc pan-sol tum ctdna 77 gen","0530U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc pan-sol tum ctdna 77 gen","0530U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc pan-sol tum ctdna 77 gen","0530U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc pan-sol tum ctdna 77 gen","0530U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2977.99","3065.58","APC"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims electrode only","0531T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Removal iims implt mntr only","0532T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Rare ds whlgen&mitochdrl dna","0532U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5270.18","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rare ds whlgen&mitochdrl dna","0532U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5182.14","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rare ds whlgen&mitochdrl dna","0532U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5131.82","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rare ds whlgen&mitochdrl dna","0532U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5282.76","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rx metab advrs gnotyp 16gens","0533U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","425.12","437.62","APC"
"Rx metab advrs gnotyp 16gens","0533U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","425.12","437.62","APC"
"Rx metab advrs gnotyp 16gens","0533U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","425.12","437.62","APC"
"Rx metab advrs gnotyp 16gens","0533U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","425.12","437.62","APC"
"Pfas lc-ms/ms plsm/srm quan","0535U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.09","","","","","","","fee schedule","63.38","65.25","APC"
"Pfas lc-ms/ms plsm/srm quan","0535U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64","","","","","","","fee schedule","63.38","65.25","APC"
"Pfas lc-ms/ms plsm/srm quan","0535U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.38","","","","","","","fee schedule","63.38","65.25","APC"
"Pfas lc-ms/ms plsm/srm quan","0535U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.25","","","","","","","fee schedule","63.38","65.25","APC"
"Rbcag ftl rhd pcr alys exon4","0536U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.12","","","","","","","fee schedule","195.84","201.6","APC"
"Rbcag ftl rhd pcr alys exon4","0536U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","197.76","","","","","","","fee schedule","195.84","201.6","APC"
"Rbcag ftl rhd pcr alys exon4","0536U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","195.84","","","","","","","fee schedule","195.84","201.6","APC"
"Rbcag ftl rhd pcr alys exon4","0536U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.6","","","","","","","fee schedule","195.84","201.6","APC"
"Onc clrct ca cfdna >2500 dmr","0537U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1566.01","","","","","","","fee schedule","1524.9","1569.75","APC"
"Onc clrct ca cfdna >2500 dmr","0537U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1539.85","","","","","","","fee schedule","1524.9","1569.75","APC"
"Onc clrct ca cfdna >2500 dmr","0537U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1524.9","","","","","","","fee schedule","1524.9","1569.75","APC"
"Onc clrct ca cfdna >2500 dmr","0537U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1569.75","","","","","","","fee schedule","1524.9","1569.75","APC"
"Onc sol tum ngts ffpe 600gen","0538U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3131.55","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tum ngts ffpe 600gen","0538U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3079.24","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tum ngts ffpe 600gen","0538U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3049.34","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tum ngts ffpe 600gen","0538U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3139.03","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tumor cfctdna 152gen","0539U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3444.71","","","","","","","fee schedule","3354.28","3452.94","APC"
"Onc sol tumor cfctdna 152gen","0539U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3387.17","","","","","","","fee schedule","3354.28","3452.94","APC"
"Onc sol tumor cfctdna 152gen","0539U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3354.28","","","","","","","fee schedule","3354.28","3452.94","APC"
"Onc sol tumor cfctdna 152gen","0539U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3452.94","","","","","","","fee schedule","3354.28","3452.94","APC"
"Trnsplj med quan dd-cfdna","0540U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2884.03","","","","","","","fee schedule","2808.32","2890.91","APC"
"Trnsplj med quan dd-cfdna","0540U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2835.85","","","","","","","fee schedule","2808.32","2890.91","APC"
"Trnsplj med quan dd-cfdna","0540U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2808.32","","","","","","","fee schedule","2808.32","2890.91","APC"
"Trnsplj med quan dd-cfdna","0540U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2890.91","","","","","","","fee schedule","2808.32","2890.91","APC"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Myocardial imaging mcg","0541T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Ta mv rpr w/artif chord tend","0543T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ta mv rpr w/artif chord tend","0543T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Onc sol tum ngs dna 517 gens","0543U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3131.55","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tum ngs dna 517 gens","0543U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3079.24","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tum ngs dna 517 gens","0543U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3049.34","","","","","","","fee schedule","3049.34","3139.03","APC"
"Onc sol tum ngs dna 517 gens","0543U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3139.03","","","","","","","fee schedule","3049.34","3139.03","APC"
"Tcat mv annulus rcnstj","0544T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tcat mv annulus rcnstj","0544T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tcat tv annulus rcnstj","0545T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tcat tv annulus rcnstj","0545T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Achr antb id imfluor livecll","0545U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","38.48","39.62","APC"
"Achr antb id imfluor livecll","0545U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","38.48","39.62","APC"
"Achr antb id imfluor livecll","0545U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","38.48","39.62","APC"
"Achr antb id imfluor livecll","0545U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","38.48","39.62","APC"
"Ldns lrp4 antb imflr livecll","0546U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","38.48","39.62","APC"
"Ldns lrp4 antb imflr livecll","0546U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","38.48","39.62","APC"
"Ldns lrp4 antb imflr livecll","0546U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","38.48","39.62","APC"
"Ldns lrp4 antb imflr livecll","0546U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","38.48","39.62","APC"
"Neurflmnt lt chn cleia plsm","0547U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","121.75","","","","","","","fee schedule","118.55","122.04","APC"
"Neurflmnt lt chn cleia plsm","0547U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","119.72","","","","","","","fee schedule","118.55","122.04","APC"
"Neurflmnt lt chn cleia plsm","0547U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","118.55","","","","","","","fee schedule","118.55","122.04","APC"
"Neurflmnt lt chn cleia plsm","0547U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","122.04","","","","","","","fee schedule","118.55","122.04","APC"
"Tprnl balo cntnc dev bi","0548T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Gfap cleia plasma","0548U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","121.75","","","","","","","fee schedule","118.55","122.04","APC"
"Gfap cleia plasma","0548U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","119.72","","","","","","","fee schedule","118.55","122.04","APC"
"Gfap cleia plasma","0548U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","118.55","","","","","","","fee schedule","118.55","122.04","APC"
"Gfap cleia plasma","0548U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","122.04","","","","","","","fee schedule","118.55","122.04","APC"
"Tprnl balo cntnc dev uni","0549T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Onc urthl dna mthyltd rt pcr","0549U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","775.2","798","APC"
"Onc urthl dna mthyltd rt pcr","0549U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","775.2","798","APC"
"Onc urthl dna mthyltd rt pcr","0549U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","775.2","798","APC"
"Onc urthl dna mthyltd rt pcr","0549U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","775.2","798","APC"
"Tprnl balo cntnc dev rmvl ea","0550T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tprnl balo cntnc dev adjmt","0551T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repr med pga embry te strux","0553U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga embry te strux","0553U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga embry te strux","0553U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga embry te strux","0553U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga 24chrm te bx qc","0554U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga 24chrm te bx qc","0554U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga 24chrm te bx qc","0554U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga 24chrm te bx qc","0554U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","774.23","797","APC"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"B1 str&fx rsk transmis data","0555T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Repr med pga embryonic te qc","0555U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga embryonic te qc","0555U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga embryonic te qc","0555U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","774.23","797","APC"
"Repr med pga embryonic te qc","0555U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","774.23","797","APC"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"B1 str & fx rsk assessment","0556T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Nfct ds p-s dna&rna 12 trgts","0556U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","145.48","149.76","APC"
"Nfct ds p-s dna&rna 12 trgts","0556U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","145.48","149.76","APC"
"Nfct ds p-s dna&rna 12 trgts","0556U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","145.48","149.76","APC"
"Nfct ds p-s dna&rna 12 trgts","0556U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","145.48","149.76","APC"
"Nfct ds bv dna mrk vag fluid","0557U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.48","","","","","","","fee schedule","268.25","276.14","APC"
"Nfct ds bv dna mrk vag fluid","0557U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","270.88","","","","","","","fee schedule","268.25","276.14","APC"
"Nfct ds bv dna mrk vag fluid","0557U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","268.25","","","","","","","fee schedule","268.25","276.14","APC"
"Nfct ds bv dna mrk vag fluid","0557U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","276.14","","","","","","","fee schedule","268.25","276.14","APC"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Ct scan f/biomchn ct alys","0558T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Onc clrct elisa bf7 ag serum","0558U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","21.23","21.85","APC"
"Onc clrct elisa bf7 ag serum","0558U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","21.23","21.85","APC"
"Onc clrct elisa bf7 ag serum","0558U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","21.23","21.85","APC"
"Onc clrct elisa bf7 ag serum","0558U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","21.23","21.85","APC"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Antmc mdl 3d print 1st cmpnt","0559T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Onc brs quan elisa bf9ag srm","0559U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","21.23","21.85","APC"
"Onc brs quan elisa bf9ag srm","0559U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","21.23","21.85","APC"
"Onc brs quan elisa bf9ag srm","0559U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","21.23","21.85","APC"
"Onc brs quan elisa bf9ag srm","0559U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","21.23","21.85","APC"
"Onc mrd gsa cfdna baseline","0560U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4062.68","","","","","","","fee schedule","3956.02","4072.37","APC"
"Onc mrd gsa cfdna baseline","0560U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3994.8","","","","","","","fee schedule","3956.02","4072.37","APC"
"Onc mrd gsa cfdna baseline","0560U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3956.02","","","","","","","fee schedule","3956.02","4072.37","APC"
"Onc mrd gsa cfdna baseline","0560U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4072.37","","","","","","","fee schedule","3956.02","4072.37","APC"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Antmc guide 3d print 1st gd","0561T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Onc mrd gsa cfdna subsequent","0561U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","832.23","","","","","","","fee schedule","810.38","834.21","APC"
"Onc mrd gsa cfdna subsequent","0561U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","818.32","","","","","","","fee schedule","810.38","834.21","APC"
"Onc mrd gsa cfdna subsequent","0561U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","810.38","","","","","","","fee schedule","810.38","834.21","APC"
"Onc mrd gsa cfdna subsequent","0561U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","834.21","","","","","","","fee schedule","810.38","834.21","APC"
"Onc sol tum tgsa 33gens snvs","0562U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","609.87","627.81","APC"
"Onc sol tum tgsa 33gens snvs","0562U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","609.87","627.81","APC"
"Onc sol tum tgsa 33gens snvs","0562U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","609.87","627.81","APC"
"Onc sol tum tgsa 33gens snvs","0562U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","609.87","627.81","APC"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","2633",""
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","2633",""
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","2633","APC 277.30"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","2633","APC 296.56"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","2633","APC 308.91"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","2633","APC"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","2633","APC"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","2633","APC"
"Evac meibomian glnd heat bi","0563T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","2633","APC"
"Nfct ds pthgn-sna 11vir&4bct","0563U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","425.12","437.62","APC"
"Nfct ds pthgn-sna 11vir&4bct","0563U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","425.12","437.62","APC"
"Nfct ds pthgn-sna 11vir&4bct","0563U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","425.12","437.62","APC"
"Nfct ds pthgn-sna 11vir&4bct","0563U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","425.12","437.62","APC"
"Onc chemo rx cytotox csc 14","0564T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.35","","","","","","","fee schedule","59.35","59.35",""
"Onc chemo rx cytotox csc 14","0564T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.35","","","","","","","fee schedule","59.35","59.35",""
"Nfct ds pthgn-sna 10vir&4bct","0564U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","425.12","437.62","APC"
"Nfct ds pthgn-sna 10vir&4bct","0564U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","425.12","437.62","APC"
"Nfct ds pthgn-sna 10vir&4bct","0564U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","425.12","437.62","APC"
"Nfct ds pthgn-sna 10vir&4bct","0564U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","425.12","437.62","APC"
"Autol cell implt adps hrvg","0565T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Autol cell implt adps hrvg","0565T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Onc hcc ngs detc 6626epigalt","0565U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1215.1","","","","","","","fee schedule","1183.2","1218","APC"
"Onc hcc ngs detc 6626epigalt","0565U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1194.8","","","","","","","fee schedule","1183.2","1218","APC"
"Onc hcc ngs detc 6626epigalt","0565U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1183.2","","","","","","","fee schedule","1183.2","1218","APC"
"Onc hcc ngs detc 6626epigalt","0565U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1218","","","","","","","fee schedule","1183.2","1218","APC"
"Autol cell implt adps njx","0566T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Autol cell implt adps njx","0566T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Onc lng qpcr-bsd alys 13dmrs","0566U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","425.12","437.62","APC"
"Onc lng qpcr-bsd alys 13dmrs","0566U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","425.12","437.62","APC"
"Onc lng qpcr-bsd alys 13dmrs","0566U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","425.12","437.62","APC"
"Onc lng qpcr-bsd alys 13dmrs","0566U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","425.12","437.62","APC"
"Rare ds whl gen seq srs&lrs","0567U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5270.18","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rare ds whl gen seq srs&lrs","0567U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5182.14","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rare ds whl gen seq srs&lrs","0567U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5131.82","","","","","","","fee schedule","5131.82","5282.76","APC"
"Rare ds whl gen seq srs&lrs","0567U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5282.76","","","","","","","fee schedule","5131.82","5282.76","APC"
"Neurol dementia ?amyl ptau","0568U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.61","","","","","","","fee schedule","914.94","941.85","APC"
"Neurol dementia ?amyl ptau","0568U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.91","","","","","","","fee schedule","914.94","941.85","APC"
"Neurol dementia ?amyl ptau","0568U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.94","","","","","","","fee schedule","914.94","941.85","APC"
"Neurol dementia ?amyl ptau","0568U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.85","","","","","","","fee schedule","914.94","941.85","APC"
"Ttvr perq appr 1st prosth","0569T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ttvr perq appr 1st prosth","0569T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ttvr perq ea addl prosth","0570T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ttvr perq ea addl prosth","0570T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Neurol tbi alys gfap&uch-l1","0570U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","265.71","273.52","APC"
"Neurol tbi alys gfap&uch-l1","0570U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","265.71","273.52","APC"
"Neurol tbi alys gfap&uch-l1","0570U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","265.71","273.52","APC"
"Neurol tbi alys gfap&uch-l1","0570U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","265.71","273.52","APC"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","31238.15","108366.8",""
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","31238.15","108366.8",""
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","31238.15","108366.8","APC 277.30"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","31238.15","108366.8","APC 296.56"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","31238.15","108366.8","APC 308.91"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj/rplcmt icds ss eltrd","0571T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","31238.15","108366.8","APC"
"Onc sol tum dna80&rna10g ngs","0571U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc sol tum dna80&rna10g ngs","0571U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc sol tum dna80&rna10g ngs","0571U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc sol tum dna80&rna10g ngs","0571U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2977.99","3065.58","APC"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insertion ss dfb electrode","0572T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Removal ss dfb electrode","0573T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev ss impl dfb eltrd","0574T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval icds ss ip","0575T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Trnsplj med lar rtpcr 4genes","0575U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","398.05","","","","","","","fee schedule","387.6","399","APC"
"Trnsplj med lar rtpcr 4genes","0575U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","391.4","","","","","","","fee schedule","387.6","399","APC"
"Trnsplj med lar rtpcr 4genes","0575U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","387.6","","","","","","","fee schedule","387.6","399","APC"
"Trnsplj med lar rtpcr 4genes","0575U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","399","","","","","","","fee schedule","387.6","399","APC"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval icds ss ip","0576T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Trnsplj med lar quan ddcfdna","0576U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3393.9","","","","","","","fee schedule","3304.8","3402","APC"
"Trnsplj med lar quan ddcfdna","0576U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3337.2","","","","","","","fee schedule","3304.8","3402","APC"
"Trnsplj med lar quan ddcfdna","0576U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3304.8","","","","","","","fee schedule","3304.8","3402","APC"
"Trnsplj med lar quan ddcfdna","0576U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3402","","","","","","","fee schedule","3304.8","3402","APC"
"Onc ovr serum alys 39 gps","0577U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","251.86","259.27","APC"
"Onc ovr serum alys 39 gps","0577U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","251.86","259.27","APC"
"Onc ovr serum alys 39 gps","0577U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","251.86","259.27","APC"
"Onc ovr serum alys 39 gps","0577U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","251.86","259.27","APC"
"Onc cutan mln rna qpcr 10gen","0578U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3950.46","4066.65","APC"
"Onc cutan mln rna qpcr 10gen","0578U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3950.46","4066.65","APC"
"Onc cutan mln rna qpcr 10gen","0578U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3950.46","4066.65","APC"
"Onc cutan mln rna qpcr 10gen","0578U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3950.46","4066.65","APC"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev icds tech","0579T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Nfro dbtc ckd elisa apoa4","0579U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.31","","","","","","","fee schedule","398.56","410.29","APC"
"Nfro dbtc ckd elisa apoa4","0579U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.47","","","","","","","fee schedule","398.56","410.29","APC"
"Nfro dbtc ckd elisa apoa4","0579U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.56","","","","","","","fee schedule","398.56","410.29","APC"
"Nfro dbtc ckd elisa apoa4","0579U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.29","","","","","","","fee schedule","398.56","410.29","APC"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl ss impl dfb pg only","0580T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Bbrgdrferi antb detc 24rprtn","0580U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.03","","","","","","","fee schedule","17.55","18.07","APC"
"Bbrgdrferi antb detc 24rprtn","0580U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.73","","","","","","","fee schedule","17.55","18.07","APC"
"Bbrgdrferi antb detc 24rprtn","0580U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.55","","","","","","","fee schedule","17.55","18.07","APC"
"Bbrgdrferi antb detc 24rprtn","0580U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.07","","","","","","","fee schedule","17.55","18.07","APC"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Abltj mal brst tum perq crtx","0581T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Trnspl med antb nohla 39trgt","0581U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","341.28","","","","","","","fee schedule","332.32","342.09","APC"
"Trnspl med antb nohla 39trgt","0581U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","335.57","","","","","","","fee schedule","332.32","342.09","APC"
"Trnspl med antb nohla 39trgt","0581U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","332.32","","","","","","","fee schedule","332.32","342.09","APC"
"Trnspl med antb nohla 39trgt","0581U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","342.09","","","","","","","fee schedule","332.32","342.09","APC"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","45549.04",""
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","45549.04",""
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40888.12","","","","","","","fee schedule","5226","45549.04","APC 277.30"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43728.03","","","","","","","fee schedule","5226","45549.04","APC 296.56"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45549.04","","","","","","","fee schedule","5226","45549.04","APC 308.91"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13484.11","","","","","","","fee schedule","5226","45549.04","APC"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13258.83","","","","","","","fee schedule","5226","45549.04","APC"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13130.11","","","","","","","fee schedule","5226","45549.04","APC"
"Trurl abltj mal prst8 tiss","0582T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13516.29","","","","","","","fee schedule","5226","45549.04","APC"
"Rare ds rpd whlgen dna vrnts","0582U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7942.35","","","","","","","fee schedule","7733.84","7961.31","APC"
"Rare ds rpd whlgen dna vrnts","0582U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7809.67","","","","","","","fee schedule","7733.84","7961.31","APC"
"Rare ds rpd whlgen dna vrnts","0582U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7733.84","","","","","","","fee schedule","7733.84","7961.31","APC"
"Rare ds rpd whlgen dna vrnts","0582U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7961.31","","","","","","","fee schedule","7733.84","7961.31","APC"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Tmpst auto tube dlvr sys","0583T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Rare ds rpd whlgen cmptr dna","0583U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3971.18","","","","","","","fee schedule","3866.92","3980.66","APC"
"Rare ds rpd whlgen cmptr dna","0583U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3904.83","","","","","","","fee schedule","3866.92","3980.66","APC"
"Rare ds rpd whlgen cmptr dna","0583U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3866.92","","","","","","","fee schedule","3866.92","3980.66","APC"
"Rare ds rpd whlgen cmptr dna","0583U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3980.66","","","","","","","fee schedule","3866.92","3980.66","APC"
"Perq islet cell transplant","0584T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq islet cell transplant","0584T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Neuro csf prion prtn qual","0584U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","566.69","","","","","","","fee schedule","551.81","568.04","APC"
"Neuro csf prion prtn qual","0584U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","557.22","","","","","","","fee schedule","551.81","568.04","APC"
"Neuro csf prion prtn qual","0584U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","551.81","","","","","","","fee schedule","551.81","568.04","APC"
"Neuro csf prion prtn qual","0584U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","568.04","","","","","","","fee schedule","551.81","568.04","APC"
"Laps islet cell transplant","0585T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Laps islet cell transplant","0585T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tgsap so neo cfdna 521 genes","0585U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2977.99","3065.58","APC"
"Tgsap so neo cfdna 521 genes","0585U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2977.99","3065.58","APC"
"Tgsap so neo cfdna 521 genes","0585U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2977.99","3065.58","APC"
"Tgsap so neo cfdna 521 genes","0585U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2977.99","3065.58","APC"
"Open islet cell transplant","0586T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Open islet cell transplant","0586T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Onc mrna gen xprsn 216 genes","0586U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc mrna gen xprsn 216 genes","0586U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc mrna gen xprsn 216 genes","0586U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc mrna gen xprsn 216 genes","0586U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2977.99","3065.58","APC"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","22002.1",""
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","22002.1",""
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19750.68","","","","","","","fee schedule","3499","22002.1","APC 277.30"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21122.48","","","","","","","fee schedule","3499","22002.1","APC 296.56"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22002.1","","","","","","","fee schedule","3499","22002.1","APC 308.91"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6513.39","","","","","","","fee schedule","3499","22002.1","APC"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6404.57","","","","","","","fee schedule","3499","22002.1","APC"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6342.39","","","","","","","fee schedule","3499","22002.1","APC"
"Perq impltj/rplcmt isdns ptn","0587T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6528.94","","","","","","","fee schedule","3499","22002.1","APC"
"Ther rx mntr 60-150rx&metabl","0587U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.87","","","","","","","fee schedule","116.72","120.15","APC"
"Ther rx mntr 60-150rx&metabl","0587U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.86","","","","","","","fee schedule","116.72","120.15","APC"
"Ther rx mntr 60-150rx&metabl","0587U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.72","","","","","","","fee schedule","116.72","120.15","APC"
"Ther rx mntr 60-150rx&metabl","0587U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.15","","","","","","","fee schedule","116.72","120.15","APC"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revision/removal isdns ptn","0588T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Nfct ds bct/vir 32genes mrna","0588U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","775.2","798","APC"
"Nfct ds bct/vir 32genes mrna","0588U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","775.2","798","APC"
"Nfct ds bct/vir 32genes mrna","0588U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","775.2","798","APC"
"Nfct ds bct/vir 32genes mrna","0588U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","775.2","798","APC"
"Pfas24cmpnd hi-perf lc-ms/ms","0589U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","208.18","","","","","","","fee schedule","202.71","208.68","APC"
"Pfas24cmpnd hi-perf lc-ms/ms","0589U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","204.7","","","","","","","fee schedule","202.71","208.68","APC"
"Pfas24cmpnd hi-perf lc-ms/ms","0589U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","202.71","","","","","","","fee schedule","202.71","208.68","APC"
"Pfas24cmpnd hi-perf lc-ms/ms","0589U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","208.68","","","","","","","fee schedule","202.71","208.68","APC"
"Onc prst8 ca 3prtns plsm srm","0591U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","775.2","798","APC"
"Onc prst8 ca 3prtns plsm srm","0591U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","775.2","798","APC"
"Onc prst8 ca 3prtns plsm srm","0591U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","775.2","798","APC"
"Onc prst8 ca 3prtns plsm srm","0591U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","775.2","798","APC"
"Onc hl neo dna tgs 417 genes","0592U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc hl neo dna tgs 417 genes","0592U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc hl neo dna tgs 417 genes","0592U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2977.99","3065.58","APC"
"Onc hl neo dna tgs 417 genes","0592U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2977.99","3065.58","APC"
"Nfct ds gu pthgn dna 46trgt","0593U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","664.99","","","","","","","fee schedule","647.54","666.58","APC"
"Nfct ds gu pthgn dna 46trgt","0593U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","653.89","","","","","","","fee schedule","647.54","666.58","APC"
"Nfct ds gu pthgn dna 46trgt","0593U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","647.54","","","","","","","fee schedule","647.54","666.58","APC"
"Nfct ds gu pthgn dna 46trgt","0593U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","666.58","","","","","","","fee schedule","647.54","666.58","APC"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Osteot hum xtrnl lngth dev","0594T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Nfct ds tfp vctrbrn&zoonotic","0595U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.48","","","","","","","fee schedule","268.25","276.14","APC"
"Nfct ds tfp vctrbrn&zoonotic","0595U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","270.88","","","","","","","fee schedule","268.25","276.14","APC"
"Nfct ds tfp vctrbrn&zoonotic","0595U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","268.25","","","","","","","fee schedule","268.25","276.14","APC"
"Nfct ds tfp vctrbrn&zoonotic","0595U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","276.14","","","","","","","fee schedule","268.25","276.14","APC"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu vlv-pmp 1st insj","0596T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Temp fml iu valve-pmp rplcmt","0597T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Ncntc r-t fluor wnd img 1st","0598T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Gi ibs igg antb 18food items","0598U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","314.25","","","","","","","fee schedule","306","315","APC"
"Gi ibs igg antb 18food items","0598U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","309","","","","","","","fee schedule","306","315","APC"
"Gi ibs igg antb 18food items","0598U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","306","","","","","","","fee schedule","306","315","APC"
"Gi ibs igg antb 18food items","0598U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","315","","","","","","","fee schedule","306","315","APC"
"Onc pncrtc ca mult ia serum","0599U","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.61","","","","","","","fee schedule","914.94","941.85","APC"
"Onc pncrtc ca mult ia serum","0599U","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.91","","","","","","","fee schedule","914.94","941.85","APC"
"Onc pncrtc ca mult ia serum","0599U","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.94","","","","","","","fee schedule","914.94","941.85","APC"
"Onc pncrtc ca mult ia serum","0599U","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.85","","","","","","","fee schedule","914.94","941.85","APC"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tum organ perq","0600T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Ire abltj 1+tumors open","0601T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain acquisj data","0609T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mrs disc pain alg alys data","0611T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Perq tcat intratrl septl sht","0613T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq tcat intratrl septl sht","0613T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","5220","76793.64",""
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","76793.64",""
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","5220","76793.64",""
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","5220","76793.64","APC 277.30"
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","5220","76793.64","APC 296.56"
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","5220","76793.64","APC 308.91"
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","5220","76793.64","APC"
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","5220","76793.64","APC"
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","5220","76793.64","APC"
"Rmvl&rplcmt ss impl dfb pg","0614T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","5220","76793.64","APC"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Eye mvmt alys w/o calbrj i&r","0615T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Insertion of iris prosthesis","0616T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Insj iris prosth w/rmvl&insj","0617T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Insj iris prosth sec io lens","0618T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cysto w/prst8 commissurotomy","0619T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Cysto w/prst8 commissurotomy","0619T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Cysto w/prst8 commissurotomy","0619T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","31849","152065.9",""
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","31849","152065.9",""
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","136505.37","","","","","","","fee schedule","31849","152065.9","APC 277.30"
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","145986.42","","","","","","","fee schedule","31849","152065.9","APC 296.56"
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","152065.9","","","","","","","fee schedule","31849","152065.9","APC 308.91"
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45016.81","","","","","","","fee schedule","31849","152065.9","APC"
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44264.74","","","","","","","fee schedule","31849","152065.9","APC"
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43834.99","","","","","","","fee schedule","31849","152065.9","APC"
"Evasc ven artlz tibl/prnl vn","0620T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45124.25","","","","","","","fee schedule","31849","152065.9","APC"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Trabeculostomy interno laser","0621T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Trabeculostomy int lsr w/scp","0622T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Trabeculostomy int lsr w/scp","0622T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc fluor lmbr 1st","0627T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc fluor lmbr ea","0628T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Perq njx algc fluor lmbr ea","0628T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc ct lmbr 1st","0629T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Perq njx algc ct lmbr ea","0630T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Perq njx algc ct lmbr ea","0630T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq tcat us abltj nrv p-art","0632T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Ct breast w/3d uni c-","0633T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c+","0634T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d uni c-/c+","0635T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Ct breast w/3d bi c-","0636T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c+","0637T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct breast w/3d bi c-/c+","0638T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ncntc nr ifr spctrsc wnd","0640T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Tcat l ventr rstrj dev implt","0643T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tcat l ventr rstrj dev implt","0643T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5664.24","29398",""
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5664.24","29398",""
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","29398","APC 277.30"
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","29398","APC 296.56"
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","29398","APC 308.91"
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","29398","APC"
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","29398","APC"
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","29398","APC"
"Tcat rmvl/dblk icar mas perq","0644T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","29398","APC"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Tcat impltj c sins rdctj dev","0645T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Ttvi/rplcmt w/prstc vlv perq","0646T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ttvi/rplcmt w/prstc vlv perq","0646T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insj gtube perq mag gastrpxy","0647T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval scrms remote","0650T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Mag ctrld capsule endoscopy","0651T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal dx br/wa","0652T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal bx 1/ml","0653T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3836.96","13310.62",""
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3836.96","13310.62",""
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","13310.62","APC 277.30"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","13310.62","APC 296.56"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","13310.62","APC 308.91"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","13310.62","APC"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","13310.62","APC"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","13310.62","APC"
"Egd flx transnasal tube/cath","0654T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","13310.62","APC"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tprnl focal abltj mal prst8","0655T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","60533.69",""
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","60533.69",""
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5226","60533.69","APC 277.30"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5226","60533.69","APC 296.56"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5226","60533.69","APC 308.91"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant","0656T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","60533.69",""
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","60533.69",""
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5226","60533.69","APC 277.30"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5226","60533.69","APC 296.56"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5226","60533.69","APC 308.91"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5226","60533.69","APC"
"Vrt bdy tethering ant 8+ seg","0657T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5226","60533.69","APC"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Elec impd spectrsc 1+skn les","0658T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Tcat intra-c nfs supersat o2","0659T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tcat intra-c nfs supersat o2","0659T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Implt ant sgm io nbio rx sys","0660T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Rmvl&Rimpltj ant sgm implt","0661T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Scalp cool 1st meas&calbrj","0662T","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Don hysterectomy open cdvr","0664T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy open cdvr","0664T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy open liv","0665T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy open liv","0665T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy laps liv","0666T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy laps liv","0666T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy rcp uter","0667T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Don hysterectomy rcp uter","0667T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bkbench prep don uter algrft","0668T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Bkbench prep don uter algrft","0668T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bkbench rcnstj don uter ven","0669T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Bkbench rcnstj don uter ven","0669T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bkbench rcnstj don uter artl","0670T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Bkbench rcnstj don uter artl","0670T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5295.75","18371.25",""
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5295.75","18371.25",""
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","18371.25","APC 277.30"
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","18371.25","APC 296.56"
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","18371.25","APC 308.91"
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","18371.25","APC"
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","18371.25","APC"
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","18371.25","APC"
"Insj ant sgm aq drg dev 1+","0671T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","18371.25","APC"
"Ndovag cryg rf remdl tiss","0672T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ndovag cryg rf remdl tiss","0672T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj b9 thyr ndul perq lasr","0673T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","30709.54","106533.01",""
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","30709.54","106533.01",""
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","30709.54","106533.01","APC 277.30"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","30709.54","106533.01","APC 296.56"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","30709.54","106533.01","APC 308.91"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","30709.54","106533.01","APC"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","30709.54","106533.01","APC"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","30709.54","106533.01","APC"
"Laps insj nw/rpcmt prm isdss","0674T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","30709.54","106533.01","APC"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Laps insj nw/rpcmt isdss 1ld","0675T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Laps insj nw/rpcmt isdss ea","0676T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Laps insj nw/rpcmt isdss ea","0676T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps repos lead isdss 1st ld","0677T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps repos lead isdss ea add","0678T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Laps repos lead isdss ea add","0678T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps rmvl lead isdss","0679T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19306.96","66976.89",""
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19306.96","66976.89",""
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","19306.96","66976.89","APC 277.30"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","19306.96","66976.89","APC 296.56"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","19306.96","66976.89","APC 308.91"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","19306.96","66976.89","APC"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","19306.96","66976.89","APC"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","19306.96","66976.89","APC"
"Insj/rplcmt pg only isdss","0680T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","19306.96","66976.89","APC"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Rlcj pulse gen only isdss","0681T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Removal pulse gen only isdss","0682T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval isdss ip","0683T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval isdss ip","0685T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Quan us tis charac w/o dx us","0689T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5376.86","APC 277.30"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5376.86","APC 296.56"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5376.86","APC 308.91"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5376.86","APC"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5376.86","APC"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5376.86","APC"
"Therapeutic ultrafiltration","0692T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5376.86","APC"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Bdy surf mapg pm/cvdfb f/up","0696T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Njx pst chmbr eye medication","0699T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Njx b1 sub mtrl sbchdrl dfct","0707T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Id ca immntx prep & 1st njx","0708T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Id ca immntx prep & 1st njx","0708T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Id ca immntx each addl njx","0709T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Id ca immntx each addl njx","0709T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"N-nvs artl plaq alys quan","0712T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tprnl lsr ablt b9 prst8 hypr","0714T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","2633",""
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","2633",""
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","2633","APC 277.30"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","2633","APC 296.56"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","2633","APC 308.91"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","2633","APC"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","2633","APC"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","2633","APC"
"Car acous wavfrm rec cad rsk","0716T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","2633","APC"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear","0717T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Adrc ther prtl rc tear njx","0718T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Pst vrt jt rplcmt lmbr 1 sgm","0719T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Pst vrt jt rplcmt lmbr 1 sgm","0719T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Prq elc nrv stim cn wo implt","0720T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Prq elc nrv stim cn wo implt","0720T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Vestibular dev impltj uni","0725T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Vestibular dev impltj uni","0725T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmvl implt vstibular dev uni","0726T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rmvl implt vstibular dev uni","0726T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmvl&rplcmt implt vstblr dev","0727T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rmvl&rplcmt implt vstblr dev","0727T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Trabeculotomy lsr w/oct gdn","0730T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Trabeculotomy lsr w/oct gdn","0730T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Augmnt ai-based fcl phnt a/r","0731T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Immntx admn electroporatn im","0732T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Immntx admn electroporatn im","0732T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Prep tum cav iort prim crnot","0735T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Prep tum cav iort prim crnot","0735T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","2633",""
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","2633",""
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","2633","APC 277.30"
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","2633","APC 296.56"
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","2633","APC 308.91"
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","2633","APC"
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","2633","APC"
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","2633","APC"
"Colonic lavage 35+l water","0736T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","2633","APC"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Xenograft impltj artclr surf","0737T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Abltj mal prst8 mag fld ndct","0739T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Abltj mal prst8 mag fld ndct","0739T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Rem auton alg nsln cal setup","0740T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem auton alg nsln data coll","0741T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"B1 str & fx rsk vrt fx assmt","0743T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Insj bioprostc vlv fem vn","0744T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Car ablt rad arr n-invas loc","0745T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Car ablt rad arr n-invas loc","0745T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Car ablt rad arr cnv loc map","0746T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Car ablt rad arr cnv loc map","0746T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Car ablt rad arrhyt dlvr rad","0747T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Car ablt rad arrhyt dlvr rad","0747T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Njx stm cl prdct anl sft tis","0748T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Njx stm cl prdct anl sft tis","0748T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt cncrt","0764T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg ecg rsk asmt prev","0765T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Tc mag stimj pn 1st tx 1nrv","0766T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Smmg cncrnt appl imu snr","0778T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Gi myoelectrical actv study","0779T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","2633",""
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","2633",""
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","2633","APC 277.30"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","2633","APC 296.56"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","2633","APC 308.91"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","2633","APC"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","2633","APC"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","2633","APC"
"Instlj fecal microbiota ssp","0780T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","2633","APC"
"Brnchsc rf dstrj pulm nrv bi","0781T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Brnchsc rf dstrj pulm nrv bi","0781T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Brnchsc rf dstrj plm nrv uni","0782T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Brnchsc rf dstrj plm nrv uni","0782T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Tc auriculr neurostimulation","0783T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplmt eltrd ra spi nstim","0784T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea spi w/nstim","0785T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Insj/rplcmt prq ra sac nstim","0786T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea sac w/nstim","0787T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","60533.69",""
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","60533.69",""
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5226","60533.69","APC 277.30"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5226","60533.69","APC 296.56"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5226","60533.69","APC 308.91"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5226","60533.69","APC"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5226","60533.69","APC"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5226","60533.69","APC"
"Revj rplcmt/rmvl vrt tethrg","0790T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5226","60533.69","APC"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq tcat thrm ablt nrv p-art","0793T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","2633",""
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","2633",""
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","2633","APC 277.30"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","2633","APC 296.56"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","2633","APC 308.91"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","2633","APC"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","2633","APC"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","2633","APC"
"Pt spec alg rx-onc tx option","0794T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","2633","APC"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm cmpl","0795T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm ra","0796T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 2chmbr ldls pm rv","0797T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv 2chmbr ldls pm cmpl","0798T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm ra","0799T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl 2chmbr ldls pm rv","0800T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl 2chmbr ldls pm","0801T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm ra","0802T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl2chmb ldls pm rv","0803T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg evl ldls pm 2chmbr ip","0804T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Tcat s&ivc prstc vl impl prq","0805T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tcat s&ivc prstc vl impl prq","0805T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tcat s&ivc prstc vl impl opn","0806T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tcat s&ivc prstc vl impl opn","0806T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys prev ct","0807T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Pulm tiss vntj alys w/ct","0808T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4140.41","23971",""
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4140.41","23971",""
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12893.55","","","","","","","fee schedule","4140.41","23971","APC 277.30"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13789.07","","","","","","","fee schedule","4140.41","23971","APC 296.56"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14363.31","","","","","","","fee schedule","4140.41","23971","APC 308.91"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4252.04","","","","","","","fee schedule","4140.41","23971","APC"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4181","","","","","","","fee schedule","4140.41","23971","APC"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4140.41","","","","","","","fee schedule","4140.41","23971","APC"
"Subrta njx rx agt w/vtrc","0810T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4262.19","","","","","","","fee schedule","4140.41","23971","APC"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mlt day uroflow setup","0811T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Rem mlt day uroflow dev sply","0812T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Egd vol adjmt bariatric balo","0813T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Prq njx biod osteo matrl fem","0814T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Prq njx biod osteo matrl fem","0814T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19306.96","66976.89",""
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19306.96","66976.89",""
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","19306.96","66976.89","APC 277.30"
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","19306.96","66976.89","APC 296.56"
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","19306.96","66976.89","APC 308.91"
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subq","0816T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19306.96","66976.89",""
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19306.96","66976.89",""
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","19306.96","66976.89","APC 277.30"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","19306.96","66976.89","APC 296.56"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","19306.96","66976.89","APC 308.91"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","19306.96","66976.89","APC"
"Opn insj/rplcmt ins ptn subf","0817T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","19306.96","66976.89","APC"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subq","0818T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl ins ptn subf","0819T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat ins 1chmbr ldls pm ra","0823T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv 1chmbr ldls pm ra","0824T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","19169.21","66499",""
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","19169.21","66499","APC 277.30"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","19169.21","66499","APC 296.56"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","19169.21","66499","APC 308.91"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","19169.21","66499","APC"
"Tcat rmv&rpl1chmb ldls pm ra","0825T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","19169.21","66499","APC"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg evl ldls pm 1chmbr ip","0826T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Opto-acoustic img breast uni","0857T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl pg wcs lv both compnt","0861T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv battery only","0862T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj pg wcs lv trnsmtr only","0863T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","862.58","APC 277.30"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","862.58","APC 296.56"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","862.58","APC 308.91"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","862.58","APC"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","862.58","APC"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","862.58","APC"
"Low ntsty eswt corpus cvrnsm","0864T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","862.58","APC"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/o dx mri","0865T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Quan mri alys brn w/dx mri","0866T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Tpla b9 prst8 hyprplsa>=50ml","0867T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Hi-res gastric ep mapping","0868T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Njx b1 sub mtrl hw fixj aug","0869T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Imp subq prtl ascts pmp sys","0870T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Imp subq prtl ascts pmp sys","0870T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rplcmt subq prtl ascites pmp","0871T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rplcmt subq prtl ascites pmp","0871T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rplcmt ndwllg bldr&prtl cath","0872T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rplcmt ndwllg bldr&prtl cath","0872T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Revj subq prtl asct pmp sys","0873T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Revj subq prtl asct pmp sys","0873T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmvl pertl ascites pmp sys","0874T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rmvl pertl ascites pmp sys","0874T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Cryotherapy oral cavity","0881T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Intraop ther estim pn ue 1st","0882T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Intraop ther estim pn ue 1st","0882T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Intraop ther estim pn ue ea","0883T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Intraop ther estim pn ue ea","0883T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6041.75","20959.15",""
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6041.75","20959.15",""
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"Esphgsc flx 1st tndsc dilat","0884T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6041.75","20959.15",""
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6041.75","20959.15",""
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"Colsc flx 1st tndsc dilat","0885T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6041.75","20959.15",""
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6041.75","20959.15",""
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"Sgmdsc flx 1st tndsc dilat","0886T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"N-invas assmt bld oxygnation","0893T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Cannulation liver allograft","0894T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cannulation liver allograft","0894T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas augmnt arrhyt alys","0897T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas prst8 cancer est map","0898T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Plmt bone marrow smplg port","0901T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Plmt bone marrow smplg port","0901T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Qtc ntrvl augmnt alg aly ecg","0902T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Ecg alg 12 ld rdcd trcg only","0904T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","692.67","APC 277.30"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","692.67","APC 296.56"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","692.67","APC 308.91"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","692.67","APC"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","692.67","APC"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","692.67","APC"
"Coms ther 1st appl<=50 sq cm","0906T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","692.67","APC"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","106533.01",""
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","106533.01",""
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","5226","106533.01","APC 277.30"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","5226","106533.01","APC 296.56"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","5226","106533.01","APC 308.91"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","5226","106533.01","APC"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","5226","106533.01","APC"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","5226","106533.01","APC"
"Opn imp int nstm sys vgs nrv","0908T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","5226","106533.01","APC"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","106533.01",""
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","106533.01",""
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","5226","106533.01","APC 277.30"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","5226","106533.01","APC 296.56"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","5226","106533.01","APC 308.91"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","5226","106533.01","APC"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","5226","106533.01","APC"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","5226","106533.01","APC"
"Rplcmt int nstim sys vgs nrv","0909T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","5226","106533.01","APC"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3479.32","12069.94",""
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3479.32","12069.94",""
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","12069.94","APC 277.30"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","12069.94","APC 296.56"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","12069.94","APC 308.91"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl int nstim sys vagus nrv","0910T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","12069.94","APC"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Elec aly nstm sys vgs nrv wo","0911T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","11488.76","39855.12",""
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","11488.76","39855.12",""
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq tcat ther rx ntrac balo1","0913T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq tcat thr rx ntrc bal sep","0914T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Prq tcat thr rx ntrc bal sep","0914T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","31238.15","108366.8",""
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","31238.15","108366.8",""
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","31238.15","108366.8","APC 277.30"
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","31238.15","108366.8","APC 296.56"
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","31238.15","108366.8","APC 308.91"
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj perm ccm-d sys pg&eltrd","0915T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","31238.15","108366.8","APC"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","22136.77","76793.64",""
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","22136.77","76793.64",""
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","22136.77","76793.64","APC 277.30"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","22136.77","76793.64","APC 296.56"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","22136.77","76793.64","APC 308.91"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj perm ccm-d sys pg only","0916T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","22136.77","76793.64","APC"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys 1 lead","0917T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8235.66","35289",""
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8235.66","35289",""
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","8235.66","35289","APC 277.30"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","8235.66","35289","APC 296.56"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","8235.66","35289","APC 308.91"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","8235.66","35289","APC"
"Insj perm ccm-d sys dual ld","0918T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","8235.66","35289","APC"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys pg only","0919T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 pac ld","0920T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys 1 dfb ld","0921T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl perm ccm-d sys dual ld","0922T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","22136.77","76793.64",""
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","22136.77","76793.64",""
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","22136.77","76793.64","APC 277.30"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","22136.77","76793.64","APC 296.56"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","22136.77","76793.64","APC 308.91"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rmvl&rplcmt perm ccm-d pg","0923T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","22136.77","76793.64","APC"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Rpos prv ccm-d trnsvns eltrd","0924T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Rlcj skin pocket ccm-d pg","0925T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval ccm-d ip","0926T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog dev eval ccm-d ip","0927T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm-d tech","0929T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1211.69","5790",""
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1211.69","5790",""
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","5790","APC 277.30"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","5790","APC 296.56"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","5790","APC 308.91"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld 1st impl","0930T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1211.69","5790",""
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1211.69","5790",""
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","5790","APC 277.30"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","5790","APC 296.56"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","5790","APC 308.91"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","5790","APC"
"Ephys eval ccm-d ld separate","0931T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","5790","APC"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"Tcat impl wrls l atr prs snr","0933T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"Cysto w/rnl pel symp dnrvtj","0935T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cysto w/rnl pel symp dnrvtj","0935T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cysto flx ins&xpns urtl scaf","0941T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cysto flx ins&xpns urtl scaf","0941T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cysto flx rmv&rplc urtl scaf","0942T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cysto flx rmv&rplc urtl scaf","0942T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cysto flx rmvl urtl scaffold","0943T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cysto flx rmvl urtl scaffold","0943T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"3d cntr simula trgt lvr les","0944T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Intraop assmt abnl tum tiss","0945T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Intraop assmt abnl tum tiss","0945T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Ortho impl mvmt alys pair ct","0946T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem interrog dev ccm tech","0949T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Abltj b9 prst8 tissue hifu","0950T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Rev s-sclp eltr ra rcvr&tlmt","0957T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Rmv s-sclp eltr ra rcvr&tlmt","0958T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Rmv/rplc magnet coil assem","0959T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Asstv alg alys acous&ecg rec","0962T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","4131.28","APC 277.30"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","4131.28","APC 296.56"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","4131.28","APC 308.91"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","4131.28","APC"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","4131.28","APC"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","4131.28","APC"
"Anosc sbmcsl njx bulking agt","0963T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","4131.28","APC"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cust prep jaw xpnsj 1arch","0964T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch non","0965T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"I&cst prp jw xpn dl arch fxd","0966T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","4131.28","APC 277.30"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","4131.28","APC 296.56"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","4131.28","APC 308.91"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","4131.28","APC"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","4131.28","APC"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","4131.28","APC"
"Tranal ins tmp clrc anst dev","0967T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","4131.28","APC"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","13517.63","APC 277.30"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","13517.63","APC 296.56"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","13517.63","APC 308.91"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt b9 brst tum perq lsr ea","0970T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","13517.63","APC 277.30"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","13517.63","APC 296.56"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","13517.63","APC 308.91"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","13517.63","APC"
"Ablt mal brst tum pq lsr uni","0971T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","13517.63","APC"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt t/a/l 1st","0973T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Slctv nzmtc dbrdmt s/n/hf 1","0975T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","3131.27","APC 277.30"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","3131.27","APC 296.56"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","3131.27","APC 308.91"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","3131.27","APC"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","3131.27","APC"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","3131.27","APC"
"Upr gi bld detcj snr capsule","0977T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","3131.27","APC"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Tcat impl wrls ivc snr","0981T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr impl ivc snr set-up","0982T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr impl ivc snr phys","0983T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","12069.94","APC 277.30"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","12069.94","APC 296.56"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","12069.94","APC 308.91"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rmvl ins ptn subq&subf","0989T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","12069.94","APC"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto lo-nrg lithtrp&mcrsphr","0991T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/o ct","0992T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"N-invas assmt car rsk w/ct","0993T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Ins&sclr fix caps bag prosth","0996T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Fna bx w/o img gdn ea addl","10004","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fna bx w/o img gdn ea addl","10004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fna bx w/o img gdn ea addl","10004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/us gdn 1st les","10005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/us gdn ea addl","10006","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fna bx w/us gdn ea addl","10006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fna bx w/us gdn ea addl","10006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/fluor gdn 1st les","10007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/fluor gdn ea addl","10008","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fna bx w/fluor gdn ea addl","10008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fna bx w/fluor gdn ea addl","10008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/ct gdn 1st les","10009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/ct gdn ea addl","10010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fna bx w/ct gdn ea addl","10010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fna bx w/ct gdn ea addl","10010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/mr gdn 1st les","10011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Fna bx w/mr gdn ea addl","10012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fna bx w/mr gdn ea addl","10012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fna bx w/mr gdn ea addl","10012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Fna w/o image","10021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Fna w/image","10022","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Air displacmnt plethysmograp","1002T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Guide cathet fluid drainage","10030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Perq dev soft tiss 1st imag","10035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Perq dev soft tiss add imag","10036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Perq dev soft tiss add imag","10036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Arthrp 1st crp/mtcrpl prostc","1003T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Acne surgery","10040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Elec alys s-scl eeg wo prgrm","1004T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of skin abscess","10060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Drainage of skin abscess","10061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of pilonidal cyst","10081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr s-scl eeg sys setup","1008T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Cptr oph alys monoc eye mvmt","1010T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Remove foreign body","10120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Remove foreign body","10121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Mtrz ab ntrno trph scl/tr mw","1012T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","19306.96","66976.89","APC 277.30"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","19306.96","66976.89","APC 296.56"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","19306.96","66976.89","APC 308.91"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","19306.96","66976.89","APC"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","19306.96","66976.89","APC"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","19306.96","66976.89","APC"
"Lap srg imp/rpl eso nea&pg/r","1013T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","19306.96","66976.89","APC"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of hematoma/fluid","10140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Lap rv/rmv eso sph nstm eltr","1014T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","12069.94","APC 277.30"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","12069.94","APC 296.56"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","12069.94","APC 308.91"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rev/rmv lw esoph sphnc npg/r","1015T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","12069.94","APC"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Puncture drainage of lesion","10160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Elec aly npgs esoph sbsq w/o","1017T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Complex drainage wound","10180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Elec alys npgs esoph sbsq w/","1018T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6608.28","22924.49","APC 277.30"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6608.28","22924.49","APC 296.56"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6608.28","22924.49","APC 308.91"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6608.28","22924.49","APC"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6608.28","22924.49","APC"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6608.28","22924.49","APC"
"Lymphovenous bypass per xtr","1019T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6608.28","22924.49","APC"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Raman spectroscopy 1+skn les","1020T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","2165.7","APC 277.30"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","2165.7","APC 296.56"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","2165.7","APC 308.91"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","2165.7","APC"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","2165.7","APC"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","2165.7","APC"
"Active thrc irrigation spx","1021T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","2165.7","APC"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"Alt elec fld dos&dlv sim mdl","1025T","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Debride infected skin","11000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Debride infected skin add-on","11001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Debride infected skin add-on","11001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Debride infected skin add-on","11001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Debride genitalia & perineum","11004","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Debride genitalia & perineum","11004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Debride genitalia & perineum","11004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Debride abdom wall","11005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Debride abdom wall","11005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Debride abdom wall","11005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Debride genit/per/abdom wall","11006","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Debride genit/per/abdom wall","11006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Debride genit/per/abdom wall","11006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove mesh from abd wall","11008","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Remove mesh from abd wall","11008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Remove mesh from abd wall","11008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","704.73","4564",""
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","4564",""
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","4564",""
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","4564","APC 277.30"
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","4564","APC 296.56"
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","4564","APC 308.91"
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin at fx site","11010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","704.73","4564",""
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","4564",""
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","4564",""
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","4564","APC 277.30"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","4564","APC 296.56"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","4564","APC 308.91"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","4564","APC"
"Debride skin musc at fx site","11011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","4564","APC"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2890.77","10028.23",""
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2890.77","10028.23",""
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deb skin bone at fx site","11012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Deb subq tissue 20 sq cm/<","11042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","4564",""
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","4564",""
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Deb musc/fascia 20 sq cm/<","11043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5701.97",""
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Deb bone 20 sq cm/<","11044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Deb subq tissue add-on","11045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Deb subq tissue add-on","11045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Deb subq tissue add-on","11045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Deb musc/fascia add-on","11046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Deb musc/fascia add-on","11046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Deb musc/fascia add-on","11046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Deb bone add-on","11047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Deb bone add-on","11047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Deb bone add-on","11047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesion","11055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions 2 to 4","11056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Trim skin lesions over 4","11057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Biopsy skin lesion","11100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Biopsy skin add-on","11101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Tangntl bx skin single les","11102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Tangntl bx skin ea sep/addl","11103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Tangntl bx skin ea sep/addl","11103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Tangntl bx skin ea sep/addl","11103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Punch bx skin single lesion","11104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Punch bx skin ea sep/addl","11105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Punch bx skin ea sep/addl","11105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Punch bx skin ea sep/addl","11105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","735.52","5220",""
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","735.52","5220",""
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Incal bx skn single les","11106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Incal bx skn ea sep/addl","11107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Incal bx skn ea sep/addl","11107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Incal bx skn ea sep/addl","11107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Removal of skin tags <w/15","11200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Remove skin tags add-on","11201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Remove skin tags add-on","11201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Remove skin tags add-on","11201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 0.5 cm/<","11300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.5 cm/<","11305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.5 cm/<","11310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 0.6-1.0 cm","11311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion 1.1-2.0 cm","11312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Shave skin lesion >2.0 cm","11313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 0.5 cm<","11400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext b9+marg 0.6-1 cm","11401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 1.1-2 cm","11402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 2.1-3cm/<","11403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg 3.1-4 cm","11404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext b9+marg >4.0 cm","11406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 0.5/<","11420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc h-f-nk-sp b9+marg 0.6-1","11421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 1.1-2","11422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 2.1-3","11423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg 3.1-4","11424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc h-f-nk-sp b9+marg >4 cm","11426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.5 cm/<","11440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 0.6-1 cm","11441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 1.1-2 cm","11442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 2.1-3 cm","11443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg 3.1-4 cm","11444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc face-mm b9+marg >4 cm","11446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal sweat gland lesion","11471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.5 cm/<","11600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 0.6-1 cm","11601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext mal+marg 1.1-2 cm","11602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 2.1-3 cm","11603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","704.73","4564",""
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","4564",""
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","4564",""
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","4564","APC 277.30"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","4564","APC 296.56"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","4564","APC 308.91"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","4564","APC"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","4564","APC"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","4564","APC"
"Exc tr-ext mal+marg 3.1-4 cm","11604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","4564","APC"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc tr-ext mal+marg >4 cm","11606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc h-f-nk-sp mal+marg 0.5/<","11620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 0.6-1","11621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 1.1-2","11622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5701.97",""
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc s/n/h/f/g mal+mrg 2.1-3","11623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc s/n/h/f/g mal+mrg 3.1-4","11624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc s/n/h/f/g mal+mrg >4 cm","11626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.5cm<","11640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 0.6-1","11641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 1.1-2","11642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc f/e/e/n/l mal+mrg 2.1-3","11643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc f/e/e/n/l mal+mrg 3.1-4","11644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc f/e/e/n/l mal+mrg >4 cm","11646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Trim nail(s) any number","11719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 1-5","11720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Debride nail 6 or more","11721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Removal of nail plate","11730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Remove nail plate add-on","11732","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Remove nail plate add-on","11732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Remove nail plate add-on","11732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Drain blood from under nail","11740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Removal of nail bed","11750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Remove nail bed/finger tip","11752","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy nail unit","11755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Repair of nail bed","11760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Reconstruction of nail bed","11762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Excision of nail fold toe","11765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst simple","11770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst exten","11771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove pilonidal cyst compl","11772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions <=w 7","11900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Inject skin lesions >7","11901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Correct skin color 6.0 cm/<","11920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Correct skn color 6.1-20.0cm","11921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Correct skin color ea 20.0cm","11922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Correct skin color ea 20.0cm","11922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Correct skin color ea 20.0cm","11922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Tx contour defects 1 cc/<","11950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 1.1-5.0cc","11951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects 5.1-10cc","11952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","735.52","5220",""
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Tx contour defects >10.0 cc","11954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","19040",""
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Insert tissue expander(s)","11960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Replace tissue expander","11970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove tissue expander(s)","11971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Remove contraceptive capsule","11976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Implant hormone pellet(s)","11980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Insert drug implant device","11981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant device","11982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Remove/insert drug implant","11983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk 2.5cm/<","12001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trnk2.6-7.5cm","12002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/ax/gen/trk7.6-12.5cm","12004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk12.6-20.0cm","12005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/a/gen/trk20.1-30.0cm","12006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","199.67","4564",""
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","4564",""
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","4564",""
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","4564","APC 277.30"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","4564","APC 296.56"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","4564","APC 308.91"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","4564","APC"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","4564","APC"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","4564","APC"
"Rpr s/n/ax/gen/trnk >30.0 cm","12007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","4564","APC"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.5 cm/<","12011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 2.6-5.0 cm","12013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 5.1-7.5 cm","12014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Rpr f/e/e/n/l/m 7.6-12.5 cm","12015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 12.6-20.0 cm","12016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Rpr fe/e/en/l/m 20.1-30.0 cm","12017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","199.67","4564",""
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","4564",""
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","4564",""
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","4564","APC 277.30"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","4564","APC 296.56"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","4564","APC 308.91"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","4564","APC"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","4564","APC"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","4564","APC"
"Rpr f/e/e/n/l/m >30.0 cm","12018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","4564","APC"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","3408",""
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","3408",""
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","3408",""
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","3408","APC 277.30"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","3408","APC 296.56"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","3408","APC 308.91"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","3408","APC"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","3408","APC"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","3408","APC"
"Closure of split wound","12020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","3408","APC"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Closure of split wound","12021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.5 cm/<","12031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/a/t/ext 2.6-7.5","12032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/tr/ext 7.6-12.5","12034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/a/t/ext 12.6-20","12035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr s/a/t/ext 20.1-30","12036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr s/tr/ext >30.0 cm","12037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit 2.5cm/<","12041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit2.6-7.5","12042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit7.6-12.5","12044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit12.6-20","12045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","735.52","4564",""
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit20.1-30","12046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr n-hf/genit >30.0cm","12047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.5 cm/<","12051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 2.6-5.0 cm","12052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 5.1-7.5 cm","12053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 7.6-12.5cm","12054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 12.6-20 cm","12055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm 20.1-30.0","12056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Intmd rpr face/mm >30.0 cm","12057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","4564",""
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","4564",""
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Cmplx rpr trunk 1.1-2.5 cm","13100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr trunk 2.6-7.5 cm","13101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr trunk addl 5cm/<","13102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr trunk addl 5cm/<","13102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr trunk addl 5cm/<","13102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr s/a/l 1.1-2.5 cm","13120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr s/a/l 2.6-7.5 cm","13121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr s/a/l addl 5 cm/>","13122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr s/a/l addl 5 cm/>","13122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr s/a/l addl 5 cm/>","13122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13133","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr f/c/c/m/n/ax/g/h/f","13133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Repair of wound or lesion","13150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 1.1-2.5 cm","13151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l 2.6-7.5 cm","13152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Cmplx rpr e/n/e/l addl 5cm/<","13153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr e/n/e/l addl 5cm/<","13153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cmplx rpr e/n/e/l addl 5cm/<","13153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","12234.34",""
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3526.71","12234.34",""
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3526.71","12234.34",""
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","12234.34","APC 277.30"
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","12234.34","APC 296.56"
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","12234.34","APC 308.91"
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","12234.34","APC"
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","12234.34","APC"
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","12234.34","APC"
"Late closure of wound","13160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","12234.34","APC"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10 sq cm/<","14000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr trunk 10.1-30sqcm","14001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10 sq cm/<","14020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr s/a/l 10.1-30 sqcm","14021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr f/c/c/m/n/a/g/h/f","14041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l 10 sq cm/<","14060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr e/n/e/l10.1-30sqcm","14061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3526.71","19040",""
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Tis trnfr any 30.1-60 sq cm","14301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Tis trnfr addl 30 sq cm/<","14302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Tis trnfr addl 30 sq cm/<","14302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Tis trnfr addl 30 sq cm/<","14302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Filleted finger/toe flap","14350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","5790",""
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","735.52","5790",""
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","735.52","5790",""
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5790","APC 277.30"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5790","APC 296.56"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5790","APC 308.91"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5790","APC"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5790","APC"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5790","APC"
"Wound prep trk/arm/leg","15002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5790","APC"
"Wound prep addl 100 cm","15003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Wound prep addl 100 cm","15003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Wound prep addl 100 cm","15003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Wound prep f/n/hf/g","15004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Wnd prep f/n/hf/g addl cm","15005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Wnd prep f/n/hf/g addl cm","15005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Wnd prep f/n/hf/g addl cm","15005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Hrv skn cll ssp agrft 1st 25","15011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Hrv skn cll ssp agrft ea add","15012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Hrv skn cll ssp agrft ea add","15012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7062.71","29398",""
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7062.71","29398",""
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21993.8","","","","","","","fee schedule","7062.71","29398","APC 277.30"
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23521.39","","","","","","","fee schedule","7062.71","29398","APC 296.56"
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24500.92","","","","","","","fee schedule","7062.71","29398","APC 308.91"
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7253.13","","","","","","","fee schedule","7062.71","29398","APC"
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7131.95","","","","","","","fee schedule","7062.71","29398","APC"
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7062.71","","","","","","","fee schedule","7062.71","29398","APC"
"Prepj skn cll ssp agrft 1st","15013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7270.44","","","","","","","fee schedule","7062.71","29398","APC"
"Prepj skn cll ssp agrft ea","15014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Prepj skn cll ssp agrft ea","15014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cl ssp agrft t/a/l 1","15015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cl ssp agrf t/a/l ea","15016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"App skn cl ssp agrf t/a/l ea","15016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cll ssp f/n/g/hf 1st","15017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"App skn cll ssp f/n/g/hf ea","15018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"App skn cll ssp f/n/g/hf ea","15018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Harvest cultured skin graft","15040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","735.52","4564",""
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","4564",""
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","4564",""
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","4564","APC 277.30"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","4564","APC 296.56"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","4564","APC 308.91"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","4564","APC"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","4564","APC"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","4564","APC"
"Skin pinch graft","15050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","4564","APC"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin splt grft trnk/arm/leg","15100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin splt grft t/a/l add-on","15101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Skin splt grft t/a/l add-on","15101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Skin splt grft t/a/l add-on","15101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm autogrft trnk/arm/leg","15110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm autogrft t/a/l add-on","15111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Epidrm autogrft t/a/l add-on","15111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Epidrm autogrft t/a/l add-on","15111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm a-grft face/nck/hf/g","15115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Epidrm a-grft f/n/hf/g addl","15116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Epidrm a-grft f/n/hf/g addl","15116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Epidrm a-grft f/n/hf/g addl","15116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","19040",""
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Skn splt a-grft fac/nck/hf/g","15120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Skn splt a-grft f/n/hf/g add","15121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Skn splt a-grft f/n/hf/g add","15121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Skn splt a-grft f/n/hf/g add","15121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","14111",""
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2053.37","14111",""
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2053.37","14111",""
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","14111","APC 277.30"
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","14111","APC 296.56"
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","14111","APC 308.91"
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","14111","APC"
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","14111","APC"
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","14111","APC"
"Derm autograft trnk/arm/leg","15130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","14111","APC"
"Derm autograft t/a/l add-on","15131","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Derm autograft t/a/l add-on","15131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Derm autograft t/a/l add-on","15131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","19040",""
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Derm autograft face/nck/hf/g","15135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Derm autograft f/n/hf/g add","15136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Derm autograft f/n/hf/g add","15136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Derm autograft f/n/hf/g add","15136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Cult skin grft t/arm/leg","15150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Cult skin grft t/a/l addl","15151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cult skin grft t/a/l addl","15151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cult skin grft t/a/l addl","15151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cult skin graft t/a/l +%","15152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cult skin graft t/a/l +%","15152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cult skin graft t/a/l +%","15152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","19040",""
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Cult skin graft f/n/hf/g","15155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Cult skin grft f/n/hfg add","15156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cult skin grft f/n/hfg add","15156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cult skin grft f/n/hfg add","15156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cult epiderm grft f/n/hfg +%","15157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Cult epiderm grft f/n/hfg +%","15157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Cult epiderm grft f/n/hfg +%","15157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","14111",""
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2053.37","14111",""
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2053.37","14111",""
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","14111","APC 277.30"
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","14111","APC 296.56"
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","14111","APC 308.91"
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","14111","APC"
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","14111","APC"
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","14111","APC"
"Skin full graft trunk","15200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","14111","APC"
"Skin full graft trunk add-on","15201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Skin full graft trunk add-on","15201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Skin full graft trunk add-on","15201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft sclp/arm/leg","15220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft add-on","15221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Skin full graft add-on","15221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Skin full graft add-on","15221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full grft face/genit/hf","15240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft add-on","15241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Skin full graft add-on","15241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Skin full graft add-on","15241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft een & lips","15260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin full graft add-on","15261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Skin full graft add-on","15261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Skin full graft add-on","15261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","5790",""
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","735.52","5790",""
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","735.52","5790",""
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5790","APC 277.30"
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5790","APC 296.56"
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5790","APC 308.91"
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft trnk/arm/leg","15271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft t/a/l add-on","15272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Skin sub graft t/a/l add-on","15272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Skin sub graft t/a/l add-on","15272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","19040",""
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2053.37","19040",""
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2053.37","19040",""
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","19040","APC 277.30"
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","19040","APC 296.56"
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","19040","APC 308.91"
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","19040","APC"
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","19040","APC"
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","19040","APC"
"Skin sub grft t/arm/lg child","15273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","19040","APC"
"Skn sub grft t/a/l child add","15274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Skn sub grft t/a/l child add","15274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Skn sub grft t/a/l child add","15274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","5790",""
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","735.52","5790",""
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","735.52","5790",""
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5790","APC 277.30"
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5790","APC 296.56"
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5790","APC 308.91"
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft face/nk/hf/g","15275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5790","APC"
"Skin sub graft f/n/hf/g addl","15276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Skin sub graft f/n/hf/g addl","15276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Skin sub graft f/n/hf/g addl","15276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skn sub grft f/n/hf/g child","15277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skn sub grft f/n/hf/g ch add","15278","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Skn sub grft f/n/hf/g ch add","15278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Skn sub grft f/n/hf/g ch add","15278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin pedicle flap trunk","15570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Skin pedicle flap arms/legs","15572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedcle fh/ch/ch/m/n/ax/g/h/f","15574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Pedicle e/n/e/l/ntroral","15576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Delay flap trunk","15600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","14111",""
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2053.37","14111",""
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2053.37","14111",""
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","14111","APC 277.30"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","14111","APC 296.56"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","14111","APC 308.91"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","14111","APC"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","14111","APC"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","14111","APC"
"Delay flap arms/legs","15610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","14111","APC"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","7123.26",""
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap f/c/c/n/ax/g/h/f","15620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Delay flap eye/nos/ear/lip","15630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2053.37","7337",""
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7337",""
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7337",""
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7337","APC 277.30"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7337","APC 296.56"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7337","APC 308.91"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7337","APC"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7337","APC"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7337","APC"
"Transfer skin pedicle flap","15650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7337","APC"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Mdfc flap w/prsrv vasc pedcl","15730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Forehead Flap w/Vasc Pedicle","15731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft head/neck","15732","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Musc myoq/fscq flp h&n pedcl","15733","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft trunk","15734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Muscle-skin graft arm","15736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Muscle-skin graft leg","15738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Island pedicle flap graft","15740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","19040",""
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Neurovascular pedicle flap","15750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Free myo/skin flap microvasc","15756","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Free myo/skin flap microvasc","15756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Free myo/skin flap microvasc","15756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Free skin flap microvasc","15757","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Free skin flap microvasc","15757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Free skin flap microvasc","15757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Free fascial flap microvasc","15758","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Free fascial flap microvasc","15758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Free fascial flap microvasc","15758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Composite skin graft","15760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol soft tiss dir exc","15769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Derma-fat-fascia graft","15770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol fat lipo 50 cc/<","15771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Grfg autol fat lipo ea addl","15772","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Grfg autol fat lipo ea addl","15772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Grfg autol fat lipo ea addl","15772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Grfg autol fat lipo 25 cc/<","15773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Gfrg autol fat lipo ea addl","15774","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Gfrg autol fat lipo ea addl","15774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Gfrg autol fat lipo ea addl","15774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl 1-15 punch grfts","15775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Hair trnspl >15 punch grafts","15776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Acellular derm matrix implt","15777","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2375","7337",""
"Acellular derm matrix implt","15777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","7337",""
"Acellular derm matrix implt","15777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","7337",""
"Impl absrb msh/prsth dly cls","15778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Impl absrb msh/prsth dly cls","15778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Dermabrasion total face","15780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Dermabrasion segmental face","15781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","10028.23",""
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2890.77","10028.23",""
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2890.77","10028.23",""
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dermabrasion other than face","15782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Dermabrasion suprfl any site","15783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Abrasion lesion single","15786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Abrasion lesions add-on","15787","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Abrasion lesions add-on","15787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Abrasion lesions add-on","15787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel face epiderm","15788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel face dermal","15789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","735.52","5220",""
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","735.52","5220",""
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel nonfacial","15792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Chemical peel nonfacial","15793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Plastic surgery neck","15819","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of lower eyelid","15821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of upper eyelid","15822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2053.37","7337",""
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7337",""
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7337",""
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7337","APC 277.30"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7337","APC 296.56"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7337","APC 308.91"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7337","APC"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7337","APC"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7337","APC"
"Revision of upper eyelid","15823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7337","APC"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of forehead wrinkles","15824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of neck wrinkles","15825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of brow wrinkles","15826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of face wrinkles","15828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3526.71","19040",""
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of skin wrinkles","15829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","5220","23971","APC 277.30"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","5220","23971","APC 296.56"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","5220","23971","APC 308.91"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","5220","23971","APC"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","5220","23971","APC"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","5220","23971","APC"
"Exc Skin Abd","15830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","5220","23971","APC"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin thigh","15832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin leg","15833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin hip","15834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin buttck","15835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excessive skin arm","15836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin arm/hand","15837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin fat pad","15838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Excise excess skin & tissue","15839","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy fascial graft","15840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy muscle graft","15841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","7123.26",""
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Nerve palsy microsurg graft","15842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Skin and muscle repair face","15845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Exc Skin Abd Add-on","15847","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Exc Skin Abd Add-on","15847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Exc Skin Abd Add-on","15847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Remove sutures same surgeon","15850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sutures diff surgeon","15851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Dressing change not for burn","15852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Removal sutr/stapl xreq anes","15853","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Removal sutr/stapl xreq anes","15853","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Removal sutr&stapl xreq anes","15854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Removal sutr&stapl xreq anes","15854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Test for blood flow in graft","15860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy head&neck","15876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy trunk","15877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Suction lipectomy upr extrem","15878","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Suction lipectomy lwr extrem","15879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of tail bone ulcer","15920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of tail bone ulcer","15922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove sacrum pressure sore","15937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Remove hip pressure sore","15944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","7123.26",""
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove hip pressure sore","15945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","14111",""
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2053.37","14111",""
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2053.37","14111",""
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","14111","APC 277.30"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","14111","APC 296.56"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","14111","APC 308.91"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","14111","APC"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","14111","APC"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","14111","APC"
"Remove hip pressure sore","15946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","14111","APC"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","14111",""
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Remove thigh pressure sore","15950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2890.77","14111",""
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Remove thigh pressure sore","15951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","14111",""
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2053.37","14111",""
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2053.37","14111",""
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","14111","APC 277.30"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","14111","APC 296.56"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","14111","APC 308.91"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","14111","APC"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","14111","APC"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","14111","APC"
"Remove thigh pressure sore","15952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","14111","APC"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove thigh pressure sore","15956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3526.71","19040",""
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Remove thigh pressure sore","15958","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Removal of pressure sore","15999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Initial treatment of burn(s)","16000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","199.67","3408",""
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","3408",""
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","3408",""
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","3408","APC 277.30"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","3408","APC 296.56"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","3408","APC 308.91"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","3408","APC"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","3408","APC"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","3408","APC"
"Dress/debrid p-thick burn s","16020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","3408","APC"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","199.67","4564",""
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","4564",""
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","4564",""
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","4564","APC 277.30"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","4564","APC 296.56"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","4564","APC 308.91"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","4564","APC"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","4564","APC"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","4564","APC"
"Dress/debrid p-thick burn m","16025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","4564","APC"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","404.56","4564",""
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","4564",""
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","4564",""
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","4564","APC 277.30"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","4564","APC 296.56"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","4564","APC 308.91"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","4564","APC"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","4564","APC"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","4564","APC"
"Dress/debrid p-thick burn l","16030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","4564","APC"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Incision of burn scab initi","16035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Escharotomy addl incision","16036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Escharotomy addl incision","16036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Escharotomy addl incision","16036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruct premalg lesion","17000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruct premalg les 2-14","17003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Destruct premalg les 2-14","17003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Destruct premalg les 2-14","17003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Destroy premal lesions 15/>","17004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","3408",""
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","3408",""
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","3408",""
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","3408","APC 277.30"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","3408","APC 296.56"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","3408","APC 308.91"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction of skin lesions","17108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruct b9 lesion 1-14","17110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruct lesion 15 or more","17111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Chemical cautery tissue","17250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","3408",""
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","3408",""
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","3408",""
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","3408","APC 277.30"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","3408","APC 296.56"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","3408","APC 308.91"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","3408","APC"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Destruction of skin lesions","17286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","3408",""
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","3408",""
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","3408",""
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","3408","APC 277.30"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","3408","APC 296.56"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","3408","APC 308.91"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","3408","APC"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","3408","APC"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","3408","APC"
"Mohs 1 stage h/n/hf/g","17311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","3408","APC"
"Mohs Addl Stage","17312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Mohs Addl Stage","17312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Mohs Addl Stage","17312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","735.52","3408",""
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","3408",""
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","3408",""
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","3408","APC 277.30"
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","3408","APC 296.56"
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","3408","APC 308.91"
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","3408","APC"
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","3408","APC"
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","3408","APC"
"Mohs 1 stage t/a/l","17313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","3408","APC"
"Mohs addl stage t/a/l","17314","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Mohs addl stage t/a/l","17314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Mohs addl stage t/a/l","17314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Mohs surg addl block","17315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Mohs surg addl block","17315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Mohs surg addl block","17315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Cryotherapy of skin","17340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Skin peel therapy","17360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Hair removal by electrolysis","17380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Skin tissue procedure","17999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Drainage of breast lesion","19000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Drain breast lesion add-on","19001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Drain breast lesion add-on","19001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Drain breast lesion add-on","19001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","14111",""
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Incision of breast lesion","19020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Injection for breast x-ray","19030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for breast x-ray","19030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for breast x-ray","19030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion strtctc","19081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast add lesion strtctc","19082","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bx breast add lesion strtctc","19082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bx breast add lesion strtctc","19082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion us imag","19083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast add lesion us imag","19084","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bx breast add lesion us imag","19084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bx breast add lesion us imag","19084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast 1st lesion mr imag","19085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast add lesion mr imag","19086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bx breast add lesion mr imag","19086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bx breast add lesion mr imag","19086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Bx breast percut w/o image","19100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy of breast open","19101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Bx Breast Percut W/Image","19102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Bx Breast Percut W/Device","19103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3896.63","19040",""
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3896.63","19040",""
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3896.63","19040",""
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","19040","APC 277.30"
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","19040","APC 296.56"
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","19040","APC 308.91"
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","19040","APC"
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","19040","APC"
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","19040","APC"
"Cryosurg ablate fa each","19105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","19040","APC"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Nipple exploration","19110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","14111",""
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Excise breast duct fistula","19112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","14111",""
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of breast lesion","19120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","14111",""
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Excision breast lesion","19125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Excision addl breast lesion","19126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Excision addl breast lesion","19126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Excision addl breast lesion","19126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Removal of chest wall lesion","19260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Perq device breast 1st imag","19281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Perq device breast ea imag","19282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perq device breast ea imag","19282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perq device breast ea imag","19282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st strtctc","19283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast add strtctc","19284","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perq dev breast add strtctc","19284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perq dev breast add strtctc","19284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st us imag","19285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast add us imag","19286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perq dev breast add us imag","19286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perq dev breast add us imag","19286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast 1st mr guide","19287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Perq dev breast add mr guide","19288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perq dev breast add mr guide","19288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perq dev breast add mr guide","19288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Prep tum cav iort prtl mast","19294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Prep tum cav iort prtl mast","19294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Prep tum cav iort prtl mast","19294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","8134.14","29398",""
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","8134.14","29398",""
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","8134.14","29398",""
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25330.32","","","","","","","fee schedule","8134.14","29398","APC 277.30"
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27089.65","","","","","","","fee schedule","8134.14","29398","APC 296.56"
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28217.78","","","","","","","fee schedule","8134.14","29398","APC 308.91"
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8353.45","","","","","","","fee schedule","8134.14","29398","APC"
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8213.89","","","","","","","fee schedule","8134.14","29398","APC"
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8134.14","","","","","","","fee schedule","8134.14","29398","APC"
"Place po breast cath for rad","19296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8373.38","","","","","","","fee schedule","8134.14","29398","APC"
"Place breast cath for rad","19297","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","29398",""
"Place breast cath for rad","19297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","13700","29398",""
"Place breast cath for rad","19297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","13700","29398",""
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","47577.31",""
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","13700","47577.31",""
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","13700","47577.31",""
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42708.84","","","","","","","fee schedule","13700","47577.31","APC 277.30"
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","45675.2","","","","","","","fee schedule","13700","47577.31","APC 296.56"
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47577.31","","","","","","","fee schedule","13700","47577.31","APC 308.91"
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14084.54","","","","","","","fee schedule","13700","47577.31","APC"
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13849.24","","","","","","","fee schedule","13700","47577.31","APC"
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13714.78","","","","","","","fee schedule","13700","47577.31","APC"
"Place breast rad tube/caths","19298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14118.16","","","","","","","fee schedule","13700","47577.31","APC"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3896.63","14111",""
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Removal of Breast Tissue","19300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","14111",""
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Partial Mastectomy","19301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","6608.28","23971",""
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6608.28","23971",""
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6608.28","23971",""
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6608.28","23971","APC 277.30"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6608.28","23971","APC 296.56"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6608.28","23971","APC 308.91"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6608.28","23971","APC"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6608.28","23971","APC"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6608.28","23971","APC"
"P-Mastectomy w/LN Removal","19302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6608.28","23971","APC"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","22924.49",""
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","22924.49",""
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","22924.49",""
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6448","22924.49","APC 277.30"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6448","22924.49","APC 296.56"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6448","22924.49","APC 308.91"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6448","22924.49","APC"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6448","22924.49","APC"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6448","22924.49","APC"
"Mast simple complete","19303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6448","22924.49","APC"
"Mast subq","19304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Mast radical","19305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Mast radical","19305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Mast radical","19305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Mast rad urban type","19306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Mast rad urban type","19306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Mast rad urban type","19306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6608.28","23971",""
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6608.28","23971",""
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6608.28","23971",""
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6608.28","23971","APC 277.30"
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6608.28","23971","APC 296.56"
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6608.28","23971","APC 308.91"
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6608.28","23971","APC"
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6608.28","23971","APC"
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6608.28","23971","APC"
"Mast mod rad","19307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6608.28","23971","APC"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","22924.49",""
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","22924.49",""
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","22924.49",""
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6448","22924.49","APC 277.30"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6448","22924.49","APC 296.56"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6448","22924.49","APC 308.91"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6448","22924.49","APC"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6448","22924.49","APC"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6448","22924.49","APC"
"Suspension of breast","19316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6448","22924.49","APC"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","23971",""
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","23971",""
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","23971",""
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6448","23971","APC 277.30"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6448","23971","APC 296.56"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6448","23971","APC 308.91"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6448","23971","APC"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6448","23971","APC"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6448","23971","APC"
"Reduction of large breast","19318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6448","23971","APC"
"Enlarge breast","19324","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","8134.14","29398",""
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","8134.14","29398",""
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","8134.14","29398",""
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25330.32","","","","","","","fee schedule","8134.14","29398","APC 277.30"
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27089.65","","","","","","","fee schedule","8134.14","29398","APC 296.56"
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28217.78","","","","","","","fee schedule","8134.14","29398","APC 308.91"
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8353.45","","","","","","","fee schedule","8134.14","29398","APC"
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8213.89","","","","","","","fee schedule","8134.14","29398","APC"
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8134.14","","","","","","","fee schedule","8134.14","29398","APC"
"Enlarge breast with implant","19325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8373.38","","","","","","","fee schedule","8134.14","29398","APC"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3408","19040","APC 277.30"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3408","19040","APC 296.56"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3408","19040","APC 308.91"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3408","19040","APC"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3408","19040","APC"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3408","19040","APC"
"Removal of breast implant","19328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3408","19040","APC"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3408","19040","APC 277.30"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3408","19040","APC 296.56"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3408","19040","APC 308.91"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3408","19040","APC"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3408","19040","APC"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3408","19040","APC"
"Removal of implant material","19330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3408","19040","APC"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","28217.78",""
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","28217.78",""
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","28217.78",""
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25330.32","","","","","","","fee schedule","4564","28217.78","APC 277.30"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27089.65","","","","","","","fee schedule","4564","28217.78","APC 296.56"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28217.78","","","","","","","fee schedule","4564","28217.78","APC 308.91"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8353.45","","","","","","","fee schedule","4564","28217.78","APC"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8213.89","","","","","","","fee schedule","4564","28217.78","APC"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8134.14","","","","","","","fee schedule","4564","28217.78","APC"
"Immediate breast prosthesis","19340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8373.38","","","","","","","fee schedule","4564","28217.78","APC"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25330.32","","","","","","","fee schedule","5220","29398","APC 277.30"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27089.65","","","","","","","fee schedule","5220","29398","APC 296.56"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28217.78","","","","","","","fee schedule","5220","29398","APC 308.91"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8353.45","","","","","","","fee schedule","5220","29398","APC"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8213.89","","","","","","","fee schedule","5220","29398","APC"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8134.14","","","","","","","fee schedule","5220","29398","APC"
"Delayed breast prosthesis","19342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8373.38","","","","","","","fee schedule","5220","29398","APC"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3896.63","14111",""
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Breast reconstruction","19350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3896.63","19040",""
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3896.63","19040",""
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3896.63","19040",""
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","19040","APC 277.30"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","19040","APC 296.56"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","19040","APC 308.91"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","19040","APC"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","19040","APC"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","19040","APC"
"Correct inverted nipple(s)","19355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","19040","APC"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","47577.31",""
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","47577.31",""
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","47577.31",""
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42708.84","","","","","","","fee schedule","7337","47577.31","APC 277.30"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","45675.2","","","","","","","fee schedule","7337","47577.31","APC 296.56"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47577.31","","","","","","","fee schedule","7337","47577.31","APC 308.91"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14084.54","","","","","","","fee schedule","7337","47577.31","APC"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13849.24","","","","","","","fee schedule","7337","47577.31","APC"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13714.78","","","","","","","fee schedule","7337","47577.31","APC"
"Breast reconstruction","19357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14118.16","","","","","","","fee schedule","7337","47577.31","APC"
"Breast reconstr w/lat flap","19361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Breast reconstr w/lat flap","19361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Breast reconstr w/lat flap","19361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Breast reconstruction","19364","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19366","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Breast reconstruction","19367","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19368","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19369","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Breast reconstruction","19369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3896.63","19040",""
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3896.63","19040",""
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3896.63","19040",""
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","19040","APC 277.30"
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","19040","APC 296.56"
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","19040","APC 308.91"
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","19040","APC"
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","19040","APC"
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","19040","APC"
"Surgery of breast capsule","19370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","19040","APC"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3896.63","19040",""
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3896.63","19040",""
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3896.63","19040",""
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","19040","APC 277.30"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","19040","APC 296.56"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","19040","APC 308.91"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","19040","APC"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","19040","APC"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","19040","APC"
"Removal of breast capsule","19371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","19040","APC"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6608.28","23971",""
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6608.28","23971",""
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6608.28","23971",""
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6608.28","23971","APC 277.30"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6608.28","23971","APC 296.56"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6608.28","23971","APC 308.91"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6608.28","23971","APC"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6608.28","23971","APC"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6608.28","23971","APC"
"Revise breast reconstruction","19380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6608.28","23971","APC"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","19040",""
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3896.63","19040",""
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3896.63","19040",""
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","19040","APC 277.30"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","19040","APC 296.56"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","19040","APC 308.91"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","19040","APC"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","19040","APC"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","19040","APC"
"Design custom breast implant","19396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","19040","APC"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","14111",""
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Breast surgery procedure","19499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"I&d abscess subfascial","20005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Explore wound neck","20100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound chest","20101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound abdomen","20102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Explore wound extremity","20103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Excise epiphyseal bar","20150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Muscle biopsy","20200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Deep muscle biopsy","20205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy muscle","20206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone biopsy trocar/needle","20220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Bone biopsy trocar/needle","20225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open superficial","20240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Bone biopsy open deep","20245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Open bone biopsy","20250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Open bone biopsy","20251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Injection of sinus tract","20500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Inject sinus tract for x-ray","20501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Inject sinus tract for x-ray","20501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Inject sinus tract for x-ray","20501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of foreign body","20520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of foreign body","20525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Ther injection carp tunnel","20526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Inj dupuytren cord w/enzyme","20527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon sheath/ligament","20550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Inj tendon origin/insertion","20551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Inj trigger point 1/2 muscl","20552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Inject trigger points 3/>","20553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","14111",""
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Place ndl musc/tis for rt","20555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","5220","APC 277.30"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","5220","APC 296.56"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","5220","APC 308.91"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 1 or 2 musc","20560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","32.68","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","32.68","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","32.68","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","28.78","5220",""
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","5220","APC 277.30"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","5220","APC 296.56"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","5220","APC 308.91"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","5220","APC"
"Ndl insj w/o njx 3+ musc","20561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","5220","APC"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/us","20604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Drain/inj joint/bursa w/us","20606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/o us","20610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Drain/inj joint/bursa w/us","20611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Aspirate/inj ganglion cyst","20612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Treatment of bone cyst","20615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Insert and remove bone pin","20650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Apply rem fixation device","20660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5551.43",""
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Application of head brace","20661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Application of pelvis brace","20662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Application of thigh brace","20663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Application of halo","20664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Removal of fixation device","20665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of support implant","20670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of support implant","20680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Apply bone fixation device","20690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","44324.22",""
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","44324.22",""
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Apply bone fixation device","20692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Adjust bone fixation device","20693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Remove bone fixation device","20694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","93677.4",""
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","13700","93677.4",""
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","13700","93677.4",""
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84091.62","","","","","","","fee schedule","13700","93677.4","APC 277.30"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89932.25","","","","","","","fee schedule","13700","93677.4","APC 296.56"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93677.4","","","","","","","fee schedule","13700","93677.4","APC 308.91"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27731.78","","","","","","","fee schedule","13700","93677.4","APC"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27268.48","","","","","","","fee schedule","13700","93677.4","APC"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27003.74","","","","","","","fee schedule","13700","93677.4","APC"
"Comp multiplane ext fixation","20696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27797.96","","","","","","","fee schedule","13700","93677.4","APC"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","1600.27","10181",""
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","10181",""
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","10181",""
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","10181","APC 277.30"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","10181","APC 296.56"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","10181","APC 308.91"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","10181","APC"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","10181","APC"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","10181","APC"
"Comp ext fixate strut change","20697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","10181","APC"
"Mnl prep&insj dp rx dlvr dev","20700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj dp rx dlvr dev","20700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj dp rx dlvr dev","20700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Rmvl deep rx delivery device","20701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Rmvl deep rx delivery device","20701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Rmvl deep rx delivery device","20701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj imed rx dev","20702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj imed rx dev","20702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj imed rx dev","20702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Rmvl imed rx delivery device","20703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Rmvl imed rx delivery device","20703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Rmvl imed rx delivery device","20703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj i-artic rx dev","20704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj i-artic rx dev","20704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Mnl prep&insj i-artic rx dev","20704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Rmvl i-artic rx delivery dev","20705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Rmvl i-artic rx delivery dev","20705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Rmvl i-artic rx delivery dev","20705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation arm complete","20802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Replant forearm complete","20805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation hand complete","20808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","29398",""
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","1600.27","29398",""
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","1600.27","29398",""
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","29398","APC 277.30"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","29398","APC 296.56"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","29398","APC 308.91"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation digit complete","20816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Replantation digit complete","20822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","29398",""
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","1600.27","29398",""
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","1600.27","29398",""
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","29398","APC 277.30"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","29398","APC 296.56"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","29398","APC 308.91"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","29398",""
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","1600.27","29398",""
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","1600.27","29398",""
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","29398","APC 277.30"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","29398","APC 296.56"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","29398","APC 308.91"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation thumb complete","20827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","29398","APC"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Replantation foot complete","20838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of bone for graft","20900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of bone for graft","20902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","735.52","5220",""
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","735.52","5220",""
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","735.52","5220",""
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2290.47","","","","","","","fee schedule","735.52","5220","APC 277.30"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2449.56","","","","","","","fee schedule","735.52","5220","APC 296.56"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2551.57","","","","","","","fee schedule","735.52","5220","APC 308.91"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","755.35","","","","","","","fee schedule","735.52","5220","APC"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","742.73","","","","","","","fee schedule","735.52","5220","APC"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","735.52","","","","","","","fee schedule","735.52","5220","APC"
"Remove cartilage for graft","20910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","757.16","","","","","","","fee schedule","735.52","5220","APC"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Remove cartilage for graft","20912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2053.37","7123.26",""
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of fascia for graft","20920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","14111",""
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2053.37","14111",""
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2053.37","14111",""
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","14111","APC 277.30"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","14111","APC 296.56"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","14111","APC 308.91"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","14111","APC"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","14111","APC"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","14111","APC"
"Removal of fascia for graft","20922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","14111","APC"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of tendon for graft","20924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of tissue for graft","20926","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Sp bone algrft morsel add-on","20930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Sp bone algrft morsel add-on","20930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Sp bone algrft morsel add-on","20930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Sp bone algrft struct add-on","20931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Sp bone algrft struct add-on","20931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Sp bone algrft struct add-on","20931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Osteoart algrft w/surf & b1","20932","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Osteoart algrft w/surf & b1","20932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Osteoart algrft w/surf & b1","20932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Hemicrt intrclry algrft prtl","20933","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Hemicrt intrclry algrft prtl","20933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Hemicrt intrclry algrft prtl","20933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Intercalary algrft compl","20934","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Intercalary algrft compl","20934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Intercalary algrft compl","20934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Sp bone agrft local add-on","20936","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft local add-on","20936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft local add-on","20936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft morsel add-on","20937","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft morsel add-on","20937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft morsel add-on","20937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft struct add-on","20938","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft struct add-on","20938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Sp bone agrft struct add-on","20938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Bone marrow aspir bone grfg","20939","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bone marrow aspir bone grfg","20939","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bone marrow aspir bone grfg","20939","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Fluid pressure muscle","20950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Fibula bone graft microvasc","20955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Iliac bone graft microvasc","20956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Mt bone graft microvasc","20957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Other bone graft microvasc","20962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft microvasc","20969","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft iliac crest","20970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft metatarsal","20972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Bone/skin graft great toe","20973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","49.75","5220",""
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","49.75","5220",""
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","49.75","5220",""
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.09","","","","","","","fee schedule","49.75","5220","APC"
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.23","","","","","","","fee schedule","49.75","5220","APC"
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.75","","","","","","","fee schedule","49.75","5220","APC"
"Electrical bone stimulation","20974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.21","","","","","","","fee schedule","49.75","5220","APC"
"Electrical bone stimulation","20975","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Electrical bone stimulation","20975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Electrical bone stimulation","20975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","28.78","5220",""
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","28.78","5220",""
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","28.78","5220",""
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","5220","APC 277.30"
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","5220","APC 296.56"
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","5220","APC 308.91"
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","5220","APC"
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","5220","APC"
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","5220","APC"
"Us bone stimulation","20979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","5220","APC"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","60533.69",""
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","60533.69",""
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Ablate bone tumor(s) perq","20982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Ablate bone tumor(s) perq","20983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Cptr-asst dir ms px","20985","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Cptr-asst dir ms px","20985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Cptr-asst dir ms px","20985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Musculoskeletal surgery","20999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of jaw joint","21010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sc <2 cm","21011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face les sbq 2 cm/>","21012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face tum deep < 2 cm","21013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2890.77","10028.23",""
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2890.77","10028.23",""
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc face tum deep 2 cm/>","21014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect face/scalp tum < 2 cm","21015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect face/scalp tum 2 cm/>","21016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Excision of bone lower jaw","21025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Excision of facial bone(s)","21026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Contour of face bone lesion","21029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Excise max/zygoma b9 tumor","21030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis mandible","21031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Remove exostosis maxilla","21032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Excise max/zygoma mal tumor","21034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excise mandible lesion","21040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Removal of jaw bone lesion","21044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Extensive jaw surgery","21045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Remove mandible cyst complex","21046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Excise lwr jaw cyst w/repair","21047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Remove maxilla cyst complex","21048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Excis uppr jaw cyst w/repair","21049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Removal of jaw joint","21050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Remove jaw joint cartilage","21060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Remove coronoid process","21070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Mnpj of tmj w/anesth","21073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Prepare face/oral prosthesis","21076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Prepare face/oral prosthesis","21089","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Maxillofacial fixation","21100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Interdental fixation","21110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Injection jaw joint x-ray","21116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection jaw joint x-ray","21116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection jaw joint x-ray","21116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruction of chin","21123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Augmentation lower jaw bone","21125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5891.41","23971",""
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation lower jaw bone","21127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Reduction of forehead","21137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reduction of forehead","21139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/o graft","21141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/o graft","21142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/o graft","21143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-1 piece w/ graft","21145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-2 piece w/ graft","21146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort i-3/> piece w/ graft","21147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii anterior intrusion","21150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort ii w/bone grafts","21151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/o lefort i","21154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/ lefort i","21155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhdw/o lefort i","21159","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lefort iii w/fhd w/ lefort i","21160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct orbit/forehead","21175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct entire forehead","21180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Contour cranial bone lesion","21181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct cranial bone","21184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of midface","21188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o graft","21193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/graft","21194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/o fixation","21195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconst lwr jaw w/fixation","21196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstr lwr jaw segment","21198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstr Lwr Jaw W/Advance","21199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct upper jaw bone","21206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation of facial bones","21208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reduction of facial bones","21209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Face bone graft","21210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Lower jaw bone graft","21215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Rib cartilage graft","21230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5226","20437.6",""
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","20437.6",""
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","20437.6",""
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5226","20437.6","APC 277.30"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5226","20437.6","APC 296.56"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5226","20437.6","APC 308.91"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5226","20437.6","APC"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5226","20437.6","APC"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5226","20437.6","APC"
"Ear cartilage graft","21235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5226","20437.6","APC"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","93677.4",""
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","93677.4",""
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","93677.4",""
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84091.62","","","","","","","fee schedule","7337","93677.4","APC 277.30"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89932.25","","","","","","","fee schedule","7337","93677.4","APC 296.56"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93677.4","","","","","","","fee schedule","7337","93677.4","APC 308.91"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27731.78","","","","","","","fee schedule","7337","93677.4","APC"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27268.48","","","","","","","fee schedule","7337","93677.4","APC"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27003.74","","","","","","","fee schedule","7337","93677.4","APC"
"Reconstruction of jaw joint","21243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27797.96","","","","","","","fee schedule","7337","93677.4","APC"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of lower jaw","21244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct lower jaw bone","21247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of jaw","21249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct lower jaw bone","21255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of orbit","21256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise eye sockets","21267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Revise eye sockets","21268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Augmentation cheek bone","21270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revision orbitofacial bones","21275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3299.54","23971",""
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Revision of eyelid","21280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3299.54","11446.28",""
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Revision of eyelid","21282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Revision of jaw muscle/bone","21295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","14111",""
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of jaw muscle/bone","21296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Cranio/maxillofacial surgery","21299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Closed tx nose fx w/o manj","21310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1544.13","5790",""
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx nose fx w/o stablj","21315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closed tx nose fx w/ stablj","21320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose fx uncomplicatd","21325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","20437.6",""
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open tx nose fx w/skele fixj","21330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx nose & septal fx","21335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Open tx septal fx w/wo stabj","21336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closed tx septal&nose fx","21337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","20437.6",""
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/o fixj","21338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","20437.6",""
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Open nasoethmoid fx w/ fixj","21339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","23971",""
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Perq tx nasoethmoid fx","21340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Open tx dprsd front sinus fx","21343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Open tx compl front sinus fx","21344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","1544.13","10181",""
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","10181",""
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","10181",""
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","10181","APC 277.30"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","10181","APC 296.56"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","10181","APC 308.91"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","10181","APC"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","10181","APC"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","10181","APC"
"Closed tx nose/jaw fx","21345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","10181","APC"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx nasomax fx w/fixj","21346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx multple","21347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Opn tx nasomax fx w/graft","21348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Perq tx malar fracture","21355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx dprsd zygomatic arch","21356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Opn tx dprsd malar fracture","21360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx complx malar fx","21365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Opn tx complx malar w/grft","21366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx transantral","21385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx periorbital","21386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit fx combined","21387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit periorbtl implt","21390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Opn tx orbit periorbt w/grft","21395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","536.74","4564",""
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","4564",""
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","4564",""
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","4564","APC 277.30"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","4564","APC 296.56"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","4564","APC 308.91"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","4564","APC"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","4564","APC"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","4564","APC"
"Closed tx orbit w/o manipulj","21400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","4564","APC"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Closed tx orbit w/manipulj","21401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/o implant","21406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/implant","21407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Opn tx orbit fx w/bone grft","21408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Treat mouth roof fracture","21421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat mouth roof fracture","21423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat craniofacial fracture","21436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Treat dental ridge fracture","21440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Treat dental ridge fracture","21445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Treat lower jaw fracture","21450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1544.13","6448",""
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","6448",""
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","6448",""
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","6448","APC 277.30"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","6448","APC 296.56"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","6448","APC 308.91"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","6448","APC"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","6448","APC"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","6448","APC"
"Treat lower jaw fracture","21451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","6448","APC"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","20437.6",""
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","20437.6",""
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Treat lower jaw fracture","21452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Treat lower jaw fracture","21453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","20437.6",""
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Treat lower jaw fracture","21454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Treat lower jaw fracture","21470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Reset dislocated jaw","21480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1544.13","5790",""
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Reset dislocated jaw","21485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Repair dislocated jaw","21490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Treat hyoid bone fracture","21495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1544.13","5790",""
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Interdental wiring","21497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Head surgery procedure","21499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drain neck/chest lesion","21501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Drain chest lesion","21502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","21510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of neck/chest","21550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck les sc 3 cm/>","21552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep 5 cm/>","21554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc neck les sc < 3 cm","21555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc neck tum deep < 5 cm","21556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect neck thorax tumor<5cm","21557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect neck tumor 5 cm/>","21558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Partial removal of rib","21600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc chest wall tumor w/ribs","21601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/o lymphadec","21602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Exc ch wal tum w/lymphadec","21603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of rib","21610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib","21615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Removal of rib and nerves","21616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Partial removal of sternum","21620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Sternal debridement","21627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Extensive sternum surgery","21630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Extensive sternum surgery","21632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","20437.6",""
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","20437.6",""
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","20437.6",""
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","3408","20437.6","APC 277.30"
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","3408","20437.6","APC 296.56"
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","3408","20437.6","APC 308.91"
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","3408","20437.6","APC"
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","3408","20437.6","APC"
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","3408","20437.6","APC"
"Hyoid myotomy & suspension","21685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","3408","20437.6","APC"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Revision of neck muscle","21700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of neck muscle/rib","21705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of neck muscle","21720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Revision of neck muscle","21725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction of sternum","21740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Repair stern/nuss w/o scope","21742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Repair sternum/nuss w/scope","21743","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair of sternum separation","21750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of rib fracture","21800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Treatment of rib fracture","21805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Optx of rib fx w/fixj scope","21811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of rib fracture","21812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of rib fracture","21813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat sternum fracture","21820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat sternum fracture","21825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Neck/chest surgery procedure","21899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy soft tissue of back","21920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","14111",""
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Biopsy soft tissue of back","21925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc back les sc < 3 cm","21930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1643.67","14111",""
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Exc back les sc 3 cm/>","21931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2890.77","10181",""
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10181",""
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10181",""
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10181","APC 277.30"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10181","APC 296.56"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10181","APC 308.91"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10181","APC"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10181","APC"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10181","APC"
"Exc back tum deep < 5 cm","21932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10181","APC"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc back tum deep 5 cm/>","21933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect back tum < 5 cm","21935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect back tum 5 cm/>","21936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"I&d p-spine c/t/cerv-thor","22010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"I&d abscess p-spine l/s/ls","22015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove extra spine segment","22103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Remove extra spine segment","22103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Remove extra spine segment","22103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove part of neck vertebra","22110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove part thorax vertebra","22112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove part lumbar vertebra","22114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove extra spine segment","22116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Remove extra spine segment","22116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Remove extra spine segment","22116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column thorac","22206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column lumbar","22207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis spine 3 column adl seg","22208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Incis spine 3 column adl seg","22208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Incis spine 3 column adl seg","22208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg cerv","22210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg thorac","22212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis 1 vertebral seg lumbar","22214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis addl spine segment","22216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Incis addl spine segment","22216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Incis addl spine segment","22216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy cervical","22220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy thoracic","22222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incis w/discectomy lumbar","22224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revise extra spine segment","22226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Revise extra spine segment","22226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Revise extra spine segment","22226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Treat spine process fracture","22305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Closed tx vert fx w/o manj","22310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Closed tx vert fx w/manj","22315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/o graft","22318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat odontoid fx w/graft","22319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat spine fracture","22325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat neck spine fracture","22326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat thorax spine fracture","22327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat each add spine fx","22328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Treat each add spine fx","22328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Treat each add spine fx","22328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulation of spine","22505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Perq cervicothoracic inject","22510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Perq lumbosacral injection","22511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Vertebroplasty addl inject","22512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Vertebroplasty addl inject","22512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Vertebroplasty addl inject","22512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Perq vertebral augmentation","22515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perq vertebral augmentation","22515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perq vertebral augmentation","22515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Percut Vertebroplasty Thor","22520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Percut Vertebroplasty Lumb","22521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Percut Vertebroplasty Addl","22522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Idet single level","22526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","19040",""
"Idet single level","22526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","13700","19040",""
"Idet single level","22526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","13700","19040",""
"Idet 1 or more levels","22527","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","19040",""
"Idet 1 or more levels","22527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","13700","19040",""
"Idet 1 or more levels","22527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","13700","19040",""
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Lat thorax spine fusion","22532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Lat lumbar spine fusion","22533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Lat thor/lumb addl seg","22534","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Lat thor/lumb addl seg","22534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Lat thor/lumb addl seg","22534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fuse&remov bel c2","22551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Addl neck spine fusion","22552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Addl neck spine fusion","22552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Addl neck spine fusion","22552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84091.62","","","","","","","fee schedule","5220","93677.4","APC 277.30"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89932.25","","","","","","","fee schedule","5220","93677.4","APC 296.56"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93677.4","","","","","","","fee schedule","5220","93677.4","APC 308.91"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27731.78","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27268.48","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27003.74","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion","22558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27797.96","","","","","","","fee schedule","5220","93677.4","APC"
"Additional spinal fusion","22585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Additional spinal fusion","22585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Additional spinal fusion","22585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Prescrl fuse w/ instr l5-s1","22586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Spine & skull spinal fusion","22590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spinal fusion","22595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Neck spine fusion","22600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Thorax spine fusion","22610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","60533.69",""
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","60533.69",""
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar spine fusion","22612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Spine fusion extra segment","22614","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Spine fusion extra segment","22614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Spine fusion extra segment","22614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84091.62","","","","","","","fee schedule","5220","93677.4","APC 277.30"
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89932.25","","","","","","","fee schedule","5220","93677.4","APC 296.56"
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93677.4","","","","","","","fee schedule","5220","93677.4","APC 308.91"
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27731.78","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27268.48","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27003.74","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion","22630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27797.96","","","","","","","fee schedule","5220","93677.4","APC"
"Spine fusion extra segment","22632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Spine fusion extra segment","22632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Spine fusion extra segment","22632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","5220","93677.4",""
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84091.62","","","","","","","fee schedule","5220","93677.4","APC 277.30"
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89932.25","","","","","","","fee schedule","5220","93677.4","APC 296.56"
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93677.4","","","","","","","fee schedule","5220","93677.4","APC 308.91"
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27731.78","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27268.48","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27003.74","","","","","","","fee schedule","5220","93677.4","APC"
"Lumbar spine fusion combined","22633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27797.96","","","","","","","fee schedule","5220","93677.4","APC"
"Spine fusion extra segment","22634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Spine fusion extra segment","22634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Spine fusion extra segment","22634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion <=6 vert seg","22800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 7-12 vert seg","22802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Post fusion 13/> vert seg","22804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 2-3 vert seg","22808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 4-7 vert seg","22810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Ant fusion 8/> vert seg","22812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 1-2 segments","22818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Kyphectomy 3 or more","22819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Exploration of spinal fusion","22830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","60533.69",""
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","60533.69",""
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5226","60533.69","APC 277.30"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5226","60533.69","APC 296.56"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5226","60533.69","APC 308.91"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg <7","22836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","60533.69",""
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","60533.69",""
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5226","60533.69","APC 277.30"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5226","60533.69","APC 296.56"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5226","60533.69","APC 308.91"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5226","60533.69","APC"
"Ant thrc vrt body tethrg 8+","22837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5226","60533.69","APC"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","60533.69",""
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","60533.69",""
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5226","60533.69","APC 277.30"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5226","60533.69","APC 296.56"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5226","60533.69","APC 308.91"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5226","60533.69","APC"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5226","60533.69","APC"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5226","60533.69","APC"
"Rev rplc/rmv thrc vrt tethrg","22838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5226","60533.69","APC"
"Insert spine fixation device","22840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22841","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22843","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22844","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insert spine fixation device","22845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22846","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22847","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert spine fixation device","22847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert pelv fixation device","22848","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert pelv fixation device","22848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert pelv fixation device","22848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reinsert spinal fixation","22849","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Insj biomechanical device","22853","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insj biomechanical device","22853","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Insj biomechanical device","22854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insj biomechanical device","22854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine fixation device","22855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","60533.69",""
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","60533.69",""
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Cerv artific diskectomy","22856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Lumbar Artif Diskectomy","22857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Second level cer diskectomy","22858","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Second level cer diskectomy","22858","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Second level cer diskectomy","22858","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insj biomechanical device","22859","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insj biomechanical device","22859","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Tot disc arthrp 2ntrspc lmbr","22860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tot disc arthrp 2ntrspc lmbr","22860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Revise cerv artific disc","22861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Revise Lumbar Artif Disc","22862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove cerv artif disc","22864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove Lumb Artif Disc","22865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","17449.63","60533.69",""
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","17449.63","60533.69",""
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","17449.63","60533.69","APC 277.30"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","17449.63","60533.69","APC 296.56"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","17449.63","60533.69","APC 308.91"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","17449.63","60533.69","APC"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","17449.63","60533.69","APC"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","17449.63","60533.69","APC"
"Insj stablj dev w/dcmprn","22867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","17449.63","60533.69","APC"
"Insj stablj dev w/dcmprn","22868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insj stablj dev w/dcmprn","22868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Insj stablj dev w/o dcmprn","22869","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Insj stablj dev w/o dcmprn","22870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insj stablj dev w/o dcmprn","22870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Spine surgery procedure","22899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2890.77","14111",""
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep < 5 cm","22900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abdl tum deep 5 cm/>","22901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","1643.67","10181",""
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","10181",""
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","10181",""
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","10181","APC 277.30"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","10181","APC 296.56"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","10181","APC 308.91"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","10181","APC"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","10181","APC"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","10181","APC"
"Exc abd les sc < 3 cm","22902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","10181","APC"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc abd les sc 3 cm/>","22903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2890.77","10181",""
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10181",""
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10181",""
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10181","APC 277.30"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10181","APC 296.56"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10181","APC 308.91"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10181","APC"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10181","APC"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10181","APC"
"Radical resect abd tumor<5cm","22904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10181","APC"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Rad resect abd tumor 5 cm/>","22905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Abdomen surgery procedure","22999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of calcium deposits","23000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release shoulder joint","23020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder lesion","23030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder bursa","23031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Drain shoulder bone lesion","23035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory shoulder surgery","23044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy shoulder tissues","23065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy shoulder tissues","23066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1643.67","14111",""
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Exc shoulder les sc 3 cm/>","23071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc shoulder tum deep 5 cm/>","23073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc shoulder les sc < 3 cm","23075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc shoulder tum deep < 5 cm","23076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect shoulder tumor < 5 cm","23077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect shoulder tumor 5 cm/>","23078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of shoulder joint","23100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3256.29","19040",""
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder joint surgery","23101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder joint lining","23105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of collarbone joint","23106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Explore treat shoulder joint","23107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal collar bone","23120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of collar bone","23125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","23971",""
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Remove shoulder bone part","23130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of bone lesion","23140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of bone lesion","23145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of bone lesion","23146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of humerus lesion","23150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of humerus lesion","23156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove collar bone lesion","23170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove shoulder blade lesion","23172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Remove humerus lesion","23174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Remove collar bone lesion","23180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Remove shoulder blade lesion","23182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Remove humerus lesion","23184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of scapula","23190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of head of humerus","23195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Resect clavicle tumor","23200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Resect scapula tumor","23210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Resect prox humerus tumor","23220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Remove shoulder foreign body","23330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Remove shoulder foreign body","23331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2890.77","10028.23",""
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2890.77","10028.23",""
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove shoulder fb deep","23333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Shoulder prosthesis removal","23335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Injection for shoulder x-ray","23350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for shoulder x-ray","23350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for shoulder x-ray","23350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfer shoulder/arm","23395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Muscle transfers","23397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fixation of shoulder blade","23400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of tendon & muscle","23405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Incise tendon(s) & muscle(s)","23406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff acute","23410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair rotator cuff chronic","23412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Release of shoulder ligament","23415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair of shoulder","23420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair biceps tendon","23430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Remove/transplant tendon","23440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair shoulder capsule","23466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct shoulder joint","23470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct shoulder joint","23472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revis reconst shoulder joint","23474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of collar bone","23480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","44324.22",""
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10181","44324.22",""
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10181","44324.22",""
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","10181","44324.22","APC 277.30"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","10181","44324.22","APC 296.56"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","10181","44324.22","APC 308.91"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","10181","44324.22","APC"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","10181","44324.22","APC"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","10181","44324.22","APC"
"Revision of collar bone","23485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","10181","44324.22","APC"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reinforce clavicle","23490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce shoulder bones","23491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle fracture","23500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat clavicle fracture","23505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle fracture","23515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat clavicle dislocation","23520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","25051.33",""
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","25051.33",""
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Treat clavicle dislocation","23532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Treat clavicle dislocation","23552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder blade fx","23570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat shoulder blade fx","23575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat scapula fracture","23585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","23605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","23615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","60533.69",""
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","60533.69",""
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","60533.69",""
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","6448","60533.69","APC 277.30"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","6448","60533.69","APC 296.56"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","6448","60533.69","APC 308.91"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","6448","60533.69","APC"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","6448","60533.69","APC"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","6448","60533.69","APC"
"Treat humerus fracture","23616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","6448","60533.69","APC"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat humerus fracture","23625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Treat humerus fracture","23630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder dislocation","23650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat shoulder dislocation","23655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat shoulder dislocation","23660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat dislocation/fracture","23670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat dislocation/fracture","23680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Fixation of shoulder","23700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Fusion of shoulder joint","23800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","44324.22",""
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10181","44324.22",""
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10181","44324.22",""
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","10181","44324.22","APC 277.30"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","10181","44324.22","APC 296.56"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","10181","44324.22","APC 308.91"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","10181","44324.22","APC"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","10181","44324.22","APC"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","10181","44324.22","APC"
"Fusion of shoulder joint","23802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","10181","44324.22","APC"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of arm & girdle","23900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation at shoulder joint","23920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","23921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Shoulder surgery procedure","23929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage of arm lesion","23930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of arm bursa","23931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Drain arm/elbow bone lesion","23935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Exploratory elbow surgery","24000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release elbow joint","24006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy arm/elbow soft tissue","24065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy arm/elbow soft tissue","24066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc arm/elbow les sc 3 cm/>","24071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Ex arm/elbow tum deep 5 cm/>","24073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc arm/elbow les sc < 3 cm","24075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Ex arm/elbow tum deep < 5 cm","24076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect arm/elbow tum < 5 cm","24077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect arm/elbow tum 5 cm/>","24079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy elbow joint lining","24100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat elbow joint","24101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint lining","24102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of elbow bursa","24105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Remove humerus lesion","24110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Remove elbow lesion","24120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft bone lesion","24125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","24126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of head of radius","24130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Removal of arm bone lesion","24134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius bone lesion","24136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Remove elbow bone lesion","24138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of arm bone","24140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Partial removal of radius","24145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of elbow","24147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Radical resection of elbow","24149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Resect distal humerus tumor","24150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius tumor","24152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of elbow joint","24155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove elbow joint implant","24160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove radius head implant","24164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of arm foreign body","24200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of arm foreign body","24201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Injection for elbow x-ray","24220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for elbow x-ray","24220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for elbow x-ray","24220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","6448",""
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","6448",""
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","6448",""
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","6448","APC 277.30"
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","6448","APC 296.56"
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","6448","APC 308.91"
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","6448","APC"
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","6448","APC"
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","6448","APC"
"Manipulate elbow w/anesth","24300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","6448","APC"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Muscle/tendon transfer","24301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Arm tendon lengthening","24305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of arm tendon","24310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of arm tendon","24320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of arm muscles","24330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of arm muscles","24331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Tenolysis triceps","24332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of biceps tendon","24340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair arm tendon/muscle","24341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of ruptured tendon","24342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repr elbow lat ligmnt w/tiss","24343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Reconstruct elbow lat ligmnt","24344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repr elbw med ligmnt w/tissu","24345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct elbow med ligmnt","24346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","14111",""
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair elbow perc","24357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","19040",""
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow w/deb open","24358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","19040",""
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair elbow deb/attch open","24359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct elbow joint","24360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct elbow joint","24361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct elbow joint","24362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Replace elbow joint","24363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct head of radius","24365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct head of radius","24366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revise reconst elbow joint","24370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Revise reconst elbow joint","24371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of humerus","24400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","44324.22",""
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","44324.22",""
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of humerus","24410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of humerus","24420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Repair of humerus","24430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Repair humerus with graft","24435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of elbow joint","24470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Decompression of forearm","24495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce humerus","24498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Treat humerus fracture","24546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","24566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treat humerus fracture","24582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat elbow fracture","24586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Treat elbow fracture","24587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow dislocation","24605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow dislocation","24615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow fracture","24620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow fracture","24635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat elbow dislocation","24640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat radius fracture","24650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat radius fracture","24655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Treat radius fracture","24665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat radius fracture","24666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat ulnar fracture","24670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat ulnar fracture","24675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat ulnar fracture","24685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of elbow joint","24800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion/graft of elbow joint","24802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of upper arm","24920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","24925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Amputation follow-up surgery","24930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Amputate upper arm & implant","24931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of amputation","24935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of upper arm","24940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Upper arm/elbow surgery","24999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of tendon sheath","25000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incise flexor carpi radialis","25001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","19040",""
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Decompress forearm 1 space","25020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 1 space","25023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 2 spaces","25024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Decompress forearm 2 spaces","25025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of forearm lesion","25028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of forearm bursa","25031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treat forearm bone lesion","25035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat wrist joint","25040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy forearm soft tissues","25065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy forearm soft tissues","25066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1643.67","14111",""
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Exc forearm les sc 3 cm/>","25071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc forearm tum deep 3 cm/>","25073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm les sc < 3 cm","25075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc forearm tum deep < 3 cm","25076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect forearm/wrist tum<3cm","25077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect forarm/wrist tum 3cm>","25078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of wrist capsule","25085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of wrist joint","25100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat wrist joint","25101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint lining","25105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint cartilage","25107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Excise tendon forearm/wrist","25109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist tendon lesion","25111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","14111",""
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Reremove wrist tendon lesion","25112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist/forearm lesion","25115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Remove wrist/forearm lesion","25116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Excise wrist tendon sheath","25118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of forearm lesion","25120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Remove/graft forearm lesion","25125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft forearm lesion","25126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist lesion","25130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove & graft wrist lesion","25136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove forearm bone lesion","25145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Resect radius/ulnar tumor","25170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bone","25210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist bones","25215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of radius","25230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of ulna","25240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Injection for wrist x-ray","25246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for wrist x-ray","25246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for wrist x-ray","25246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Remove forearm foreign body","25248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of wrist prosthesis","25250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of wrist prosthesis","25251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulate wrist w/anesthes","25259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair forearm tendon/muscle","25263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon/muscle","25274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair forearm tendon sheath","25275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revise wrist/forearm tendon","25280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incise wrist/forearm tendon","25290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release wrist/forearm tendon","25295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of tendons at wrist","25301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant forearm tendon","25310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","23971",""
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Transplant forearm tendon","25312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revise palsy hand tendon(s)","25315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revise palsy hand tendon(s)","25316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/revise wrist joint","25320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","23971",""
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revise wrist joint","25332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Realignment of hand","25335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct ulna/radioulnar","25337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of radius","25350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of radius","25355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of ulna","25360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revise radius & ulna","25365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius or ulna","25370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","23971",""
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revise radius & ulna","25375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Shorten radius or ulna","25390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","44324.22",""
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","44324.22",""
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Lengthen radius or ulna","25391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Shorten radius & ulna","25392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Lengthen radius & ulna","25393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","23971",""
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Repair carpal bone shorten","25394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair radius or ulna","25400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius or ulna","25405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair radius & ulna","25415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius & ulna","25420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft radius or ulna","25425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","23971",""
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Repair/graft radius & ulna","25426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Vasc graft into carpal bone","25430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair nonunion carpal bone","25431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft wrist bone","25440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct wrist joint","25441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct wrist joint","25442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct wrist joint","25444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct wrist joint","25445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Wrist replacement","25446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","23971",""
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Repair wrist joints","25447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Arthrp ntrcrpl/crp/mtcrp ssp","25448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove wrist joint implant","25449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revision of wrist joint","25455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Reinforce radius","25490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce ulna","25491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Reinforce radius and ulna","25492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of radius","25500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of radius","25515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Treat fracture of radius","25525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Treat fracture of radius","25526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of ulna","25530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat fracture of ulna","25535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture of ulna","25545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius & ulna","25560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius & ulna","25565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius & ulna","25574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius/ulna","25575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius/ulna","25600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat fracture radius/ulna","25605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat Fx Distal Radial","25606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Extra-Articul","25607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Rad Intra-Articul","25608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Treat Fx Radial 3+ Frag","25609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat wrist bone fracture","25628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat wrist bone fracture","25645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat wrist bone fracture","25650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Pin ulnar styloid fracture","25651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat fracture ulnar styloid","25652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist dislocation","25670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Pin radioulnar dislocation","25671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist dislocation","25676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","245.48","4564",""
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","4564",""
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","4564",""
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","4564","APC 277.30"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","4564","APC 296.56"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","4564","APC 308.91"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","4564","APC"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","4564","APC"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","4564","APC"
"Treat wrist fracture","25680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","4564","APC"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist fracture","25685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat wrist dislocation","25690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treat wrist dislocation","25695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Fusion of wrist joint","25800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Fusion/graft of wrist joint","25805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion/graft of wrist joint","25810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of hand bones","25820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Fuse hand bones with graft","25825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fusion radioulnar jnt/ulna","25830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation follow-up surgery","25909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Amputation of forearm","25915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate hand at wrist","25920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Amputate hand at wrist","25922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","25924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of hand","25927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","25929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","25931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Forearm or wrist surgery","25999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of finger abscess","26010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of finger abscess","26011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drain hand tendon sheath","26020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursa","26025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Drainage of palm bursas","26030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat hand bone lesion","26034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","11296.24",""
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","11296.24",""
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Decompress fingers/hand","26037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","6448",""
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","6448",""
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","6448",""
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","6448","APC 277.30"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","6448","APC 296.56"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","6448","APC 308.91"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","6448","APC"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","6448","APC"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","6448","APC"
"Release palm contracture","26040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","6448","APC"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Incise finger tendon sheath","26055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Explore/treat hand joint","26070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","11296.24",""
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Explore/treat finger joint","26075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","6448",""
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","6448",""
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","6448",""
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","6448","APC 277.30"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","6448","APC 296.56"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","6448","APC 308.91"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","6448","APC"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","6448","APC"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","6448","APC"
"Explore/treat finger joint","26080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","6448","APC"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy hand joint lining","26100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy finger joint lining","26105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Biopsy finger joint lining","26110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1643.67","14111",""
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand les sc 1.5 cm/>","26111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1643.67","14111",""
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand tum deep 1.5 cm/>","26113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand les sc < 1.5 cm","26115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc hand tum deep < 1.5 cm","26116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Rad resect hand tumor < 3 cm","26117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Rad resect hand tumor 3 cm/>","26118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm contracture","26125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Release palm contracture","26125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Release palm contracture","26125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Remove wrist joint lining","26130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revise finger joint each","26135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Revise finger joint each","26140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Tendon excision palm/finger","26145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Remove tendon sheath lesion","26160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of palm tendon each","26170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger tendon","26180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","6448",""
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","6448",""
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","6448",""
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","6448","APC 277.30"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","6448","APC 296.56"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","6448","APC 308.91"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","6448","APC"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","6448","APC"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","6448","APC"
"Remove finger bone","26185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","6448","APC"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Remove hand bone lesion","26200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft bone lesion","26205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of finger lesion","26210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Remove/graft finger lesion","26215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3256.29","11296.24",""
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Partial removal of hand bone","26230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Partial removal finger bone","26236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Extensive hand surgery","26250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Resect prox finger tumor","26260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Resect distal finger tumor","26262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of implant from hand","26320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Manipulate finger w/anesth","26340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Manipulat palm cord post inj","26341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revise hand/finger tendon","26390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft hand tendon","26392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Repair hand tendon","26410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft hand tendon","26412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Excision hand/finger tendon","26415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Graft hand or finger tendon","26416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","6448",""
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","6448",""
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","6448",""
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","6448","APC 277.30"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","6448","APC 296.56"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","6448","APC 308.91"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","6448","APC"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","6448","APC"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","6448","APC"
"Repair finger tendon","26418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","6448","APC"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger/hand tendon","26426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Repair finger tendon","26432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair finger tendon","26433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair/graft finger tendon","26434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Realignment of tendons","26437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Release palm/finger tendon","26440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release palm & finger tendon","26442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release hand/finger tendon","26445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release forearm/hand tendon","26449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Incision of palm tendon","26450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Incision of finger tendon","26455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Incise hand/finger tendon","26460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fusion of finger tendons","26471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Fusion of finger tendons","26474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon lengthening","26476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tendon shortening","26477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Lengthening of hand tendon","26478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Shortening of hand tendon","26479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant hand tendon","26480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft hand tendon","26483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant palm tendon","26485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Transplant/graft palm tendon","26489","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Tendon transfer with graft","26492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon/muscle transfer","26494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revise thumb tendon","26496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Finger tendon transfer","26498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of finger","26499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5226","25051.33",""
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","25051.33",""
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","25051.33",""
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5226","25051.33","APC 277.30"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5226","25051.33","APC 296.56"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5226","25051.33","APC 308.91"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5226","25051.33","APC"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5226","25051.33","APC"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5226","25051.33","APC"
"Hand tendon reconstruction","26500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5226","25051.33","APC"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Hand tendon reconstruction","26502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release thumb contracture","26508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Thumb tendon transfer","26510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","19040",""
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joint","26516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joints","26517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of knuckle joints","26518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release knuckle contracture","26520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Release finger contracture","26525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revise knuckle joint","26530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise knuckle with implant","26531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","23971",""
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Revise finger joint","26535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revise/implant finger joint","26536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint","26540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3256.29","19040",""
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair hand joint with graft","26541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand joint with graft","26542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct finger joint","26545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair nonunion hand","26546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruct finger joint","26548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Construct thumb replacement","26550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Great toe-hand transfer","26551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Single transfer toe-hand","26553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Double transfer toe-hand","26554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Positional change of finger","26555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Toe joint transfer","26556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Repair of web finger","26560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of web finger","26562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Correct metacarpal flaw","26565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Correct finger deformity","26567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthen metacarpal/finger","26568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair hand deformity","26580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","11296.24",""
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Reconstruct extra finger","26587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1600.27","7337",""
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","7337",""
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","7337",""
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","7337","APC 277.30"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","7337","APC 296.56"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","7337","APC 308.91"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","7337","APC"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","7337","APC"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","7337","APC"
"Repair finger deformity","26590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","7337","APC"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair muscles of hand","26591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Release muscles of hand","26593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Excision constricting tissue","26596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat metacarpal fracture","26600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","245.48","4564",""
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","4564",""
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","4564",""
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","4564","APC 277.30"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","4564","APC 296.56"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","4564","APC 308.91"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","4564","APC"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","4564","APC"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","4564","APC"
"Treat metacarpal fracture","26605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","4564","APC"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat metacarpal fracture","26607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metacarpal fracture","26608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","29398",""
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat metacarpal fracture","26615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat thumb dislocation","26641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thumb fracture","26645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat thumb fracture","26650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","29398",""
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat thumb fracture","26665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat hand dislocation","26670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hand dislocation","26675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Pin hand dislocation","26676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat hand dislocation","26685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat hand dislocation","26686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat knuckle dislocation","26700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat knuckle dislocation","26705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Pin knuckle dislocation","26706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat knuckle dislocation","26715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat finger fracture each","26742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger fracture each","26755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Pin finger fracture each","26756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger fracture each","26765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger dislocation","26770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Treat finger dislocation","26775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Pin finger dislocation","26776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat finger dislocation","26785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Thumb fusion with graft","26820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of thumb","26841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Thumb fusion with graft","26842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of hand joint","26843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion/graft of hand joint","26844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle","26850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of knuckle with graft","26852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of finger joint","26860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion of finger jnt add-on","26861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Fusion of finger jnt add-on","26861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Fusion of finger jnt add-on","26861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Fusion/graft of finger joint","26862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Fuse/graft added joint","26863","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fuse/graft added joint","26863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fuse/graft added joint","26863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Amputate metacarpal bone","26910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","11296.24",""
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","11296.24",""
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Amputation of finger/thumb","26952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Hand/finger surgery","26989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of pelvis lesion","26990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","14111",""
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of pelvis bursa","26991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","26992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of hip tendon","27000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendon","27001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Incision of hip tendon","27003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip tendon","27005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip tendons","27006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Incision of hip/thigh fascia","27025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","25051.33",""
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Buttock fasciotomy","27027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Drainage of hip joint","27030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Exploration of hip joint","27033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Denervation of hip joint","27035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Excision of hip joint/muscle","27036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of soft tissues","27041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip pelvis les sc 3 cm/>","27043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip/pelv tum deep 5 cm/>","27045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelvis les sc < 3 cm","27047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc hip/pelv tum deep < 5 cm","27048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect hip/pelv tum < 5 cm","27049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of sacroiliac joint","27050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Biopsy of hip joint","27052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of hip joint lining","27054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1600.27","14111",""
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Buttock fasciotomy w/dbrdmt","27057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect hip/pelv tum 5 cm/>","27059","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","7221.37","25051.33",""
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Removal of ischial bursa","27060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","14111",""
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Remove femur lesion/bursa","27062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","7221.37","25051.33",""
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","7221.37","25051.33",""
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove hip bone les super","27065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove hip bone les deep","27066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove/graft hip bone lesion","27067","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Part remove hip bone super","27070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Part removal hip bone deep","27071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tumor","27075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum incl acetabul","27076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Resect hip tum w/innom bone","27077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Rsect hip tum incl femur","27078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of tail bone","27080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","10028.23",""
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove hip foreign body","27086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Remove hip foreign body","27087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of hip prosthesis","27090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","44324.22",""
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","44324.22",""
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Removal of hip prosthesis","27091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Injection for hip x-ray","27093","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for hip x-ray","27093","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for hip x-ray","27093","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for hip x-ray","27095","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for hip x-ray","27095","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for hip x-ray","27095","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Inject sacroiliac joint","27096","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Inject sacroiliac joint","27096","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Inject sacroiliac joint","27096","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of hip tendon","27097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Transfer tendon to pelvis","27098","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of abdominal muscle","27100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","23971",""
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of spinal muscle","27105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of iliopsoas muscle","27110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","23971",""
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Transfer of iliopsoas muscle","27111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruction of hip socket","27120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction of hip socket","27122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Partial hip replacement","27125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Total hip arthroplasty","27132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revise hip joint replacement","27138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Transplant femur ridge","27140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bone","27146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bone","27147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incision of hip bones","27151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of hip bones","27156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of pelvis","27158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incision of neck of femur","27161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incision/fixation of femur","27165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft femur head/neck","27170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat slipped epiphysis","27178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revise head/neck of femur","27179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat slipped epiphysis","27181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Revision of femur epiphysis","27185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reinforce hip bones","27187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat pelvic ring fracture","27193","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Treat pelvic ring fracture","27194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","2633",""
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","2633",""
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","2633","APC 277.30"
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","2633","APC 296.56"
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","2633","APC 308.91"
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","2633",""
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","2633",""
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","2633","APC 277.30"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","2633","APC 296.56"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","2633","APC 308.91"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","2633","APC"
"Clsd tx pelvic ring fx","27198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","2633","APC"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat tail bone fracture","27200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","29398",""
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Treat tail bone fracture","27202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Treat pelvic fracture(s)","27215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3499","5220",""
"Treat pelvic fracture(s)","27215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","5220",""
"Treat pelvic fracture(s)","27215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","5220",""
"Treat pelvic ring fracture","27216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Treat pelvic ring fracture","27216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Treat pelvic ring fracture","27216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Treat pelvic ring fracture","27217","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat pelvic ring fracture","27217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Treat pelvic ring fracture","27217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat pelvic ring fracture","27218","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat pelvic ring fracture","27218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Treat pelvic ring fracture","27218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip socket fracture","27222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip wall fracture","27226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip fracture(s)","27228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fracture","27238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5790",""
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat thigh fracture","27248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip dislocation","27254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip dislocation","27256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat hip dislocation","27266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Cltx thigh fx","27267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","19040",""
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Cltx thigh fx w/mnpj","27268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","25051.33",""
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","25051.33",""
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Optx thigh fx","27269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Manipulation of hip joint","27275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","17449.63","60533.69",""
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","17449.63","60533.69",""
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","17449.63","60533.69","APC 277.30"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","17449.63","60533.69","APC 296.56"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","17449.63","60533.69","APC 308.91"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","17449.63","60533.69","APC"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","17449.63","60533.69","APC"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","17449.63","60533.69","APC"
"Arthrd si jt prq wo tfxj dev","27278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","17449.63","60533.69","APC"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Arthrodesis sacroiliac joint","27279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Fusion of sacroiliac joint","27280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Fusion of pubic bones","27282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of hip joint","27286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Amputation of leg at hip","27295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Pelvis/hip joint surgery","27299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","14111",""
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drain thigh/knee lesion","27301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Drainage of bone lesion","27303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incise thigh tendon & fascia","27305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of thigh tendons","27307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of knee joint","27310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy thigh soft tissues","27323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy thigh soft tissues","27324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy hamstring","27325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Neurectomy popliteal","27326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1643.67","14111",""
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","14111",""
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1643.67","14111",""
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","14111","APC 277.30"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","14111","APC 296.56"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","14111","APC 308.91"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","14111","APC"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","14111","APC"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","14111","APC"
"Exc thigh/knee les sc < 3 cm","27327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","14111","APC"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc thigh/knee tum deep <5cm","27328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2890.77","10028.23",""
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect thigh/knee tum < 5 cm","27329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy knee joint lining","27330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat knee joint","27331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of knee cartilage","27333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove knee joint lining","27334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Remove knee joint lining","27335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee les sc 3 cm/>","27337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc thigh/knee tum dep 5cm/>","27339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of kneecap bursa","27340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of knee cyst","27345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Remove knee cyst","27347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Removal of kneecap","27350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove femur lesion","27355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","44324.22",""
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","44324.22",""
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Remove femur lesion/graft","27356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove femur lesion/graft","27357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Remove femur lesion/fixation","27358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","7337",""
"Remove femur lesion/fixation","27358","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2375","7337",""
"Remove femur lesion/fixation","27358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","7337",""
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal leg bone(s)","27360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect thigh/knee tum 5 cm/>","27364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Resect femur/knee tumor","27365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Njx cntrst kne arthg/ct/mri","27369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Njx cntrst kne arthg/ct/mri","27369","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Njx cntrst kne arthg/ct/mri","27369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2890.77","14111",""
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Removal of foreign body","27372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","25051.33",""
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","25051.33",""
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","25051.33",""
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","3408","25051.33","APC 277.30"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","3408","25051.33","APC 296.56"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","3408","25051.33","APC 308.91"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","3408","25051.33","APC"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","3408","25051.33","APC"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","3408","25051.33","APC"
"Repair of kneecap tendon","27380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","3408","25051.33","APC"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft kneecap tendon","27381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of thigh muscle","27385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of thigh muscle","27386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendon","27390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendons","27391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of thigh tendons","27392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Lengthening of thigh tendon","27393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthening of thigh tendons","27394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","23971",""
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Lengthening of thigh tendons","27395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Transplant of thigh tendon","27396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Transplants of thigh tendons","27397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revise thigh muscles/tendons","27400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee cartilage","27403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligament","27405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Repair of knee ligament","27407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of knee ligaments","27409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Autochondrocyte implant knee","27412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Osteochondral knee allograft","27415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","25051.33",""
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteochondral knee autograft","27416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair degenerated kneecap","27418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of unstable kneecap","27420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7221.37","25051.33",""
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of unstable kneecap","27422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision/removal of kneecap","27424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3256.29","19040",""
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Lat retinacular release open","27425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction knee","27427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Reconstruction knee","27429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of thigh muscles","27430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of knee joint","27435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revise kneecap","27437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Revise kneecap with implant","27438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","44324.22",""
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of knee joint","27445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of knee joint","27445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of knee joint","27445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of knee joint","27446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Total knee arthroplasty","27447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incision of thigh","27450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Realignment of thigh bone","27454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Realignment of knee","27455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Realignment of knee","27457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteot femur imed lngth dev","27458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Shortening of thigh bone","27465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Lengthening of thigh bone","27466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Shorten/lengthen thighs","27468","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Shorten/lengthen thighs","27468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Shorten/lengthen thighs","27468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair of thigh","27470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of thigh","27472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Surgery to stop leg growth","27485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revise/replace knee joint","27486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","60533.69",""
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","60533.69",""
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Revise/replace knee joint","27487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Removal of knee prosthesis","27488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reinforce thigh","27495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","19040",""
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of thigh/knee","27496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of thigh/knee","27497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","19040",""
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Decompression of thigh/knee","27498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of thigh/knee","27499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","245.48","4564",""
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","4564",""
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","4564",""
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","4564","APC 277.30"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","4564","APC 296.56"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","4564","APC 308.91"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of thigh fracture","27501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of thigh fracture","27502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","44324.22",""
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treatment of thigh fracture","27514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fx growth plate","27516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fx growth plate","27517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat thigh fx growth plate","27519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap fracture","27520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat kneecap fracture","27524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture","27530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat knee fracture","27532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture(s)","27538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee fracture","27540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee dislocation","27550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat knee dislocation","27552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat knee dislocation","27558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","29398","APC 277.30"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","29398","APC 296.56"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","29398","APC 308.91"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","29398","APC"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","29398","APC"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","29398","APC"
"Treat kneecap dislocation","27566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","29398","APC"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Fixation of knee joint","27570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Fusion of knee","27580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","35289","APC 277.30"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","35289","APC 296.56"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","35289","APC 308.91"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","35289","APC 277.30"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","35289","APC 296.56"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","35289","APC 308.91"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","3256.29","35289",""
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","35289","APC 277.30"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","35289","APC 296.56"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","35289","APC 308.91"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","35289","APC"
"Amputate leg at thigh","27592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","35289","APC"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputate lower leg at knee","27598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Leg surgery procedure","27599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of lower leg","27602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drain lower leg lesion","27603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Drain lower leg bursa","27604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","14111",""
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of achilles tendon","27605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of achilles tendon","27606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat lower leg bone lesion","27607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat ankle joint","27610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Exploration of ankle joint","27612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy lower leg soft tissue","27613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy lower leg soft tissue","27614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect leg/ankle tum < 5 cm","27615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect leg/ankle tum 5 cm/>","27616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc leg/ankle tum < 3 cm","27618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc leg/ankle tum deep <5 cm","27619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Explore/treat ankle joint","27620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove ankle joint lining","27626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of tendon lesion","27630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle les sc 3 cm/>","27632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc leg/ankle tum dep 5 cm/>","27634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove lower leg bone lesion","27635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Remove/graft leg bone lesion","27638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of tibia","27640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Partial removal of fibula","27641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Resect tibia tumor","27645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Resect fibula tumor","27646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Resect talus/calcaneus tum","27647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Injection for ankle x-ray","27648","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for ankle x-ray","27648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for ankle x-ray","27648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair achilles tendon","27650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft achilles tendon","27652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of achilles tendon","27654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair leg fascia defect","27656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of leg tendon each","27658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of leg tendon each","27665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair lower leg tendons","27675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair lower leg tendons","27676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendon","27680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Release of lower leg tendons","27681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of lower leg tendon","27685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revise lower leg tendons","27686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Revision of calf tendon","27687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","25051.33",""
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","25051.33",""
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revise lower leg tendon","27691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Revise additional leg tendon","27692","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Revise additional leg tendon","27692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Revise additional leg tendon","27692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligaments","27696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","25051.33",""
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Repair of ankle ligament","27698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7221.37","25051.33",""
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7221.37","25051.33",""
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of ankle joint","27700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","93677.4",""
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","93677.4",""
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","93677.4",""
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84091.62","","","","","","","fee schedule","5220","93677.4","APC 277.30"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89932.25","","","","","","","fee schedule","5220","93677.4","APC 296.56"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93677.4","","","","","","","fee schedule","5220","93677.4","APC 308.91"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27731.78","","","","","","","fee schedule","5220","93677.4","APC"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27268.48","","","","","","","fee schedule","5220","93677.4","APC"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27003.74","","","","","","","fee schedule","5220","93677.4","APC"
"Reconstruct ankle joint","27702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27797.96","","","","","","","fee schedule","5220","93677.4","APC"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","60533.69",""
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","60533.69",""
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","60533.69",""
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","5220","60533.69","APC 277.30"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","5220","60533.69","APC 296.56"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","5220","60533.69","APC 308.91"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","5220","60533.69","APC"
"Reconstruction ankle joint","27703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","5220","60533.69","APC"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Removal of ankle implant","27704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","25051.33",""
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","25051.33",""
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of tibia","27705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of fibula","27707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","44324.22",""
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","44324.22",""
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","44324.22",""
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","4564","44324.22","APC 277.30"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","4564","44324.22","APC 296.56"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","4564","44324.22","APC 308.91"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","4564","44324.22","APC"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","4564","44324.22","APC"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","4564","44324.22","APC"
"Incision of tibia & fibula","27709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","4564","44324.22","APC"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Realignment of lower leg","27712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Osteot tibia imed lngth dev","27713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Revision of lower leg","27715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Repair of tibia","27720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Repair/graft of tibia","27722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of tibia","27724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair of lower leg","27725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Repair fibula nonunion","27726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Repair of lower leg","27727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of tibia epiphysis","27730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of fibula epiphysis","27732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair lower leg epiphyses","27734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of leg epiphyses","27740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3256.29","23971",""
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","23971",""
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3256.29","23971",""
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","23971","APC 277.30"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","23971","APC 296.56"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","23971","APC 308.91"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","23971","APC"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","23971","APC"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","23971","APC"
"Repair of leg epiphyses","27742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","23971","APC"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reinforce tibia","27745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of tibia fracture","27750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of tibia fracture","27752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of tibia fracture","27756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of tibia fracture","27759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Cltx medial ankle fx","27760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Cltx med ankle fx w/mnpj","27762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Optx medial ankle fx","27766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Cltx post ankle fx","27767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Cltx post ankle fx w/mnpj","27768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Optx post ankle fx","27769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of fibula fracture","27780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of fibula fracture","27781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treatment of fibula fracture","27784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1600.27","5551.43",""
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treatment of ankle fracture","27823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg fracture","27824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat lower leg fracture","27825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat lower leg fracture","27826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Treat lower leg fracture","27827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat lower leg fracture","27828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","29398","APC 277.30"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","29398","APC 296.56"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","29398","APC 308.91"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg joint","27829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg dislocation","27830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3256.29","11296.24",""
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3256.29","11296.24",""
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat lower leg dislocation","27831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","29398","APC 277.30"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","29398","APC 296.56"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","29398","APC 308.91"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","29398","APC"
"Treat lower leg dislocation","27832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","29398","APC"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat ankle dislocation","27840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat ankle dislocation","27842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle dislocation","27848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fixation of ankle joint","27860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of ankle joint open","27870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of tibiofibular joint","27871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","35289","APC 277.30"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","35289","APC 296.56"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","35289","APC 308.91"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","35289","APC"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","35289","APC"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","35289","APC"
"Amputation of lower leg","27880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","35289","APC"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of lower leg","27882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation follow-up surgery","27886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of foot at ankle","27888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Amputation of foot at ankle","27889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of leg","27893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Decompression of leg","27894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Leg/ankle surgery procedure","27899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of bursa of foot","28001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of foot infection","28002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treatment of foot infection","28003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot bone lesion","28005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of foot fascia","28008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendons","28011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of foot joint","28022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Exploration of toe joint","28024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1943.35","14111",""
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Decompression of tibia nerve","28035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum sc 1.5 cm/>","28039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum dep 1.5cm/>","28041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Exc foot/toe tum sc < 1.5 cm","28043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Exc foot/toe tum deep <1.5cm","28045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect foot/toe tumor < 3 cm","28046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2890.77","14111",""
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Resect foot/toe tumor 3 cm/>","28047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of foot joint lining","28052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Biopsy of toe joint lining","28054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1943.35","14111",""
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Neurectomy foot","28055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal foot fascia","28060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot fascia","28062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of foot joint lining","28070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot joint lining","28072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot lesion","28080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Excise foot tendon sheath","28088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot lesion","28090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28092","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of ankle/heel lesion","28100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of foot lesion","28104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove/graft foot lesion","28107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of toe lesions","28108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of metatarsal","28113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal heads","28114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot","28116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel bone","28118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of heel spur","28119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3256.29","14111",""
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Part removal of ankle/heel","28120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of ankle bone","28130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of metatarsal","28140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of toe","28150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of toe","28160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Resect tarsal tumor","28171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Resect metatarsal tumor","28173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Resect phalanx of toe tumor","28175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Removal of foot foreign body","28190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of foot foreign body","28192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","6448",""
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1643.67","6448",""
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","6448",""
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","6448","APC 277.30"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","6448","APC 296.56"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","6448","APC 308.91"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","6448","APC"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","6448","APC"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","6448","APC"
"Removal of foot foreign body","28193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","6448","APC"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot tendon","28200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair/graft of foot tendon","28202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot tendon","28208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair/graft of foot tendon","28210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Release of foot tendon","28220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendon","28225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot tendons","28226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon(s)","28230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of toe tendon","28232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Incision of foot tendon","28234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Revision of foot tendon","28238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release of big toe","28240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot fascia","28250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release of midfoot joint","28260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Revision of foot tendon","28261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","25051.33",""
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","25051.33",""
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Revision of foot and ankle","28262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","1600.27","23971",""
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","23971",""
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","1600.27","23971",""
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","23971","APC 277.30"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","23971","APC 296.56"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","23971","APC 308.91"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","23971","APC"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","23971","APC"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","23971","APC"
"Release of midfoot joint","28264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","23971","APC"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Release of foot contracture","28270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","14111",""
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Release of toe joint each","28272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Fusion of toes","28280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of hammertoe","28286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial removal of foot bone","28288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Corrj halux rigdus w/o implt","28289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Correction of bunion","28290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Corrj halux rigdus w/implt","28291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Correction of bunion","28293","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Correction of bunion","28294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","44324.22",""
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","44324.22",""
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Correction hallux valgus","28297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25051.33",""
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Correction hallux valgus","28298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","25051.33",""
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Correction hallux valgus","28299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","29398","APC 277.30"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","29398","APC 296.56"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","29398","APC 308.91"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","29398","APC"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","29398","APC"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","29398","APC"
"Incision of heel bone","28300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","29398","APC"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of ankle bone","28302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","29398","APC 277.30"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","29398","APC 296.56"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","29398","APC 308.91"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","29398","APC"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","29398","APC"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","29398","APC"
"Incision of midfoot bones","28304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","29398","APC"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Incise/graft midfoot bones","28305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","25051.33",""
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","25051.33",""
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","25051.33",""
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","25051.33",""
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of metatarsal","28308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Incision of metatarsals","28309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of big toe","28310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Revision of toe","28312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair deformity of toe","28313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Removal of sesamoid bone","28315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Repair of foot bones","28320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","25051.33",""
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","25051.33",""
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Repair of metatarsals","28322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe tissue","28340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Resect enlarged toe","28341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","14111",""
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair extra toe(s)","28344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","14111",""
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Repair webbed toe(s)","28345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Reconstruct cleft foot","28360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of heel fracture","28400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","4564",""
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","245.48","4564",""
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","4564",""
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","4564","APC 277.30"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","4564","APC 296.56"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","4564","APC 308.91"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of heel fracture","28405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","4564","APC"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treatment of heel fracture","28406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat heel fracture","28415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Treat/graft heel fracture","28420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of ankle fracture","28430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","5790",""
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of ankle fracture","28435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treatment of ankle fracture","28436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat ankle fracture","28445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Osteochondral talus autogrft","28446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat midfoot fracture each","28450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1600.27","5551.43",""
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","5551.43",""
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1600.27","5551.43",""
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5551.43","APC 277.30"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5551.43","APC 296.56"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5551.43","APC 308.91"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat midfoot fracture each","28455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5551.43","APC"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","25051.33",""
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","25051.33",""
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","25051.33",""
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","25051.33","APC 277.30"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","25051.33","APC 296.56"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","25051.33","APC 308.91"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","25051.33","APC"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","25051.33","APC"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","25051.33","APC"
"Treat midfoot fracture","28456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","25051.33","APC"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Treat midfoot fracture each","28465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metatarsal fracture","28476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Treat metatarsal fracture","28485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat big toe fracture","28505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treatment of toe fracture","28515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe fracture","28525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat sesamoid bone fracture","28530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat sesamoid bone fracture","28531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","14111",""
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1600.27","14111",""
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1600.27","14111",""
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1600.27","14111",""
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","14111","APC 277.30"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","14111","APC 296.56"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","14111","APC 308.91"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","14111","APC"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","14111","APC"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","14111","APC"
"Treat foot dislocation","28546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","14111","APC"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","4564","29398","APC 277.30"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","4564","29398","APC 296.56"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","4564","29398","APC 308.91"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","4564","29398","APC"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","4564","29398","APC"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","4564","29398","APC"
"Repair foot dislocation","28555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","4564","29398","APC"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3256.29","11296.24",""
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3256.29","11296.24",""
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3256.29","11296.24",""
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat foot dislocation","28575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Treat foot dislocation","28576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Repair foot dislocation","28585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","3408",""
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","245.48","3408",""
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","3408",""
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","3408","APC 277.30"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","3408","APC 296.56"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","3408","APC 308.91"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","3408","APC"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","3408","APC"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","3408","APC"
"Treat foot dislocation","28605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","3408","APC"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat foot dislocation","28606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Repair foot dislocation","28615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1600.27","5790",""
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1600.27","5790",""
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1600.27","5790",""
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","5790","APC 277.30"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","5790","APC 296.56"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","5790","APC 308.91"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","5790","APC"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","5790","APC"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","5790","APC"
"Treat toe dislocation","28635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","5790","APC"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair toe dislocation","28645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","3408",""
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","278.35","3408",""
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","3408",""
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","3408","APC 277.30"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","3408","APC 296.56"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","3408","APC 308.91"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","3408","APC"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","3408","APC"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","3408","APC"
"Treat toe dislocation","28665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","3408","APC"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Treat toe dislocation","28666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Repair of toe dislocation","28675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","60533.69",""
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","60533.69",""
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","60533.69",""
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","6448","60533.69","APC 277.30"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","6448","60533.69","APC 296.56"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","6448","60533.69","APC 308.91"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","6448","60533.69","APC"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","6448","60533.69","APC"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","6448","60533.69","APC"
"Fusion of foot bones","28705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","6448","60533.69","APC"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Fusion of foot bones","28735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","44324.22",""
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","44324.22",""
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","44324.22",""
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","7337","44324.22","APC 277.30"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","7337","44324.22","APC 296.56"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","7337","44324.22","APC 308.91"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","7337","44324.22","APC"
"Revision of foot bones","28737","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","7337","44324.22","APC"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Fusion of foot bones","28740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","25051.33",""
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","25051.33",""
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","25051.33",""
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","25051.33","APC 277.30"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","25051.33","APC 296.56"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","25051.33","APC 308.91"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of big toe joint","28755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","25051.33","APC"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Fusion of big toe joint","28760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation of midfoot","28800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","14111",""
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation thru metatarsal","28805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation toe & metatarsal","28810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Amputation of toe","28820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","14111",""
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","14111","APC 296.56"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","14111","APC 308.91"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","14111","APC"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","14111","APC"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","14111","APC"
"Partial amputation of toe","28825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","14111","APC"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","19040",""
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Hi enrgy eswt plantar fascia","28890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Foot/toes surgery procedure","28899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","3408",""
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","278.35","3408",""
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","3408",""
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","3408","APC 277.30"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","3408","APC 296.56"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","3408","APC 308.91"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","3408","APC"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","3408","APC"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","3408","APC"
"Application of body cast","29000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","3408","APC"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Application of body cast","29025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Application of body cast","29044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of body cast","29046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of figure eight","29049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of shoulder cast","29058","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of long arm cast","29065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of forearm cast","29075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Apply hand/wrist cast","29085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Apply finger cast","29086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Apply long arm splint","29105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Apply forearm splint","29126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Application of finger splint","29130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Application of finger splint","29131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of chest","29200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of shoulder","29240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of elbow or wrist","29260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of hand or finger","29280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip cast","29305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of hip casts","29325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Apply long leg cast brace","29358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Application of long leg cast","29365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","78.62","5220",""
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","78.62","5220",""
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","78.62","5220",""
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","78.62","","","","","","","fee schedule","78.62","5220",""
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","78.62","","","","","","","fee schedule","78.62","5220",""
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","78.62","","","","","","","fee schedule","78.62","5220",""
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","78.62","5220","APC 277.30"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","78.62","5220","APC 296.56"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","78.62","5220","APC 308.91"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","78.62","5220","APC"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","78.62","5220","APC"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","78.62","5220","APC"
"Apply short leg cast","29405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","78.62","5220","APC"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Apply short leg cast","29435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Addition of walker to cast","29440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Apply rigid leg cast","29445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Application of leg cast","29450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Application long leg splint","29505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Application lower leg splint","29515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of hip","29520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of knee","29530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of ankle and/or ft","29540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Strapping of toes","29550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Application of paste boot","29580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Apply multlay comprs lwr leg","29581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Apply multlay comprs upr leg","29582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Apply multlay comprs upr arm","29583","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Appl multlay comprs arm/hand","29584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Removal/revision of cast","29715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Repair of body cast","29720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Windowing of cast","29730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of cast","29740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","278.35","5220",""
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","278.35","5220",""
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","278.35","5220",""
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","866.8","","","","","","","fee schedule","278.35","5220","APC 277.30"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","927","","","","","","","fee schedule","278.35","5220","APC 296.56"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","965.61","","","","","","","fee schedule","278.35","5220","APC 308.91"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.85","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.08","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.35","","","","","","","fee schedule","278.35","5220","APC"
"Wedging of clubfoot cast","29750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.54","","","","","","","fee schedule","278.35","5220","APC"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","161.72","5220",""
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","161.72","5220",""
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","161.72","5220",""
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","503.61","","","","","","","fee schedule","161.72","5220","APC 277.30"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","538.59","","","","","","","fee schedule","161.72","5220","APC 296.56"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","561.02","","","","","","","fee schedule","161.72","5220","APC 308.91"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.08","","","","","","","fee schedule","161.72","5220","APC"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.31","","","","","","","fee schedule","161.72","5220","APC"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.72","","","","","","","fee schedule","161.72","5220","APC"
"Casting/strapping procedure","29799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.48","","","","","","","fee schedule","161.72","5220","APC"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Jaw arthroscopy/surgery","29804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy dx","29805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy/surgery","29822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Shoulder arthroscopy/surgery","29826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Shoulder arthroscopy/surgery","29826","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Shoulder arthroscopy/surgery","29826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7221.37","29398",""
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscop rotator cuff repr","29827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscopy biceps tenodesis","29828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy","29830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy/surgery","29835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Elbow arthroscopy/surgery","29836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Elbow arthroscopy/surgery","29838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy","29840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Wrist arthroscopy/surgery","29847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1600.27","19040",""
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Wrist endoscopy/surgery","29848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","19040",""
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Knee arthroscopy/surgery","29850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","1600.27","23971",""
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1600.27","23971",""
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","1600.27","23971",""
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","23971","APC 277.30"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","23971","APC 296.56"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","23971","APC 308.91"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","23971","APC"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","23971","APC"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","23971","APC"
"Knee arthroscopy/surgery","29851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","23971","APC"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Tibial arthroscopy/surgery","29855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","44324.22",""
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","44324.22",""
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","44324.22",""
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","6448","44324.22","APC 277.30"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","6448","44324.22","APC 296.56"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","6448","44324.22","APC 308.91"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","6448","44324.22","APC"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","6448","44324.22","APC"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","6448","44324.22","APC"
"Tibial arthroscopy/surgery","29856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","6448","44324.22","APC"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Hip arthroscopy dx","29860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6448","29398",""
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","29398",""
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6448","29398",""
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","6448","29398","APC 277.30"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","6448","29398","APC 296.56"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","6448","29398","APC 308.91"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","6448","29398","APC"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","6448","29398","APC"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","6448","29398","APC"
"Hip arthro w/fb removal","29861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","6448","29398","APC"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthr0 w/debridement","29862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","29398",""
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Hip arthr0 w/synovectomy","29863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Autgrft implnt knee w/scope","29866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Allgrft implnt knee w/scope","29867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Meniscal trnspl knee w/scpe","29868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy dx","29870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/drainage","29871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Knee arthroscopy/surgery","29881","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
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"Knee arthroscopy/surgery","29887","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25051.33",""
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"Knee arthroscopy/surgery","29887","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Knee arthroscopy/surgery","29887","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Knee arthroscopy/surgery","29887","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Knee arthroscopy/surgery","29888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
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"Knee arthroscopy/surgery","29888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
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"Knee arthroscopy/surgery","29889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
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"Knee arthroscopy/surgery","29889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
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"Knee arthroscopy/surgery","29889","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Knee arthroscopy/surgery","29889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Ankle arthroscopy/surgery","29891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
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"Ankle arthroscopy/surgery","29892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
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"Ankle arthroscopy/surgery","29892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Scope plantar fasciotomy","29893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3256.29","14111",""
"Scope plantar fasciotomy","29893","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","14111",""
"Scope plantar fasciotomy","29893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3256.29","14111",""
"Scope plantar fasciotomy","29893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","14111","APC 277.30"
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"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
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"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Ankle arthroscopy/surgery","29899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Mcp joint arthroscopy dx","29900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Mcp joint arthroscopy surg","29901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1600.27","19040",""
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1600.27","19040",""
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1600.27","19040",""
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4983.36","","","","","","","fee schedule","1600.27","19040","APC 277.30"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.48","","","","","","","fee schedule","1600.27","19040","APC 296.56"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5551.43","","","","","","","fee schedule","1600.27","19040","APC 308.91"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1643.42","","","","","","","fee schedule","1600.27","19040","APC"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1615.96","","","","","","","fee schedule","1600.27","19040","APC"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1600.27","","","","","","","fee schedule","1600.27","19040","APC"
"Mcp joint arthroscopy surg","29902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1647.34","","","","","","","fee schedule","1600.27","19040","APC"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","19040",""
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/fb rmvl","29904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","25051.33",""
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Subtalar arthro w/exc","29905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3256.29","19040",""
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/deb","29906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","12777.04","44324.22",""
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Subtalar arthro w/fusion","29907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/femoroplasty","29914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro acetabuloplasty","29915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Hip arthro w/labral repair","29916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","245.48","5220",""
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","245.48","5220",""
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","245.48","5220",""
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","764.45","","","","","","","fee schedule","245.48","5220","APC 277.30"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","817.55","","","","","","","fee schedule","245.48","5220","APC 296.56"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","851.59","","","","","","","fee schedule","245.48","5220","APC 308.91"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.1","","","","","","","fee schedule","245.48","5220","APC"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.89","","","","","","","fee schedule","245.48","5220","APC"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.48","","","","","","","fee schedule","245.48","5220","APC"
"Arthroscopy of joint","29999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.7","","","","","","","fee schedule","245.48","5220","APC"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of nose lesion","30000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Drainage of nose lesion","30020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Intranasal biopsy","30100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose polyp(s)","30110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of nose polyp(s)","30115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of intranasal lesion","30117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of intranasal lesion","30118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","14111",""
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Revision of nose","30120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose lesion","30124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Removal of nose lesion","30125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excise inferior turbinate","30130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Resect inferior turbinate","30140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Partial removal of nose","30150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of nose","30160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Injection treatment of nose","30200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Nasal sinus therapy","30210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Insert nasal septal button","30220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Remove nasal foreign body","30300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Remove nasal foreign body","30310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1544.13","5790",""
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Remove nasal foreign body","30320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of nose","30400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of nose","30420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Revision of nose","30430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of nose","30462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5891.41","23971",""
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair Nasal Stenosis","30465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/implt","30468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Rpr nsl vlv collapse w/rmdlg","30469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of nasal septum","30520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal defect","30545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","4564",""
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","536.74","4564",""
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","4564",""
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","4564","APC 277.30"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","4564","APC 296.56"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","4564","APC 308.91"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","4564","APC"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","4564","APC"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","4564","APC"
"Release of nasal adhesions","30560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","4564","APC"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair upper jaw fistula","30580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair mouth/nose fistula","30600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Intranasal reconstruction","30620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair nasal septum defect","30630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate superf","30801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Ablate inf turbinate submuc","30802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Control of nosebleed","30901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","3408",""
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","132.41","3408",""
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","3408",""
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","3408","APC 277.30"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","3408","APC 296.56"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","3408","APC 308.91"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","3408",""
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","132.41","3408",""
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","3408",""
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","3408","APC 277.30"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","3408","APC 296.56"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","3408","APC 308.91"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","3408","APC"
"Control of nosebleed","30905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","3408","APC"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Repeat control of nosebleed","30906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","19040",""
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation nasal sinus artery","30915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation upper jaw artery","30920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Ther fx nasal inf turbinate","30930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Nasal surgery procedure","30999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Irrigation maxillary sinus","31000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Irrigation sphenoid sinus","31002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration maxillary sinus","31020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Exploration maxillary sinus","31030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Explore sinus remove polyps","31032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Exploration behind upper jaw","31040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Exploration sphenoid sinus","31050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Sphenoid sinus surgery","31051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Exploration of frontal sinus","31070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of frontal sinus","31075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of frontal sinus","31087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Exploration of sinuses","31090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Removal of ethmoid sinus","31200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","7337",""
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1544.13","7337",""
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","7337",""
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","7337","APC 277.30"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","7337","APC 296.56"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","7337","APC 308.91"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","7337","APC"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","7337","APC"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","7337","APC"
"Removal of ethmoid sinus","31201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","7337","APC"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of ethmoid sinus","31205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of upper jaw","31225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of upper jaw","31225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of upper jaw","31225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of upper jaw","31230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of upper jaw","31230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of upper jaw","31230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","198.65","5220",""
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","198.65","5220",""
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","198.65","5220",""
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","618.61","","","","","","","fee schedule","198.65","5220","APC 277.30"
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","661.57","","","","","","","fee schedule","198.65","5220","APC 296.56"
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","689.12","","","","","","","fee schedule","198.65","5220","APC 308.91"
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204","","","","","","","fee schedule","198.65","5220","APC"
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.6","","","","","","","fee schedule","198.65","5220","APC"
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.65","","","","","","","fee schedule","198.65","5220","APC"
"Nasal endoscopy dx","31231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.49","","","","","","","fee schedule","198.65","5220","APC"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","4564",""
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","389.24","4564",""
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","4564",""
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","4564","APC 277.30"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","4564","APC 296.56"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","4564","APC 308.91"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","4564","APC"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","4564","APC"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","4564","APC"
"Nasal/sinus endoscopy dx","31233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","4564","APC"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy dx","31235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3710.44","14111",""
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Nasal/sinus endoscopy surg","31239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1771.35","14111",""
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","14111",""
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1771.35","14111",""
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","14111","APC 277.30"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","14111","APC 296.56"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","14111","APC 308.91"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","14111","APC"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","14111","APC"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","14111","APC"
"Nasal/sinus endoscopy surg","31240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","14111","APC"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1771.35","14111",""
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1771.35","14111",""
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1771.35","14111",""
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","14111","APC 277.30"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","14111","APC 296.56"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","14111","APC 308.91"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","14111","APC"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","14111","APC"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","14111","APC"
"Nsl/sins ndsc w/artery lig","31241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","14111","APC"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc rf abltj pnn","31242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sinus ndsc cryoabltj pnn","31243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc total","31253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","24365.15",""
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","24365.15",""
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Revision of ethmoid sinus","31254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7023.57","24365.15",""
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Removal of ethmoid sinus","31255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3710.44","14111",""
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Exploration maxillary sinus","31256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc tot w/sphendt","31257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc sphn tiss rmvl","31259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","24365.15",""
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","24365.15",""
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Endoscopy maxillary sinus","31267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Sinus endoscopy surgical","31276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Nasal/sinus endoscopy surg","31290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Nasal/sinus endoscopy surg","31290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Nasal/sinus endoscopy surg","31291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Nasal/sinus endoscopy surg","31291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Nasal/sinus endoscopy surg","31291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nasal/sinus endoscopy surg","31294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","7023.57","24365.15",""
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Sinus endo w/balloon dil","31297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Nsl/sins ndsc w/sins dilat","31298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Sinus surgery procedure","31299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3299.54","14111",""
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of larynx lesion","31300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Diagnostic incision larynx","31320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Removal of larynx","31360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of larynx","31360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of larynx","31360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of larynx","31365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of larynx","31365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of larynx","31365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31367","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31368","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31375","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of larynx","31382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of larynx & pharynx","31390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of larynx & pharynx","31390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of larynx & pharynx","31390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruct larynx & pharynx","31395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruct larynx & pharynx","31395","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruct larynx & pharynx","31395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Revision of larynx","31400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Removal of epiglottis","31420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Insert emergency airway","31500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Change of windpipe airway","31502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","198.65","5220",""
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","198.65","5220",""
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","198.65","5220",""
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","618.61","","","","","","","fee schedule","198.65","5220","APC 277.30"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","661.57","","","","","","","fee schedule","198.65","5220","APC 296.56"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","689.12","","","","","","","fee schedule","198.65","5220","APC 308.91"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204","","","","","","","fee schedule","198.65","5220","APC"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.6","","","","","","","fee schedule","198.65","5220","APC"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.65","","","","","","","fee schedule","198.65","5220","APC"
"Diagnostic laryngoscopy","31505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.49","","","","","","","fee schedule","198.65","5220","APC"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","12871.73","APC 277.30"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","12871.73","APC 296.56"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","12871.73","APC 308.91"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy with biopsy","31510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","12871.73","APC"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","198.65","4564",""
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","198.65","4564",""
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","198.65","4564",""
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","618.61","","","","","","","fee schedule","198.65","4564","APC 277.30"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","661.57","","","","","","","fee schedule","198.65","4564","APC 296.56"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","689.12","","","","","","","fee schedule","198.65","4564","APC 308.91"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204","","","","","","","fee schedule","198.65","4564","APC"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.6","","","","","","","fee schedule","198.65","4564","APC"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.65","","","","","","","fee schedule","198.65","4564","APC"
"Remove foreign body larynx","31511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.49","","","","","","","fee schedule","198.65","4564","APC"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","14111",""
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Removal of larynx lesion","31512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","4564",""
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","389.24","4564",""
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","4564",""
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","4564","APC 277.30"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","4564","APC 296.56"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","4564","APC 308.91"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","4564","APC"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","4564","APC"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","4564","APC"
"Injection into vocal cord","31513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","4564","APC"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","3408",""
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","389.24","3408",""
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","3408",""
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","3408","APC 277.30"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","3408","APC 296.56"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","3408","APC 308.91"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoscopy for aspiration","31515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","3408","APC"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","5220",""
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","389.24","5220",""
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","5220",""
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","5220","APC 277.30"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","5220","APC 296.56"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","5220","APC 308.91"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","5220","APC"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","5220","APC"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","5220","APC"
"Dx laryngoscopy newborn","31520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","5220","APC"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1771.35","6144.91",""
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy excl nb","31525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx laryngoscopy w/oper scope","31526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3408","14111","APC 277.30"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3408","14111","APC 296.56"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3408","14111","APC 308.91"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3408","14111","APC"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3408","14111","APC"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3408","14111","APC"
"Laryngoscopy for treatment","31527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3408","14111","APC"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy and dilation","31529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy w/fb removal","31530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","12871.73","APC 277.30"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","12871.73","APC 296.56"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","12871.73","APC 308.91"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy w/fb & op scope","31531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/biopsy","31535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/bx & op scope","31536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscopy w/exc of tumor","31540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3710.44","14111",""
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Larynscop w/tumr exc + scope","31541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3710.44","14111",""
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Remove vc lesion w/scope","31545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6448","24365.15",""
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","24365.15",""
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6448","24365.15",""
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","6448","24365.15","APC 277.30"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","6448","24365.15","APC 296.56"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","6448","24365.15","APC 308.91"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","6448","24365.15","APC"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","6448","24365.15","APC"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","6448","24365.15","APC"
"Remove vc lesion scope/graft","31546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","6448","24365.15","APC"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal sten","31554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7023.57","24365.15",""
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Laryngoscop w/arytenoidectom","31560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","7023.57","24365.15",""
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7023.57","24365.15",""
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","7023.57","24365.15",""
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Larynscop remve cart + scop","31561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3710.44","12871.73",""
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","12871.73","APC 277.30"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","12871.73","APC 296.56"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","12871.73","APC 308.91"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscope w/vc inj","31570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Laryngoscop w/vc inj + scope","31571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Largsc w/laser dstrj les","31572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/ther injection","31573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/njx augmentation","31574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","198.65","5220",""
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","198.65","5220",""
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","198.65","5220",""
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","618.61","","","","","","","fee schedule","198.65","5220","APC 277.30"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","661.57","","","","","","","fee schedule","198.65","5220","APC 296.56"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","689.12","","","","","","","fee schedule","198.65","5220","APC 308.91"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204","","","","","","","fee schedule","198.65","5220","APC"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.6","","","","","","","fee schedule","198.65","5220","APC"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.65","","","","","","","fee schedule","198.65","5220","APC"
"Diagnostic laryngoscopy","31575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.49","","","","","","","fee schedule","198.65","5220","APC"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Laryngoscopy with biopsy","31576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","4564",""
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","389.24","4564",""
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","4564",""
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","4564","APC 277.30"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","4564","APC 296.56"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","4564","APC 308.91"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","4564","APC"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","4564","APC"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","4564","APC"
"Largsc w/rmvl foreign bdy(s)","31577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","4564","APC"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3710.44","12871.73",""
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","12871.73",""
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3710.44","12871.73",""
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","12871.73","APC 277.30"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","12871.73","APC 296.56"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","12871.73","APC 308.91"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","12871.73","APC"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","12871.73","APC"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","12871.73","APC"
"Largsc w/removal lesion","31578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","12871.73","APC"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","3408",""
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","389.24","3408",""
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","3408",""
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","3408","APC 277.30"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","3408","APC 296.56"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","3408","APC 308.91"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoscopy telescopic","31579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","3408","APC"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty laryngeal web","31580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of larynx","31582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","20437.6",""
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","20437.6",""
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Laryngoplasty fx rdctj fixj","31584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Laryngoplasty cricoid split","31587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Revision of larynx","31588","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reinnervate larynx","31590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Laryngoplasty medialization","31591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Cricotracheal resection","31592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Larynx nerve surgery","31595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Larynx surgery procedure","31599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of windpipe","31600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of windpipe","31603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Incision of windpipe","31605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Incision of windpipe","31610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Surgery/speech prosthesis","31611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","14111",""
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Puncture/clear windpipe","31612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair windpipe opening","31613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Repair windpipe opening","31614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Visualization of windpipe","31615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/wash","31622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/brush","31623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dx bronchoscope/lavage","31624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/biopsy(s)","31625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Bronchoscopy w/markers","31626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Navigational bronchoscopy","31627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Navigational bronchoscopy","31627","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Navigational bronchoscopy","31627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3710.44","12871.73",""
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","12871.73",""
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3710.44","12871.73",""
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","12871.73","APC 277.30"
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","12871.73","APC 296.56"
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","12871.73","APC 308.91"
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","12871.73","APC"
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","12871.73","APC"
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","12871.73","APC"
"Bronchoscopy/lung bx each","31628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","12871.73","APC"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","19040","APC 277.30"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","19040","APC 296.56"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","19040","APC 308.91"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy/needle bx each","31629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","19040","APC 277.30"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","19040","APC 296.56"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","19040","APC 308.91"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy dilate/fx repr","31630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","4564","24365.15","APC 277.30"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","4564","24365.15","APC 296.56"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","4564","24365.15","APC 308.91"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy dilate w/stent","31631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy/lung bx addl","31632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Bronchoscopy/lung bx addl","31632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Bronchoscopy/lung bx addl","31632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Bronchoscopy/needle bx addl","31633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Bronchoscopy/needle bx addl","31633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Bronchoscopy/needle bx addl","31633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","24365.15",""
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","24365.15",""
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","24365.15",""
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","5220","24365.15","APC 277.30"
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","5220","24365.15","APC 296.56"
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","5220","24365.15","APC 308.91"
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","5220","24365.15","APC"
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","5220","24365.15","APC"
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","5220","24365.15","APC"
"Bronch w/balloon occlusion","31634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","5220","24365.15","APC"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy w/fb removal","31635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","4564","24365.15","APC 277.30"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","4564","24365.15","APC 296.56"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","4564","24365.15","APC 308.91"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy bronch stents","31636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy stent add-on","31637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Bronchoscopy stent add-on","31637","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Bronchoscopy stent add-on","31637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","24365.15",""
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","4564","24365.15","APC 277.30"
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","4564","24365.15","APC 296.56"
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","4564","24365.15","APC 308.91"
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy revise stent","31638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","4564","24365.15","APC"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","19040","APC 277.30"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","19040","APC 296.56"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","19040","APC 308.91"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy w/tumor excise","31640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3710.44","19040",""
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","19040","APC 277.30"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","19040","APC 296.56"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","19040","APC 308.91"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchoscopy treat blockage","31641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","19040","APC"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1771.35","6144.91",""
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Diag bronchoscope/catheter","31643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy clear airways","31645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","3408",""
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","389.24","3408",""
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","3408",""
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","3408","APC 277.30"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","3408","APC 296.56"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","3408","APC 308.91"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","3408","APC"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","3408","APC"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","3408","APC"
"Bronchoscopy reclear airway","31646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","3408","APC"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7023.57","24365.15",""
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronchial valve init insert","31647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3710.44","19040",""
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3710.44","19040",""
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3710.44","19040",""
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","19040","APC 277.30"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","19040","APC 296.56"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","19040","APC 308.91"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchial valve remov init","31648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","19040","APC"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchial valve remov addl","31649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Bronchial valve addl insert","31651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","10181",""
"Bronchial valve addl insert","31651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2375","10181",""
"Bronchial valve addl insert","31651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","10181",""
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3710.44","14111",""
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 1/2 node","31652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3710.44","14111",""
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3710.44","14111",""
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3710.44","14111",""
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11554.6","","","","","","","fee schedule","3710.44","14111","APC 277.30"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12357.13","","","","","","","fee schedule","3710.44","14111","APC 296.56"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12871.73","","","","","","","fee schedule","3710.44","14111","APC 308.91"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3810.48","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3746.82","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3710.44","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus samplng 3/> node","31653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3819.58","","","","","","","fee schedule","3710.44","14111","APC"
"Bronch ebus ivntj perph les","31654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bronch ebus ivntj perph les","31654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bronch ebus ivntj perph les","31654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7023.57","24365.15",""
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 1 lobe","31660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7023.57","24365.15",""
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7023.57","24365.15",""
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7023.57","24365.15",""
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21871.92","","","","","","","fee schedule","7023.57","24365.15","APC 277.30"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23391.05","","","","","","","fee schedule","7023.57","24365.15","APC 296.56"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24365.15","","","","","","","fee schedule","7023.57","24365.15","APC 308.91"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.93","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7092.43","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7023.57","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronch thermoplsty 2/> lobes","31661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7230.15","","","","","","","fee schedule","7023.57","24365.15","APC"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","389.24","3408",""
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","389.24","3408",""
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","389.24","3408",""
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1212.12","","","","","","","fee schedule","389.24","3408","APC 277.30"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1296.31","","","","","","","fee schedule","389.24","3408","APC 296.56"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.3","","","","","","","fee schedule","389.24","3408","APC 308.91"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.73","","","","","","","fee schedule","389.24","3408","APC"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.06","","","","","","","fee schedule","389.24","3408","APC"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.24","","","","","","","fee schedule","389.24","3408","APC"
"Bronchial brush biopsy","31717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.69","","","","","","","fee schedule","389.24","3408","APC"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","217.93","3408",""
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","217.93","3408",""
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","217.93","3408",""
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","3408","APC 277.30"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","3408","APC 296.56"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","3408","APC 308.91"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","3408","APC"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","3408","APC"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","3408","APC"
"Clearance of airways","31720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","3408","APC"
"Clearance of airways","31725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Clearance of airways","31725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Clearance of airways","31725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1771.35","6144.91",""
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1771.35","6144.91",""
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1771.35","6144.91",""
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Intro windpipe wire/tube","31730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair of windpipe","31750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Repair of windpipe","31755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Repair of windpipe","31760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe","31760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe","31760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruction of windpipe","31766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruction of windpipe","31766","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruction of windpipe","31766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair/graft of bronchus","31770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair/graft of bronchus","31770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair/graft of bronchus","31770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruct bronchus","31775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruct bronchus","31775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruct bronchus","31775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruct windpipe","31780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruct windpipe","31780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruct windpipe","31780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruct windpipe","31781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruct windpipe","31781","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruct windpipe","31781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","20437.6",""
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove windpipe lesion","31785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove windpipe lesion","31786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove windpipe lesion","31786","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove windpipe lesion","31786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe injury","31800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe injury","31800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe injury","31800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe injury","31805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe injury","31805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of windpipe injury","31805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","14111",""
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Closure of windpipe lesion","31820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of windpipe defect","31825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Revise windpipe scar","31830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","198.65","5220",""
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","198.65","5220",""
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","198.65","5220",""
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","618.61","","","","","","","fee schedule","198.65","5220","APC 277.30"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","661.57","","","","","","","fee schedule","198.65","5220","APC 296.56"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","689.12","","","","","","","fee schedule","198.65","5220","APC 308.91"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204","","","","","","","fee schedule","198.65","5220","APC"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.6","","","","","","","fee schedule","198.65","5220","APC"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.65","","","","","","","fee schedule","198.65","5220","APC"
"Airways surgical procedure","31899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.49","","","","","","","fee schedule","198.65","5220","APC"
"Thoracostomy w/rib resection","32035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracostomy w/rib resection","32035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracostomy w/rib resection","32035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracostomy w/flap drainage","32036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracostomy w/flap drainage","32036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracostomy w/flap drainage","32036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open wedge/bx lung infiltr","32096","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open wedge/bx lung infiltr","32096","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open wedge/bx lung infiltr","32096","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open wedge/bx lung nodule","32097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open wedge/bx lung nodule","32097","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open wedge/bx lung nodule","32097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open biopsy of lung pleura","32098","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open biopsy of lung pleura","32098","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open biopsy of lung pleura","32098","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","32100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","32100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","32100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore/repair chest","32110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore/repair chest","32110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore/repair chest","32110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Re-exploration of chest","32120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Re-exploration of chest","32120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Re-exploration of chest","32120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore chest free adhesions","32124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore chest free adhesions","32124","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore chest free adhesions","32124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion(s)","32140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion(s)","32140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion(s)","32140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove/treat lung lesions","32141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove/treat lung lesions","32141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove/treat lung lesions","32141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion(s)","32150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion(s)","32150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion(s)","32150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove lung foreign body","32151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove lung foreign body","32151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove lung foreign body","32151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open chest heart massage","32160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open chest heart massage","32160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open chest heart massage","32160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain open lung lesion","32200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drain open lung lesion","32200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drain open lung lesion","32200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain, percut, lung lesion","32201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Treat chest lining","32215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat chest lining","32215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat chest lining","32215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release of lung","32220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release of lung","32220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release of lung","32220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial release of lung","32225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial release of lung","32225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial release of lung","32225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of chest lining","32310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of chest lining","32310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of chest lining","32310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Free/remove chest lining","32320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Free/remove chest lining","32320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Free/remove chest lining","32320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy chest lining","32400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Percut bx lung/mediastinum","32405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Core ndl bx lng/med perq","32408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Remove lung pneumonectomy","32440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove lung pneumonectomy","32440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove lung pneumonectomy","32440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Sleeve pneumonectomy","32442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Sleeve pneumonectomy","32442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Sleeve pneumonectomy","32442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of lung extrapleural","32445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of lung extrapleural","32445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of lung extrapleural","32445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of lung","32480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of lung","32480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of lung","32480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bilobectomy","32482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bilobectomy","32482","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bilobectomy","32482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Segmentectomy","32484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Segmentectomy","32484","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Segmentectomy","32484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Sleeve lobectomy","32486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Sleeve lobectomy","32486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Sleeve lobectomy","32486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Completion pneumonectomy","32488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Completion pneumonectomy","32488","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Completion pneumonectomy","32488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lung volume reduction","32491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lung volume reduction","32491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lung volume reduction","32491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bronchus add-on","32501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bronchus add-on","32501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bronchus add-on","32501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect apical lung tumor","32503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect apical lung tumor","32503","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect apical lung tumor","32503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect apical lung tum/chest","32504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect apical lung tum/chest","32504","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect apical lung tum/chest","32504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung initial","32505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung initial","32505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung initial","32505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung add-on","32506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung add-on","32506","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung add-on","32506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung diag","32507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung diag","32507","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Wedge resect of lung diag","32507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion","32540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion","32540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of lung lesion","32540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3563.21","19040",""
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Insert pleural cath","32550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insertion of chest tube","32551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Remove lung catheter","32552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1377.48","7337",""
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1377.48","7337",""
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1377.48","7337",""
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4289.59","","","","","","","fee schedule","1377.48","7337","APC 277.30"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4587.52","","","","","","","fee schedule","1377.48","7337","APC 296.56"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4778.57","","","","","","","fee schedule","1377.48","7337","APC 308.91"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.62","","","","","","","fee schedule","1377.48","7337","APC"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.99","","","","","","","fee schedule","1377.48","7337","APC"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.48","","","","","","","fee schedule","1377.48","7337","APC"
"Ins mark thor for rt perq","32553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1418","","","","","","","fee schedule","1377.48","7337","APC"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/o imaging","32554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Aspirate pleura w/ imaging","32555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insert cath pleura w/o image","32556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert cath pleura w/ image","32557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Treat pleurodesis w/agent","32560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin init day","32561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Lyse chest fibrin subq day","32562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy diagnostic","32601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","36698.4",""
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","36698.4",""
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Thoracoscopy wbx sac","32604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy w/bx med space","32606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","10578.79","36698.4",""
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","10578.79","36698.4",""
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx infiltrate","32607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","10578.79","36698.4",""
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","10578.79","36698.4",""
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx nodule","32608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","23971",""
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Thoracoscopy w/bx pleura","32609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Thoracoscopy w/pleurodesis","32650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy w/pleurodesis","32650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy w/pleurodesis","32650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy remove cortex","32651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy remove cortex","32651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy remove cortex","32651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy rem totl cortex","32652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy rem totl cortex","32652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy rem totl cortex","32652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy remov fb/fibrin","32653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Thoracoscopy remov fb/fibrin","32653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Thoracoscopy remov fb/fibrin","32653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Thoracoscopy contrl bleeding","32654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy contrl bleeding","32654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy contrl bleeding","32654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy resect bullae","32655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy resect bullae","32655","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy resect bullae","32655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy w/pleurectomy","32656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy w/pleurectomy","32656","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy w/pleurectomy","32656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Thoracoscopy w/sac fb remove","32658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/sac fb remove","32658","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/sac fb remove","32658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/sac drainage","32659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/sac drainage","32659","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/sac drainage","32659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/pericard exc","32661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/pericard exc","32661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/pericard exc","32661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/mediast exc","32662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/mediast exc","32662","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/mediast exc","32662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/lobectomy","32663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/lobectomy","32663","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/lobectomy","32663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/ th nrv exc","32664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Thoracoscopy w/ th nrv exc","32664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Thoracoscopy w/ th nrv exc","32664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Thoracoscop w/esoph musc exc","32665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscop w/esoph musc exc","32665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscop w/esoph musc exc","32665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/wedge resect","32666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/wedge resect","32666","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/wedge resect","32666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/w resect addl","32667","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/w resect addl","32667","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/w resect addl","32667","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/w resect diag","32668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/w resect diag","32668","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/w resect diag","32668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy remove segment","32669","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy remove segment","32669","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy remove segment","32669","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy bilobectomy","32670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy bilobectomy","32670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy bilobectomy","32670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy pneumonectomy","32671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy pneumonectomy","32671","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy pneumonectomy","32671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy for lvrs","32672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy for lvrs","32672","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy for lvrs","32672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/thymus resect","32673","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/thymus resect","32673","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy w/thymus resect","32673","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy lymph node exc","32674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy lymph node exc","32674","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoscopy lymph node exc","32674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thorax stereo rad targetw/tx","32701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair lung hernia","32800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair lung hernia","32800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair lung hernia","32800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Close chest after drainage","32810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Close chest after drainage","32810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Close chest after drainage","32810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Close bronchial fistula","32815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Close bronchial fistula","32815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Close bronchial fistula","32815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruct injured chest","32820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruct injured chest","32820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruct injured chest","32820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Donor pneumonectomy","32850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Donor pneumonectomy","32850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Donor pneumonectomy","32850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lung transplant single","32851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lung transplant single","32851","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lung transplant single","32851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lung transplant with bypass","32852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lung transplant with bypass","32852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lung transplant with bypass","32852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lung transplant double","32853","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lung transplant double","32853","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lung transplant double","32853","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lung transplant with bypass","32854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lung transplant with bypass","32854","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lung transplant with bypass","32854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prepare donor lung single","32855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prepare donor lung single","32855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prepare donor lung single","32855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prepare donor lung double","32856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prepare donor lung double","32856","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prepare donor lung double","32856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of rib(s)","32900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of rib(s)","32900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of rib(s)","32900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise & repair chest wall","32905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise & repair chest wall","32905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise & repair chest wall","32905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise & repair chest wall","32906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise & repair chest wall","32906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise & repair chest wall","32906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of lung","32940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of lung","32940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of lung","32940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Therapeutic pneumothorax","32960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Ablate pulm tumor perq crybl","32994","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Total lung lavage","32997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Total lung lavage","32997","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Total lung lavage","32997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","29398",""
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Perq rf ablate tx pul tumor","32998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Chest surgery procedure","32999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Drainage of heart sac","33010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Repeat drainage of heart sac","33011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1566.6","5434.61",""
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Pericardiocentesis w/imaging","33016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Prcrd drg 6yr+ w/o cgen car","33017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prcrd drg 6yr+ w/o cgen car","33017","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prcrd drg 6yr+ w/o cgen car","33017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prcrd drg 0-5yr or w/anomly","33018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prcrd drg 0-5yr or w/anomly","33018","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prcrd drg 0-5yr or w/anomly","33018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Perq prcrd drg insj cath ct","33019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Perq prcrd drg insj cath ct","33019","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Perq prcrd drg insj cath ct","33019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of heart sac","33020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of heart sac","33020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of heart sac","33020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of heart sac","33025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of heart sac","33025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of heart sac","33025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of heart sac","33030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of heart sac","33030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of heart sac","33030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of heart sac","33031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of heart sac","33031","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of heart sac","33031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect heart sac lesion","33050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect heart sac lesion","33050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect heart sac lesion","33050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Heart revascularize (tmr)","33140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Heart revascularize (tmr)","33140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Heart revascularize (tmr)","33140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Heart Tmr W/Other Procedure","33141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Heart Tmr W/Other Procedure","33141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Heart Tmr W/Other Procedure","33141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert epicard eltrd open","33202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert epicard eltrd open","33202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert epicard eltrd open","33202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert epicard eltrd endo","33203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert epicard eltrd endo","33203","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert epicard eltrd endo","33203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm atrial","33206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Insert heart pm ventricular","33207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Insrt heart pm atrial & vent","33208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","29398","APC"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","29398","APC"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","29398","APC"
"Insert electrd/pm cath sngl","33210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","29398","APC"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","29398","APC"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","29398","APC"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","29398","APC"
"Insert card electrodes dual","33211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","29398","APC"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","45084","APC 277.30"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","45084","APC 296.56"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","45084","APC 308.91"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen sngl lead","33212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Insert pulse gen dual leads","33213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Upgrade of pacemaker system","33214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Reposition pacing-defib lead","33215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","29398","APC"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","29398","APC"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","29398","APC"
"Insert 1 electrode pm-defib","33216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","29398","APC"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","29398","APC"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","29398","APC"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","29398","APC"
"Insert 2 electrode pm-defib","33217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","29398","APC"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib one","33218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Repair lead pace-defib dual","33220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","66499",""
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","66499",""
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","66499",""
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","5220","66499","APC 277.30"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","5220","66499","APC 296.56"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","5220","66499","APC 308.91"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","5220","66499","APC"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","5220","66499","APC"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","5220","66499","APC"
"Insert pulse gen mult leads","33221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","5220","66499","APC"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocation pocket pacemaker","33222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2053.37","7123.26",""
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Relocate pocket for defib","33223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Insert pacing lead & connect","33224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"L ventric pacing lead add-on","33225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"L ventric pacing lead add-on","33225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"L ventric pacing lead add-on","33225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Reposition l ventric lead","33226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","45084","APC 277.30"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","45084","APC 296.56"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","45084","APC 308.91"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","45084","APC"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","45084","APC"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","45084","APC"
"Remove&replace pm gen singl","33227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","45084","APC"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","45084",""
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45084",""
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","45084",""
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32392","","","","","","","fee schedule","5220","45084","APC 277.30"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34641.8","","","","","","","fee schedule","5220","45084","APC 296.56"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36084.43","","","","","","","fee schedule","5220","45084","APC 308.91"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10682.25","","","","","","","fee schedule","5220","45084","APC"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10503.79","","","","","","","fee schedule","5220","45084","APC"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10401.81","","","","","","","fee schedule","5220","45084","APC"
"Remv&replc pm gen dual lead","33228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10707.75","","","","","","","fee schedule","5220","45084","APC"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45084","","","","","","","fee schedule","5220","66499",""
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","66499",""
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41044","","","","","","","fee schedule","5220","66499",""
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","5220","66499","APC 277.30"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","5220","66499","APC 296.56"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","5220","66499","APC 308.91"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","5220","66499","APC"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","5220","66499","APC"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","5220","66499","APC"
"Remv&replc pm gen mult leads","33229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","5220","66499","APC"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","5220","138244","APC 277.30"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","5220","138244","APC 296.56"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","5220","138244","APC 308.91"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/dual leads","33230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","5220","138244","APC 277.30"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","5220","138244","APC 296.56"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","5220","138244","APC 308.91"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/mult leads","33231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","5220","138244","APC"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","28569.93",""
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","28569.93",""
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","28569.93",""
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","4564","28569.93","APC 277.30"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","4564","28569.93","APC 296.56"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","4564","28569.93","APC 308.91"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","4564","28569.93","APC"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","4564","28569.93","APC"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","4564","28569.93","APC"
"Removal of pm generator","33233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","4564","28569.93","APC"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Removal of pacemaker system","33234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Removal pacemaker electrode","33235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Remove electrode/thoracotomy","33236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33237","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove electrode/thoracotomy","33238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","5220","138244","APC 277.30"
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","5220","138244","APC 296.56"
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","5220","138244","APC 308.91"
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","5220","138244","APC"
"Insrt pulse gen w/singl lead","33240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","5220","138244","APC"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Remove pulse generator","33241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Remove eltrd/thoracotomy","33243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Remove eltrd/thoracotomy","33243","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Remove eltrd/thoracotomy","33243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Remove elctrd transvenously","33244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","5220","138244","APC 277.30"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","5220","138244","APC 296.56"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","5220","138244","APC 308.91"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","5220","138244","APC"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","5220","138244","APC"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","5220","138244","APC"
"Insj/rplcmt defib w/lead(s)","33249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","5220","138244","APC"
"Ablate heart dysrhythm focus","33250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd","33254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd","33254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd","33254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/o bypass ext","33255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/o bypass ext","33255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/o bypass ext","33255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/bypass exten","33256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/bypass exten","33256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/bypass exten","33256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd add-on","33257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd add-on","33257","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd add-on","33257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria x10sv add-on","33258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria x10sv add-on","33258","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria x10sv add-on","33258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/bypass add-on","33259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/bypass add-on","33259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria w/bypass add-on","33259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate heart dysrhythm focus","33261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","5220","138244","APC 277.30"
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","5220","138244","APC 296.56"
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","5220","138244","APC 308.91"
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","5220","138244","APC"
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","5220","138244","APC"
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","5220","138244","APC"
"Rmvl& replc pulse gen 1 lead","33262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68935.54","","","","","","","fee schedule","5220","138244","APC 277.30"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73723.49","","","","","","","fee schedule","5220","138244","APC 296.56"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76793.64","","","","","","","fee schedule","5220","138244","APC 308.91"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22733.6","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22353.8","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22136.77","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen 2 lead","33263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22787.85","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","5220","138244","APC 277.30"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","5220","138244","APC 296.56"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","5220","138244","APC 308.91"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","5220","138244","APC"
"Rmvl & rplcmt dfb gen mlt ld","33264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","5220","138244","APC"
"Ablate atria lmtd endo","33265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd endo","33265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria lmtd endo","33265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ablate atria x10sv endo","33266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ablate atria x10sv endo","33266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ablate atria x10sv endo","33266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excl laa open any method","33267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Excl laa open any method","33267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Excl laa opn oth px any meth","33268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Excl laa opn oth px any meth","33268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Excl laa thrscp any method","33269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Excl laa thrscp any method","33269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97277.9","","","","","","","fee schedule","5220","138244","APC 277.30"
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104034.38","","","","","","","fee schedule","5220","138244","APC 296.56"
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108366.8","","","","","","","fee schedule","5220","138244","APC 308.91"
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32080.35","","","","","","","fee schedule","5220","138244","APC"
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31544.41","","","","","","","fee schedule","5220","138244","APC"
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31238.15","","","","","","","fee schedule","5220","138244","APC"
"Ins/rep subq defibrillator","33270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32156.92","","","","","","","fee schedule","5220","138244","APC"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","5220","138244",""
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","138244",""
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","5220","138244",""
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","138244","APC 277.30"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","138244","APC 296.56"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","138244","APC 308.91"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","138244","APC"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","138244","APC"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","138244","APC"
"Insj subq impltbl dfb elctrd","33271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","138244","APC"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138244","","","","","","","fee schedule","3719.02","138244",""
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","138244",""
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","125655","","","","","","","fee schedule","3719.02","138244",""
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","138244","APC 277.30"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","138244","APC 296.56"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","138244","APC 308.91"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","138244","APC"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","138244","APC"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","138244","APC"
"Rmvl of subq defibrillator","33272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","138244","APC"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3719.02","19040",""
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Repos prev impltbl subq dfb","33273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","5220","66499",""
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","66499",""
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","5220","66499",""
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59694.32","","","","","","","fee schedule","5220","66499","APC 277.30"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63840.42","","","","","","","fee schedule","5220","66499","APC 296.56"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66499","","","","","","","fee schedule","5220","66499","APC 308.91"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19686.02","","","","","","","fee schedule","5220","66499","APC"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19357.14","","","","","","","fee schedule","5220","66499","APC"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19169.21","","","","","","","fee schedule","5220","66499","APC"
"Tcat insj/rpl perm ldls pm","33274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19733.01","","","","","","","fee schedule","5220","66499","APC"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Tcat rmvl perm ldls pm","33275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","43834.99","152065.9",""
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","43834.99","152065.9",""
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","136505.37","","","","","","","fee schedule","43834.99","152065.9","APC 277.30"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","145986.42","","","","","","","fee schedule","43834.99","152065.9","APC 296.56"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","152065.9","","","","","","","fee schedule","43834.99","152065.9","APC 308.91"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45016.81","","","","","","","fee schedule","43834.99","152065.9","APC"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44264.74","","","","","","","fee schedule","43834.99","152065.9","APC"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43834.99","","","","","","","fee schedule","43834.99","152065.9","APC"
"Insj phrnc nrv stim sys","33276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45124.25","","","","","","","fee schedule","43834.99","152065.9","APC"
"Insj phrnc nrv stim transvns","33277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Insj phrnc nrv stim transvns","33277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim sys","33278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim transvns","33279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Rmvl phrnc nrv stim pg only","33280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Reposg phrnc nrv stim trnsvn","33281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Remove pat-active ht record","33284","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25646.44","","","","","","","fee schedule","5220","35289","APC 277.30"
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27427.72","","","","","","","fee schedule","5220","35289","APC 296.56"
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28569.93","","","","","","","fee schedule","5220","35289","APC 308.91"
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8457.69","","","","","","","fee schedule","5220","35289","APC"
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8316.4","","","","","","","fee schedule","5220","35289","APC"
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8235.66","","","","","","","fee schedule","5220","35289","APC"
"Insj subq car rhythm mntr","33285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8477.88","","","","","","","fee schedule","5220","35289","APC"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Rmvl subq car rhythm mntr","33286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","30709.54","106533.01",""
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","30709.54","106533.01",""
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","30709.54","106533.01","APC 277.30"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","30709.54","106533.01","APC 296.56"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","30709.54","106533.01","APC 308.91"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rmv&rplcmt phrnc nrv stim pg","33287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Rmv&rplcmt phrnc nrv stim ld","33288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","5220","99026.31",""
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","99026.31",""
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","5220","99026.31",""
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","88893.19","","","","","","","fee schedule","5220","99026.31","APC 277.30"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95067.31","","","","","","","fee schedule","5220","99026.31","APC 296.56"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99026.31","","","","","","","fee schedule","5220","99026.31","APC 308.91"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29315.24","","","","","","","fee schedule","5220","99026.31","APC"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28825.49","","","","","","","fee schedule","5220","99026.31","APC"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28545.63","","","","","","","fee schedule","5220","99026.31","APC"
"Tcat impl wrls p-art prs snr","33289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29385.21","","","","","","","fee schedule","5220","99026.31","APC"
"Repair of heart wound","33300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart wound","33300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart wound","33300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart wound","33305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart wound","33305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart wound","33305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploratory heart surgery","33310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploratory heart surgery","33310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploratory heart surgery","33310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploratory heart surgery","33315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploratory heart surgery","33315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploratory heart surgery","33315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair major blood vessel(s)","33320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair major blood vessel(s)","33320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair major blood vessel(s)","33320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair major vessel","33321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair major vessel","33321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair major vessel","33321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair major blood vessel(s)","33322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair major blood vessel(s)","33322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair major blood vessel(s)","33322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert major vessel graft","33330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert major vessel graft","33330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert major vessel graft","33330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert major vessel graft","33335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert major vessel graft","33335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert major vessel graft","33335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Perq clsr tcat l atr apndge","33340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","21639","23971",""
"Perq clsr tcat l atr apndge","33340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","21639","23971",""
"Replace aortic valve perq","33361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve perq","33361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve perq","33361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33363","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33364","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve open","33365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Trcath replace aortic valve","33366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Trcath replace aortic valve","33366","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Trcath replace aortic valve","33366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33367","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33368","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33369","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace aortic valve w/byp","33369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tcat plmt&rmvl cepd perq","33370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Tcat plmt&rmvl cepd perq","33370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Valvuloplasty aortic valve","33390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Valvuloplasty aortic valve","33390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Valvuloplasty aortic valve","33391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Valvuloplasty aortic valve","33391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Prepare heart-aorta conduit","33404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prepare heart-aorta conduit","33404","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prepare heart-aorta conduit","33404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement aortic valve opn","33410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33411","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33413","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement of aortic valve","33413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of aortic valve","33414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of aortic valve","33414","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of aortic valve","33414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision subvalvular tissue","33415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision subvalvular tissue","33415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision subvalvular tissue","33415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise ventricle muscle","33416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise ventricle muscle","33416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise ventricle muscle","33416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of aortic valve","33417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of aortic valve","33417","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of aortic valve","33417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair tcat mitral valve","33418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair tcat mitral valve","33418","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair tcat mitral valve","33418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair tcat mitral valve","33419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Repair tcat mitral valve","33419","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Repair tcat mitral valve","33419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Revision of mitral valve","33420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of mitral valve","33420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of mitral valve","33420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of mitral valve","33422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of mitral valve","33422","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of mitral valve","33422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33427","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of mitral valve","33427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement of mitral valve","33430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement of mitral valve","33430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement of mitral valve","33430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rplcmt a-valve tlcj autol pv","33440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rplcmt a-valve tlcj autol pv","33440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rplcmt a-valve tlcj autol pv","33440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of tricuspid valve","33460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of tricuspid valve","33460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of tricuspid valve","33460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Valvuloplasty tricuspid","33463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Valvuloplasty tricuspid","33463","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Valvuloplasty tricuspid","33463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Valvuloplasty tricuspid","33464","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Valvuloplasty tricuspid","33464","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Valvuloplasty tricuspid","33464","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace tricuspid valve","33465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace tricuspid valve","33465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace tricuspid valve","33465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of tricuspid valve","33468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of tricuspid valve","33468","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of tricuspid valve","33468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of pulmonary valve","33470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Valvotomy pulmonary valve","33471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Revision of pulmonary valve","33474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of pulmonary valve","33474","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of pulmonary valve","33474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replacement pulmonary valve","33475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replacement pulmonary valve","33475","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replacement pulmonary valve","33475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of heart chamber","33476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of heart chamber","33476","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of heart chamber","33476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant tcat pulm vlv perq","33477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant tcat pulm vlv perq","33477","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant tcat pulm vlv perq","33477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of heart chamber","33478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of heart chamber","33478","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of heart chamber","33478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair prosth valve clot","33496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair prosth valve clot","33496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair prosth valve clot","33496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart vessel fistula","33500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart vessel fistula","33500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart vessel fistula","33500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart vessel fistula","33501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart vessel fistula","33501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart vessel fistula","33501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Coronary artery correction","33502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Coronary artery correction","33502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Coronary artery correction","33502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Coronary artery graft","33503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Coronary artery graft","33503","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Coronary artery graft","33503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Coronary artery graft","33504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Coronary artery graft","33504","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Coronary artery graft","33504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery w/tunnel","33505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery w/tunnel","33505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery w/tunnel","33505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery translocation","33506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery translocation","33506","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery translocation","33506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair art intramural","33507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair art intramural","33507","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair art intramural","33507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endoscopic vein harvest","33508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Endoscopic vein harvest","33508","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Endoscopic vein harvest","33508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ndsc hrv uxtr art 1 sgm cab","33509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ndsc hrv uxtr art 1 sgm cab","33509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cabg vein single","33510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg vein single","33510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg vein single","33510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg vein two","33511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg vein two","33511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg vein two","33511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg vein three","33512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg vein three","33512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg vein three","33512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg vein four","33513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg vein four","33513","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg vein four","33513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg vein five","33514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg vein five","33514","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg vein five","33514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg vein six or more","33516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg vein six or more","33516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg vein six or more","33516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein single","33517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein single","33517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein single","33517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein two","33518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein two","33518","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein two","33518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein three","33519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein three","33519","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein three","33519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein four","33521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein four","33521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein four","33521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein five","33522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein five","33522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg artery-vein five","33522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg art-vein six or more","33523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg art-vein six or more","33523","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg art-vein six or more","33523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Coronary artery bypass/reop","33530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Coronary artery bypass/reop","33530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Coronary artery bypass/reop","33530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg arterial single","33533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg arterial single","33533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg arterial single","33533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg arterial two","33534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg arterial two","33534","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg arterial two","33534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg arterial three","33535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg arterial three","33535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg arterial three","33535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cabg arterial four or more","33536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cabg arterial four or more","33536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cabg arterial four or more","33536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of heart lesion","33542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart damage","33545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart damage","33545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart damage","33545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Restore/remodel ventricle","33548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Restore/remodel ventricle","33548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Restore/remodel ventricle","33548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open coronary endarterectomy","33572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open coronary endarterectomy","33572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open coronary endarterectomy","33572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Closure of valve","33600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Closure of valve","33600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Closure of valve","33600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Closure of valve","33602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Closure of valve","33602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Closure of valve","33602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Anastomosis/artery-aorta","33606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Anastomosis/artery-aorta","33606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Anastomosis/artery-aorta","33606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair anomaly w/conduit","33608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair anomaly w/conduit","33608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair anomaly w/conduit","33608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair by enlargement","33610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair by enlargement","33610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair by enlargement","33610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair double ventricle","33611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair double ventricle","33611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair double ventricle","33611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair double ventricle","33612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair double ventricle","33612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair double ventricle","33612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair modified fontan","33615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair modified fontan","33615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair modified fontan","33615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair single ventricle","33617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair single ventricle","33617","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair single ventricle","33617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair single ventricle","33619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair single ventricle","33619","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair single ventricle","33619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Apply r&l pulm art bands","33620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Apply r&l pulm art bands","33620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Apply r&l pulm art bands","33620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transthor cath for stent","33621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transthor cath for stent","33621","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transthor cath for stent","33621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Redo compl cardiac anomaly","33622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Redo compl cardiac anomaly","33622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Redo compl cardiac anomaly","33622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of heart veins","33645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of heart veins","33645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of heart veins","33645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defects","33647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defects","33647","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defects","33647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart chambers","33670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart chambers","33670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart chambers","33670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Close Mult Vsd","33675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Close Mult Vsd","33675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Close Mult Vsd","33675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Close mult vsd w/resection","33676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Close mult vsd w/resection","33676","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Close mult vsd w/resection","33676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cl mult vsd w/rem pul band","33677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cl mult vsd w/rem pul band","33677","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cl mult vsd w/rem pul band","33677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33681","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33684","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33688","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart septum defect","33688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reinforce pulmonary artery","33690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reinforce pulmonary artery","33690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reinforce pulmonary artery","33690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33692","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33694","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33697","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defects","33710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defect","33720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of heart defect","33720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of heart defect","33720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of heart defect","33722","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair Venous Anomaly","33724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair Venous Anomaly","33724","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair Venous Anomaly","33724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair Pul Venous Stenosis","33726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair Pul Venous Stenosis","33726","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair Pul Venous Stenosis","33726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart-vein defect(s)","33730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair heart-vein defect(s)","33730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair heart-vein defect(s)","33730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair heart-vein defect","33732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Thoracic aortic graft","33875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracoabdominal graft","33877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracoabdominal graft","33877","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracoabdominal graft","33877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc taa repr incl subcl","33880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc taa repr incl subcl","33880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc taa repr incl subcl","33880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc taa repr w/o subcl","33881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc taa repr w/o subcl","33881","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc taa repr w/o subcl","33881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert endovasc prosth taa","33883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert endovasc prosth taa","33883","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert endovasc prosth taa","33883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc prosth taa add-on","33884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc prosth taa add-on","33884","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc prosth taa add-on","33884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc prosth delayed","33886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc prosth delayed","33886","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc prosth delayed","33886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Artery transpose/endovas taa","33889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Artery transpose/endovas taa","33889","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Artery transpose/endovas taa","33889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Car-car bp grft/endovas taa","33891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Car-car bp grft/endovas taa","33891","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Car-car bp grft/endovas taa","33891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc st rpr thrc/aa acrs br","33894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Evasc st rpr thrc/aa acrs br","33894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Evasc st rpr thrc/aa x crsg","33895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Evasc st rpr thrc/aa x crsg","33895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq trluml angp nt/recr coa","33897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq trluml angp nt/recr coa","33897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt uni","33900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 nm nt bi","33901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq p-art revsc 1 abnor uni","33902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc 1 abnor bi","33903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Perq p-art revsc each addl","33904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Perq p-art revsc each addl","33904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Remove lung artery emboli","33910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove lung artery emboli","33910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove lung artery emboli","33910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove lung artery emboli","33915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove lung artery emboli","33915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove lung artery emboli","33915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgery of great vessel","33916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgery of great vessel","33916","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgery of great vessel","33916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair pulmonary artery","33917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair pulmonary artery","33917","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair pulmonary artery","33917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair pulmonary atresia","33920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair pulmonary atresia","33920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair pulmonary atresia","33920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transect pulmonary artery","33922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transect pulmonary artery","33922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transect pulmonary artery","33922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove pulmonary shunt","33924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove pulmonary shunt","33924","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove pulmonary shunt","33924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rpr pul art unifocal w/o cpb","33925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rpr pul art unifocal w/o cpb","33925","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rpr pul art unifocal w/o cpb","33925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repr pul art unifocal w/cpb","33926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repr pul art unifocal w/cpb","33926","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repr pul art unifocal w/cpb","33926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Impltj tot rplcmt hrt sys","33927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Impltj tot rplcmt hrt sys","33927","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Impltj tot rplcmt hrt sys","33927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rmvl & rplcmt tot hrt sys","33928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rmvl & rplcmt tot hrt sys","33928","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rmvl & rplcmt tot hrt sys","33928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rmvl rplcmt hrt sys f/trnspl","33929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rmvl rplcmt hrt sys f/trnspl","33929","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rmvl rplcmt hrt sys f/trnspl","33929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of donor heart/lung","33930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of donor heart/lung","33930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of donor heart/lung","33930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prepare donor heart/lung","33933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prepare donor heart/lung","33933","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prepare donor heart/lung","33933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transplantation heart/lung","33935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transplantation heart/lung","33935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transplantation heart/lung","33935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of donor heart","33940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of donor heart","33940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of donor heart","33940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prepare donor heart","33944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prepare donor heart","33944","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prepare donor heart","33944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transplantation of heart","33945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transplantation of heart","33945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transplantation of heart","33945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ecmo/ecls initiation venous","33946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ecmo/ecls initiation venous","33946","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ecmo/ecls initiation venous","33946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
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"Reposition vad diff session","33993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insj perq vad r hrt venous","33995","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Insj perq vad r hrt venous","33995","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmvl perq right heart vad","33997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rmvl perq right heart vad","33997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Cardiac surgery procedure","33999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Removal of artery clot","34001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of arm artery clot","34111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of artery clot","34201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Removal of leg artery clot","34203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Removal of vein clot","34401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of vein clot","34401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of vein clot","34401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of vein clot","34451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of vein clot","34451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Removal of vein clot","34471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of vein clot","34490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair valve femoral vein","34501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Reconstruct vena cava","34502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruct vena cava","34502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruct vena cava","34502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Transposition of vein valve","34510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Cross-over vein graft","34520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Leg vein fusion","34530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Evasc rpr a-ao ndgft","34701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-ao ndgft","34701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-ao ndgft","34701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-ao ndgft rpt","34702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-ao ndgft rpt","34702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-ao ndgft rpt","34702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-unilac ndgft","34703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-unilac ndgft","34703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-unilac ndgft","34703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-unilac ndgft rpt","34704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-unilac ndgft rpt","34704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-unilac ndgft rpt","34704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evac rpr a-biiliac ndgft","34705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evac rpr a-biiliac ndgft","34705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evac rpr a-biiliac ndgft","34705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-biiliac rpt","34706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-biiliac rpt","34706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-biiliac rpt","34706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr ilio-iliac ndgft","34707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr ilio-iliac ndgft","34707","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr ilio-iliac ndgft","34707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr ilio-iliac rpt","34708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr ilio-iliac rpt","34708","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr ilio-iliac rpt","34708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Plmt xtn prosth evasc rpr","34709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Plmt xtn prosth evasc rpr","34709","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Plmt xtn prosth evasc rpr","34709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Dlyd plmt xtn prosth 1st vsl","34710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Dlyd plmt xtn prosth 1st vsl","34710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Dlyd plmt xtn prosth 1st vsl","34710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Dlyd plmt xtn prosth ea addl","34711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Dlyd plmt xtn prosth ea addl","34711","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Dlyd plmt xtn prosth ea addl","34711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tcat dlvr enhncd fixj dev","34712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tcat dlvr enhncd fixj dev","34712","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tcat dlvr enhncd fixj dev","34712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Perq access & clsr fem art","34713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perq access & clsr fem art","34713","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perq access & clsr fem art","34713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Opn fem art expos cndt crtj","34714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Opn fem art expos cndt crtj","34714","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Opn fem art expos cndt crtj","34714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Opn ax/subcla art expos","34715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Opn ax/subcla art expos","34715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Opn ax/subcla art expos","34715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Opn ax/subcla art expos cndt","34716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Opn ax/subcla art expos cndt","34716","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Opn ax/subcla art expos cndt","34716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Evasc rpr a-iliac ndgft","34717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-iliac ndgft","34717","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr a-iliac ndgft","34717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc rpr n/a a-iliac ndgft","34718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc rpr n/a a-iliac ndgft","34718","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc rpr n/a a-iliac ndgft","34718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovas iliac a device addon","34808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovas iliac a device addon","34808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovas iliac a device addon","34808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth femorl","34812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth femorl","34812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth femorl","34812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Femoral endovas graft add-on","34813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Femoral endovas graft add-on","34813","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Femoral endovas graft add-on","34813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth iliac","34820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth iliac","34820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth iliac","34820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open Aortic Tube Prosth Repr","34830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open Aortic Tube Prosth Repr","34830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open Aortic Tube Prosth Repr","34830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open Aortoiliac Prosth Repr","34831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open Aortoiliac Prosth Repr","34831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open Aortoiliac Prosth Repr","34831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open Aortofemor Prosth Repr","34832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open Aortofemor Prosth Repr","34832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open Aortofemor Prosth Repr","34832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth iliac","34833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth iliac","34833","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Xpose for endoprosth iliac","34833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Xpose endoprosth brachial","34834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Xpose endoprosth brachial","34834","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Xpose endoprosth brachial","34834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Plnning pt spec fenest graft","34839","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Endovasc visc aorta 1 graft","34841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 1 graft","34841","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 1 graft","34841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 2 graft","34842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 2 graft","34842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 2 graft","34842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 3 graft","34843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 3 graft","34843","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 3 graft","34843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 4 graft","34844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 4 graft","34844","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Endovasc visc aorta 4 graft","34844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 1 prosth","34845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 1 prosth","34845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 1 prosth","34845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 2 prosth","34846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 2 prosth","34846","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 2 prosth","34846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 3 prosth","34847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 3 prosth","34847","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 3 prosth","34847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 4+ prost","34848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 4+ prost","34848","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Visc & infraren abd 4+ prost","34848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture neck","35002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture neck","35002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture neck","35002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of artery","35011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Repair artery rupture arm","35013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture arm","35013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture arm","35013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture chest","35022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture chest","35022","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture chest","35022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of arm artery","35045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Repair defect of artery","35081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35082","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35091","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35092","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35092","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35092","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture aorta","35103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture spleen","35112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture spleen","35112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture spleen","35112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture belly","35122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture belly","35122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture belly","35122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35131","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture groin","35132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture groin","35132","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture groin","35132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture thigh","35142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture thigh","35142","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair artery rupture thigh","35142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair defect of artery","35151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair ruptd popliteal art","35152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair ruptd popliteal art","35152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair ruptd popliteal art","35152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1566.6","5434.61",""
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair blood vessel lesion","35180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair blood vessel lesion","35182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5537.77","29398",""
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Repair blood vessel lesion","35188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Repair blood vessel lesion","35189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35189","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
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"Repair blood vessel lesion","35206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
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"Repair blood vessel lesion","35206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
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"Repair blood vessel lesion","35207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3142.32","19040",""
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"Repair blood vessel lesion","35207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
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"Repair blood vessel lesion","35207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
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"Repair blood vessel lesion","35226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Repair blood vessel lesion","35231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
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"Repair blood vessel lesion","35231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
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"Repair blood vessel lesion","35256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Repair blood vessel lesion","35256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
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"Repair blood vessel lesion","35256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Repair blood vessel lesion","35261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Repair blood vessel lesion","35261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
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"Repair blood vessel lesion","35261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
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"Repair blood vessel lesion","35266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
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"Repair blood vessel lesion","35266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
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"Repair blood vessel lesion","35271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair blood vessel lesion","35286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Repair blood vessel lesion","35286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
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"Repair blood vessel lesion","35286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Repair blood vessel lesion","35286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of Artery","35306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35351","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35363","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35371","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Rechanneling of artery","35372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Reoperation carotid add-on","35390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reoperation carotid add-on","35390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reoperation carotid add-on","35390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Angioscopy","35400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Angioscopy","35400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Angioscopy","35400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Harvest vein for bypass","35500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Harvest vein for bypass","35500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Harvest vein for bypass","35500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Art byp grft ipsilat carotid","35501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft ipsilat carotid","35501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft ipsilat carotid","35501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-carotid","35506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-carotid","35506","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-carotid","35506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft carotid-vertbrl","35508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft carotid-vertbrl","35508","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft carotid-vertbrl","35508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft contral carotid","35509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft contral carotid","35509","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft contral carotid","35509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft carotid-brchial","35510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft carotid-brchial","35510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft carotid-brchial","35510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-subclav","35511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-subclav","35511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-subclav","35511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-brchial","35512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-brchial","35512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-brchial","35512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-vertbrl","35515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-vertbrl","35515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-vertbrl","35515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-axilary","35516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-axilary","35516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft subclav-axilary","35516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft axillary-axilry","35518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft axillary-axilry","35518","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft axillary-axilry","35518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill-femoral","35521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill-femoral","35521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill-femoral","35521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill-brachial","35522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill-brachial","35522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill-brachial","35522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft brchl-ulnr-rdl","35523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft brchl-ulnr-rdl","35523","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft brchl-ulnr-rdl","35523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft brachial-brchl","35525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft brachial-brchl","35525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft brachial-brchl","35525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft aor/carot/innom","35526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft aor/carot/innom","35526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft aor/carot/innom","35526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft aorcel/aormesen","35531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft aorcel/aormesen","35531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft aorcel/aormesen","35531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill/fem/fem","35533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill/fem/fem","35533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft axill/fem/fem","35533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft hepatorenal","35535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft hepatorenal","35535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft hepatorenal","35535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft splenorenal","35536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft splenorenal","35536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft splenorenal","35536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art byp grft aortoiliac","35537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art byp grft aortoiliac","35537","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art byp grft aortoiliac","35537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
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"Composite byp grft pros&vein","35681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Composite byp grft 2 veins","35682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Composite byp grft 2 veins","35682","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Composite byp grft 2 veins","35682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Composite byp grft 3/> segmt","35683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Composite byp grft 3/> segmt","35683","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Composite byp grft 3/> segmt","35683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bypass graft patency/patch","35685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bypass graft patency/patch","35685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bypass graft patency/patch","35685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bypass graft/av fist patency","35686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bypass graft/av fist patency","35686","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bypass graft/av fist patency","35686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Art trnsposj vertbrl carotid","35691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art trnsposj vertbrl carotid","35691","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art trnsposj vertbrl carotid","35691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art trnsposj subclavian","35693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art trnsposj subclavian","35693","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art trnsposj subclavian","35693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art trnsposj subclav carotid","35694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art trnsposj subclav carotid","35694","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art trnsposj subclav carotid","35694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Art trnsposj carotid subclav","35695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Art trnsposj carotid subclav","35695","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Art trnsposj carotid subclav","35695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reimplant artery each","35697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reimplant artery each","35697","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reimplant artery each","35697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reoperation bypass graft","35700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reoperation bypass graft","35700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reoperation bypass graft","35700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration carotid artery","35701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration carotid artery","35701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration carotid artery","35701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Expl n/flwd surg uxtr art","35702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Expl n/flwd surg uxtr art","35702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Expl n/flwd surg uxtr art","35702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Expl n/flwd surg lxtr art","35703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Expl n/flwd surg lxtr art","35703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Expl n/flwd surg lxtr art","35703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Explore neck vessels","35800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Explore chest vessels","35820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore chest vessels","35820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore chest vessels","35820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore abdominal vessels","35840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore abdominal vessels","35840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore abdominal vessels","35840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Explore limb vessels","35860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Repair vessel graft defect","35870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair vessel graft defect","35870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair vessel graft defect","35870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5537.77","29398",""
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5537.77","29398",""
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Removal of clot in graft","35876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35879","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Revise graft w/vein","35881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5537.77","29398",""
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Revise Graft w/Nonauto Graft","35883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5537.77","29398",""
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Revise graft w/vein","35884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Excision graft neck","35901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision graft neck","35901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision graft neck","35901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Excision graft extremity","35903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Excision graft thorax","35905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision graft thorax","35905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision graft thorax","35905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision graft abdomen","35907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision graft abdomen","35907","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision graft abdomen","35907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Place needle in vein","36000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place needle in vein","36000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place needle in vein","36000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Pseudoaneurysm injection trt","36002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Injection ext venography","36005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection ext venography","36005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection ext venography","36005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in vein","36012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Establish access to artery","36100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Establish access to artery","36100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Establish access to artery","36100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Establish access to artery","36140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Establish access to artery","36140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Establish access to artery","36140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Intro of needle/cath for dialysis","36147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Establish access to aorta","36160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Establish access to aorta","36160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Establish access to aorta","36160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in aorta","36200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in aorta","36200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in aorta","36200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36217","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36218","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place catheter in artery","36218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath thoracic aorta","36221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath carotid/inom art","36222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotid/inom art","36223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Place cath carotd art","36224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath subclavian art","36225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Place cath vertebral art","36226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Place cath xtrnl carotid","36227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place cath xtrnl carotid","36227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place cath xtrnl carotid","36227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Place cath intracranial art","36228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Place cath intracranial art","36228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Place cath intracranial art","36228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 1st","36245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 1st","36245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 1st","36245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 2nd","36246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 2nd","36246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 2nd","36246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 3rd","36247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 3rd","36247","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art 3rd","36247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art addl","36248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art addl","36248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Ins cath abd/l-ext art addl","36248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st unilat","36251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 1st bilat","36252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Ins cath ren art 2nd+ unilat","36253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ins cath ren art 2nd+ bilat","36254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Insertion of infusion pump","36260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3719.02","19040",""
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3719.02","19040",""
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3719.02","19040",""
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3719.02","19040","APC 277.30"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3719.02","19040","APC 296.56"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3719.02","19040","APC 308.91"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3719.02","19040","APC"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3719.02","19040","APC"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3719.02","19040","APC"
"Revision of infusion pump","36261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3719.02","19040","APC"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11581.29","","","","","","","fee schedule","3408","19040","APC 277.30"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12385.67","","","","","","","fee schedule","3408","19040","APC 296.56"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12901.47","","","","","","","fee schedule","3408","19040","APC 308.91"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3819.28","","","","","","","fee schedule","3408","19040","APC"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3755.48","","","","","","","fee schedule","3408","19040","APC"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3719.02","","","","","","","fee schedule","3408","19040","APC"
"Removal of infusion pump","36262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3828.4","","","","","","","fee schedule","3408","19040","APC"
"Vessel injection procedure","36299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Vessel injection procedure","36299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Vessel injection procedure","36299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Non-routine bl draw 3/> yrs","36410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.11","","","","","","","fee schedule","52.11","52.11",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.09","","","","","","","fee schedule","3.6","16.42",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.09","","","","","","","fee schedule","3.6","16.42",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.09","","","","","","","fee schedule","3.6","16.42",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3.6","","","","","","","fee schedule","3.6","16.42",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","16.42","","","","","","","fee schedule","3.6","16.42",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3.6","","","","","","","fee schedule","3.6","16.42",""
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.78","","","","","","","fee schedule","3.6","16.42","APC"
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.62","","","","","","","fee schedule","3.6","16.42","APC"
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.53","","","","","","","fee schedule","3.6","16.42","APC"
"Routine venipuncture","36415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.81","","","","","","","fee schedule","3.6","16.42","APC"
"Capillary blood draw","36416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3.44","","","","","","","fee schedule","3.44","16.78",""
"Capillary blood draw","36416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","16.78","","","","","","","fee schedule","3.44","16.78",""
"Capillary blood draw","36416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3.44","","","","","","","fee schedule","3.44","16.78",""
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Vein access cutdown < 1 yr","36420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Vein access cutdown > 1 yr","36425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Blood transfusion service","36430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Bl push transfuse 2 yr/<","36440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse nb","36450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Bl exchange/transfuse non-nb","36455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","2633",""
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","2633",""
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","2633","APC 277.30"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","2633","APC 296.56"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","2633","APC 308.91"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","2633","APC"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","2633","APC"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","2633","APC"
"Prtl exchange transfuse nb","36456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","2633","APC"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Transfusion service fetal","36460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt 1 vein","36465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Njx noncmpnd sclrsnt mlt vn","36466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Injection(s) spider veins","36468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Injection(s), spider veins","36469","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of vein","36470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Injection therapy of veins","36471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous mchnchem 1st vein","36473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous mchnchem add-on","36474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Endovenous mchnchem add-on","36474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3142.32","19040",""
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous rf 1st vein","36475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous rf vein add-on","36476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Endovenous rf vein add-on","36476","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Endovenous rf vein add-on","36476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3142.32","19040",""
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous laser 1st vein","36478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Endovenous laser vein addon","36479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Endovenous laser vein addon","36479","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Endovenous laser vein addon","36479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Insertion of catheter vein","36481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36481","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Endoven ther chem adhes 1st","36482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Endoven ther chem adhes sbsq","36483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Endoven ther chem adhes sbsq","36483","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Endoven ther chem adhes sbsq","36483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insertion of catheter vein","36510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis wbc","36511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis rbc","36512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","5220",""
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","439.06","5220",""
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","5220",""
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","5220","APC 277.30"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","5220","APC 296.56"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","5220","APC 308.91"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","5220","APC"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","5220","APC"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","5220","APC"
"Apheresis platelets","36513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","5220","APC"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis plasma","36514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4334.59","23971",""
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Apheresis selective","36516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4334.59","23971",""
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Photopheresis","36522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","10900.88",""
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3142.32","10900.88",""
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","10900.88",""
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","10900.88",""
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3142.32","10900.88",""
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","10900.88",""
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert non-tunnel cv cath","36556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","4564","29398","APC 277.30"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","4564","29398","APC 296.56"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","4564","29398","APC 308.91"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","4564","29398","APC"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","4564","29398","APC"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","4564","29398","APC"
"Insert tunneled cv cath","36557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","4564","29398","APC"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Insert tunneled cv cath","36563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5537.77","29398",""
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Insert tunneled cv cath","36566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picc cath","36569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insert picvad cath","36571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Insj picc rs&i <5 yr","36572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1566.6","5790",""
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1566.6","5790",""
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1566.6","5790",""
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5790","APC 277.30"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5790","APC 296.56"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5790","APC 308.91"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5790","APC"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5790","APC"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5790","APC"
"Insj picc rs&i 5 yr+","36573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5790","APC"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","4564",""
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","624.29","4564",""
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","4564",""
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","4564","APC 277.30"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","4564","APC 296.56"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","4564","APC 308.91"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","4564","APC"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","4564","APC"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","4564","APC"
"Repair tunneled cv cath","36575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","4564","APC"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1566.6","5434.61",""
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Repair tunneled cv cath","36576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace cvad cath","36580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Replace tunneled cv cath","36583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace picc cath","36584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Replace picvad cath","36585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","3880",""
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","624.29","3880",""
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","3880",""
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","3880","APC 277.30"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","3880","APC 296.56"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","3880","APC 308.91"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","3880","APC"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","3880","APC"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","3880","APC"
"Removal tunneled cv cath","36589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","3880","APC"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1566.6","5790",""
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5790",""
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1566.6","5790",""
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5790","APC 277.30"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5790","APC 296.56"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5790","APC 308.91"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5790","APC"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5790","APC"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5790","APC"
"Removal tunneled cv cath","36590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5790","APC"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Draw blood off venous device","36591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Collect blood from picc","36592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","328.72","5220",""
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","328.72","5220",""
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","328.72","5220",""
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","5220","APC 277.30"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","5220","APC 296.56"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","5220","APC 308.91"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","5220","APC"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","5220","APC"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","5220","APC"
"Declot vascular device","36593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","5220","APC"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3142.32","19040",""
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Mech remov tunneled cv cath","36595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Mech remov tunneled cv cath","36596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1566.6","5434.61",""
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Reposition venous catheter","36597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","211.68","3408",""
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","211.68","3408",""
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","211.68","3408",""
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","3408","APC 277.30"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","3408","APC 296.56"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","3408","APC 308.91"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","3408","APC"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","3408","APC"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","3408","APC"
"Inj w/fluor eval cv device","36598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","3408","APC"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Withdrawal of arterial blood","36600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Insertion catheter artery","36620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insertion catheter artery","36620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insertion catheter artery","36620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insertion catheter artery","36625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insertion catheter artery","36625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insertion catheter artery","36625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3142.32","19040",""
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion catheter artery","36640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion catheter artery","36660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insertion catheter artery","36660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insertion catheter artery","36660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Insert needle bone cavity","36680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion of cannula","36810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Insertion of cannula","36815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm cephalic","36818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Av fuse uppr arm basilic","36819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Av fusion/forearm vein","36820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Av fusion direct any site","36821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insertion of cannula(s)","36823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Insertion of cannula(s)","36823","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Insertion of cannula(s)","36823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5537.77","29398",""
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein autograft","36825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5537.77","29398",""
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Artery-vein nonautograft","36830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5537.77","29398",""
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Open thrombect av fistula","36831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5537.77","29398",""
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision open","36832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5537.77","29398",""
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Av fistula revision","36833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3142.32","19040",""
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Artery to vein shunt","36835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crtj uxtr 1 acs","36836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq av fstl crt uxtr sep acs","36837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Dist revas ligation hemo","36838","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1566.6","5434.61",""
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"External cannula declotting","36860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Cannula declotting","36861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Av Fistula Revision, Open","36870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1566.6","5790",""
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1566.6","5790",""
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5790","APC 277.30"
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5790","APC 296.56"
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5790","APC 308.91"
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5790","APC"
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5790","APC"
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5790","APC"
"Intro cath dialysis circuit","36901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5790","APC"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5664.24","29398",""
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5664.24","29398",""
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","29398","APC 277.30"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","29398","APC 296.56"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","29398","APC 308.91"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","29398","APC"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","29398","APC"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","29398","APC"
"Intro cath dialysis circuit","36902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","29398","APC"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Intro cath dialysis circuit","36903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5664.24","29398",""
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5664.24","29398",""
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","29398","APC 277.30"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","29398","APC 296.56"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","29398","APC 308.91"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","29398","APC"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","29398","APC"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","29398","APC"
"Thrmbc/nfs dialysis circuit","36904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","29398","APC"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Thrmbc/nfs dialysis circuit","36905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","18243.62","63288.08",""
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","18243.62","63288.08",""
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Thrmbc/nfs dialysis circuit","36906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Balo angiop ctr dialysis seg","36907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Balo angiop ctr dialysis seg","36907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Stent plmt ctr dialysis seg","36908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Stent plmt ctr dialysis seg","36908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Dialysis circuit embolj","36909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Dialysis circuit embolj","36909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Revision of circulation","37140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of circulation","37180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Splice spleen/kidney veins","37181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Splice spleen/kidney veins","37181","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Splice spleen/kidney veins","37181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Insert hepatic shunt (tips)","37182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5220","35289","APC 277.30"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5220","35289","APC 296.56"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5220","35289","APC 308.91"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5220","35289","APC"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5220","35289","APC"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5220","35289","APC"
"Remove hepatic shunt (tips)","37183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5220","35289","APC"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","13700","63288.08",""
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","63288.08",""
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","13700","63288.08",""
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","13700","63288.08","APC 277.30"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","13700","63288.08","APC 296.56"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","13700","63288.08","APC 308.91"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","13700","63288.08","APC"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","13700","63288.08","APC"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","13700","63288.08","APC"
"Prim art m-thrmbc 1st vsl","37184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","13700","63288.08","APC"
"Prim art m-thrmbc sbsq vsl","37185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Prim art m-thrmbc sbsq vsl","37185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Prim art m-thrmbc sbsq vsl","37185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Sec art thrombectomy add-on","37186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Sec art thrombectomy add-on","37186","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Sec art thrombectomy add-on","37186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","11488.76","39855.12",""
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","11488.76","39855.12",""
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","11488.76","39855.12",""
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Venous mech thrombectomy","37187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3142.32","19040",""
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Venous m-thrombectomy add-on","37188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Ins endovas vena cava filtr","37191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Redo endovas vena cava filtr","37192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Rem endovas vena cava filter","37193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","328.72","3408",""
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","328.72","3408",""
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","328.72","3408",""
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","3408","APC 277.30"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","3408","APC 296.56"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","3408","APC 308.91"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","3408","APC"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","3408","APC"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","3408","APC"
"Thrombolytic therapy stroke","37195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","3408","APC"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3142.32","19040",""
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Remove intrvas foreign body","37197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3408","29398",""
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","29398",""
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3408","29398",""
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","3408","29398","APC 277.30"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","3408","29398","APC 296.56"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","3408","29398","APC 308.91"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","3408","29398","APC"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","3408","29398","APC"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","3408","29398","APC"
"Transcatheter biopsy","37200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","3408","29398","APC"
"Transcatheter therapy infuse","37202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Embolization Uterine Fibroid","37210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5537.77","29398",""
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5537.77","29398",""
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5537.77","29398",""
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","29398","APC 277.30"
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","29398","APC 296.56"
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","29398","APC 308.91"
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","29398","APC"
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","29398","APC"
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","29398","APC"
"Thrombolytic art therapy","37211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","29398","APC"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3142.32","19040",""
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Thrombolytic venous therapy","37212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","13700",""
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3142.32","13700",""
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","13700",""
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","13700","APC 277.30"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","13700","APC 296.56"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","13700","APC 308.91"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","13700","APC"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","13700","APC"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","13700","APC"
"Thromblytic art/ven therapy","37213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","13700","APC"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","13700",""
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3142.32","13700",""
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","13700",""
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","13700","APC 277.30"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","13700","APC 296.56"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","13700","APC 308.91"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","13700","APC"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","13700","APC"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","13700","APC"
"Cessj therapy cath removal","37214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","13700","APC"
"Transcath stent cca w/eps","37215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transcath stent cca w/eps","37215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transcath stent cca w/eps","37215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transcath stent cca w/o eps","37216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transcath stent cca w/o eps","37216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transcath stent cca w/o eps","37216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Stent placemt retro carotid","37217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Stent placemt retro carotid","37217","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Stent placemt retro carotid","37217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Stent placemt ante carotid","37218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Stent placemt ante carotid","37218","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Stent placemt ante carotid","37218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Iliac revasc","37220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Iliac revasc","37220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Iliac revasc","37220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Iliac revasc w/stent","37221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Iliac revasc w/stent","37221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Iliac revasc w/stent","37221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Iliac revasc add-on","37222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Iliac revasc add-on","37222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Iliac revasc add-on","37222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Iliac revasc w/stent add-on","37223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Iliac revasc w/stent add-on","37223","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Iliac revasc w/stent add-on","37223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Fem/popl revas w/tla","37224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Fem/popl revas w/tla","37224","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Fem/popl revas w/tla","37224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Fem/popl revas w/ather","37225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Fem/popl revas w/ather","37225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Fem/popl revas w/ather","37225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Fem/popl revasc w/stent","37226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Fem/popl revasc w/stent","37226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Fem/popl revasc w/stent","37226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Fem/popl revasc stnt & ather","37227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","5220","50815",""
"Fem/popl revasc stnt & ather","37227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","50815",""
"Fem/popl revasc stnt & ather","37227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","5220","50815",""
"Tib/per revasc w/tla","37228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc w/tla","37228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc w/tla","37228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc w/ather","37229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Tib/per revasc w/ather","37229","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Tib/per revasc w/ather","37229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Tib/per revasc w/stent","37230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Tib/per revasc w/stent","37230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Tib/per revasc w/stent","37230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Tib/per revasc stent & ather","37231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","5220","50815",""
"Tib/per revasc stent & ather","37231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","50815",""
"Tib/per revasc stent & ather","37231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","5220","50815",""
"Tib/per revasc add-on","37232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc add-on","37232","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc add-on","37232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Tibper revasc w/ather add-on","37233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Tibper revasc w/ather add-on","37233","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Tibper revasc w/ather add-on","37233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Revsc opn/prq tib/pero stent","37234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Revsc opn/prq tib/pero stent","37234","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Revsc opn/prq tib/pero stent","37234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc stnt & ather","37235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc stnt & ather","37235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Tib/per revasc stnt & ather","37235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent 1st","37236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent ea add","37237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Open/perq place stent ea add","37237","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Open/perq place stent ea add","37237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent same","37238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Open/perq place stent ea add","37239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Open/perq place stent ea add","37239","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Open/perq place stent ea add","37239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude venous","37241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Vasc embolize/occlude artery","37242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude organ","37243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Vasc embolize/occlude bleed","37244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5664.24","29398",""
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5664.24","29398",""
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","29398","APC 277.30"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","29398","APC 296.56"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","29398","APC 308.91"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop 1st art","37246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop addl art","37247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Trluml balo angiop addl art","37247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5664.24","29398",""
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5664.24","29398",""
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","29398","APC 277.30"
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","29398","APC 296.56"
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","29398","APC 308.91"
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop 1st vein","37248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","29398","APC"
"Trluml balo angiop addl vein","37249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Trluml balo angiop addl vein","37249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Intrvasc us noncoronary 1st","37252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Intrvasc us noncoronary 1st","37252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Intrvasc us noncoronary 1st","37252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Intrvasc us noncoronary addl","37253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Intrvasc us noncoronary addl","37253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Intrvasc us noncoronary addl","37253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","19649.53","APC 277.30"
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","19649.53","APC 296.56"
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","19649.53","APC 308.91"
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio sf 1st","37254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","19649.53","APC 277.30"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","19649.53","APC 296.56"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","19649.53","APC 308.91"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt angio cplx 1","37256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt stent sf 1st","37258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc ivt st cplx 1st","37260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","19649.53","APC 277.30"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","19649.53","APC 296.56"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","19649.53","APC 308.91"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evasc fpvt angio sf 1","37263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","19649.53","APC 277.30"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","19649.53","APC 296.56"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","19649.53","APC 308.91"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evsc fpvt angio cplx 1","37265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","19649.53","APC"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc fpvt stent sf 1st","37267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc fpvt st cplx 1st","37269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc sf 1st","37271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc fpvt athrc cplx 1","37273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athrc sf 1","37275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc fpvt st athr cpx 1","37277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc tpvt angio sf 1st","37280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Rvsc evsc tpvt angio cplx 1","37282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st sf 1st","37284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc tpvt st cplx 1st","37286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc sf 1st","37288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evsc tpvt athrc cplx 1","37290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athrc sf 1","37292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Rvsc evsc tpvt st athr cpx 1","37294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evasc imvt angio sf 1","37296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revsc evsc imvt angio cplx 1","37298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Endoscopy ligate perf veins","37500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Endoscopy ligate perf veins","37500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Endoscopy ligate perf veins","37500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Vascular endoscopy procedure","37501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","10900.88",""
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","10900.88",""
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","10900.88",""
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck vein","37565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of neck artery","37606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligation of a-v fistula","37607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1643.67","5790",""
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Temporal artery procedure","37609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","10900.88",""
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","10900.88",""
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","10900.88",""
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of neck artery","37615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligation of chest artery","37616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ligation of chest artery","37616","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ligation of chest artery","37616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19210.81",""
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19210.81",""
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19210.81",""
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","19210.81","APC 277.30"
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","19210.81","APC 296.56"
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","19210.81","APC 308.91"
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","19210.81","APC"
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","19210.81","APC"
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","19210.81","APC"
"Ligation of abdomen artery","37617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","19210.81","APC"
"Ligation of extremity artery","37618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ligation of extremity artery","37618","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ligation of extremity artery","37618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5220","29398","APC 277.30"
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5220","29398","APC 296.56"
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5220","29398","APC 308.91"
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5220","29398","APC"
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5220","29398","APC"
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5220","29398","APC"
"Ligation of inf vena cava","37619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5220","29398","APC"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","19040",""
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Revision of major vein","37650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Revision of major vein","37660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of major vein","37660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of major vein","37660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","19040",""
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Revise leg vein","37700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip short leg vein","37718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/strip long leg vein","37722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of leg veins/lesion","37735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate leg veins radical","37760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","10900.88",""
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3142.32","10900.88",""
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","10900.88",""
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligate leg veins open","37761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Stab phleb veins xtr 10-20","37765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Phleb veins - extrem 20+","37766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3142.32","10900.88",""
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","10900.88",""
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3142.32","10900.88",""
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Revision of leg vein","37780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Ligate/divide/excise vein","37785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Revascularization penis","37788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revascularization penis","37788","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revascularization penis","37788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Penile venous occlusion","37790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","624.29","5220",""
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","624.29","5220",""
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","624.29","5220",""
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","5220","APC 277.30"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","5220","APC 296.56"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","5220","APC 308.91"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","5220","APC"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","5220","APC"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","5220","APC"
"Vascular surgery procedure","37799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","5220","APC"
"Removal of spleen total","38100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of spleen total","38100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of spleen total","38100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of spleen partial","38101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of spleen partial","38101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of spleen partial","38101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of spleen total","38102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of spleen total","38102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of spleen total","38102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of ruptured spleen","38115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of ruptured spleen","38115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of ruptured spleen","38115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy splenectomy","38120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc spleen","38129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Injection for spleen x-ray","38200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for spleen x-ray","38200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for spleen x-ray","38200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bl donor search management","38204","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Harvest allogeneic stem cell","38205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Harvest allogeneic stem cell","38205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Harvest allogeneic stem cell","38205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Harvest auto stem cells","38206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Cryopreserve stem cells","38207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Thaw preserved stem cells","38208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Wash harvest stem cells","38209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"T-cell depletion of harvest","38210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Tumor cell deplete of harvst","38211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Rbc depletion of harvest","38212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Platelet deplete of harvest","38213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Volume deplete of harvest","38214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","3408",""
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","439.06","3408",""
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","3408",""
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","3408","APC 277.30"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","3408","APC 296.56"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","3408","APC 308.91"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","3408","APC"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","3408","APC"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","3408","APC"
"Harvest stem cell concentrte","38215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","3408","APC"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow aspiration","38220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Bone marrow biopsy","38221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Dx bone marrow bx & aspir","38222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Car-t hrv bld-drv t lymphcyt","38225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Car-t hrv bld-drv t lymphcyt","38225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Car-t prep t lymphcyt f/trns","38226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Car-t prep t lymphcyt f/trns","38226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Car-t receipt&prepj admn","38227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Car-t receipt&prepj admn","38227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","328.72","2633",""
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","328.72","2633",""
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","2633","APC 277.30"
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","2633","APC 296.56"
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","2633","APC 308.91"
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","2633","APC"
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","2633","APC"
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","2633","APC"
"Car-t admn autologous","38228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","2633","APC"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Bone marrow harvest allogen","38230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4334.59","23971",""
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4334.59","23971",""
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4334.59","23971",""
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13498.23","","","","","","","fee schedule","4334.59","23971","APC 277.30"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14435.76","","","","","","","fee schedule","4334.59","23971","APC 296.56"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15036.92","","","","","","","fee schedule","4334.59","23971","APC 308.91"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4451.45","","","","","","","fee schedule","4334.59","23971","APC"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4377.09","","","","","","","fee schedule","4334.59","23971","APC"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4334.59","","","","","","","fee schedule","4334.59","23971","APC"
"Bone marrow harvest autolog","38232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4462.08","","","","","","","fee schedule","4334.59","23971","APC"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","217159.59",""
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","217159.59",""
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","217159.59",""
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","194938.18","","","","","","","fee schedule","5220","217159.59","APC 277.30"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","208477.71","","","","","","","fee schedule","5220","217159.59","APC 296.56"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","217159.59","","","","","","","fee schedule","5220","217159.59","APC 308.91"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64286.82","","","","","","","fee schedule","5220","217159.59","APC"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63212.81","","","","","","","fee schedule","5220","217159.59","APC"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62599.09","","","","","","","fee schedule","5220","217159.59","APC"
"Transplt allo hct/donor","38240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64440.24","","","","","","","fee schedule","5220","217159.59","APC"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt autol hct/donor","38241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Transplt allo lymphocytes","38242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1549.95","5790",""
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1549.95","5790",""
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1549.95","5790",""
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4826.66","","","","","","","fee schedule","1549.95","5790","APC 277.30"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5161.89","","","","","","","fee schedule","1549.95","5790","APC 296.56"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5376.86","","","","","","","fee schedule","1549.95","5790","APC 308.91"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1591.74","","","","","","","fee schedule","1549.95","5790","APC"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1565.14","","","","","","","fee schedule","1549.95","5790","APC"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1549.95","","","","","","","fee schedule","1549.95","5790","APC"
"Transplj hematopoietic boost","38243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1595.54","","","","","","","fee schedule","1549.95","5790","APC"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","10028.23",""
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage lymph node lesion","38300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","14111",""
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Drainage lymph node lesion","38305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Incision of lymph channels","38308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Thoracic duct procedure","38380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38381","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Thoracic duct procedure","38382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy lymph nodes","38505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Biopsy/removal lymph nodes","38530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3896.63","19040",""
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","19040",""
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3896.63","19040",""
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","19040","APC 277.30"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","19040","APC 296.56"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","19040","APC 308.91"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","19040","APC"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","19040","APC"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","19040","APC"
"Open bx/exc inguinofem nodes","38531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","19040","APC"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","4564","29398","APC 277.30"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","4564","29398","APC 296.56"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","4564","29398","APC 308.91"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","4564","29398","APC"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","4564","29398","APC"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","4564","29398","APC"
"Explore deep node(s) neck","38542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","4564","29398","APC"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3896.63","14111",""
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3896.63","14111",""
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3896.63","14111",""
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12134.4","","","","","","","fee schedule","3896.63","14111","APC 277.30"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12977.2","","","","","","","fee schedule","3896.63","14111","APC 296.56"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13517.63","","","","","","","fee schedule","3896.63","14111","APC 308.91"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4001.69","","","","","","","fee schedule","3896.63","14111","APC"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3934.84","","","","","","","fee schedule","3896.63","14111","APC"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3896.63","","","","","","","fee schedule","3896.63","14111","APC"
"Removal neck/armpit lesion","38550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4011.24","","","","","","","fee schedule","3896.63","14111","APC"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6448","22924.49",""
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","22924.49",""
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6448","22924.49",""
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","6448","22924.49","APC 277.30"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","6448","22924.49","APC 296.56"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","6448","22924.49","APC 308.91"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","6448","22924.49","APC"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","6448","22924.49","APC"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","6448","22924.49","APC"
"Removal neck/armpit lesion","38555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","6448","22924.49","APC"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25330.32","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27089.65","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28217.78","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8353.45","","","","","","","fee schedule","5220","29398","APC"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8213.89","","","","","","","fee schedule","5220","29398","APC"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8134.14","","","","","","","fee schedule","5220","29398","APC"
"Removal pelvic lymph nodes","38562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8373.38","","","","","","","fee schedule","5220","29398","APC"
"Removal abdomen lymph nodes","38564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal abdomen lymph nodes","38564","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal abdomen lymph nodes","38564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lymph node biop","38570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy lymphadenectomy","38572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laps pelvic lymphadec","38573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc lymphatic","38589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","22924.49",""
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","22924.49",""
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","22924.49",""
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","4564","22924.49","APC 277.30"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","4564","22924.49","APC 296.56"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","4564","22924.49","APC 308.91"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","4564","22924.49","APC"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","4564","22924.49","APC"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","4564","22924.49","APC"
"Removal of lymph nodes neck","38700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","4564","22924.49","APC"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","22924.49",""
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","22924.49",""
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","22924.49",""
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","5220","22924.49","APC 277.30"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","5220","22924.49","APC 296.56"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","5220","22924.49","APC 308.91"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","5220","22924.49","APC"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","5220","22924.49","APC"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","5220","22924.49","APC"
"Removal of lymph nodes neck","38720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","5220","22924.49","APC"
"Removal of lymph nodes neck","38724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Removal of lymph nodes neck","38724","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Removal of lymph nodes neck","38724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","4564","29398","APC 277.30"
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","4564","29398","APC 296.56"
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","4564","29398","APC 308.91"
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","4564","29398","APC"
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","4564","29398","APC"
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","4564","29398","APC"
"Remove armpit lymph nodes","38740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","4564","29398","APC"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","29398",""
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Remove armpit lymph nodes","38745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thoracic lymph nodes","38746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove thoracic lymph nodes","38746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove thoracic lymph nodes","38746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove abdominal lymph nodes","38747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove abdominal lymph nodes","38747","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove abdominal lymph nodes","38747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","22924.49",""
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","22924.49",""
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","22924.49",""
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20578.68","","","","","","","fee schedule","4564","22924.49","APC 277.30"
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22007.99","","","","","","","fee schedule","4564","22924.49","APC 296.56"
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22924.49","","","","","","","fee schedule","4564","22924.49","APC 308.91"
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6786.45","","","","","","","fee schedule","4564","22924.49","APC"
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6673.07","","","","","","","fee schedule","4564","22924.49","APC"
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6608.28","","","","","","","fee schedule","4564","22924.49","APC"
"Remove groin lymph nodes","38760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6802.65","","","","","","","fee schedule","4564","22924.49","APC"
"Remove groin lymph nodes","38765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove groin lymph nodes","38765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove groin lymph nodes","38765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove pelvis lymph nodes","38770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove pelvis lymph nodes","38770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove pelvis lymph nodes","38770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove abdomen lymph nodes","38780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove abdomen lymph nodes","38780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove abdomen lymph nodes","38780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Inject for lymphatic x-ray","38790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Inject for lymphatic x-ray","38790","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Inject for lymphatic x-ray","38790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","397.85","3408",""
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","397.85","3408",""
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","397.85","3408",""
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","3408","APC 277.30"
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","3408","APC 296.56"
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","3408","APC 308.91"
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","3408","APC"
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","3408","APC"
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","3408","APC"
"Ra tracer id of sentinl node","38792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","3408","APC"
"Access thoracic lymph duct","38794","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Access thoracic lymph duct","38794","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Access thoracic lymph duct","38794","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Io map of sent lymph node","38900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Io map of sent lymph node","38900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Io map of sent lymph node","38900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","439.06","5220",""
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","439.06","5220",""
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","439.06","5220",""
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1367.25","","","","","","","fee schedule","439.06","5220","APC 277.30"
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1462.22","","","","","","","fee schedule","439.06","5220","APC 296.56"
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1523.11","","","","","","","fee schedule","439.06","5220","APC 308.91"
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","450.89","","","","","","","fee schedule","439.06","5220","APC"
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","443.36","","","","","","","fee schedule","439.06","5220","APC"
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","439.06","","","","","","","fee schedule","439.06","5220","APC"
"Blood/lymph system procedure","38999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","451.97","","","","","","","fee schedule","439.06","5220","APC"
"Exploration of chest","39000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","39000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","39000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","39010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","39010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of chest","39010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect mediastinal cyst","39200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect mediastinal cyst","39200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect mediastinal cyst","39200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect mediastinal tumor","39220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect mediastinal tumor","39220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect mediastinal tumor","39220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/medstnl bx","39401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Mediastinoscpy w/lmph nod bx","39402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Chest procedure","39499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Chest procedure","39499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Chest procedure","39499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair diaphragm laceration","39501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair diaphragm laceration","39501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair diaphragm laceration","39501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39503","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of diaphragm hernia","39541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of diaphragm","39545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of diaphragm","39545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of diaphragm","39545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect diaphragm simple","39560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect diaphragm simple","39560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect diaphragm simple","39560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect diaphragm complex","39561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect diaphragm complex","39561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect diaphragm complex","39561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Diaphragm surgery procedure","39599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Diaphragm surgery procedure","39599","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Diaphragm surgery procedure","39599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Biopsy of lip","40490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Partial excision of lip","40510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Partial excision of lip","40520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruct lip with flap","40525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruct lip with flap","40527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Partial removal of lip","40530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Repair lip","40654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","23971",""
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Repair cleft lip/nasal","40720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Repair cleft lip/nasal","40761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Lip surgery procedure","40799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of mouth lesion","40800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","4564",""
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","536.74","4564",""
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","4564",""
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","4564","APC 277.30"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","4564","APC 296.56"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","4564","APC 308.91"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","4564","APC"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","4564","APC"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","4564","APC"
"Drainage of mouth lesion","40801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","4564","APC"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Removal foreign body mouth","40804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","4564",""
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","536.74","4564",""
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","4564",""
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","4564","APC 277.30"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","4564","APC 296.56"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","4564","APC 308.91"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","4564","APC"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","4564","APC"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","4564","APC"
"Removal foreign body mouth","40805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","4564","APC"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Incision of lip fold","40806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Biopsy of mouth lesion","40808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of mouth lesion","40810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Excise/repair mouth lesion","40812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excise/repair mouth lesion","40814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","40816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Excise oral mucosa for graft","40818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Excise lip or cheek fold","40819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Treatment of mouth lesion","40820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Repair mouth laceration","40830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Repair mouth laceration","40831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of mouth","40840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruction of mouth","40845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Mouth surgery procedure","40899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of mouth lesion","41005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of tongue fold","41010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","20437.6",""
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","20437.6",""
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","20437.6",""
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","3408","20437.6","APC 277.30"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","3408","20437.6","APC 296.56"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","3408","20437.6","APC 308.91"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","3408","20437.6","APC"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","3408","20437.6","APC"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","3408","20437.6","APC"
"Drainage of mouth lesion","41016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","3408","20437.6","APC"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of mouth lesion","41018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Place needles h&n for rt","41019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Biopsy of tongue","41100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of tongue","41105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of floor of mouth","41108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tongue lesion","41114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of tongue fold","41115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","14111",""
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of mouth lesion","41116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of tongue","41120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of tongue","41130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of tongue","41130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of tongue","41130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tongue and neck surgery","41135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Tongue and neck surgery","41135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Tongue and neck surgery","41135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Removal of tongue","41140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of tongue","41140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of tongue","41140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tongue removal neck surgery","41145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tongue removal neck surgery","41145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tongue removal neck surgery","41145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tongue mouth jaw surgery","41150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tongue mouth jaw surgery","41150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tongue mouth jaw surgery","41150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tongue mouth neck surgery","41153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tongue mouth neck surgery","41153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tongue mouth neck surgery","41153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tongue jaw & neck surgery","41155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tongue jaw & neck surgery","41155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tongue jaw & neck surgery","41155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","4564",""
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","444.58","4564",""
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","4564",""
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","4564","APC 277.30"
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","4564","APC 296.56"
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","4564","APC 308.91"
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","4564","APC"
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","4564","APC"
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","4564","APC"
"Repair tongue laceration","41250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","4564","APC"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","4564",""
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","235.71","4564",""
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","4564",""
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","4564","APC 277.30"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","4564","APC 296.56"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","4564","APC 308.91"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","4564",""
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","235.71","4564",""
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","4564",""
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","4564","APC 277.30"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","4564","APC 296.56"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","4564","APC 308.91"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","4564","APC"
"Repair tongue laceration","41252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","4564","APC"
"Fixation of tongue","41500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Tongue to lip surgery","41510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Tongue suspension","41512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","23971",""
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruction tongue fold","41520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Tongue base vol reduction","41530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Tongue and mouth surgery","41599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","3408",""
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","132.41","3408",""
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","3408",""
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","3408","APC 277.30"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","3408","APC 296.56"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","3408","APC 308.91"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","3408","APC"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","3408","APC"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","3408","APC"
"Drainage of gum lesion","41800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","3408","APC"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body gum","41805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Removal foreign body jawbone","41806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","14111",""
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision gum each quadrant","41820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum flap","41821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of gum lesion","41823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of gum lesion","41825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of gum lesion","41826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Excision of gum lesion","41827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of gum lesion","41828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of gum tissue","41830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Treatment of gum lesion","41850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Gum graft","41870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Repair gum","41872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Repair tooth socket","41874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Dental surgery procedure","41899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","4564",""
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","235.71","4564",""
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","4564",""
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","4564","APC 277.30"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","4564","APC 296.56"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","4564","APC 308.91"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","4564","APC"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","4564","APC"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","4564","APC"
"Drainage mouth roof lesion","42000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","4564","APC"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy roof of mouth","42100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Excision lesion mouth roof","42107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","20437.6",""
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove palate/lesion","42120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Excision of uvula","42140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","20437.6",""
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Repair palate pharynx/uvula","42145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Treatment mouth roof lesion","42160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Repair palate","42180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Repair palate","42182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3299.54","23971",""
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruct cleft palate","42205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Reconstruct cleft palate","42225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Lengthening of palate","42226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Lengthening of palate","42227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair palate","42235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","20437.6",""
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Repair nose to lip fistula","42260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Preparation palate mold","42280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","20437.6",""
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","20437.6",""
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Insertion palate prosthesis","42281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Palate/uvula surgery","42299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of salivary gland","42300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Drainage of salivary gland","42305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Drainage of salivary gland","42320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of salivary stone","42335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of salivary stone","42340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of salivary gland","42400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1544.13","5790",""
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of salivary gland","42405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Excision of salivary cyst","42408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of salivary cyst","42408","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Excision of salivary cyst","42408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of salivary cyst","42408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of salivary cyst","42408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of salivary cyst","42408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
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"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
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"Drainage of salivary cyst","42409","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
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"Excise parotid gland/lesion","42410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
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"Excise parotid gland/lesion","42410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Excise parotid gland/lesion","42410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Excise parotid gland/lesion","42410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Excise parotid gland/lesion","42410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
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"Excise parotid gland/lesion","42415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
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"Excise parotid gland/lesion","42415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
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"Excise parotid gland/lesion","42426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Excise parotid gland/lesion","42426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Excise parotid gland/lesion","42426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
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"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Excise submaxillary gland","42440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Excise sublingual gland","42450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
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"Repair salivary duct","42500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
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"Repair salivary duct","42505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair salivary duct","42505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Repair salivary duct","42505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair salivary duct","42505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
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"Parotid duct diversion","42507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
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"Parotid duct diversion","42507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Parotid duct diversion","42507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
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"Parotid duct diversion","42509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Parotid duct diversion","42509","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","23971",""
"Parotid duct diversion","42509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Parotid duct diversion","42509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
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"Parotid duct diversion","42509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","23971",""
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Parotid duct diversion","42510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Injection for salivary x-ray","42550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for salivary x-ray","42550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for salivary x-ray","42550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closure of salivary fistula","42600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Dilation of salivary duct","42650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Dilation of salivary duct","42660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Ligation of salivary duct","42665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Salivary surgery procedure","42699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of tonsil abscess","42700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of throat abscess","42720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","23971","APC 277.30"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","23971","APC 296.56"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","23971","APC 308.91"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","23971","APC"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","23971","APC"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","23971","APC"
"Drainage of throat abscess","42725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","23971","APC"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1544.13","5356.68",""
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1544.13","5356.68",""
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Biopsy of throat","42800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Biopsy of throat","42802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","11446.28",""
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of upper nose/throat","42804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Biopsy of upper nose/throat","42806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excise pharynx lesion","42808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","3408",""
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","444.58","3408",""
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","3408",""
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","3408","APC 277.30"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","3408","APC 296.56"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","3408","APC 308.91"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","3408","APC"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","3408","APC"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","3408","APC"
"Remove pharynx foreign body","42809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","3408","APC"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of neck cyst","42810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Excision of neck cyst","42815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Remove tonsils and adenoids","42820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3299.54","14111",""
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Remove tonsils and adenoids","42821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5891.41","20437.6",""
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Removal of tonsils","42825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of tonsils","42826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Removal of adenoids","42836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive surgery of throat","42842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Extensive surgery of throat","42844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Extensive surgery of throat","42845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive surgery of throat","42845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive surgery of throat","42845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of tonsil tags","42860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Excision of lingual tonsil","42870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Partial removal of pharynx","42890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of pharyngeal walls","42892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revision of pharyngeal walls","42894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of pharyngeal walls","42894","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of pharyngeal walls","42894","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Repair throat wound","42900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Reconstruction of throat","42950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Repair throat esophagus","42953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair throat esophagus","42953","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair throat esophagus","42953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1544.13","5790",""
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Surgical opening of throat","42955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Control throat bleeding","42960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Control throat bleeding","42961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Control throat bleeding","42961","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Control throat bleeding","42961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Control throat bleeding","42962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Control nose/throat bleeding","42970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Control nose/throat bleeding","42971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Control nose/throat bleeding","42971","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Control nose/throat bleeding","42971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Control nose/throat bleeding","42972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","1771.35","6144.91",""
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","1771.35","6144.91",""
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5516.12","","","","","","","fee schedule","1771.35","6144.91","APC 277.30"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5899.25","","","","","","","fee schedule","1771.35","6144.91","APC 296.56"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6144.91","","","","","","","fee schedule","1771.35","6144.91","APC 308.91"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1819.11","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1788.72","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1771.35","","","","","","","fee schedule","1771.35","6144.91","APC"
"Dise eval slp do brth flx dx","42975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1823.45","","","","","","","fee schedule","1771.35","6144.91","APC"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Throat surgery procedure","42999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Incision of esophagus","43020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Throat muscle surgery","43030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Incision of esophagus","43045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of esophagus","43045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of esophagus","43045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of esophagus lesion","43100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of esophagus lesion","43100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of esophagus lesion","43100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of esophagus lesion","43101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of esophagus lesion","43101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of esophagus lesion","43101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43113","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43117","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43118","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43123","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of esophagus","43123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43124","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus","43124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Removal of esophagus pouch","43130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Removal of esophagus pouch","43135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus pouch","43135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of esophagus pouch","43135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Esophagoscopy rigid trnso","43180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy rigid trnso dx","43191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso inject","43192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso biopsy","43193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp rig trnso rem fb","43194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3836.96","13310.62",""
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","13310.62",""
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3836.96","13310.62",""
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","13310.62","APC 277.30"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","13310.62","APC 296.56"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","13310.62","APC 308.91"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","13310.62","APC"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","13310.62","APC"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","13310.62","APC"
"Esophagoscopy rigid balloon","43195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","13310.62","APC"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscp guide wire dilat","43196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flex dx brush","43197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Esophagosc flex trnsn biopsy","43198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Esophagoscopy flexible brush","43200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/submucous inj","43201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex biopsy","43202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph scope w/sclerosis inj","43204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagus endoscopy/ligation","43205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","7337",""
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1909.69","7337",""
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","7337",""
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","7337","APC 277.30"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","7337","APC 296.56"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","7337","APC 308.91"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","7337","APC"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","7337","APC"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","7337","APC"
"Esoph optical endomicroscopy","43206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","7337","APC"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","36698.4",""
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","36698.4",""
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Egd esophagogastrc fndoplsty","43210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop mucosal resect","43211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","20959.15",""
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","20959.15",""
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Esophagoscop stent placement","43212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy retro balloon","43213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagosc dilate balloon 30","43214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy flex remove fb","43215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1909.69","14111",""
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","14111",""
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1909.69","14111",""
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","14111","APC 277.30"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","14111","APC 296.56"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","14111","APC 308.91"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","14111","APC"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","14111","APC"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","14111","APC"
"Esophagoscopy lesion removal","43216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","14111","APC"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy snare les remv","43217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagus endoscopy","43219","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy balloon <30mm","43220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph endoscopy dilation","43226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy control bleed","43227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph endoscopy, ablation","43228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","14111",""
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Esophagoscopy lesion ablate","43229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscop ultrasound exam","43231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esophagoscopy w/us needle bx","43232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd balloon dil esoph30 mm/>","43233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Egd diagnostic brush wash","43235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","902.63","5790",""
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Uppr gi scope w/submuc inj","43236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Endoscopic us exam esoph","43237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","902.63","5790",""
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Egd biopsy single/multiple","43239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20959.15",""
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20959.15",""
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20959.15",""
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","4564","20959.15","APC 277.30"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","4564","20959.15","APC 296.56"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","4564","20959.15","APC 308.91"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","4564","20959.15","APC"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","4564","20959.15","APC"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","4564","20959.15","APC"
"Egd w/transmural drain cyst","43240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","4564","20959.15","APC"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd tube/cath insertion","43241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us fine needle bx/aspir","43242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd injection varices","43243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd varices ligation","43244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd dilate stricture","43245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd place gastrostomy tube","43246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","902.63","5790",""
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Egd remove foreign body","43247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","902.63","5790",""
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Egd guide wire insertion","43248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Esoph egd dilation <30 mm","43249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd cautery tumor polyp","43250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd remove lesion snare","43251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","7337",""
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1909.69","7337",""
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","7337",""
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","7337","APC 277.30"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","7337","APC 296.56"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","7337","APC 308.91"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","7337","APC"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","7337","APC"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","7337","APC"
"Egd optical endomicroscopy","43252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","7337","APC"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us transmural injxn/mark","43253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd endo mucosal resection","43254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd control bleeding any","43255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Uppr Gi Endoscopy W Stent","43256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","14111",""
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Egd w/thrml txmnt gerd","43257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Operative upper GI endoscopy","43258","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd us exam duodenum/jejunum","43259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3836.96","14111",""
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp w/specimen collection","43260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3836.96","14111",""
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3836.96","14111",""
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Endo cholangiopancreatograph","43262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1909.69","14111",""
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","14111",""
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1909.69","14111",""
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","14111","APC 277.30"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","14111","APC 296.56"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","14111","APC 308.91"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","14111","APC"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","14111","APC"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","14111","APC"
"Ercp sphincter pressure meas","43263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","14111","APC"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3836.96","14111",""
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp remove duct calculi","43264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20959.15",""
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20959.15",""
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20959.15",""
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","4564","20959.15","APC 277.30"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","4564","20959.15","APC 296.56"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","4564","20959.15","APC 308.91"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","4564","20959.15","APC"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","4564","20959.15","APC"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","4564","20959.15","APC"
"Ercp lithotripsy calculi","43265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","4564","20959.15","APC"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","20959.15",""
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","20959.15",""
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Egd endoscopic stent place","43266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Endo cholangiopancreatograph","43267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Endo cholangiopancreatograph","43268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Endo cholangiopancreatograph","43269","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd lesion ablation","43270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Endo cholangiopancreatograph","43271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Endo cholangiopancreatograph","43272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Endoscopic pancreatoscopy","43273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Endoscopic pancreatoscopy","43273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Endoscopic pancreatoscopy","43273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20959.15",""
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20959.15",""
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp duct stent placement","43274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Ercp remove forgn body duct","43275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20959.15",""
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20959.15",""
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp stent exchange w/dilate","43276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","14111",""
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp ea duct/ampulla dilate","43277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","14111",""
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Ercp lesion ablate w/dilate","43278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Lap myotomy heller","43279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Lap myotomy heller","43279","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Lap myotomy heller","43279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy fundoplasty","43280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesophag hern repair","43281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Lap paraesoph her rpr w/mesh","43282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Lap esoph lengthening","43283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap esoph lengthening","43283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap esoph lengthening","43283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps esophgl sphnctr agmntj","43284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Rmvl esophgl sphnctr dev","43285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Esphg tot w/laps moblj","43286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esphg tot w/laps moblj","43286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esphg tot w/laps moblj","43286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esphg dstl 2/3 w/laps moblj","43287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esphg dstl 2/3 w/laps moblj","43287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esphg dstl 2/3 w/laps moblj","43287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esphg thrsc moblj","43288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esphg thrsc moblj","43288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esphg thrsc moblj","43288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc esoph","43289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx trnsorl dplmnt balo","43290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Egd flx trnsorl rmvl balo","43291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Repair of esophagus","43300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of esophagus","43300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of esophagus","43300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair esophagus and fistula","43305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair esophagus and fistula","43305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair esophagus and fistula","43305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of esophagus","43310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of esophagus","43310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of esophagus","43310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair esophagus and fistula","43312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair esophagus and fistula","43312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair esophagus and fistula","43312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esophagoplasty congenital","43313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esophagoplasty congenital","43313","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esophagoplasty congenital","43313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tracheo-esophagoplasty cong","43314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tracheo-esophagoplasty cong","43314","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tracheo-esophagoplasty cong","43314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse esophagus & stomach","43320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse esophagus & stomach","43320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse esophagus & stomach","43320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise esophagus & stomach","43325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise esophagus & stomach","43325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise esophagus & stomach","43325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esoph fundoplasty lap","43327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esoph fundoplasty lap","43327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esoph fundoplasty lap","43327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esoph fundoplasty thor","43328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esoph fundoplasty thor","43328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esoph fundoplasty thor","43328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esophagomyotomy abdominal","43330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esophagomyotomy abdominal","43330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esophagomyotomy abdominal","43330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esophagomyotomy thoracic","43331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Esophagomyotomy thoracic","43331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Esophagomyotomy thoracic","43331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transab esoph hiat hern rpr","43332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transab esoph hiat hern rpr","43332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transab esoph hiat hern rpr","43332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transab esoph hiat hern rpr","43333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transab esoph hiat hern rpr","43333","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transab esoph hiat hern rpr","43333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transthor diaphrag hern rpr","43334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Transthor diaphrag hern rpr","43335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Thorabd diaphr hern repair","43336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Thorabd diaphr hern repair","43337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Thorabd diaphr hern repair","43337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Esoph lengthening","43338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Esoph lengthening","43338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse esophagus & intestine","43340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Fuse esophagus & intestine","43341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Fuse esophagus & intestine","43341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical opening esophagus","43351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
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"Surgical opening esophagus","43352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Gastrointestinal repair","43360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Gastrointestinal repair","43360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Gastrointestinal repair","43360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Gastrointestinal repair","43361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Gastrointestinal repair","43361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Gastrointestinal repair","43361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ligate esophagus veins","43400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Ligate esophagus veins","43400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Ligate esophagus veins","43400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Ligate/staple esophagus","43405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ligate/staple esophagus","43405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ligate/staple esophagus","43405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair esophagus wound","43410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair esophagus wound","43410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair esophagus wound","43410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair esophagus wound","43415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair esophagus wound","43415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair esophagus wound","43415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair esophagus opening","43420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair esophagus opening","43425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair esophagus opening","43425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair esophagus opening","43425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Dilate esophagus 1/mult pass","43450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Dilate esophagus","43453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Dilate esophagus","43456","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Dilate esophagus","43458","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Pressure treatment esophagus","43460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pressure treatment esophagus","43460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pressure treatment esophagus","43460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Free jejunum flap microvasc","43496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Free jejunum flap microvasc","43496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Free jejunum flap microvasc","43496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","6041.75","20959.15",""
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","6041.75","20959.15",""
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"Transorl lwr esophgl myotomy","43497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Esophagus surgery procedure","43499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Surgical opening of stomach","43500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgical opening of stomach","43500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgical opening of stomach","43500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical repair of stomach","43501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgical repair of stomach","43501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgical repair of stomach","43501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical repair of stomach","43502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgical repair of stomach","43502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgical repair of stomach","43502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Surgical opening of stomach","43510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Incision of pyloric muscle","43520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of pyloric muscle","43520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of pyloric muscle","43520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Biopsy of stomach","43605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Biopsy of stomach","43605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Biopsy of stomach","43605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Excision of stomach lesion","43610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of stomach lesion","43610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of stomach lesion","43610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of stomach lesion","43611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of stomach lesion","43611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of stomach lesion","43611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43621","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach","43622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of stomach partial","43635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Vagotomy & pylorus repair","43640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Vagotomy & pylorus repair","43640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Vagotomy & pylorus repair","43640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Vagotomy & pylorus repair","43641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Vagotomy & pylorus repair","43641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Vagotomy & pylorus repair","43641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap gastric bypass/roux-en-y","43644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Lap gastric bypass/roux-en-y","43644","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Lap gastric bypass/roux-en-y","43644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Lap gastr bypass incl smll i","43645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Lap gastr bypass incl smll i","43645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Lap gastr bypass incl smll i","43645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","11089.19","38469",""
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Lap impl electrode antrum","43647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","10578.79","36698.4",""
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","10578.79","36698.4",""
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap revise/remv eltrd antrum","43648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy vagus nerve","43652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy gastrostomy","43653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc stom","43659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Nasal/orogastric w/tube plmt","43752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","3408",""
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","214.89","3408",""
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","3408",""
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","3408","APC 277.30"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","3408","APC 296.56"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","3408","APC 308.91"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","3408","APC"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","3408","APC"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","3408","APC"
"Tx gastro intub w/asp","43753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","3408","APC"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","3408",""
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","214.89","3408",""
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","3408",""
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","3408","APC 277.30"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","3408","APC 296.56"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","3408","APC 308.91"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","3408","APC"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","3408","APC"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","3408","APC"
"Dx gastr intub w/asp spec","43754","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","3408","APC"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","3408",""
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","128.06","3408",""
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","3408",""
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","3408","APC 277.30"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","3408","APC 296.56"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","3408","APC 308.91"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","3408","APC"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","3408","APC"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","3408","APC"
"Dx gastr intub w/asp specs","43755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","3408","APC"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp spec","43756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Dx duod intub w/asp specs","43757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Change gastrostomy tube","43760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Reposition gastrostomy tube","43761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube no revj trc","43762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Rplc gtube  revj gstrst trc","43763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Lap place gastr adj device","43770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Lap revise gastr adj device","43771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Lap revise gastr adj device","43771","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Lap revise gastr adj device","43771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3836.96","19040",""
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","19040",""
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3836.96","19040",""
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","19040","APC 277.30"
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","19040","APC 296.56"
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","19040","APC 308.91"
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","19040","APC"
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","19040","APC"
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","19040","APC"
"Lap rmvl gastr adj device","43772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","19040","APC"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Lap replace gastr adj device","43773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","3836.96","35289",""
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","35289",""
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","3836.96","35289",""
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","35289","APC 277.30"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","35289","APC 296.56"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","35289","APC 308.91"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","35289","APC"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","35289","APC"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","35289","APC"
"Lap rmvl gastr adj all parts","43774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","35289","APC"
"Lap sleeve gastrectomy","43775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Lap sleeve gastrectomy","43775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Lap sleeve gastrectomy","43775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Reconstruction of pylorus","43800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruction of pylorus","43800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruction of pylorus","43800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of stomach and bowel","43825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1909.69","14111",""
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","14111",""
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1909.69","14111",""
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","14111","APC 277.30"
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","14111","APC 296.56"
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","14111","APC 308.91"
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","14111","APC"
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","14111","APC"
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","14111","APC"
"Place gastrostomy tube","43830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","14111","APC"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Place gastrostomy tube","43831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Place gastrostomy tube","43832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Place gastrostomy tube","43832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Place gastrostomy tube","43832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3836.96","19040",""
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","19040",""
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3836.96","19040",""
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","19040","APC 277.30"
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","19040","APC 296.56"
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","19040","APC 308.91"
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","19040","APC"
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","19040","APC"
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","19040","APC"
"Repair of stomach lesion","43840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","19040","APC"
"V-band gastroplasty","43842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"V-band gastroplasty","43842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"V-band gastroplasty","43842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Gastroplasty w/o v-band","43843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Gastroplasty w/o v-band","43843","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Gastroplasty w/o v-band","43843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Gastroplasty duodenal switch","43845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Gastroplasty duodenal switch","43845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Gastroplasty duodenal switch","43845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Gastric bypass for obesity","43846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Gastric bypass for obesity","43846","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Gastric bypass for obesity","43846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Gastric bypass incl small i","43847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Gastric bypass incl small i","43847","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Gastric bypass incl small i","43847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision gastroplasty","43848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision gastroplasty","43848","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision gastroplasty","43848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise stomach-bowel fusion","43850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Revise stomach-bowel fusion","43855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Revise stomach-bowel fusion","43860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise stomach-bowel fusion","43860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise stomach-bowel fusion","43860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise stomach-bowel fusion","43865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise stomach-bowel fusion","43865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise stomach-bowel fusion","43865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3408","14111","APC 277.30"
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3408","14111","APC 296.56"
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3408","14111","APC 308.91"
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3408","14111","APC"
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3408","14111","APC"
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3408","14111","APC"
"Repair stomach opening","43870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3408","14111","APC"
"Repair stomach-bowel fistula","43880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair stomach-bowel fistula","43880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair stomach-bowel fistula","43880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Impl/redo electrd antrum","43881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Impl/redo electrd antrum","43881","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Impl/redo electrd antrum","43881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise/remove electrd antrum","43882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise/remove electrd antrum","43882","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise/remove electrd antrum","43882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3408","19040","APC 277.30"
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3408","19040","APC 296.56"
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3408","19040","APC 308.91"
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3408","19040","APC"
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3408","19040","APC"
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3408","19040","APC"
"Revise gastric port open","43886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3408","19040","APC"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Remove gastric port open","43887","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3526.71","19040",""
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Change gastric port open","43888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Gstr rstcv px trnsorl esg","43889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Stomach surgery procedure","43999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Freeing of bowel adhesion","44005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Freeing of bowel adhesion","44005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Freeing of bowel adhesion","44005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of small bowel","44010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of small bowel","44010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of small bowel","44010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert needle cath bowel","44015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert needle cath bowel","44015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert needle cath bowel","44015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore small intestine","44020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore small intestine","44020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore small intestine","44020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Decompress small bowel","44021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Decompress small bowel","44021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Decompress small bowel","44021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of large bowel","44025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of large bowel","44025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of large bowel","44025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reduce bowel obstruction","44050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reduce bowel obstruction","44050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reduce bowel obstruction","44050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Correct malrotation of bowel","44055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Correct malrotation of bowel","44055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Correct malrotation of bowel","44055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Biopsy of bowel","44100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Excise intestine lesion(s)","44110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excise intestine lesion(s)","44110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excise intestine lesion(s)","44110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of bowel lesion(s)","44111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of bowel lesion(s)","44111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of bowel lesion(s)","44111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of small intestine","44125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Enterectomy w/o taper cong","44126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Enterectomy w/o taper cong","44126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Enterectomy w/o taper cong","44126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Enterectomy w/taper cong","44127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Enterectomy w/taper cong","44127","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Enterectomy w/taper cong","44127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Enterectomy cong add-on","44128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Enterectomy cong add-on","44128","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Enterectomy cong add-on","44128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bowel to bowel fusion","44130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bowel to bowel fusion","44130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bowel to bowel fusion","44130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Enterectomy cadaver donor","44132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Enterectomy cadaver donor","44132","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Enterectomy cadaver donor","44132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Enterectomy live donor","44133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Enterectomy live donor","44133","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Enterectomy live donor","44133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intestine transplnt cadaver","44135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intestine transplnt cadaver","44135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intestine transplnt cadaver","44135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intestine transplant live","44136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intestine transplant live","44136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intestine transplant live","44136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove intestinal allograft","44137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove intestinal allograft","44137","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove intestinal allograft","44137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Mobilization of colon","44139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Mobilization of colon","44139","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Mobilization of colon","44139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44144","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of colon","44147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of colon","44150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of colon","44150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of colon","44150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of colon/ileostomy","44156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Colectomy w/Ileoanal Anast","44157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Colectomy w/Ileoanal Anast","44157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Colectomy w/Ileoanal Anast","44157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Colectomy w/Neo-Rectum Pouch","44158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Colectomy w/Neo-Rectum Pouch","44158","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Colectomy w/Neo-Rectum Pouch","44158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of colon","44160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of colon","44160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of colon","44160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Lap enterolysis","44180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Lap jejunostomy","44186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ileo/jejuno-stomy","44187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap ileo/jejuno-stomy","44187","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap ileo/jejuno-stomy","44187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap colostomy","44188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap colostomy","44188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap colostomy","44188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap enterectomy","44202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lap enterectomy","44202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lap enterectomy","44202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lap resect s/intestine addl","44203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lap resect s/intestine addl","44203","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lap resect s/intestine addl","44203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo partial colectomy","44204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo partial colectomy","44204","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo partial colectomy","44204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Lap colectomy part w/ileum","44205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap colectomy part w/ileum","44205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap colectomy part w/ileum","44205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap part colectomy w/stoma","44206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap part colectomy w/stoma","44206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap part colectomy w/stoma","44206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"L colectomy/coloproctostomy","44207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"L colectomy/coloproctostomy","44207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"L colectomy/coloproctostomy","44207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"L colectomy/coloproctostomy","44208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"L colectomy/coloproctostomy","44208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"L colectomy/coloproctostomy","44208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo total proctocolectomy","44210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparo total proctocolectomy","44210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparo total proctocolectomy","44210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap colectomy w/proctectomy","44211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap colectomy w/proctectomy","44211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap colectomy w/proctectomy","44211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo total proctocolectomy","44212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparo total proctocolectomy","44212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparo total proctocolectomy","44212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap mobil splenic fl add-on","44213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap mobil splenic fl add-on","44213","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap mobil splenic fl add-on","44213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap close enterostomy","44227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap close enterostomy","44227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap close enterostomy","44227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc intestine","44238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Open bowel to skin","44300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Ileostomy/jejunostomy","44310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ileostomy/jejunostomy","44310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ileostomy/jejunostomy","44310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3408","19040","APC 277.30"
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3408","19040","APC 296.56"
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3408","19040","APC 308.91"
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3408","19040","APC"
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3408","19040","APC"
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3408","19040","APC"
"Revision of ileostomy","44312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3408","19040","APC"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of ileostomy","44314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Devise bowel pouch","44316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Devise bowel pouch","44316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Devise bowel pouch","44316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Colostomy","44320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Colostomy","44320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Colostomy","44320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Colostomy with biopsies","44322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Colostomy with biopsies","44322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Colostomy with biopsies","44322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3526.71","19040",""
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10982.43","","","","","","","fee schedule","3526.71","19040","APC 277.30"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11745.22","","","","","","","fee schedule","3526.71","19040","APC 296.56"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12234.34","","","","","","","fee schedule","3526.71","19040","APC 308.91"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3621.79","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3561.29","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3526.71","","","","","","","fee schedule","3526.71","19040","APC"
"Revision of colostomy","44346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3630.44","","","","","","","fee schedule","3526.71","19040","APC"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6041.75","20959.15",""
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6041.75","20959.15",""
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6041.75","20959.15",""
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"Small Bowel Endoscopy/Stent","44370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy/biopsy","44377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6041.75","20959.15",""
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6041.75","20959.15",""
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6041.75","20959.15",""
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","6041.75","20959.15","APC 277.30"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","6041.75","20959.15","APC 296.56"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","6041.75","20959.15","APC 308.91"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","6041.75","20959.15","APC"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","6041.75","20959.15","APC"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","6041.75","20959.15","APC"
"S Bowel Endoscope W/Stent","44379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","6041.75","20959.15","APC"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy br/wa","44380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy br/wa","44381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Small bowel endoscopy","44382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Ileoscopy W/Stent","44383","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Small bowel endoscopy","44384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy of bowel pouch","44385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Endoscopy bowel pouch/biop","44386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy thru stoma spx","44388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy with biopsy","44389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy for foreign body","44390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy for bleeding","44391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy & polypectomy","44392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy, lesion removal","44393","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/snare","44394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy W Stent","44397","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy with ablation","44401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","20959.15",""
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","20959.15",""
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/stent plcmt","44402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/resection","44403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/injection","44404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/dilation","44405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ultrasound","44406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ndl aspir/bx","44407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy w/decompression","44408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Intro gastrointestinal tube","44500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3836.96","14111",""
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Suture small intestine","44602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Suture small intestine","44603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Suture small intestine","44603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Suture small intestine","44603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Suture large intestine","44604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Suture large intestine","44604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Suture large intestine","44604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of bowel lesion","44605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of bowel lesion","44605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of bowel lesion","44605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intestinal stricturoplasty","44615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intestinal stricturoplasty","44615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intestinal stricturoplasty","44615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44626","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel opening","44626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel-skin fistula","44640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel-skin fistula","44640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel-skin fistula","44640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel fistula","44650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel fistula","44650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel fistula","44650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel-bladder fistula","44660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel-bladder fistula","44660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel-bladder fistula","44660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair bowel-bladder fistula","44661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair bowel-bladder fistula","44661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair bowel-bladder fistula","44661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical revision intestine","44680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgical revision intestine","44680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgical revision intestine","44680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Suspend bowel w/prosthesis","44700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Suspend bowel w/prosthesis","44700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Suspend bowel w/prosthesis","44700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intraop colon lavage add-on","44701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Intraop colon lavage add-on","44701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Intraop colon lavage add-on","44701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Prepare fecal microbiota","44705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Prepare donor intestine","44715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prepare donor intestine","44715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prepare donor intestine","44715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor intestine/venous","44720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor intestine/venous","44720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor intestine/venous","44720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor intestine/artery","44721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor intestine/artery","44721","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor intestine/artery","44721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Unlisted px small intestine","44799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Excision of bowel pouch","44800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of bowel pouch","44800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of bowel pouch","44800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of mesentery lesion","44820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of mesentery lesion","44820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of mesentery lesion","44820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of mesentery","44850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of mesentery","44850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of mesentery","44850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bowel surgery procedure","44899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bowel surgery procedure","44899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bowel surgery procedure","44899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain appendix abscess open","44900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drain appendix abscess open","44900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drain appendix abscess open","44900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","22350.2",""
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","22350.2",""
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","22350.2",""
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","5220","22350.2","APC 277.30"
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","5220","22350.2","APC 296.56"
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","5220","22350.2","APC 308.91"
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","5220","22350.2","APC"
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","5220","22350.2","APC"
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","5220","22350.2","APC"
"Appendectomy","44950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","5220","22350.2","APC"
"Appendectomy add-on","44955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Appendectomy add-on","44955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Appendectomy add-on","44955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Appendectomy","44960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Appendectomy","44960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Appendectomy","44960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy appendectomy","44970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc app","44979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of pelvic abscess","45000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of rectal abscess","45005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","9582.68",""
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Drainage of rectal abscess","45020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","9582.68",""
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Biopsy of rectum","45100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","14111",""
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of anorectal lesion","45108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of rectum","45110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial proctectomy","45113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial proctectomy","45113","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial proctectomy","45113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45114","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of rectum","45116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove rectum w/reservoir","45119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove rectum w/reservoir","45119","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove rectum w/reservoir","45119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of rectum","45120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of rectum and colon","45121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of rectum and colon","45121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of rectum and colon","45121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial proctectomy","45123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Partial proctectomy","45123","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Partial proctectomy","45123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Pelvic exenteration","45126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pelvic exenteration","45126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pelvic exenteration","45126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of rectal prolapse","45130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of rectal prolapse","45130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of rectal prolapse","45130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of rectal prolapse","45135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of rectal prolapse","45135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of rectal prolapse","45135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excise ileoanal reservior","45136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excise ileoanal reservior","45136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excise ileoanal reservior","45136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Excision of rectal stricture","45150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","14111",""
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of rectal lesion","45160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2762.33","14111",""
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Exc rect tum transanal part","45171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2762.33","19040",""
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Exc rect tum transanal full","45172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2762.33","14111",""
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction rectal tumor","45190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Proctosigmoidoscopy dx","45300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy dilate","45303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy w/bx","45305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy fb","45307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","9582.68",""
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Proctosigmoidoscopy removal","45308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy removal","45315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy bleed","45317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy ablate","45320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy volvul","45321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","20959.15",""
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","20959.15",""
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","20959.15",""
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","3408","20959.15","APC 277.30"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","3408","20959.15","APC 296.56"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","3408","20959.15","APC 308.91"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","3408","20959.15","APC"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","3408","20959.15","APC"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","3408","20959.15","APC"
"Proctosigmoidoscopy W/Stent","45327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","3408","20959.15","APC"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Diagnostic sigmoidoscopy","45330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy and biopsy","45331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/fb removal","45332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy & polypectomy","45333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy for bleeding","45334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy w/submuc inj","45335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy & decompress","45337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/tumr remove","45338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy","45339","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sig w/tndsc balloon dilation","45340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy W/Ultrasound","45341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy W/Us Guide Bx","45342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmodoscopy W/Stent","45345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/ablation","45346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","20959.15",""
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","20959.15",""
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Sigmoidoscopy w/plcmt stent","45347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","9582.68",""
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Sigmoidoscopy w/resection","45349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Sgmdsc w/band ligation","45350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Surgical colonoscopy","45355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","925.49","5790",""
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Diagnostic colonoscopy","45378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/fb removal","45379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy and biopsy","45380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy submucous njx","45381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/control bleed","45382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Lesion removal colonoscopy","45383","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/lesion removal","45385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/balloon dilat","45386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy W/Stent","45387","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/ablation","45388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","20959.15",""
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20959.15",""
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","20959.15",""
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18814.45","","","","","","","fee schedule","5220","20959.15","APC 277.30"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20121.21","","","","","","","fee schedule","5220","20959.15","APC 296.56"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20959.15","","","","","","","fee schedule","5220","20959.15","APC 308.91"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6204.64","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6100.98","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6041.75","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/stent plcmt","45389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6219.45","","","","","","","fee schedule","5220","20959.15","APC"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","9582.68",""
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Colonoscopy w/resection","45390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscope us","45391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/endoscopic fnb","45392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/decompression","45393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Lap removal of rectum","45395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap removal of rectum","45395","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap removal of rectum","45395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lap remove rectum w/pouch","45397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap remove rectum w/pouch","45397","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap remove rectum w/pouch","45397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Colonoscopy w/band ligation","45398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5790",""
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Unlisted procedure colon","45399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Laparoscopic proc","45400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Laparoscopic proc","45400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Laparoscopic proc","45400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Lap proctopexy w/sig resect","45402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Lap proctopexy w/sig resect","45402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Lap proctopexy w/sig resect","45402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc rectum","45499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","14111",""
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of rectum","45500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","19040",""
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of rectum","45505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","5220",""
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5220",""
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","5220",""
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5220","APC 277.30"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5220","APC 296.56"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5220","APC 308.91"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5220","APC"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5220","APC"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5220","APC"
"Treatment of rectal prolapse","45520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5220","APC"
"Correct rectal prolapse","45540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Correct rectal prolapse","45540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Correct rectal prolapse","45540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","19040",""
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Correct rectal prolapse","45541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Repair rectum/remove sigmoid","45550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair rectum/remove sigmoid","45550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair rectum/remove sigmoid","45550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","19040",""
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of rectocele","45560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Exploration/repair of rectum","45562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration/repair of rectum","45562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration/repair of rectum","45562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration/repair of rectum","45563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration/repair of rectum","45563","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration/repair of rectum","45563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair rect/bladder fistula","45800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair rect/bladder fistula","45800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair rect/bladder fistula","45800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair fistula w/colostomy","45805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair fistula w/colostomy","45805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair fistula w/colostomy","45805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair rectourethral fistula","45820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair rectourethral fistula","45820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair rectourethral fistula","45820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair fistula w/colostomy","45825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair fistula w/colostomy","45825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair fistula w/colostomy","45825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Reduction of rectal prolapse","45900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of anal sphincter","45905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Dilation of rectal narrowing","45910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Remove rectal obstruction","45915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","9582.68",""
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Surg dx exam anorectal","45990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","5220",""
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5220",""
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","5220",""
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5220","APC 277.30"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5220","APC 296.56"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5220","APC 308.91"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5220","APC"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5220","APC"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5220","APC"
"Rectum surgery procedure","45999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5220","APC"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Placement of seton","46020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Removal of rectal marker","46030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Incision of rectal abscess","46040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","14111",""
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Incision of rectal abscess","46045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Incision of anal abscess","46050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of rectal abscess","46060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal septum","46070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incision of anal sphincter","46080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Incise external hemorrhoid","46083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","14111",""
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of anal fissure","46200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Excise anal ext tag/papilla","46220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Ligation of hemorrhoid(s)","46221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","9582.68",""
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of anal tags","46230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove ext hem groups 2+","46250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove int/ext hem 1 group","46255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp & fiss","46257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grp w/fistu","46258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem groups 2+","46260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps & fiss","46261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove in/ex hem grps w/fist","46262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist subq","46270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist inter","46275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist complex","46280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove anal fist 2 stage","46285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2762.33","19040",""
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair anal fistula","46288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Removal of hemorrhoid clot","46320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","5220",""
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5220",""
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","5220",""
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5220","APC 277.30"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5220","APC 296.56"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5220","APC 308.91"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5220","APC"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5220","APC"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5220","APC"
"Injection into hemorrhoid(s)","46500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5220","APC"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1190.9","5790",""
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Chemodenervation anal musc","46505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Diagnostic anoscopy spx","46600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Diagnostic anoscopy","46601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and dilation","46604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy and biopsy","46606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Diagnostic anoscopy & biopsy","46607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy remove for body","46608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy remove lesion","46610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","925.49","5790",""
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","5790",""
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","925.49","5790",""
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5790","APC 277.30"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5790","APC 296.56"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5790","APC 308.91"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy","46611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5790","APC"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy remove lesions","46612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","5790",""
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","5790","APC 277.30"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","5790","APC 296.56"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","5790","APC 308.91"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy control bleeding","46614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","5790","APC"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Anoscopy","46615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of anal stricture","46700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Repair of anal stricture","46705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of anal stricture","46705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of anal stricture","46705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Repr of anal fistula w/glue","46706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2762.33","19040",""
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair anorectal fist w/plug","46707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Repr per/vag pouch sngl proc","46710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repr per/vag pouch sngl proc","46710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repr per/vag pouch sngl proc","46710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repr per/vag pouch dbl proc","46712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repr per/vag pouch dbl proc","46712","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repr per/vag pouch dbl proc","46712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rep perf anoper fistu","46715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rep perf anoper fistu","46715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rep perf anoper fistu","46715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rep perf anoper/vestib fistu","46716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Rep perf anoper/vestib fistu","46716","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Rep perf anoper/vestib fistu","46716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Construction of absent anus","46740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of imperforated anus","46742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of imperforated anus","46742","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of imperforated anus","46742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46744","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46748","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46748","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of cloacal anomaly","46748","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of anal sphincter","46751","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of anal sphincter","46751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Reconstruction of anus","46753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","9582.68",""
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Removal of suture from anus","46754","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Repair of anal sphincter","46761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Implant artificial sphincter","46762","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","10181",""
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","3408",""
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","404.56","3408",""
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","3408",""
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","3408","APC 277.30"
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","3408","APC 296.56"
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","3408","APC 308.91"
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","3408","APC"
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","3408","APC"
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","3408","APC"
"Destruction anal lesion(s)","46900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","3408","APC"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction anal lesion(s)","46910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Cryosurgery anal lesion(s)","46916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Laser surgery anal lesions","46917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Excision of anal lesion(s)","46922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Destruction anal lesion(s)","46924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1190.9","7337",""
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1190.9","7337",""
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1190.9","7337",""
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","7337","APC 277.30"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","7337","APC 296.56"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","7337","APC 308.91"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","7337","APC"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","7337","APC"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","7337","APC"
"Destroy internal hemorrhoids","46930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","7337","APC"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2762.33","9582.68",""
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","9582.68",""
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2762.33","9582.68",""
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","9582.68","APC 277.30"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","9582.68","APC 296.56"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","9582.68","APC 308.91"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","9582.68","APC"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","9582.68","APC"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","9582.68","APC"
"Treatment of anal fissure","46940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","9582.68","APC"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","3880",""
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","925.49","3880",""
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","3880",""
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3880","APC 277.30"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3880","APC 296.56"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3880","APC 308.91"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3880","APC"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3880","APC"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3880","APC"
"Treatment of anal fissure","46942","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3880","APC"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grp","46945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2762.33","14111",""
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Remove by ligat int hem grps","46946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2762.33","19040",""
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2762.33","19040",""
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2762.33","19040",""
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","19040","APC 277.30"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","19040","APC 296.56"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","19040","APC 308.91"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","19040","APC"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","19040","APC"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","19040","APC"
"Hemorrhoidopexy by stapling","46947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","19040","APC"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2762.33","14111",""
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Int hrhc tranal dartlzj 2+","46948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","5220",""
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5220",""
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","5220",""
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5220","APC 277.30"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5220","APC 296.56"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5220","APC 308.91"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5220","APC"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5220","APC"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5220","APC"
"Anus surgery procedure","46999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5220","APC"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy of liver","47000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy liver add-on","47001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Needle biopsy liver add-on","47001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Needle biopsy liver add-on","47001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Open drainage liver lesion","47010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open drainage liver lesion","47010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open drainage liver lesion","47010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Inject/aspirate liver cyst","47015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Inject/aspirate liver cyst","47015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Inject/aspirate liver cyst","47015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Wedge biopsy of liver","47100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Wedge biopsy of liver","47100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Wedge biopsy of liver","47100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Partial removal of liver","47120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive removal of liver","47122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive removal of liver","47122","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive removal of liver","47122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of liver","47130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of donor liver","47133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of donor liver","47133","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of donor liver","47133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transplantation of liver","47135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transplantation of liver","47135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transplantation of liver","47135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47142","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal donor liver","47142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor liver whole","47143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor liver whole","47143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor liver whole","47143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor liver 3-segment","47144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor liver 3-segment","47144","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor liver 3-segment","47144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor liver lobe split","47145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor liver lobe split","47145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor liver lobe split","47145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor liver/venous","47146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor liver/venous","47146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor liver/venous","47146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor liver/arterial","47147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor liver/arterial","47147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor liver/arterial","47147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgery for liver lesion","47300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgery for liver lesion","47300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgery for liver lesion","47300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair liver wound","47362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver tumor rf","47370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate liver cryosurg","47371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope procedure liver","47379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Open ablate liver tumor rf","47380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open ablate liver tumor rf","47380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open ablate liver tumor rf","47380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open ablate liver tumor cryo","47381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open ablate liver tumor cryo","47381","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open ablate liver tumor cryo","47381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Percut ablate liver rf","47382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Perq abltj lvr cryoablation","47383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj ire liver 1+ tum perq","47384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Liver surgery procedure","47399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Incision of liver duct","47400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of liver duct","47400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of liver duct","47400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of bile duct","47420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of bile duct","47420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of bile duct","47420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of bile duct","47425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of bile duct","47425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of bile duct","47425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise bile duct sphincter","47460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise bile duct sphincter","47460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise bile duct sphincter","47460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of gallbladder","47480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of gallbladder","47480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of gallbladder","47480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Incision of gallbladder","47490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Insert catheter, bile duct","47510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","4564",""
"Insert bile duct drain","47511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Change bile duct catheter","47525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Revise/reinsert bile tube","47530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Injection for cholangiogram","47532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Plmt biliary drainage cath","47534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Conversion ext bil drg cath","47535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Exchange biliary drg cath","47536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Removal biliary drg cath","47537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Perq plmt bile duct stent","47540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","22350.2",""
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","22350.2",""
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","22350.2",""
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","5220","22350.2","APC 277.30"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","5220","22350.2","APC 296.56"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","5220","22350.2","APC 308.91"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","5220","22350.2","APC"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","5220","22350.2","APC"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","5220","22350.2","APC"
"Plmt access bil tree sm bwl","47541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","5220","22350.2","APC"
"Dilate biliary duct/ampulla","47542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Dilate biliary duct/ampulla","47542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Dilate biliary duct/ampulla","47542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Endoluminal bx biliary tree","47543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Endoluminal bx biliary tree","47543","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Endoluminal bx biliary tree","47543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Removal duct glbldr calculi","47544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Removal duct glbldr calculi","47544","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Removal duct glbldr calculi","47544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Bile duct endoscopy add-on","47550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bile duct endoscopy add-on","47550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bile duct endoscopy add-on","47550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","22350.2",""
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","22350.2",""
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","22350.2",""
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","4564","22350.2","APC 277.30"
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","4564","22350.2","APC 296.56"
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","4564","22350.2","APC 308.91"
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","4564","22350.2","APC"
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","4564","22350.2","APC"
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","4564","22350.2","APC"
"Biliary endo perq dx w/speci","47552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","4564","22350.2","APC"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","5220","29398","APC 277.30"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","5220","29398","APC 296.56"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","5220","29398","APC 308.91"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","5220","29398","APC"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","5220","29398","APC"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","5220","29398","APC"
"Biliary endoscopy thru skin","47553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","5220","29398","APC"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Biliary endoscopy thru skin","47554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","22350.2",""
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","22350.2",""
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","22350.2",""
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","5220","22350.2","APC 277.30"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","5220","22350.2","APC 296.56"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","5220","22350.2","APC 308.91"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","5220","22350.2","APC"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","5220","22350.2","APC"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","5220","22350.2","APC"
"Biliary endoscopy thru skin","47555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","5220","22350.2","APC"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Biliary endoscopy thru skin","47556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy w/cholangio","47560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Laparo w/cholangio/biopsy","47561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopic cholecystectomy","47562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Laparo cholecystectomy/graph","47563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo cholecystectomy/explr","47564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo cholecystoenterostomy","47570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparo cholecystoenterostomy","47570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparo cholecystoenterostomy","47570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc biliary","47579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Removal of gallbladder","47600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of gallbladder","47600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of gallbladder","47600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Removal of gallbladder","47605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of gallbladder","47620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove bile duct stone","47630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Exploration of bile ducts","47700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of bile ducts","47700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of bile ducts","47700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bile duct revision","47701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bile duct revision","47701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bile duct revision","47701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct tumor","47711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct tumor","47711","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct tumor","47711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct tumor","47712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct tumor","47712","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct tumor","47712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct cyst","47715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct cyst","47715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of bile duct cyst","47715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse upper gi structures","47721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse upper gi structures","47721","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse upper gi structures","47721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47741","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse gallbladder & bowel","47741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse liver ducts & bowel","47765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse liver ducts & bowel","47765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse liver ducts & bowel","47765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse bile ducts and bowel","47785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reconstruction of bile ducts","47800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reconstruction of bile ducts","47800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reconstruction of bile ducts","47800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Placement bile duct support","47801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Placement bile duct support","47801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Placement bile duct support","47801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse liver duct & intestine","47802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Suture bile duct injury","47900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Suture bile duct injury","47900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Suture bile duct injury","47900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Bile tract surgery procedure","47999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Drainage of abdomen","48000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drainage of abdomen","48000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drainage of abdomen","48000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Placement of drain pancreas","48001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Placement of drain pancreas","48001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Placement of drain pancreas","48001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pancreatic stone","48020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pancreatic stone","48020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pancreatic stone","48020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Biopsy of pancreas open","48100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Biopsy of pancreas open","48100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Biopsy of pancreas open","48100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy pancreas","48102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Resect/Debride Pancreas","48105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/Debride Pancreas","48105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/Debride Pancreas","48105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pancreas lesion","48120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pancreas lesion","48120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pancreas lesion","48120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pancreatic duct","48148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pancreatic duct","48148","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pancreatic duct","48148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of pancreas","48150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pancreatectomy","48154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pancreas","48155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pancreas","48155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pancreas","48155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pancreas removal/transplant","48160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pancreas removal/transplant","48160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pancreas removal/transplant","48160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Injection intraop add-on","48400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Injection intraop add-on","48400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Injection intraop add-on","48400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgery of pancreatic cyst","48500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Surgery of pancreatic cyst","48500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Surgery of pancreatic cyst","48500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain pancreatic pseudocyst","48510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drain pancreatic pseudocyst","48510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drain pancreatic pseudocyst","48510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse pancreas cyst and bowel","48520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse pancreas cyst and bowel","48520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse pancreas cyst and bowel","48520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse pancreas cyst and bowel","48540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse pancreas cyst and bowel","48540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse pancreas cyst and bowel","48540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pancreatorrhaphy","48545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pancreatorrhaphy","48545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pancreatorrhaphy","48545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Duodenal exclusion","48547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Duodenal exclusion","48547","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Duodenal exclusion","48547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fuse Pancreas and Bowel","48548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fuse Pancreas and Bowel","48548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fuse Pancreas and Bowel","48548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Donor pancreatectomy","48550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Prep donor pancreas","48551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Prep donor pancreas/venous","48552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Transpl allograft pancreas","48554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Removal allograft pancreas","48556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Pancreas surgery procedure","48999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Exploration of abdomen","49000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Exploration of abdomen","49000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Exploration of abdomen","49000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Reopening of abdomen","49002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reopening of abdomen","49002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reopening of abdomen","49002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","22350.2",""
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","22350.2",""
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","22350.2",""
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","5220","22350.2","APC 277.30"
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","5220","22350.2","APC 296.56"
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","5220","22350.2","APC 308.91"
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","5220","22350.2","APC"
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","5220","22350.2","APC"
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","5220","22350.2","APC"
"Exploration behind abdomen","49010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","5220","22350.2","APC"
"Prpertl pel pack hemrrg trma","49013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prpertl pel pack hemrrg trma","49013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prpertl pel pack hemrrg trma","49013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reexploration pelvic wound","49014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reexploration pelvic wound","49014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reexploration pelvic wound","49014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drainage abdom abscess open","49020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drainage abdom abscess open","49020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drainage abdom abscess open","49020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain open abdom abscess","49040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drain open abdom abscess","49040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drain open abdom abscess","49040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain open retroperi abscess","49060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drain open retroperi abscess","49060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drain open retroperi abscess","49060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drain to peritoneal cavity","49062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drain to peritoneal cavity","49062","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drain to peritoneal cavity","49062","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis","49082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Abd paracentesis w/imaging","49083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Peritoneal lavage","49084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy abdominal mass","49180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5701.97",""
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Sclerotx fluid collection","49185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Opn exc/dstr ntra-abd 5 cm/<","49186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","12739","14111",""
"Opn exc/dstr ntra-abd 5 cm/<","49186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","12739","14111",""
"Opn exc/dstr ntra-abd 5.1-10","49187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","12739","14111",""
"Opn exc/dstr ntra-abd 5.1-10","49187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","12739","14111",""
"Opn exc/dst ntra-abd 10.1-20","49188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","12739","14111",""
"Opn exc/dst ntra-abd 10.1-20","49188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","12739","14111",""
"Opn exc/dst ntra-abd 20.1-30","49189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Opn exc/dst ntra-abd 20.1-30","49189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Opn exc/dstr ntra-abd >30 cm","49190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Opn exc/dstr ntra-abd >30 cm","49190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Exc abd tum 5 cm or less","49203","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Exc abd tum over 5 cm","49204","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Exc abd tum over 10 cm","49205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Excise sacral spine tumor","49215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excise sacral spine tumor","49215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excise sacral spine tumor","49215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Excision of umbilicus","49250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","22350.2",""
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","22350.2",""
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","22350.2",""
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","5220","22350.2","APC 277.30"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","5220","22350.2","APC 296.56"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","5220","22350.2","APC 308.91"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","5220","22350.2","APC"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","5220","22350.2","APC"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","5220","22350.2","APC"
"Removal of omentum","49255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","5220","22350.2","APC"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Diag laparo separate proc","49320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy biopsy","49321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopy aspiration","49322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","23971",""
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Laparo drain lymphocele","49323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","23971",""
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Lap insert tunnel ip cath","49324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","23971",""
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Lap Revision Perm IP Cath","49325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Lap w/Omentopexy Add-on","49326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Lap w/Omentopexy Add-on","49326","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Lap w/Omentopexy Add-on","49326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Lap ins device for rt","49327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Lap ins device for rt","49327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Lap ins device for rt","49327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc abdm/per/oment","49329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Air injection into abdomen","49400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Air injection into abdomen","49400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Air injection into abdomen","49400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3563.21","19040",""
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Remove foreign body adbomen","49402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid colxn visc","49405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid peri/retro","49406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Image cath fluid trns/vgnl","49407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1377.48","5790",""
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1377.48","5790",""
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1377.48","5790",""
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4289.59","","","","","","","fee schedule","1377.48","5790","APC 277.30"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4587.52","","","","","","","fee schedule","1377.48","5790","APC 296.56"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4778.57","","","","","","","fee schedule","1377.48","5790","APC 308.91"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.62","","","","","","","fee schedule","1377.48","5790","APC"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.99","","","","","","","fee schedule","1377.48","5790","APC"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.48","","","","","","","fee schedule","1377.48","5790","APC"
"Ins mark abd/pel for rt perq","49411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1418","","","","","","","fee schedule","1377.48","5790","APC"
"Ins device for rt guide open","49412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ins device for rt guide open","49412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ins device for rt guide open","49412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3563.21","19040",""
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Insert tun ip cath perc","49418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3408","29398",""
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","29398",""
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3408","29398",""
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","3408","29398","APC 277.30"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","3408","29398","APC 296.56"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","3408","29398","APC 308.91"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","3408","29398","APC"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","3408","29398","APC"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","3408","29398","APC"
"Insert tun ip cath w/port","49419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","3408","29398","APC"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3408","19040","APC 277.30"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3408","19040","APC 296.56"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3408","19040","APC 308.91"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3408","19040","APC"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3408","19040","APC"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3408","19040","APC"
"Ins tun ip cath for dial opn","49421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3408","19040","APC"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3142.32","19040",""
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Remove tunneled ip cath","49422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Exchange drainage catheter","49423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Assess cyst contrast inject","49424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Assess cyst contrast inject","49424","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Assess cyst contrast inject","49424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert abdomen-venous drain","49425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert abdomen-venous drain","49425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert abdomen-venous drain","49425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3563.21","19040",""
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Revise abdomen-venous shunt","49426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Injection abdominal shunt","49427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection abdominal shunt","49427","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection abdominal shunt","49427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Ligation of shunt","49428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ligation of shunt","49428","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ligation of shunt","49428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Removal of shunt","49429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Insert Subq Exten to IP Cath","49435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","5790",""
"Insert Subq Exten to IP Cath","49435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","5790",""
"Insert Subq Exten to IP Cath","49435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","5790",""
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1909.69","6624.83",""
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Embedded IP Cath Exit-Site","49436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place gastrostomy tube perc","49440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place duod/jej tube perc","49441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1190.9","7337",""
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1190.9","7337",""
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1190.9","7337",""
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3708.54","","","","","","","fee schedule","1190.9","7337","APC 277.30"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3966.11","","","","","","","fee schedule","1190.9","7337","APC 296.56"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4131.28","","","","","","","fee schedule","1190.9","7337","APC 308.91"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1223","","","","","","","fee schedule","1190.9","7337","APC"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1202.57","","","","","","","fee schedule","1190.9","7337","APC"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1190.9","","","","","","","fee schedule","1190.9","7337","APC"
"Place cecostomy tube perc","49442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1225.92","","","","","","","fee schedule","1190.9","7337","APC"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1909.69","6624.83",""
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1909.69","6624.83",""
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1909.69","6624.83",""
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5946.93","","","","","","","fee schedule","1909.69","6624.83","APC 277.30"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6359.97","","","","","","","fee schedule","1909.69","6624.83","APC 296.56"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6624.83","","","","","","","fee schedule","1909.69","6624.83","APC 308.91"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1961.18","","","","","","","fee schedule","1909.69","6624.83","APC"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1928.42","","","","","","","fee schedule","1909.69","6624.83","APC"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1909.69","","","","","","","fee schedule","1909.69","6624.83","APC"
"Change g-tube to g-j perc","49446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1965.86","","","","","","","fee schedule","1909.69","6624.83","APC"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Replace g/c tube perc","49450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Replace duod/jej tube perc","49451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Replace g-j tube perc","49452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","902.63","5790",""
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Fix g/colon tube w/device","49460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","237.46","5220",""
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","237.46","5220",""
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","237.46","5220",""
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5220","APC 277.30"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5220","APC 296.56"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5220","APC 308.91"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5220","APC"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5220","APC"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5220","APC"
"Fluoro exam of g/colon tube","49465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5220","APC"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","20871.56",""
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20871.56",""
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","20871.56",""
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","20871.56","APC 277.30"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","20871.56","APC 296.56"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","20871.56","APC 308.91"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","20871.56","APC"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","20871.56","APC"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","20871.56","APC"
"Rpr hern preemie reduc","49491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","20871.56","APC"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hern premie blocked","49492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby reduc","49495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia baby blocked","49496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr ing hernia init reduce","49500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ing hernia init blocked","49501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init reduc >5 yr","49505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3563.21","19040",""
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Prp i/hern init block >5 yr","49507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3563.21","19040",""
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair ing hernia reduce","49520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6442.74","22350.2",""
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6442.74","22350.2",""
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6442.74","22350.2",""
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rerepair ing hernia blocked","49521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Repair ing hernia sliding","49525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","20871.56",""
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20871.56",""
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","20871.56",""
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","4564","20871.56","APC 277.30"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","4564","20871.56","APC 296.56"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","4564","20871.56","APC 308.91"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","4564","20871.56","APC"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","4564","20871.56","APC"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","4564","20871.56","APC"
"Repair lumbar hernia","49540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","4564","20871.56","APC"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3563.21","19040",""
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr rem hernia init reduce","49550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3563.21","19040",""
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr fem hernia init blocked","49553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3563.21","19040",""
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia reduce","49555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3563.21","19040",""
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rerepair fem hernia blocked","49557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr ventral hern init reduc","49560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Rpr ventral hern init block","49561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Rerepair ventrl hern reduce","49565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Rerepair ventrl hern block","49566","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Hernia repair w/mesh","49568","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","10181",""
"Rpr epigastric hern reduce","49570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Rpr epigastric hern blocked","49572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Rpr umbil hern reduc < 5 yr","49580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Rpr umbil hern block < 5 yr","49582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Rpr umbil hern reduc > 5 yr","49585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Rpr umbil hern block > 5 yr","49587","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Repair spigelian hernia","49590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn 1st < 3 cm rdc","49591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st < 3 ncr/strn","49592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st 3-10 rdc","49593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st 3-10 ncr/strn","49594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st > 10 rdc","49595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn 1st > 10 ncr/strn","49596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rpr aa hrn 1st > 10 ncr/strn","49596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Repair umbilical lesion","49600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Repair umbilical lesion","49605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair umbilical lesion","49611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn rcr < 3 rdc","49613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn rcr < 3 ncr/strn","49614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6442.74","22350.2",""
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn rcr 3-10 rdc","49615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Rpr aa hrn rcr 3-10 ncr/strn","49616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rpr aa hrn rcr 3-10 ncr/strn","49616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Rpr aa hrn rcr > 10 rdc","49617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rpr aa hrn rcr > 10 rdc","49617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Rpr aa hrn rcr > 10 ncr/strn","49618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rpr aa hrn rcr > 10 ncr/strn","49618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Rpr parastomal hernia rdc","49621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rpr parastomal hernia rdc","49621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Rpr parastomal hrna ncr/strn","49622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Rpr parastomal hrna ncr/strn","49622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Rmvl ninfct mesh hernia rpr","49623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Rmvl ninfct mesh hernia rpr","49623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","29398",""
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair init","49650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","6016.5","29398",""
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Lap ing hernia repair recur","49651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Lap vent/abd hernia repair","49652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Lap vent/abd hern proc comp","49653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Lap inc hernia repair","49654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Lap inc hern repair comp","49655","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Lap inc hernia repair recur","49656","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Lap inc hern recur comp","49657","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","13700",""
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc hernia repair","49659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Repair of abdominal wall","49900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of abdominal wall","49900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of abdominal wall","49900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Omental flap extra-abdom","49904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Omental flap extra-abdom","49904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Omental flap extra-abdom","49904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Omental flap intra-abdom","49905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Omental flap intra-abdom","49905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Omental flap intra-abdom","49905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Free omental flap microvasc","49906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Free omental flap microvasc","49906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Free omental flap microvasc","49906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","902.63","5790",""
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Abdomen surgery procedure","49999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Exploration of kidney","50010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Renal abscess open drain","50020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of kidney","50040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Drainage of kidney","50040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Drainage of kidney","50040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Exploration of kidney","50045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of kidney","50065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of kidney","50065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of kidney","50065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of kidney","50070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of kidney","50070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of kidney","50070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","32681.98",""
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","32681.98",""
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","32681.98",""
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","5220","32681.98","APC 277.30"
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","5220","32681.98","APC 296.56"
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","5220","32681.98","APC 308.91"
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","32681.98",""
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","32681.98",""
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","32681.98",""
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","5220","32681.98","APC 277.30"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","5220","32681.98","APC 296.56"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","5220","32681.98","APC 308.91"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","5220","32681.98","APC"
"Removal of kidney stone","50081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","5220","32681.98","APC"
"Revise kidney blood vessels","50100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise kidney blood vessels","50100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise kidney blood vessels","50100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore and drain kidney","50125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore and drain kidney","50125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore and drain kidney","50125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney stone","50130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration of kidney","50135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Renal biopsy perq","50200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Renal biopsy open","50205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Renal biopsy open","50205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Renal biopsy open","50205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove kidney open","50220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove kidney open","50220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove kidney open","50220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal kidney open complex","50225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal kidney open complex","50225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal kidney open complex","50225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal kidney open radical","50230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal kidney open radical","50230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal kidney open radical","50230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney & ureter","50234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney & ureter","50234","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney & ureter","50234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney & ureter","50236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney & ureter","50236","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney & ureter","50236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of kidney","50240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of kidney","50240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of kidney","50240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Cryoablate renal mass open","50250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cryoablate renal mass open","50250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cryoablate renal mass open","50250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney lesion","50280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney lesion","50280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney lesion","50280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney lesion","50290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney lesion","50290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney lesion","50290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove cadaver donor kidney","50300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove cadaver donor kidney","50300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove cadaver donor kidney","50300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove kidney living donor","50320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove kidney living donor","50320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove kidney living donor","50320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep cadaver renal allograft","50323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep cadaver renal allograft","50323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep cadaver renal allograft","50323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep donor renal graft","50325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep donor renal graft","50325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep donor renal graft","50325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/venous","50327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/venous","50327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/venous","50327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/arterial","50328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/arterial","50328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/arterial","50328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/ureteral","50329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/ureteral","50329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Prep renal graft/ureteral","50329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of kidney","50340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of kidney","50340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of kidney","50340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transplantation of kidney","50360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transplantation of kidney","50360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transplantation of kidney","50360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transplantation of kidney","50365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transplantation of kidney","50365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transplantation of kidney","50365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove transplanted kidney","50370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove transplanted kidney","50370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove transplanted kidney","50370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reimplantation of kidney","50380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reimplantation of kidney","50380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reimplantation of kidney","50380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Change ureter stent percut","50382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Remove ureter stent percut","50384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2080.35","14111",""
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Change stent via transureth","50385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Remove stent via transureth","50386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7216.83",""
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","7216.83",""
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7216.83",""
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Change nephroureteral cath","50387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","693.95","3880",""
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Remove renal tube w/fluoro","50389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Drainage of kidney lesion","50390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Instll rx agnt into rnal tub","50391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Insert kidney drain","50392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Insert ureteral tube","50393","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Create passage to kidney","50395","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","693.95","3880",""
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Measure kidney pressure","50396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Change kidney tube","50398","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Revision of kidney/ureter","50400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Revision of kidney/ureter","50400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Revision of kidney/ureter","50400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Revision of kidney/ureter","50405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Revision of kidney/ureter","50405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Revision of kidney/ureter","50405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","5220",""
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","5220",""
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","5220",""
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5220","APC 277.30"
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5220","APC 296.56"
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5220","APC 308.91"
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","5220",""
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","5220",""
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","5220",""
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5220","APC 277.30"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5220","APC 296.56"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5220","APC 308.91"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5220","APC"
"Njx px nfrosgrm &/urtrgrm","50431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5220","APC"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Plmt nephrostomy catheter","50432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Plmt nephroureteral catheter","50433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2080.35","7216.83",""
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","7216.83",""
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2080.35","7216.83",""
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Convert nephrostomy catheter","50434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2080.35","7216.83",""
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","7216.83",""
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2080.35","7216.83",""
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Exchange nephrostomy cath","50435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Dilat xst trc ndurlgc px","50436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Dilat xst trc new access rcs","50437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Repair of kidney wound","50500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of kidney wound","50500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of kidney wound","50500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Close kidney-skin fistula","50520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","5220",""
"Close kidney-skin fistula","50520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3499","5220",""
"Close kidney-skin fistula","50520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","5220",""
"Close nephrovisceral fistula","50525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Close nephrovisceral fistula","50525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Close nephrovisceral fistula","50525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Close nephrovisceral fistula","50526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Close nephrovisceral fistula","50526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Close nephrovisceral fistula","50526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of horseshoe kidney","50540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of horseshoe kidney","50540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of horseshoe kidney","50540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","36698.4",""
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","36698.4",""
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo ablate renal cyst","50541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","36698.4",""
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo ablate renal mass","50542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo partial nephrectomy","50543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy pyeloplasty","50544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo Radical Nephrectomy","50545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparo Radical Nephrectomy","50545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparo Radical Nephrectomy","50545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscopic nephrectomy","50546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparoscopic nephrectomy","50546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparoscopic nephrectomy","50546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo removal donor kidney","50547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparo removal donor kidney","50547","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparo removal donor kidney","50547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo remove w/ureter","50548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Laparo remove w/ureter","50548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Laparo remove w/ureter","50548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc renal","50549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy","50553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3408","32681.98",""
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","32681.98",""
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3408","32681.98",""
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","3408","32681.98","APC 277.30"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","3408","32681.98","APC 296.56"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","3408","32681.98","APC 308.91"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & biopsy","50555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","32681.98",""
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","32681.98",""
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","32681.98",""
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","3408","32681.98","APC 277.30"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","3408","32681.98","APC 296.56"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","3408","32681.98","APC 308.91"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & treatment","50557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Kidney endoscopy & treatment","50561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3408","32681.98",""
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","32681.98",""
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3408","32681.98",""
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","3408","32681.98","APC 277.30"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","3408","32681.98","APC 296.56"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","3408","32681.98","APC 308.91"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","3408","32681.98","APC"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","3408","32681.98","APC"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","3408","32681.98","APC"
"Renal scope w/tumor resect","50562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","3408","32681.98","APC"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3408","12169.63",""
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","12169.63",""
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3408","12169.63",""
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","12169.63","APC 277.30"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","12169.63","APC 296.56"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","12169.63","APC 308.91"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy","50570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","693.95","3880",""
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Kidney endoscopy","50572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3408","12169.63",""
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","12169.63",""
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3408","12169.63",""
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","12169.63","APC 277.30"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","12169.63","APC 296.56"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","12169.63","APC 308.91"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy & biopsy","50574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","12169.63","APC"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","23971","APC 277.30"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","23971","APC 296.56"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","23971","APC 308.91"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","23971","APC"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","23971","APC"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","23971","APC"
"Kidney endoscopy","50575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","23971","APC"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","32681.98",""
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","32681.98",""
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","32681.98",""
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","5220","32681.98","APC 277.30"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","5220","32681.98","APC 296.56"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","5220","32681.98","APC 308.91"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","5220","32681.98","APC"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","5220","32681.98","APC"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","5220","32681.98","APC"
"Kidney endoscopy & treatment","50576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","5220","32681.98","APC"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","18511.05",""
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","18511.05",""
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","18511.05",""
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","18511.05","APC 277.30"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","18511.05","APC 296.56"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","18511.05","APC 308.91"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","18511.05","APC"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","18511.05","APC"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","18511.05","APC"
"Kidney endoscopy & treatment","50580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","18511.05","APC"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3508.06","29398",""
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3508.06","29398",""
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3508.06","29398",""
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","29398","APC 277.30"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","29398","APC 296.56"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","29398","APC 308.91"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","29398","APC"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","29398","APC"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","29398","APC"
"Fragmenting of kidney stone","50590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","29398","APC"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3408","29398",""
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","29398",""
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3408","29398",""
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","3408","29398","APC 277.30"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","3408","29398","APC 296.56"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","3408","29398","APC 308.91"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","3408","29398","APC"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","3408","29398","APC"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","3408","29398","APC"
"Perc rf ablate renal tumor","50592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","3408","29398","APC"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Perc cryo ablate renal tum","50593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Exploration of ureter","50600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Exploration of ureter","50600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Exploration of ureter","50600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert ureteral support","50605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Insert ureteral support","50605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Insert ureteral support","50605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endoluminal bx urtr rnl plvs","50606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Endoluminal bx urtr rnl plvs","50606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Endoluminal bx urtr rnl plvs","50606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Removal of ureter stone","50610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of ureter stone","50630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of ureter","50650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of ureter","50650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of ureter","50650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of ureter","50660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of ureter","50660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of ureter","50660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Injection for ureter x-ray","50684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for ureter x-ray","50684","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for ureter x-ray","50684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","5220",""
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","128.06","5220",""
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","5220",""
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","5220","APC 277.30"
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","5220","APC 296.56"
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","5220","APC 308.91"
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","5220","APC"
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","5220","APC"
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","5220","APC"
"Measure ureter pressure","50686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","5220","APC"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7216.83",""
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","7216.83",""
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7216.83",""
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Change of ureter tube/stent","50688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Injection for ureter x-ray","50690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for ureter x-ray","50690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for ureter x-ray","50690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Plmt ureteral stent prq","50695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of ureter","50700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of ureter","50700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of ureter","50700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ureteral embolization/occl","50705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Ureteral embolization/occl","50705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Ureteral embolization/occl","50705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Balloon dilate urtrl strix","50706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Balloon dilate urtrl strix","50706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Balloon dilate urtrl strix","50706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Release of ureter","50715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50722","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release/revise ureter","50725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release/revise ureter","50725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release/revise ureter","50725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Revise ureter","50727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Revise ureter","50728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise ureter","50728","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise ureter","50728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & kidney","50740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & kidney","50740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & kidney","50740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & kidney","50750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & kidney","50750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & kidney","50750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of ureters","50760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of ureters","50760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of ureters","50760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Splicing of ureters","50770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Splicing of ureters","50770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Splicing of ureters","50770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Reimplant ureter in bladder","50780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Reimplant ureter in bladder","50780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Reimplant ureter in bladder","50782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50782","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50783","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reimplant ureter in bladder","50785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant ureter in bowel","50800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant ureter in bowel","50800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant ureter in bowel","50800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & bowel","50810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & bowel","50810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of ureter & bowel","50810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Urine shunt to intestine","50815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Urine shunt to intestine","50815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Urine shunt to intestine","50815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Construct bowel bladder","50820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Construct bowel bladder","50820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Construct bowel bladder","50820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Construct bowel bladder","50825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Construct bowel bladder","50825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Construct bowel bladder","50825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise urine flow","50830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise urine flow","50830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise urine flow","50830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace ureter by bowel","50840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace ureter by bowel","50840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace ureter by bowel","50840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Appendico-vesicostomy","50845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Appendico-vesicostomy","50845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Appendico-vesicostomy","50845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transplant ureter to skin","50860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transplant ureter to skin","50860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transplant ureter to skin","50860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of ureter","50900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of ureter","50900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of ureter","50900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Closure ureter/skin fistula","50920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Closure ureter/skin fistula","50920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Closure ureter/skin fistula","50920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Closure ureter/bowel fistula","50930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Closure ureter/bowel fistula","50930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Closure ureter/bowel fistula","50930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release of ureter","50940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy ureterolithotomy","50945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo New Ureter/Bladder","50948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc ureter","50949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3408","12169.63",""
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","12169.63",""
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3408","12169.63",""
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","12169.63","APC 277.30"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","12169.63","APC 296.56"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","12169.63","APC 308.91"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3408","12169.63",""
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","12169.63",""
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3408","12169.63",""
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","12169.63","APC 277.30"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","12169.63","APC 296.56"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","12169.63","APC 308.91"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","12169.63","APC"
"Endoscopy of ureter","50953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & biopsy","50955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3408","12169.63",""
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","12169.63",""
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3408","12169.63",""
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","12169.63","APC 277.30"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","12169.63","APC 296.56"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","12169.63","APC 308.91"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy","50970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3408","12169.63",""
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","12169.63",""
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3408","12169.63",""
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","12169.63","APC 277.30"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","12169.63","APC 296.56"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","12169.63","APC 308.91"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy & catheter","50972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","12169.63","APC"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & biopsy","50974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Ureter endoscopy & treatment","50980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Incise & treat bladder","51020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Incise & treat bladder","51030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2080.35","14111",""
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Incise & drain bladder","51040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2080.35","7216.83",""
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2080.35","7216.83",""
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2080.35","7216.83",""
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Incise bladder/drain ureter","51045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","18511.05",""
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of bladder stone","51050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","2080.35","23971",""
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","23971",""
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","2080.35","23971",""
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","23971","APC 277.30"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","23971","APC 296.56"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","23971","APC 308.91"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","23971","APC"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","23971","APC"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","23971","APC"
"Removal of ureter stone","51060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","23971","APC"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Remove ureter calculus","51065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","10028.23",""
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drainage of bladder abscess","51080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Drain bladder by needle","51100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","854.62","5790",""
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","854.62","5790",""
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","854.62","5790",""
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","5790","APC 277.30"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","5790","APC 296.56"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","5790","APC 308.91"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","5790","APC"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","5790","APC"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","5790","APC"
"Drain bladder by trocar/cath","51101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","5790","APC"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Drain bl w/cath insertion","51102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6016.5","20871.56",""
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","20871.56",""
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6016.5","20871.56",""
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","20871.56","APC 277.30"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","20871.56","APC 296.56"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","20871.56","APC 308.91"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","20871.56","APC"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","20871.56","APC"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","20871.56","APC"
"Removal of bladder cyst","51500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","20871.56","APC"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of bladder lesion","51520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of bladder lesion","51525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Removal of bladder lesion","51525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Removal of bladder lesion","51525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Removal of bladder lesion","51530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Removal of bladder lesion","51530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Removal of bladder lesion","51530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of ureter lesion","51535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Partial removal of bladder","51550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of bladder","51550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of bladder","51550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of bladder","51555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Partial removal of bladder","51555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Partial removal of bladder","51555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise bladder & ureter(s)","51565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise bladder & ureter(s)","51565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise bladder & ureter(s)","51565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of bladder","51570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of bladder","51570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of bladder","51570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of bladder & nodes","51575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of bladder & nodes","51575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of bladder & nodes","51575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of bladder & nodes","51585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of bladder & nodes","51585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of bladder & nodes","51585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove bladder/revise tract","51595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove bladder/create pouch","51596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove bladder/create pouch","51596","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove bladder/create pouch","51596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pelvic structures","51597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pelvic structures","51597","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pelvic structures","51597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Injection for bladder x-ray","51600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for bladder x-ray","51600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for bladder x-ray","51600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Preparation for bladder xray","51605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Preparation for bladder xray","51605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Preparation for bladder xray","51605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection for bladder x-ray","51610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for bladder x-ray","51610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for bladder x-ray","51610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Irrigation of bladder","51700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Insert bladder catheter","51701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Insert temp bladder cath","51702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","3408",""
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","128.06","3408",""
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","3408",""
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","3408","APC 277.30"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","3408","APC 296.56"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","3408","APC 308.91"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","3408","APC"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","3408","APC"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","3408","APC"
"Insert bladder cath complex","51703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","3408","APC"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Change of bladder tube","51705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","693.95","3880",""
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Change of bladder tube","51710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Endoscopic injection/implant","51715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","693.95","3408",""
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","693.95","3408",""
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","693.95","3408",""
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3408","APC 277.30"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3408","APC 296.56"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3408","APC 308.91"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3408","APC"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3408","APC"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3408","APC"
"Treatment of bladder lesion","51720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3408","APC"
"Ins trurl ablt trnsdc thr us","51721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ins trurl ablt trnsdc thr us","51721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Simple cystometrogram","51725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Complex cystometrogram","51726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5220","APC 277.30"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5220","APC 296.56"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5220","APC 308.91"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/up","51727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5220","APC 277.30"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5220","APC 296.56"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5220","APC 308.91"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp","51728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","5220",""
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5220","APC 277.30"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5220","APC 296.56"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5220","APC 308.91"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5220","APC"
"Cystometrogram w/vp&up","51729","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5220","APC"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Urine flow measurement","51736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","5220",""
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","214.89","5220",""
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","5220",""
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","5220","APC 277.30"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","5220","APC 296.56"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","5220","APC 308.91"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","5220","APC"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","5220","APC"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","5220","APC"
"Electro-uroflowmetry first","51741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","5220","APC"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","5220",""
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","128.06","5220",""
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","5220",""
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","5220","APC 277.30"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","5220","APC 296.56"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","5220","APC 308.91"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","5220","APC"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","5220","APC"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","5220","APC"
"Anal/urinary muscle study","51784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","5220","APC"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Anal/urinary muscle study","51785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Urinary reflex study","51792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Intraabdominal pressure test","51797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Intraabdominal pressure test","51797","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Intraabdominal pressure test","51797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Us urine capacity measure","51798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Revision of bladder/urethra","51800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of bladder/urethra","51800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of bladder/urethra","51800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of urinary tract","51820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of urinary tract","51820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of urinary tract","51820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Attach bladder/urethra","51840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Attach bladder/urethra","51841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Attach bladder/urethra","51841","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Attach bladder/urethra","51841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","23971",""
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder neck","51845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","32681.98",""
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","32681.98",""
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","32681.98",""
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","5220","32681.98","APC 277.30"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","5220","32681.98","APC 296.56"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","5220","32681.98","APC 308.91"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","5220","32681.98","APC"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","5220","32681.98","APC"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","5220","32681.98","APC"
"Repair of bladder wound","51860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","5220","32681.98","APC"
"Repair of bladder wound","51865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Repair of bladder wound","51865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Repair of bladder wound","51865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Repair of bladder opening","51880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Repair bladder/vagina lesion","51900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Repair bladder/vagina lesion","51900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Repair bladder/vagina lesion","51900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Close bladder-uterus fistula","51920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Close bladder-uterus fistula","51920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Close bladder-uterus fistula","51920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Hysterectomy/bladder repair","51925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Hysterectomy/bladder repair","51925","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Hysterectomy/bladder repair","51925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Correction of bladder defect","51940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Correction of bladder defect","51940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Correction of bladder defect","51940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of bladder & bowel","51960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of bladder & bowel","51960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of bladder & bowel","51960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Construct bladder opening","51980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Construct bladder opening","51980","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Construct bladder opening","51980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo urethral suspension","51990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo sling operation","51992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc bla","51999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","3880",""
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","693.95","3880",""
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","3880",""
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","3880","APC 277.30"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","3880","APC 296.56"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","3880","APC 308.91"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","3880","APC"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","3880","APC"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","3880","APC"
"Cystoscopy","52000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","3880","APC"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3508.06","12169.63",""
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","12169.63",""
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3508.06","12169.63",""
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Cystoscopy removal of clots","52001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy & ureter catheter","52005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and biopsy","52007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","4564",""
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","693.95","4564",""
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","4564",""
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","4564","APC 277.30"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","4564","APC 296.56"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","4564","APC 308.91"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","4564","APC"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","4564","APC"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","4564","APC"
"Cystoscopy & duct catheter","52010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","4564","APC"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy w/biopsy(s)","52204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","18511.05",""
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","18511.05",""
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","18511.05",""
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","18511.05","APC 277.30"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","18511.05","APC 296.56"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","18511.05","APC 308.91"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","18511.05","APC"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","18511.05","APC"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","18511.05","APC"
"Cystoscopy and treatment","52240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","18511.05","APC"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and radiotracer","52250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy & revise urethra","52270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy & revise urethra","52275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy implant stent","52282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cysto rx balo cath urtl strx","52284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","693.95","5790",""
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","693.95","5790",""
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","693.95","5790",""
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5790","APC 277.30"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5790","APC 296.56"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5790","APC 308.91"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5790","APC"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5790","APC"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5790","APC"
"Cystoscopy and treatment","52285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5790","APC"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7337",""
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2080.35","7337",""
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7337",""
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7337","APC 277.30"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7337","APC 296.56"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7337","APC 308.91"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7337","APC"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7337","APC"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7337","APC"
"Cystoscopy chemodenervation","52287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7337","APC"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","18511.05",""
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","18511.05",""
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","18511.05",""
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","18511.05","APC 277.30"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","18511.05","APC 296.56"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","18511.05","APC 308.91"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","18511.05","APC"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","18511.05","APC"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","18511.05","APC"
"Cystoscopy and treatment","52305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","18511.05","APC"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","7216.83",""
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Cystoscopy and treatment","52315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Remove bladder stone","52317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Remove bladder stone","52318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","18511.05",""
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy stone removal","52325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","23971","APC 277.30"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","23971","APC 296.56"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","23971","APC 308.91"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","23971","APC"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","23971","APC"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","23971","APC"
"Cystoscopy inject material","52327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","23971","APC"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystoscopy and treatment","52332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Create passage to kidney","52334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Ureter Stricture Tx","52341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Up Stricture Tx","52342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto W/Renal Stricture Tx","52343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/uretero stricture tx","52344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cysto/Uretero W/Up Stricture","52345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","18511.05",""
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","18511.05",""
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","18511.05",""
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","18511.05","APC 277.30"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","18511.05","APC 296.56"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","18511.05","APC 308.91"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","18511.05","APC"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","18511.05","APC"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","18511.05","APC"
"Cystouretero W/Renal Strict","52346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","18511.05","APC"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero & or pyeloscope","52351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero w/stone remove","52352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5336.05","23971",""
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","23971",""
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5336.05","23971",""
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","23971","APC 277.30"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","23971","APC 296.56"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","23971","APC 308.91"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","23971","APC"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","23971","APC"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","23971","APC"
"Cystouretero W/Lithotripsy","52353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","23971","APC"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","18511.05",""
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Biopsy","52354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","18511.05",""
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystouretero W/Excise Tumor","52355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","23971","APC 277.30"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","23971","APC 296.56"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","23971","APC 308.91"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","23971","APC"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","23971","APC"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","23971","APC"
"Cysto/uretero w/lithotripsy","52356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","23971","APC"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystouretero W/Congen Repr","52400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Cystourethro cut ejacul duct","52402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Cystourethro w/implant","52441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Cystourethro w/implant","52441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Cystourethro w/implant","52441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Cystourethro w/addl implant","52442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Cystourethro w/addl implant","52442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Cystourethro w/addl implant","52442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto 1st trurl prst8 comis","52443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of prostate","52450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Revision of bladder neck","52500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Trurl rbtc wtrjt rescj prst8","52597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5336.05","23971",""
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","23971",""
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5336.05","23971",""
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","23971","APC 277.30"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","23971","APC 296.56"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","23971","APC 308.91"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","23971","APC"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","23971","APC"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","23971","APC"
"Prostatectomy (TURP)","52601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","23971","APC"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","23971","APC 277.30"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","23971","APC 296.56"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","23971","APC 308.91"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","23971","APC"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","23971","APC"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","23971","APC"
"Remove prostate regrowth","52630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","23971","APC"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Relieve bladder contracture","52640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Laser surgery of prostate","52647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","13700","23971",""
"Laser surgery of prostate","52647","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","13700","23971",""
"Laser surgery of prostate","52647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","13700","23971",""
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5336.05","23971",""
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5336.05","23971",""
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5336.05","23971",""
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","23971","APC 277.30"
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","23971","APC 296.56"
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","23971","APC 308.91"
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","23971","APC"
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","23971","APC"
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","23971","APC"
"Laser surgery of prostate","52648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","23971","APC"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5336.05","23971",""
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5336.05","23971",""
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5336.05","23971",""
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","23971","APC 277.30"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","23971","APC 296.56"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","23971","APC 308.91"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","23971","APC"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","23971","APC"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","23971","APC"
"Prostate laser enucleation","52649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","23971","APC"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of prostate abscess","52700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","18511.05",""
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","18511.05",""
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","18511.05",""
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","18511.05","APC 277.30"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","18511.05","APC 296.56"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","18511.05","APC 308.91"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","18511.05","APC"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","18511.05","APC"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","18511.05","APC"
"Incision of urethra","53010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","18511.05","APC"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Incision of urethra","53025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of urethra abscess","53040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urethra abscess","53060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","693.95","14111",""
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","14111",""
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","693.95","14111",""
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","14111","APC 277.30"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","14111","APC 296.56"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","14111","APC 308.91"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","14111","APC"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","14111","APC"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","14111","APC"
"Drainage of urinary leakage","53080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","14111","APC"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of urinary leakage","53085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Biopsy of urethra","53200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3508.06","19040",""
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of urethra","53210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5336.05","18511.05",""
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Removal of urethra","53215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","19040",""
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Treatment of urethra lesion","53220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Removal of urethra lesion","53230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","18511.05",""
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","18511.05",""
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","18511.05",""
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","18511.05","APC 277.30"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","18511.05","APC 296.56"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","18511.05","APC 308.91"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","18511.05","APC"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","18511.05","APC"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","18511.05","APC"
"Removal of urethra lesion","53235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","18511.05","APC"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","19040",""
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Surgery for urethra pouch","53240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of urethra gland","53250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Treatment of urethra lesion","53260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Treatment of urethra lesion","53265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of urethra gland","53270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra defect","53275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","19040","APC 277.30"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","19040","APC 296.56"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","19040","APC 308.91"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","19040","APC"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","19040","APC"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","19040","APC"
"Revise urethra stage 1","53400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","19040","APC"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Revise urethra stage 2","53405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruction of urethra","53415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruction of urethra","53415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","19040","APC 277.30"
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","19040","APC 296.56"
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","19040","APC 308.91"
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","19040","APC"
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","19040","APC"
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","19040","APC"
"Reconstruct urethra stage 1","53420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","19040","APC"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra stage 2","53425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Reconstruction of urethra","53430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Reconstruct urethra/bladder","53431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","4564","45549.04",""
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","45549.04",""
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","4564","45549.04",""
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40888.12","","","","","","","fee schedule","4564","45549.04","APC 277.30"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43728.03","","","","","","","fee schedule","4564","45549.04","APC 296.56"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45549.04","","","","","","","fee schedule","4564","45549.04","APC 308.91"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13484.11","","","","","","","fee schedule","4564","45549.04","APC"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13258.83","","","","","","","fee schedule","4564","45549.04","APC"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13130.11","","","","","","","fee schedule","4564","45549.04","APC"
"Male sling procedure","53440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13516.29","","","","","","","fee schedule","4564","45549.04","APC"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","19040","APC 277.30"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","19040","APC 296.56"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","19040","APC 308.91"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","19040","APC"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","19040","APC"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","19040","APC"
"Remove/revise male sling","53442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","19040","APC"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","4564","71554.8",""
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","71554.8",""
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","4564","71554.8",""
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","4564","71554.8","APC 277.30"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","4564","71554.8","APC 296.56"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","4564","71554.8","APC 308.91"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","4564","71554.8","APC"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","4564","71554.8","APC"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","4564","71554.8","APC"
"Insert tandem cuff","53444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","4564","71554.8","APC"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","3408","71554.8",""
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","71554.8",""
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","3408","71554.8",""
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","3408","71554.8","APC 277.30"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","3408","71554.8","APC 296.56"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","3408","71554.8","APC 308.91"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","3408","71554.8","APC"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","3408","71554.8","APC"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","3408","71554.8","APC"
"Insert uro/ves nck sphincter","53445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","3408","71554.8","APC"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3408","29398",""
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","29398",""
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3408","29398",""
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","3408","29398","APC 277.30"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","3408","29398","APC 296.56"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","3408","29398","APC 308.91"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","3408","29398","APC"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","3408","29398","APC"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","3408","29398","APC"
"Remove uro sphincter","53446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","3408","29398","APC"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","3408","71554.8",""
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","71554.8",""
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","3408","71554.8",""
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","3408","71554.8","APC 277.30"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","3408","71554.8","APC 296.56"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","3408","71554.8","APC 308.91"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","3408","71554.8","APC"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","3408","71554.8","APC"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","3408","71554.8","APC"
"Remove/replace ur sphincter","53447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","3408","71554.8","APC"
"Remov/replc ur sphinctr comp","53448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","5220",""
"Remov/replc ur sphinctr comp","53448","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3499","5220",""
"Remov/replc ur sphinctr comp","53448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","5220",""
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","32681.98",""
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","32681.98",""
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","32681.98",""
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","3408","32681.98","APC 277.30"
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","3408","32681.98","APC 296.56"
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","3408","32681.98","APC 308.91"
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","3408","32681.98","APC"
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","3408","32681.98","APC"
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","3408","32681.98","APC"
"Repair uro sphincter","53449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","3408","32681.98","APC"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","19040","APC 277.30"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","19040","APC 296.56"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","19040","APC 308.91"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","19040","APC"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","19040","APC"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","19040","APC"
"Revision of urethra","53450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","19040","APC"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","13130.11","45549.04",""
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","13130.11","45549.04",""
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40888.12","","","","","","","fee schedule","13130.11","45549.04","APC 277.30"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43728.03","","","","","","","fee schedule","13130.11","45549.04","APC 296.56"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45549.04","","","","","","","fee schedule","13130.11","45549.04","APC 308.91"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13484.11","","","","","","","fee schedule","13130.11","45549.04","APC"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13258.83","","","","","","","fee schedule","13130.11","45549.04","APC"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13130.11","","","","","","","fee schedule","13130.11","45549.04","APC"
"Tprnl balo cntnc dev bi","53451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13516.29","","","","","","","fee schedule","13130.11","45549.04","APC"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","9421.01","32681.98",""
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","9421.01","32681.98",""
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Tprnl balo cntnc dev uni","53452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Tprnl balo cntnc dev rmvl ea","53453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","2633",""
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","2633",""
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","2633","APC 277.30"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","2633","APC 296.56"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","2633","APC 308.91"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","2633","APC"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","2633","APC"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","2633","APC"
"Tprnl balo cntnc dev adjmt","53454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","2633","APC"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Revision of urethra","53460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Urethrlys transvag w/ scope","53500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra injury","53502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","18511.05",""
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","18511.05",""
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","18511.05",""
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","18511.05","APC 277.30"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","18511.05","APC 296.56"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","18511.05","APC 308.91"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","18511.05","APC"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","18511.05","APC"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","18511.05","APC"
"Repair of urethra injury","53510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","18511.05","APC"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra injury","53515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4564","19040",""
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","19040",""
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4564","19040",""
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","19040","APC 277.30"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","19040","APC 296.56"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","19040","APC 308.91"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","19040","APC"
"Repair of urethra defect","53520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","19040","APC"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","3408",""
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","132.41","3408",""
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","3408",""
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","3408","APC 277.30"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","3408","APC 296.56"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","3408","APC 308.91"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","3408","APC"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","3408","APC"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","3408","APC"
"Dilate urethra stricture","53601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","3408","APC"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3508.06","12169.63",""
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","12169.63",""
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3508.06","12169.63",""
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Dilate urethra stricture","53605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","693.95","5220",""
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","693.95","5220",""
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","693.95","5220",""
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","5220","APC 277.30"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","5220","APC 296.56"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","5220","APC 308.91"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","5220","APC"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","5220","APC"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","5220","APC"
"Dilate urethra stricture","53620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","5220","APC"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Dilate urethra stricture","53621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","5220",""
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","128.06","5220",""
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","5220",""
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","5220","APC 277.30"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","5220","APC 296.56"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","5220","APC 308.91"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","5220","APC"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","5220","APC"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","5220","APC"
"Dilation of urethra","53660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","5220","APC"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Dilation of urethra","53661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Dilation of urethra","53665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3508.06","12169.63",""
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","12169.63",""
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3508.06","12169.63",""
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostatic microwave thermotx","53850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","23971",""
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Prostatic rf thermotx","53852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Trurl dstrj prst8 tiss rf wv","53854","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2080.35","7216.83",""
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","7216.83",""
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2080.35","7216.83",""
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"Insert prost urethral stent","53855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2080.35","10181",""
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2080.35","10181",""
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2080.35","10181",""
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","10181","APC 277.30"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","10181","APC 296.56"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","10181","APC 308.91"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","10181","APC"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","10181","APC"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","10181","APC"
"Transurethral rf treatment","53860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","10181","APC"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","9421.01","32681.98",""
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","9421.01","32681.98",""
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto insj dev ischmc rmdlg","53865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","2633",""
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","2633",""
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","2633","APC 277.30"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","2633","APC 296.56"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","2633","APC 308.91"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","2633","APC"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","2633","APC"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","2633","APC"
"Cathj rmvl dev ischmc rmdlg","53866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","2633","APC"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Urology surgery procedure","53899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Slitting of prepuce","54000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Slitting of prepuce","54001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","6448",""
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1643.67","6448",""
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","6448",""
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","6448","APC 277.30"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","6448","APC 296.56"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","6448","APC 308.91"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","6448","APC"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","6448","APC"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","6448","APC"
"Drain penis lesion","54015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","6448","APC"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","404.56","5220",""
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","404.56","5220",""
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","404.56","5220",""
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","5220","APC 277.30"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","5220","APC 296.56"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","5220","APC 308.91"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","5220","APC"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","5220","APC"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","5220","APC"
"Destruction penis lesion(s)","54050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","5220","APC"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Cryosurgery penis lesion(s)","54056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Laser surg penis lesion(s)","54057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Excision of penis lesion(s)","54060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destruction penis lesion(s)","54065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of penis","54100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Biopsy of penis","54105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","23971",""
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Treatment of penis lesion","54110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","23971",""
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","23971",""
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","23971",""
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","23971","APC 277.30"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","23971","APC 296.56"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","23971","APC 308.91"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","23971","APC"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","23971","APC"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","23971","APC"
"Treat penis lesion graft","54111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","23971","APC"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","32681.98",""
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","32681.98",""
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","32681.98",""
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","4564","32681.98","APC 277.30"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","4564","32681.98","APC 296.56"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","4564","32681.98","APC 308.91"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","4564","32681.98","APC"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","4564","32681.98","APC"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","4564","32681.98","APC"
"Treat penis lesion graft","54112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","4564","32681.98","APC"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"Treatment of penis lesion","54115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","19040",""
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Partial removal of penis","54120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of penis","54125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of penis","54125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of penis","54125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove penis & nodes","54130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove penis & nodes","54130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove penis & nodes","54130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove penis & nodes","54135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove penis & nodes","54135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove penis & nodes","54135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Circumcision w/regionl block","54150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","693.95","14111",""
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","693.95","14111",""
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","693.95","14111",""
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2161.01","","","","","","","fee schedule","693.95","14111","APC 277.30"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2311.1","","","","","","","fee schedule","693.95","14111","APC 296.56"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2407.35","","","","","","","fee schedule","693.95","14111","APC 308.91"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.66","","","","","","","fee schedule","693.95","14111","APC"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.75","","","","","","","fee schedule","693.95","14111","APC"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.95","","","","","","","fee schedule","693.95","14111","APC"
"Circumcision neonate","54160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.36","","","","","","","fee schedule","693.95","14111","APC"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Circum 28 days or older","54161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Lysis penil circumic lesion","54162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Repair of circumcision","54163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Frenulotomy of penis","54164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5336.05","19040",""
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5336.05","19040",""
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5336.05","19040",""
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","19040","APC 277.30"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","19040","APC 296.56"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","19040","APC 308.91"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","19040","APC"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","19040","APC"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","19040","APC"
"Treatment of penis lesion","54205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","19040","APC"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Treatment of penis lesion","54220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Prepare penis study","54230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Prepare penis study","54230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Prepare penis study","54230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","248.65","5790",""
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5790",""
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","248.65","5790",""
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5790","APC 277.30"
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5790","APC 296.56"
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5790","APC 308.91"
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5790","APC"
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5790","APC"
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5790","APC"
"Dynamic cavernosometry","54231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5790","APC"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Penile injection","54235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","5220",""
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","214.89","5220",""
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","5220",""
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","5220","APC 277.30"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","5220","APC 296.56"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","5220","APC 308.91"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","5220","APC"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","5220","APC"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","5220","APC"
"Penis study","54240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","5220","APC"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Penis study","54250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","23971",""
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","23971",""
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Revision of penis","54304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of urethra","54308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","23971","APC"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","32681.98",""
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","32681.98",""
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","32681.98",""
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","5220","32681.98","APC 277.30"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","5220","32681.98","APC 296.56"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","5220","32681.98","APC 308.91"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","5220","32681.98","APC"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","5220","32681.98","APC"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","5220","32681.98","APC"
"Reconstruction of urethra","54316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","5220","32681.98","APC"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","23971",""
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Reconstruction of urethra","54324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Reconstruction of urethra","54326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","23971",""
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Revise penis/urethra","54328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Revise penis/urethra","54336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Secondary urethral surgery","54340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","32681.98",""
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","32681.98",""
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","32681.98",""
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","5220","32681.98","APC 277.30"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","5220","32681.98","APC 296.56"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","5220","32681.98","APC 308.91"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","5220","32681.98","APC"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","5220","32681.98","APC"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","5220","32681.98","APC"
"Secondary urethral surgery","54344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","5220","32681.98","APC"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","19040","APC 277.30"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","19040","APC 296.56"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","19040","APC 308.91"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","19040","APC"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","19040","APC"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","19040","APC"
"Secondary urethral surgery","54348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","19040","APC"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","23971","APC 277.30"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","23971","APC 296.56"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","23971","APC 308.91"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","23971","APC"
"Reconstruct urethra/penis","54352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","23971","APC"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3508.06","23971",""
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","23971",""
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3508.06","23971",""
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","23971","APC 277.30"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","23971","APC 296.56"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","23971","APC 308.91"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","23971","APC"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","23971","APC"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","23971","APC"
"Penis plastic surgery","54360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","23971","APC"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2080.35","19040",""
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","19040",""
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2080.35","19040",""
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","19040","APC 277.30"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","19040","APC 296.56"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","19040","APC 308.91"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2080.35","19040",""
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","19040",""
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2080.35","19040",""
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","19040","APC 277.30"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","19040","APC 296.56"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","19040","APC 308.91"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis","54385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","19040","APC"
"Repair penis and bladder","54390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Repair penis and bladder","54390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Repair penis and bladder","54390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","45549.04",""
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","45549.04",""
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","45549.04",""
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40888.12","","","","","","","fee schedule","5220","45549.04","APC 277.30"
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43728.03","","","","","","","fee schedule","5220","45549.04","APC 296.56"
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45549.04","","","","","","","fee schedule","5220","45549.04","APC 308.91"
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13484.11","","","","","","","fee schedule","5220","45549.04","APC"
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13258.83","","","","","","","fee schedule","5220","45549.04","APC"
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13130.11","","","","","","","fee schedule","5220","45549.04","APC"
"Insert semi-rigid prosthesis","54400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13516.29","","","","","","","fee schedule","5220","45549.04","APC"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","5220","71554.8",""
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","71554.8",""
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","5220","71554.8",""
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","5220","71554.8","APC 277.30"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","5220","71554.8","APC 296.56"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","5220","71554.8","APC 308.91"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","5220","71554.8","APC"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","5220","71554.8","APC"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","5220","71554.8","APC"
"Insert self-contd prosthesis","54401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","5220","71554.8","APC"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","5220","71554.8",""
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","71554.8",""
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","5220","71554.8",""
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","5220","71554.8","APC 277.30"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","5220","71554.8","APC 296.56"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","5220","71554.8","APC 308.91"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","5220","71554.8","APC"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","5220","71554.8","APC"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","5220","71554.8","APC"
"Insert multi-comp penis pros","54405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","5220","71554.8","APC"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Remove muti-comp penis pros","54406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","23971","APC 277.30"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","23971","APC 296.56"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","23971","APC 308.91"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","23971","APC"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","23971","APC"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","23971","APC"
"Repair multi-comp penis pros","54408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","23971","APC"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","5220","71554.8",""
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","71554.8",""
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","5220","71554.8",""
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","5220","71554.8","APC 277.30"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","5220","71554.8","APC 296.56"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","5220","71554.8","APC 308.91"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","5220","71554.8","APC"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","5220","71554.8","APC"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","5220","71554.8","APC"
"Remove/replace penis prosth","54410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","5220","71554.8","APC"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","71554.8",""
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","71554.8",""
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","71554.8",""
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","2375","71554.8","APC 277.30"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","2375","71554.8","APC 296.56"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","2375","71554.8","APC 308.91"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","2375","71554.8","APC"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","2375","71554.8","APC"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","2375","71554.8","APC"
"Remov/replc penis pros comp","54411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","2375","71554.8","APC"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Remove self-contd penis pros","54415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","5220","71554.8",""
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","71554.8",""
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","5220","71554.8",""
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","5220","71554.8","APC 277.30"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","5220","71554.8","APC 296.56"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","5220","71554.8","APC 308.91"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","5220","71554.8","APC"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","5220","71554.8","APC"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","5220","71554.8","APC"
"Remv/repl penis contain pros","54416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","5220","71554.8","APC"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","71554.8",""
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3499","71554.8",""
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","71554.8",""
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64232.77","","","","","","","fee schedule","3499","71554.8","APC 277.30"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68694.09","","","","","","","fee schedule","3499","71554.8","APC 296.56"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71554.8","","","","","","","fee schedule","3499","71554.8","APC 308.91"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21182.72","","","","","","","fee schedule","3499","71554.8","APC"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20828.83","","","","","","","fee schedule","3499","71554.8","APC"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20626.61","","","","","","","fee schedule","3499","71554.8","APC"
"Remv/replc penis pros compl","54417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21233.27","","","","","","","fee schedule","3499","71554.8","APC"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","19040",""
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of penis","54430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of penis","54430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","19040",""
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Revision of penis","54435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Repair corporeal tear","54437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Replantation of penis","54438","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","19040",""
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Repair of penis","54440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","3408",""
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","248.65","3408",""
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","3408",""
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","3408","APC 277.30"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","3408","APC 296.56"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","3408","APC 308.91"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","3408","APC"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","3408","APC"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","3408","APC"
"Preputial stretching","54450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","3408","APC"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","10028.23",""
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy of testis","54500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Biopsy of testis","54505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Excise Lesion Testis","54512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of testis","54520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Orchiectomy partial","54522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of testis","54530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Extensive testis surgery","54535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Exploration for testis","54550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2080.35","14111",""
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Exploration for testis","54560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Reduce testis torsion","54600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Suspension of testis","54620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3563.21","19040",""
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Suspension of testis","54640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Orchiopexy (Fowler-Stephens)","54650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","18511.05",""
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","18511.05",""
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","18511.05",""
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","18511.05","APC 277.30"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","18511.05","APC 296.56"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","18511.05","APC 308.91"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","18511.05","APC"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","18511.05","APC"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","18511.05","APC"
"Revision of testis","54660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","18511.05","APC"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Repair testis injury","54670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Relocation of testis(es)","54680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiectomy","54690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy orchiopexy","54692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparoscope proc testis","54699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Drainage of scrotum","54700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1643.67","5701.97",""
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5701.97","APC 277.30"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5701.97","APC 296.56"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5701.97","APC 308.91"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5701.97","APC"
"Biopsy of epididymis","54800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5701.97","APC"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Remove epididymis lesion","54830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2080.35","14111",""
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Remove epididymis lesion","54840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","14111",""
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of epididymis","54861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Explore Epididymis","54865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2080.35","14111",""
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Fusion of spermatic ducts","54900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Fusion of spermatic ducts","54901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Drainage of hydrocele","55000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3563.21","19040",""
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydrocele","55040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3563.21","19040",""
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Removal of hydroceles","55041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Repair of hydrocele","55060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Drainage of scrotum abscess","55100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Explore scrotum","55110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of scrotum lesion","55120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Removal of scrotum","55150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3408","23971",""
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","23971",""
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3408","23971",""
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","23971","APC 277.30"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","23971","APC 296.56"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","23971","APC 308.91"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","23971","APC"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","23971","APC"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","23971","APC"
"Revision of scrotum","55175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","23971","APC"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","18511.05",""
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","18511.05",""
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","18511.05",""
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","4564","18511.05","APC 277.30"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","4564","18511.05","APC 296.56"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","4564","18511.05","APC 308.91"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","4564","18511.05","APC"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","4564","18511.05","APC"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","4564","18511.05","APC"
"Revision of scrotum","55180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","4564","18511.05","APC"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Incision of sperm duct","55200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2080.35","14111",""
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Removal of sperm duct(s)","55250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Prepare sperm duct x-ray","55300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Prepare sperm duct x-ray","55300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Prepare sperm duct x-ray","55300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Repair of sperm duct","55400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3508.06","19040",""
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","19040",""
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3508.06","19040",""
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","19040","APC 277.30"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","19040","APC 296.56"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","19040","APC 308.91"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of hydrocele","55500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","19040","APC"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of sperm cord lesion","55520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3508.06","14111",""
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Revise spermatic cord veins","55530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","6442.74","22350.2",""
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6442.74","22350.2",""
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","6442.74","22350.2",""
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Revise spermatic cord veins","55535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3563.21","19040",""
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3563.21","19040",""
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3563.21","19040",""
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11096.1","","","","","","","fee schedule","3563.21","19040","APC 277.30"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11866.78","","","","","","","fee schedule","3563.21","19040","APC 296.56"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12360.96","","","","","","","fee schedule","3563.21","19040","APC 308.91"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3659.28","","","","","","","fee schedule","3563.21","19040","APC"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3598.14","","","","","","","fee schedule","3563.21","19040","APC"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3563.21","","","","","","","fee schedule","3563.21","19040","APC"
"Revise hernia & sperm veins","55540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3668.01","","","","","","","fee schedule","3563.21","19040","APC"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","29398",""
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo ligate spermatic vein","55550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc spermatic cord","55559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2080.35","14111",""
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2080.35","14111",""
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2080.35","14111",""
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","14111","APC 277.30"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","14111","APC 296.56"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","14111","APC 308.91"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","14111","APC"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","14111","APC"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","14111","APC"
"Incise sperm duct pouch","55600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","14111","APC"
"Incise sperm duct pouch","55605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","5220",""
"Incise sperm duct pouch","55605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3499","5220",""
"Incise sperm duct pouch","55605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","5220",""
"Remove sperm duct pouch","55650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","5220",""
"Remove sperm duct pouch","55650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3499","5220",""
"Remove sperm duct pouch","55650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","5220",""
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Remove sperm pouch lesion","55680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Biopsy of prostate","55700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","5790",""
"Biopsy of prostate","55700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","5790",""
"Biopsy of prostate","55700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","5790",""
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3508.06","12169.63",""
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","12169.63",""
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3508.06","12169.63",""
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Biopsy of prostate","55705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3508.06","12169.63",""
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","12169.63",""
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3508.06","12169.63",""
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Prostate saturation sampling","55706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us guided","55707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct us w/mri fus 1","55708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl us guided","55709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprn us w/mri fus 1","55710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 trct mri-us 1st","55711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 tprnl mri-us 1st","55712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri bx 1","55713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Bx prst8 in-bore ct/mri 1","55714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14111",""
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14111",""
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14111",""
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3408","14111","APC 277.30"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3408","14111","APC 296.56"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3408","14111","APC 308.91"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3408","14111","APC"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3408","14111","APC"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3408","14111","APC"
"Drainage of prostate abscess","55720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3408","14111","APC"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3508.06","14111",""
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3508.06","14111",""
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3508.06","14111",""
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","14111","APC 277.30"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","14111","APC 296.56"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","14111","APC 308.91"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","14111","APC"
"Drainage of prostate abscess","55725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","14111","APC"
"Removal of prostate","55801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of prostate","55831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55842","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55842","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55845","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","18511.05",""
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","18511.05",""
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","18511.05",""
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","18511.05","APC 277.30"
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","18511.05","APC 296.56"
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","18511.05","APC 308.91"
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","18511.05","APC"
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","18511.05","APC"
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","18511.05","APC"
"Surgical exposure prostate","55860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","18511.05","APC"
"Extensive prostate surgery","55862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55862","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive prostate surgery","55865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","36698.4",""
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","36698.4",""
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparo radical prostatectomy","55866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps surg prst8ect smpl stot","55867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct lymph nod bx","55868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap srg prst8ct bi pl lmphad","55869","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Electroejaculation","55870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","9421.01","35289",""
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","9421.01","35289",""
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","9421.01","35289",""
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","35289","APC 277.30"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","35289","APC 296.56"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","35289","APC 308.91"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","35289","APC"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","35289","APC"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","35289","APC"
"Cryoablate Prostate","55873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","35289","APC"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5220","29398","APC 277.30"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5220","29398","APC 296.56"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5220","29398","APC 308.91"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5220","29398","APC"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5220","29398","APC"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5220","29398","APC"
"Tprnl plmt biodegrdabl matrl","55874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5220","29398","APC"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5336.05","23971",""
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5336.05","23971",""
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5336.05","23971",""
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","23971","APC 277.30"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","23971","APC 296.56"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","23971","APC 308.91"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","23971","APC"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","23971","APC"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","23971","APC"
"Transperi needle place pros","55875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","23971","APC"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1377.48","5790",""
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1377.48","5790",""
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1377.48","5790",""
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4289.59","","","","","","","fee schedule","1377.48","5790","APC 277.30"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4587.52","","","","","","","fee schedule","1377.48","5790","APC 296.56"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4778.57","","","","","","","fee schedule","1377.48","5790","APC 308.91"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.62","","","","","","","fee schedule","1377.48","5790","APC"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.99","","","","","","","fee schedule","1377.48","5790","APC"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.48","","","","","","","fee schedule","1377.48","5790","APC"
"Place rt device/marker pros","55876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1418","","","","","","","fee schedule","1377.48","5790","APC"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj ire prst8 1+ tum perq","55877","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","9421.01","32681.98",""
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","9421.01","32681.98",""
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Abltj mal prst8 tiss hifu","55880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Ablt trurl prst8 tis thrm us","55881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ablt trurl prst8 tis thrm us","55881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","13130.11","45549.04",""
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","13130.11","45549.04",""
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40888.12","","","","","","","fee schedule","13130.11","45549.04","APC 277.30"
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43728.03","","","","","","","fee schedule","13130.11","45549.04","APC 296.56"
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45549.04","","","","","","","fee schedule","13130.11","45549.04","APC 308.91"
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13484.11","","","","","","","fee schedule","13130.11","45549.04","APC"
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13258.83","","","","","","","fee schedule","13130.11","45549.04","APC"
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13130.11","","","","","","","fee schedule","13130.11","45549.04","APC"
"Ablt trurl prst8 tis trnsdcr","55882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13516.29","","","","","","","fee schedule","13130.11","45549.04","APC"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","248.65","5220",""
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","248.65","5220",""
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","248.65","5220",""
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","774.31","","","","","","","fee schedule","248.65","5220","APC 277.30"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.09","","","","","","","fee schedule","248.65","5220","APC 296.56"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","862.58","","","","","","","fee schedule","248.65","5220","APC 308.91"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.35","","","","","","","fee schedule","248.65","5220","APC"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.09","","","","","","","fee schedule","248.65","5220","APC"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.65","","","","","","","fee schedule","248.65","5220","APC"
"Genital surgery procedure","55899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.96","","","","","","","fee schedule","248.65","5220","APC"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","19040",""
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Place needles pelvic for rt","55920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Sex transformation m to f","55970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3508.06","12169.63",""
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10924.34","","","","","","","fee schedule","3508.06","12169.63","APC 277.30"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11683.1","","","","","","","fee schedule","3508.06","12169.63","APC 296.56"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12169.63","","","","","","","fee schedule","3508.06","12169.63","APC 308.91"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3602.64","","","","","","","fee schedule","3508.06","12169.63","APC"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3542.45","","","","","","","fee schedule","3508.06","12169.63","APC"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3508.06","","","","","","","fee schedule","3508.06","12169.63","APC"
"Sex transformation f to m","55980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3611.23","","","","","","","fee schedule","3508.06","12169.63","APC"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","4564",""
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","303.27","4564",""
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","4564",""
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","4564","APC 277.30"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","4564","APC 296.56"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","4564","APC 308.91"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","4564","APC"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","4564","APC"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","4564","APC"
"I & D of vulva/perineum","56405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","4564","APC"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","3408",""
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","201.2","3408",""
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","3408",""
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","3408","APC 277.30"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","3408","APC 296.56"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","3408","APC 308.91"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","3408","APC"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","3408","APC"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","3408","APC"
"Drainage of gland abscess","56420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","3408","APC"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Surgery for vulva lesion","56440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Lysis of labial lesion(s)","56441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Hymenotomy","56442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesions sim","56501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2053.37","7123.26",""
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2053.37","7123.26",""
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Destroy vulva lesion/s compl","56515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vulva/perineum","56605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vulva/perineum","56606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Biopsy of vulva/perineum","56606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Biopsy of vulva/perineum","56606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of vulva","56620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3221.58","14111",""
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Complete removal of vulva","56625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Extensive vulva surgery","56630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Extensive vulva surgery","56631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56637","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Extensive vulva surgery","56640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive vulva surgery","56640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive vulva surgery","56640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of hymen","56700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina gland lesion","56740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","56800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair clitoris","56805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of perineum","56810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Exam of vulva w/scope","56820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Exam/biopsy of vulva w/scope","56821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Exploration of vagina","57000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of pelvic abscess","57010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","17270.44",""
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","17270.44",""
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","17270.44",""
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4564","17270.44","APC 277.30"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4564","17270.44","APC 296.56"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4564","17270.44","APC 308.91"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4564","17270.44","APC"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4564","17270.44","APC"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4564","17270.44","APC"
"Drainage of pelvic fluid","57020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4564","17270.44","APC"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2890.77","10028.23",""
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"I & d vaginal hematoma pp","57022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2890.77","14111",""
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","14111",""
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2890.77","14111",""
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","14111","APC 277.30"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","14111","APC 296.56"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","14111","APC 308.91"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","14111","APC"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","14111","APC"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","14111","APC"
"I & d vag hematoma non-ob","57023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","14111","APC"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions simple","57061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Destroy vag lesions complex","57065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vagina","57100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of vagina","57105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina wall partial","57106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina tissue part","57107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Vaginectomy partial w/nodes","57109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina wall complete","57110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vagina wall complete","57110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vagina wall complete","57110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vagina tissue compl","57111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Remove vagina tissue compl","57111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Remove vagina tissue compl","57111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Closure of vagina","57120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vagina lesion","57135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Treat vagina infection","57150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","3499","17270.44",""
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3499","17270.44",""
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","3499","17270.44",""
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","3499","17270.44","APC 277.30"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","3499","17270.44","APC 296.56"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","3499","17270.44","APC 308.91"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","3499","17270.44","APC"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","3499","17270.44","APC"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","3499","17270.44","APC"
"Insert uteri tandem/ovoids","57155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","3499","17270.44","APC"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Ins vag brachytx device","57156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Insert pessary/other device","57160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Fitting of diaphragm/cap","57170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","3408",""
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","201.2","3408",""
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","3408",""
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","3408","APC 277.30"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","3408","APC 296.56"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","3408","APC 308.91"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","3408","APC"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","3408","APC"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","3408","APC"
"Treat vaginal bleeding","57180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","3408","APC"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of vagina","57200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair vagina/perineum","57210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","23971",""
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Revision of urethra","57220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair of urethral lesion","57230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4978.43","19040",""
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder & vagina","57240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4978.43","19040",""
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Repair rectum & vagina","57250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4978.43","19040",""
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Repair of vagina","57260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4978.43","23971",""
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Extensive repair of vagina","57265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Insert mesh/pelvic flr addon","57267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","10181",""
"Insert mesh/pelvic flr addon","57267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2375","10181",""
"Insert mesh/pelvic flr addon","57267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","10181",""
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair of bowel bulge","57268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair of bowel pouch","57270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Repair of bowel pouch","57270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Repair of bowel pouch","57270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Suspension of vagina","57280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Suspension of vagina","57280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Suspension of vagina","57280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25601.02",""
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25601.02",""
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy extraperitoneal","57282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25601.02",""
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25601.02",""
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Colpopexy intraperitoneal","57283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","23971",""
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Repair paravag defect open","57284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7379.83","25601.02",""
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7379.83","25601.02",""
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7379.83","25601.02",""
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","7379.83","25601.02","APC 277.30"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","7379.83","25601.02","APC 296.56"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","7379.83","25601.02","APC 308.91"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","7379.83","25601.02","APC"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","7379.83","25601.02","APC"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","7379.83","25601.02","APC"
"Repair paravag defect vag","57285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","7379.83","25601.02","APC"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3221.58","19040",""
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","19040",""
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3221.58","19040",""
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","19040","APC 277.30"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","19040","APC 296.56"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","19040","APC 308.91"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","19040","APC"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","19040","APC"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","19040","APC"
"Revise/Remove Sling Repair","57287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","19040","APC"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4978.43","23971",""
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder defect","57288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7337","25601.02",""
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","25601.02",""
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7337","25601.02",""
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","7337","25601.02","APC 277.30"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","7337","25601.02","APC 296.56"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","7337","25601.02","APC 308.91"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","7337","25601.02","APC"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","7337","25601.02","APC"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","7337","25601.02","APC"
"Repair bladder & vagina","57289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","7337","25601.02","APC"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4978.43","17270.44",""
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Construction of vagina","57291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Construct vagina with graft","57292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Revise vag graft via vagina","57295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Revise vag graft open abd","57296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise vag graft open abd","57296","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise vag graft open abd","57296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Repair rectum-vagina fistula","57300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Repair rectum-vagina fistula","57305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair rectum-vagina fistula","57305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair rectum-vagina fistula","57305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fistula repair & colostomy","57307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fistula repair & colostomy","57307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fistula repair & colostomy","57307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fistula repair transperine","57308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Fistula repair transperine","57308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Fistula repair transperine","57308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25601.02",""
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25601.02",""
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Repair urethrovaginal lesion","57310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Repair urethrovaginal lesion","57311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Repair urethrovaginal lesion","57311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Repair urethrovaginal lesion","57311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder-vagina lesion","57320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25601.02",""
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25601.02",""
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Repair bladder-vagina lesion","57330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Repair vagina","57335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of vagina","57400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Pelvic examination","57410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Remove vaginal foreign body","57415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Exam of vagina w/scope","57420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Exam/biopsy of vag w/scope","57421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Repair paravag defect lap","57423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","36698.4",""
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","36698.4",""
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","36698.4",""
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","5220","36698.4","APC 277.30"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","5220","36698.4","APC 296.56"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","5220","36698.4","APC 308.91"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","5220","36698.4","APC"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","5220","36698.4","APC"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","5220","36698.4","APC"
"Laparoscopy surg colpopexy","57425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","5220","36698.4","APC"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7379.83","25601.02",""
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","7379.83","25601.02",""
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7379.83","25601.02",""
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","7379.83","25601.02","APC 277.30"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","7379.83","25601.02","APC 296.56"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","7379.83","25601.02","APC 308.91"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","7379.83","25601.02","APC"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","7379.83","25601.02","APC"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","7379.83","25601.02","APC"
"Revise prosth vag graft lap","57426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","7379.83","25601.02","APC"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","3408",""
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","201.2","3408",""
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","3408",""
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","3408","APC 277.30"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","3408","APC 296.56"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","3408","APC 308.91"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","3408","APC"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","3408","APC"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","3408","APC"
"Exam of cervix w/scope","57452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","3408","APC"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Bx/curett of cervix w/scope","57454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Biopsy of cervix w/scope","57455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Endocerv curettage w/scope","57456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Bx of cervix w/scope leep","57460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Conz of cervix w/scope leep","57461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Cam cervix uteri drg colp","57465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Cam cervix uteri drg colp","57465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Biopsy of cervix","57500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Endocervical curettage","57505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Cauterization of cervix","57510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Cryocautery of cervix","57511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Laser surgery of cervix","57513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Conization of cervix","57522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of cervix","57530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of cervix radical","57531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of cervix radical","57531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of cervix radical","57531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of residual cervix","57540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of residual cervix","57540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of residual cervix","57540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove cervix/repair pelvis","57545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove cervix/repair pelvis","57545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove cervix/repair pelvis","57545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Removal of residual cervix","57550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Remove cervix/repair vagina","57555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4978.43","23971",""
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Remove cervix repair bowel","57556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"D&C oF Cervical Stump","57558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","57720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation of cervical canal","57800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Biopsy of uterus lining","58100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Bx done w/colposcopy add-on","58110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Bx done w/colposcopy add-on","58110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Bx done w/colposcopy add-on","58110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3221.58","14111",""
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Dilation and curettage","58120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Myomectomy abdom method","58140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Myomectomy abdom method","58140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Myomectomy abdom method","58140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Myomectomy vag method","58145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Myomectomy abdom complex","58146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Myomectomy abdom complex","58146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Myomectomy abdom complex","58146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Total hysterectomy","58150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Total hysterectomy","58150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Total hysterectomy","58150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Total hysterectomy","58152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Total hysterectomy","58152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Total hysterectomy","58152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Partial hysterectomy","58180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Partial hysterectomy","58180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Partial hysterectomy","58180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Extensive hysterectomy","58200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pelvis contents","58240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pelvis contents","58240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pelvis contents","58240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","19040",""
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Vaginal hysterectomy","58260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst including t/o","58262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/t/o & vag repair","58263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/urinary repair","58267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Vag hyst w/urinary repair","58267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Vag hyst w/urinary repair","58267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Vag hyst w/enterocele repair","58270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Hysterectomy/revise vagina","58275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Hysterectomy/revise vagina","58275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Hysterectomy/revise vagina","58275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Hysterectomy/revise vagina","58280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Hysterectomy/revise vagina","58280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Hysterectomy/revise vagina","58280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Extensive hysterectomy","58285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive hysterectomy","58285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25601.02",""
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25601.02",""
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst complex","58290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","23971",""
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst incl t/o complex","58291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25601.02",""
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25601.02",""
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst t/o & repair compl","58292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","23971",""
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Vag hyst w/enterocele compl","58294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Insert intrauterine device","58300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Insert intrauterine device","58300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Insert intrauterine device","58300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Remove intrauterine device","58301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Artificial insemination","58321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","3408",""
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","201.2","3408",""
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","3408",""
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","3408","APC 277.30"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","3408","APC 296.56"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","3408","APC 308.91"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","3408","APC"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","3408","APC"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","3408","APC"
"Artificial insemination","58322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","3408","APC"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","3408",""
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","201.2","3408",""
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","3408",""
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","3408","APC 277.30"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","3408","APC 296.56"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","3408","APC 308.91"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","3408","APC"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","3408","APC"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","3408","APC"
"Sperm washing","58323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","3408","APC"
"Catheter for hysterography","58340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Catheter for hysterography","58340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Catheter for hysterography","58340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Reopen fallopian tube","58345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","17270.44",""
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","17270.44",""
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","17270.44",""
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4564","17270.44","APC 277.30"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4564","17270.44","APC 296.56"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4564","17270.44","APC 308.91"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4564","17270.44","APC"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4564","17270.44","APC"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4564","17270.44","APC"
"Insert heyman uteri capsule","58346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4564","17270.44","APC"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Reopen fallopian tube","58350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4978.43","19040",""
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Endometr ablate thermal","58353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","23971",""
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Endometrial cryoablation","58356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Suspension of uterus","58400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Suspension of uterus","58400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Suspension of uterus","58400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Suspension of uterus","58410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Suspension of uterus","58410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Suspension of uterus","58410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of ruptured uterus","58520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of ruptured uterus","58520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of ruptured uterus","58520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revision of uterus","58540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of uterus","58540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of uterus","58540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh uterus 250 g or less","58541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lsh w/t/o ut 250 g or less","58542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH Uterus Above 250 g","58543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"LSH w/t/o Uterus Above 250 g","58544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6016.5","23971",""
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","23971","APC 277.30"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","23971","APC 296.56"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","23971","APC 308.91"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","23971","APC"
"Laparoscopic myomectomy","58545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","23971","APC"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo-myomectomy complex","58546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Lap Radical Hyst","58548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Lap Radical Hyst","58548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Lap Radical Hyst","58548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6016.5","29398",""
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo-asst vag hysterectomy","58550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst incl t/o","58552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst complex","58553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparo-vag hyst w/t/o compl","58554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy dx sep proc","58555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy biopsy","58558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","17270.44",""
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","17270.44",""
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","17270.44",""
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4564","17270.44","APC 277.30"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4564","17270.44","APC 296.56"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4564","17270.44","APC 308.91"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4564","17270.44","APC"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4564","17270.44","APC"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4564","17270.44","APC"
"Hysteroscopy lysis","58559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4564","17270.44","APC"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy resect septum","58560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy remove myoma","58561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy remove fb","58562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy ablation","58563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4978.43","23971",""
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4978.43","23971",""
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4978.43","23971",""
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","23971","APC 277.30"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","23971","APC 296.56"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","23971","APC 308.91"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","23971","APC"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","23971","APC"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","23971","APC"
"Hysteroscopy sterilization","58565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","23971","APC"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus 250 g or less","58570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o 250 g or less","58571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh uterus over 250 g","58572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Tlh w/t/o uterus over 250 g","58573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps tot hyst resj mal","58575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Laps tot hyst resj mal","58575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Laps tot hyst resj mal","58575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc uterus","58578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Hysteroscope procedure","58579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7379.83","25601.02",""
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7379.83","25601.02",""
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","7379.83","25601.02","APC 277.30"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","7379.83","25601.02","APC 296.56"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","7379.83","25601.02","APC 308.91"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","7379.83","25601.02","APC"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","7379.83","25601.02","APC"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","7379.83","25601.02","APC"
"Transcrv abltj utrn fibrd rf","58580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","7379.83","25601.02","APC"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Division of fallopian tube","58600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Division of fallopian tube","58605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Division of fallopian tube","58605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Division of fallopian tube","58605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Ligate oviduct(s) add-on","58611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Ligate oviduct(s) add-on","58611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Ligate oviduct(s) add-on","58611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Occlude fallopian tube(s)","58615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy lysis","58660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy remove adnexa","58661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy excise lesions","58662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal cautery","58670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy tubal block","58671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy fimbrioplasty","58672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7337","36698.4",""
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","7337","36698.4","APC 277.30"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","7337","36698.4","APC 296.56"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","7337","36698.4","APC 308.91"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","7337","36698.4","APC"
"Laparoscopy salpingostomy","58673","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","7337","36698.4","APC"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laps abltj uterine fibroids","58674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc oviduct-ovary","58679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Removal of fallopian tube","58700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Removal of fallopian tube","58700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Removal of fallopian tube","58700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Removal of ovary/tube(s)","58720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of ovary/tube(s)","58720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of ovary/tube(s)","58720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Adhesiolysis tube ovary","58740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Adhesiolysis tube ovary","58740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Adhesiolysis tube ovary","58740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Repair oviduct","58750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Repair oviduct","58750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Repair oviduct","58750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Revise ovarian tube(s)","58752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Revise ovarian tube(s)","58752","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Revise ovarian tube(s)","58752","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Fimbrioplasty","58760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Fimbrioplasty","58760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Fimbrioplasty","58760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Create new tubal opening","58770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Drainage of ovarian cyst(s)","58805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Drain ovary abscess open","58820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Drain ovary abscess percut","58822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Drain ovary abscess percut","58822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Drain ovary abscess percut","58822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Transposition ovary(s)","58825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Transposition ovary(s)","58825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Transposition ovary(s)","58825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Biopsy of ovary(s)","58900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","25601.02",""
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25601.02",""
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","25601.02",""
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22981.33","","","","","","","fee schedule","5220","25601.02","APC 277.30"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24577.51","","","","","","","fee schedule","5220","25601.02","APC 296.56"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25601.02","","","","","","","fee schedule","5220","25601.02","APC 308.91"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7578.8","","","","","","","fee schedule","5220","25601.02","APC"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7452.18","","","","","","","fee schedule","5220","25601.02","APC"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7379.83","","","","","","","fee schedule","5220","25601.02","APC"
"Partial removal of ovary(s)","58920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7596.88","","","","","","","fee schedule","5220","25601.02","APC"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","4978.43","19040",""
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","19040",""
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","4978.43","19040",""
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","19040","APC 277.30"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","19040","APC 296.56"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","19040","APC 308.91"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","19040","APC"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","19040","APC"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","19040","APC"
"Removal of ovarian cyst(s)","58925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","19040","APC"
"Removal of ovary(s)","58940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Removal of ovary(s)","58940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Removal of ovary(s)","58940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Removal of ovary(s)","58943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Removal of ovary(s)","58943","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Removal of ovary(s)","58943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Resect ovarian malignancy","58950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Resect ovarian malignancy","58950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Resect ovarian malignancy","58950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Resect ovarian malignancy","58951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect ovarian malignancy","58951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect ovarian malignancy","58951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect ovarian malignancy","58952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect ovarian malignancy","58952","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect ovarian malignancy","58952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tah rad dissect for debulk","58953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tah rad dissect for debulk","58953","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tah rad dissect for debulk","58953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Tah rad debulk/lymph remove","58954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Tah rad debulk/lymph remove","58954","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Tah rad debulk/lymph remove","58954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bso omentectomy w/tah","58956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bso omentectomy w/tah","58956","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bso omentectomy w/tah","58956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect Recurrent Gyn Mal","58957","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Resect Recur Gyn Mal w/Lym","58958","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect Recur Gyn Mal w/Lym","58958","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect Recur Gyn Mal w/Lym","58958","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Exploration of abdomen","58960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Exploration of abdomen","58960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Exploration of abdomen","58960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Retrieval of oocyte","58970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","3880",""
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","916.63","3880",""
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","3880",""
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","3880","APC 277.30"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","3880","APC 296.56"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","3880","APC 308.91"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","3880","APC"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","3880","APC"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","3880","APC"
"Transfer of embryo","58974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","3880","APC"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Transfer of embryo","58976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Genital surgery procedure","58999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","5220",""
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","916.63","5220",""
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","5220",""
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","5220","APC 277.30"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","5220","APC 296.56"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","5220","APC 308.91"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","5220","APC"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","5220","APC"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","5220","APC"
"Amniocentesis diagnostic","59000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","5220","APC"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","5220",""
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","303.27","5220",""
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","5220",""
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","5220","APC 277.30"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","5220","APC 296.56"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","5220","APC 308.91"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","5220","APC"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","5220","APC"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","5220","APC"
"Amniocentesis therapeutic","59001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","5220","APC"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","5220",""
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","303.27","5220",""
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","5220",""
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","5220","APC 277.30"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","5220","APC 296.56"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","5220","APC 308.91"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","5220","APC"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","5220","APC"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","5220","APC"
"Fetal cord puncture prenatal","59012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","5220","APC"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","916.63","5220",""
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","916.63","5220",""
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","916.63","5220",""
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2854.45","","","","","","","fee schedule","916.63","5220","APC 277.30"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3052.7","","","","","","","fee schedule","916.63","5220","APC 296.56"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3179.83","","","","","","","fee schedule","916.63","5220","APC 308.91"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","941.34","","","","","","","fee schedule","916.63","5220","APC"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","925.61","","","","","","","fee schedule","916.63","5220","APC"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","916.63","","","","","","","fee schedule","916.63","5220","APC"
"Chorion biopsy","59015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","943.59","","","","","","","fee schedule","916.63","5220","APC"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Fetal contract stress test","59020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","608","","","","","","","fee schedule","201.2","5220",""
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","625","","","","","","","fee schedule","201.2","5220",""
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","611","","","","","","","fee schedule","201.2","5220",""
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Fetal non-stress test","59025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","5220",""
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","303.27","5220",""
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","5220",""
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","5220","APC 277.30"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","5220","APC 296.56"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","5220","APC 308.91"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","5220","APC"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","5220","APC"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","5220","APC"
"Fetal scalp blood sample","59030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","5220","APC"
"Fetal monitor w/report","59050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Fetal monitor w/report","59050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Fetal monitor w/report","59050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Fetal monitor/interpret only","59051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fetal monitor/interpret only","59051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fetal monitor/interpret only","59051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Transabdom amnioinfus w/us","59070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Umbilical cord occlud w/us","59072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Fetal fluid drainage w/us","59074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Fetal shunt placement w/us","59076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4978.43","17270.44",""
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Remove uterus lesion","59100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"Treat ectopic pregnancy","59120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Treat ectopic pregnancy","59120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Treat ectopic pregnancy","59120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Treat ectopic pregnancy","59121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Treat ectopic pregnancy","59121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Treat ectopic pregnancy","59121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Treat ectopic pregnancy","59130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Treat ectopic pregnancy","59136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Treat ectopic pregnancy","59151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"D & c after delivery","59160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Insert cervical dilator","59200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Episiotomy or vaginal repair","59300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","59320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Revision of cervix","59325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revision of cervix","59325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revision of cervix","59325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of uterus","59350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Obstetrical care","59400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Obstetrical care","59409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Obstetrical care","59410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3221.58","14111",""
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Antepartum manipulation","59412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Deliver placenta","59414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Cesarean delivery","59510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cesarean delivery only","59514","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cesarean delivery","59515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Remove uterus after cesarean","59525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Vbac delivery","59610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3221.58","14111",""
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Vbac delivery only","59612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Vbac care after delivery","59614","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Attempted vbac delivery","59618","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Attempted vbac delivery only","59620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Attempted vbac after care","59622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Care of miscarriage","59820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Treatment of miscarriage","59821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Treat uterus infection","59830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat uterus infection","59830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat uterus infection","59830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Abortion","59850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","5790",""
"Abortion","59850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","5790",""
"Abortion","59850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","5790",""
"Abortion","59851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","5790",""
"Abortion","59851","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","5790",""
"Abortion","59851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","5790",""
"Abortion","59852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Abortion","59852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Abortion","59852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abortion","59855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Abortion","59855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Abortion","59855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abortion","59856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Abortion","59856","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Abortion","59856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abortion","59857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Abortion","59857","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Abortion","59857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","303.27","3408",""
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","303.27","3408",""
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","303.27","3408",""
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","944.39","","","","","","","fee schedule","303.27","3408","APC 277.30"
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1009.99","","","","","","","fee schedule","303.27","3408","APC 296.56"
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1052.05","","","","","","","fee schedule","303.27","3408","APC 308.91"
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","311.44","","","","","","","fee schedule","303.27","3408","APC"
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","306.24","","","","","","","fee schedule","303.27","3408","APC"
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","303.27","","","","","","","fee schedule","303.27","3408","APC"
"Abortion (mpr)","59866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","312.19","","","","","","","fee schedule","303.27","3408","APC"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3221.58","14111",""
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","14111",""
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3221.58","14111",""
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","14111","APC 277.30"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","14111","APC 296.56"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","14111","APC 308.91"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","14111","APC"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","14111","APC"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","14111","APC"
"Evacuate mole of uterus","59870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","14111","APC"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3221.58","19040",""
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3221.58","19040",""
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3221.58","19040",""
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10032.24","","","","","","","fee schedule","3221.58","19040","APC 277.30"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10729.04","","","","","","","fee schedule","3221.58","19040","APC 296.56"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11175.84","","","","","","","fee schedule","3221.58","19040","APC 308.91"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3308.44","","","","","","","fee schedule","3221.58","19040","APC"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3253.17","","","","","","","fee schedule","3221.58","19040","APC"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3221.58","","","","","","","fee schedule","3221.58","19040","APC"
"Remove cerclage suture","59871","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3316.33","","","","","","","fee schedule","3221.58","19040","APC"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Fetal invas px w/us","59897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc ob care/deliver","59898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","201.2","5220",""
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","201.2","5220",""
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","201.2","5220",""
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","5220","APC 277.30"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","5220","APC 296.56"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","5220","APC 308.91"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","5220","APC"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","5220","APC"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","5220","APC"
"Maternity care procedure","59899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","5220","APC"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1544.13","5790",""
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Drain thyroid/tongue cyst","60000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Biopsy of thyroid","60100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","4564","29398","APC 277.30"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","4564","29398","APC 296.56"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","4564","29398","APC 308.91"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","4564","29398","APC"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","4564","29398","APC"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","4564","29398","APC"
"Remove thyroid lesion","60200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","4564","29398","APC"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Partial thyroid excision","60212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","4564","29398",""
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","29398",""
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","4564","29398",""
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","4564","29398","APC 277.30"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","4564","29398","APC 296.56"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","4564","29398","APC 308.91"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","4564","29398","APC"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","4564","29398","APC"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","4564","29398","APC"
"Partial removal of thyroid","60220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","4564","29398","APC"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Partial removal of thyroid","60225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Removal of thyroid","60240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Extensive thyroid surgery","60254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Extensive thyroid surgery","60254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Extensive thyroid surgery","60254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Repeat thyroid surgery","60260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of thyroid","60270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of thyroid","60270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Removal of thyroid","60271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","29398",""
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6016.5","29398",""
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6016.5","29398",""
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6016.5","29398",""
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","6016.5","29398","APC 277.30"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","6016.5","29398","APC 296.56"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","6016.5","29398","APC 308.91"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","6016.5","29398","APC"
"Remove thyroid duct lesion","60281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","6016.5","29398","APC"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Aspir/inj thyroid cyst","60300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Explore parathyroid glands","60500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5891.41","23971",""
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Re-explore parathyroids","60502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Explore parathyroid glands","60505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore parathyroid glands","60505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore parathyroid glands","60505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Autotransplant parathyroid","60512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Autotransplant parathyroid","60512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Autotransplant parathyroid","60512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Removal of thymus gland","60520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Removal of thymus gland","60521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of thymus gland","60521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of thymus gland","60521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of thymus gland","60522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of thymus gland","60522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of thymus gland","60522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore adrenal gland","60540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore adrenal gland","60540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore adrenal gland","60540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Explore adrenal gland","60545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore adrenal gland","60545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore adrenal gland","60545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove carotid body lesion","60600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove carotid body lesion","60600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove carotid body lesion","60600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove carotid body lesion","60605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove carotid body lesion","60605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove carotid body lesion","60605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Laparoscopy adrenalectomy","60650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparoscopy adrenalectomy","60650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparoscopy adrenalectomy","60650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","23971","APC 277.30"
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","23971","APC 296.56"
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","23971","APC 308.91"
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","23971","APC"
"Laparo proc endocrine","60659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","23971","APC"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj 1/+thyr ndul 1lobe prq","60660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Abltj 1/+thyr ndul addl prq","60661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Abltj 1/+thyr ndul addl prq","60661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18735.82","","","","","","","fee schedule","5220","29398","APC 277.30"
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20037.13","","","","","","","fee schedule","5220","29398","APC 296.56"
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20871.56","","","","","","","fee schedule","5220","29398","APC 308.91"
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6178.71","","","","","","","fee schedule","5220","29398","APC"
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6075.48","","","","","","","fee schedule","5220","29398","APC"
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6016.5","","","","","","","fee schedule","5220","29398","APC"
"Endocrine surgery procedure","60699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6193.46","","","","","","","fee schedule","5220","29398","APC"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Remove cranial cavity fluid","61001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Remove brain cavity fluid","61020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Injection into brain canal","61026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Remove brain canal fluid","61050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Injection into brain canal","61055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Brain canal shunt procedure","61070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Twist drill hole","61105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Twist drill hole","61105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Twist drill hole","61105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drill skull for implantation","61107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drill skull for implantation","61107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drill skull for implantation","61107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drill skull for drainage","61108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drill skull for drainage","61108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drill skull for drainage","61108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Burr hole for puncture","61120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Burr hole for puncture","61120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Burr hole for puncture","61120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull for biopsy","61140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull for biopsy","61140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull for biopsy","61140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61151","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull & remove clot","61154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull & remove clot","61154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull & remove clot","61154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull for drainage","61156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull implant device","61210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull implant device","61210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull implant device","61210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Insert brain-fluid device","61215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Pierce skull & explore","61250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull & explore","61250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull & explore","61250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Pierce skull & explore","61253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Pierce skull & explore","61253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Pierce skull & explore","61253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for exploration","61304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for exploration","61304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for exploration","61304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for exploration","61305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for exploration","61305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for exploration","61305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61313","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61314","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implt cran bone flap to abdo","61316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implt cran bone flap to abdo","61316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implt cran bone flap to abdo","61316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Open skull for drainage","61321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Decompressive craniotomy","61322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Decompressive craniotomy","61322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Decompressive craniotomy","61322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Decompressive lobectomy","61323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Decompressive lobectomy","61323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Decompressive lobectomy","61323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Decompress eye socket","61330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Explore orbit/remove lesion","61333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Explore orbit/remove lesion","61333","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Explore orbit/remove lesion","61333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Subtemporal decompression","61340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Subtemporal decompression","61340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Subtemporal decompression","61340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull (press relief)","61343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull (press relief)","61343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull (press relief)","61343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Relieve cranial pressure","61345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Relieve cranial pressure","61345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Relieve cranial pressure","61345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull for surgery","61450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull for surgery","61450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull for surgery","61450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull for brain wound","61458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull for brain wound","61458","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull for brain wound","61458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull for surgery","61460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull for surgery","61460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull for surgery","61460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of skull lesion","61500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Removal of skull lesion","61500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Removal of skull lesion","61500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove infected skull bone","61501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove infected skull bone","61501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove infected skull bone","61501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove brain lining lesion","61512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove brain lining lesion","61512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove brain lining lesion","61512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain abscess","61514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain abscess","61514","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain abscess","61514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implt brain chemotx add-on","61517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implt brain chemotx add-on","61517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implt brain chemotx add-on","61517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61518","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove brain lining lesion","61519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove brain lining lesion","61519","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove brain lining lesion","61519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain abscess","61522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain abscess","61522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain abscess","61522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61524","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61534","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove brain electrodes","61535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove brain electrodes","61535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove brain electrodes","61535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain lesion","61536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61537","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61538","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61539","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of brain tissue","61541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of brain tissue","61541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of brain tissue","61541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61543","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove & treat brain lesion","61544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove & treat brain lesion","61544","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove & treat brain lesion","61544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of brain tumor","61545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of brain tumor","61545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of brain tumor","61545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pituitary gland","61546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pituitary gland","61546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pituitary gland","61546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of pituitary gland","61548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of pituitary gland","61548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of pituitary gland","61548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release of skull seams","61550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release of skull seams","61550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release of skull seams","61550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release of skull seams","61552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Release of skull seams","61552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Release of skull seams","61552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull/sutures","61556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull/sutures","61556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull/sutures","61556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull/sutures","61557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull/sutures","61557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull/sutures","61557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of skull/sutures","61558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of skull/sutures","61558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of skull/sutures","61558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of skull/sutures","61559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of skull/sutures","61559","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of skull/sutures","61559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of skull tumor","61563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of skull tumor","61563","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of skull tumor","61563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excision of skull tumor","61564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excision of skull tumor","61564","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excision of skull tumor","61564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61566","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Removal of brain tissue","61566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of brain tissue","61567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of brain tissue","61567","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of brain tissue","61567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove foreign body brain","61570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove foreign body brain","61570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove foreign body brain","61570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull for brain wound","61571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull for brain wound","61571","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull for brain wound","61571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Skull base/brainstem surgery","61575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Skull base/brainstem surgery","61575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Skull base/brainstem surgery","61575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Skull base/brainstem surgery","61576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Skull base/brainstem surgery","61576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Skull base/brainstem surgery","61576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61581","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61583","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Craniofacial approach skull","61583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61584","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect nasopharynx skull","61586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect nasopharynx skull","61586","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect nasopharynx skull","61586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Infratemporal approach/skull","61590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Infratemporal approach/skull","61590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Infratemporal approach/skull","61590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Infratemporal approach/skull","61591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Infratemporal approach/skull","61591","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Infratemporal approach/skull","61591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61592","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Orbitocranial approach/skull","61592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transtemporal approach/skull","61595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transtemporal approach/skull","61595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transtemporal approach/skull","61595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transcochlear approach/skull","61596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transcochlear approach/skull","61596","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transcochlear approach/skull","61596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transcondylar approach/skull","61597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transcondylar approach/skull","61597","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transcondylar approach/skull","61597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transpetrosal approach/skull","61598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transpetrosal approach/skull","61598","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transpetrosal approach/skull","61598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise cranial lesion","61608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Transect artery sinus","61611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Transect artery sinus","61611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Transect artery sinus","61611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove aneurysm sinus","61613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove aneurysm sinus","61613","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove aneurysm sinus","61613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise lesion skull","61615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise lesion skull","61615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise lesion skull","61615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Resect/excise lesion skull","61616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Resect/excise lesion skull","61616","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Resect/excise lesion skull","61616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair dura","61618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair dura","61618","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair dura","61618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair dura","61619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair dura","61619","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair dura","61619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Endovasc tempory vessel occl","61623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Transcath occlusion cns","61624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Transcath occlusion non-cns","61626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Intracranial angioplasty","61630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial angioplasty","61630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial angioplasty","61630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracran angioplsty w/stent","61635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracran angioplsty w/stent","61635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracran angioplsty w/stent","61635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Dilate ic vasospasm init","61640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Dilate ic vasospasm init","61640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Dilate ic vasospasm init","61640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Dilate ic vasospasm add-on","61641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","5790",""
"Dilate ic vasospasm add-on","61641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","5790",""
"Dilate ic vasospasm add-on","61641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","5790",""
"Dilate ic vasospasm add-on","61642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","4564","5790",""
"Dilate ic vasospasm add-on","61642","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","5790",""
"Dilate ic vasospasm add-on","61642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","4564","5790",""
"Perq art m-thrombect &/nfs","61645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Perq art m-thrombect &/nfs","61645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Perq art m-thrombect &/nfs","61645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc prlng admn rx agnt 1st","61650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc prlng admn rx agnt 1st","61650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc prlng admn rx agnt 1st","61650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Evasc prlng admn rx agnt add","61651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Evasc prlng admn rx agnt add","61651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Evasc prlng admn rx agnt add","61651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61682","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61684","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61686","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61692","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Intracranial vessel surgery","61692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr complx","61697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr complx","61697","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr complx","61697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr complx","61698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr complx","61698","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr complx","61698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr simple","61700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr simple","61700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Brain aneurysm repr simple","61700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Inner skull vessel surgery","61702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Inner skull vessel surgery","61702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Inner skull vessel surgery","61702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Clamp neck artery","61703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Clamp neck artery","61703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Clamp neck artery","61703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61708","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise circulation to head","61710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of skull arteries","61711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of skull arteries","61711","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of skull arteries","61711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Mrgfus strtctc ablt trgt icr","61715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Incise skull/brain surgery","61720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Incise skull/brain surgery","61735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull/brain surgery","61735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull/brain surgery","61735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Litt icr 1 traj 1 smpl les","61736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Litt icr 1 traj 1 smpl les","61736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Litt icr mlt trj mlt/cplx ls","61737","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Litt icr mlt trj mlt/cplx ls","61737","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Incise skull/brain biopsy","61750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull/brain biopsy","61750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull/brain biopsy","61750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Brain biopsy w/ct/mr guide","61751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Brain biopsy w/ct/mr guide","61751","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Brain biopsy w/ct/mr guide","61751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant brain electrodes","61760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3399.75","23971",""
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Incise skull for treatment","61770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Scan proc cranial intra","61781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Scan proc cranial intra","61781","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Scan proc cranial intra","61781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Scan proc cranial extra","61782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Scan proc cranial extra","61782","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Scan proc cranial extra","61782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Scan proc spinal","61783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Scan proc spinal","61783","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Scan proc spinal","61783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal nerve","61790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Treat trigeminal tract","61791","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Srs cranial lesion simple","61796","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Srs cranial lesion simple","61796","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Srs cranial lesion simple","61796","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Srs cran les simple addl","61797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Srs cran les simple addl","61797","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Srs cran les simple addl","61797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Srs cranial lesion complex","61798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Srs cranial lesion complex","61798","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Srs cranial lesion complex","61798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Srs cran les complex addl","61799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Srs cran les complex addl","61799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Srs cran les complex addl","61799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Apply srs headframe add-on","61800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Apply srs headframe add-on","61800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Apply srs headframe add-on","61800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Implant neuroelectrodes","61850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrodes","61850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrodes","61850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrodes","61860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrodes","61860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrodes","61860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrode","61863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrode","61863","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrode","61863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrde addl","61864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrde addl","61864","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrde addl","61864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrode","61867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrode","61867","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrode","61867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrde addl","61868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrde addl","61868","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrde addl","61868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3479.32","19040",""
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revise/remove neuroelectrode","61880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","4564","106533.01",""
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","106533.01",""
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","4564","106533.01",""
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","4564","106533.01","APC 277.30"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","4564","106533.01","APC 296.56"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","4564","106533.01","APC 308.91"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","4564","106533.01","APC"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","4564","106533.01","APC"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","4564","106533.01","APC"
"Insrt/redo neurostim 1 array","61885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","4564","106533.01","APC"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","5220","106533.01",""
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","106533.01",""
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","5220","106533.01",""
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","5220","106533.01","APC 277.30"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","5220","106533.01","APC 296.56"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","5220","106533.01","APC 308.91"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","5220","106533.01","APC"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","5220","106533.01","APC"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","5220","106533.01","APC"
"Implant neurostim arrays","61886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","5220","106533.01","APC"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","38469",""
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","38469",""
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","38469",""
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","3408","38469","APC 277.30"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","3408","38469","APC 296.56"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","3408","38469","APC 308.91"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","3408","38469","APC"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","3408","38469","APC"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","3408","38469","APC"
"Revise/remove neuroreceiver","61888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","3408","38469","APC"
"Ins sk-mnt crnl nstm pg/rcvr","61889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ins sk-mnt crnl nstm pg/rcvr","61889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","30709.54","106533.01",""
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","30709.54","106533.01",""
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","30709.54","106533.01","APC 277.30"
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","30709.54","106533.01","APC 296.56"
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","30709.54","106533.01","APC 308.91"
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rev/rplcmt sk-mnt crnl nstm","61891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv sk-mnt crnl nstm pg/rcvr","61892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","23971",""
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Treat skull fracture","62000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Treat skull fracture","62005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treat skull fracture","62005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treat skull fracture","62005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Treatment of head injury","62010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Treatment of head injury","62010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Treatment of head injury","62010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair brain fluid leakage","62100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair brain fluid leakage","62100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair brain fluid leakage","62100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reduction of skull defect","62115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reduction of skull defect","62115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reduction of skull defect","62115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Reduction of skull defect","62117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Reduction of skull defect","62117","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Reduction of skull defect","62117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair skull cavity lesion","62120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair skull cavity lesion","62120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair skull cavity lesion","62120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise skull repair","62121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise skull repair","62121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise skull repair","62121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of skull defect","62140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of skull defect","62140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of skull defect","62140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of skull defect","62141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of skull defect","62141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of skull defect","62141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove skull plate/flap","62142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove skull plate/flap","62142","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove skull plate/flap","62142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace skull plate/flap","62143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace skull plate/flap","62143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace skull plate/flap","62143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of skull & brain","62145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of skull & brain","62145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of skull & brain","62145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of skull with graft","62146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of skull with graft","62146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of skull with graft","62146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of skull with graft","62147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of skull with graft","62147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of skull with graft","62147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Retr bone flap to fix skull","62148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Retr bone flap to fix skull","62148","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Retr bone flap to fix skull","62148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Neuroendoscopy add-on","62160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Neuroendoscopy add-on","62160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Neuroendoscopy add-on","62160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Dissect brain w/scope","62161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Dissect brain w/scope","62161","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Dissect brain w/scope","62161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove colloid cyst w/scope","62162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove colloid cyst w/scope","62162","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove colloid cyst w/scope","62162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove brain tumor w/scope","62164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove brain tumor w/scope","62164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove brain tumor w/scope","62164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove pituit tumor w/scope","62165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove pituit tumor w/scope","62165","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove pituit tumor w/scope","62165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62192","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Replace/irrigate catheter","62194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Establish brain cavity shunt","62200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Brain cavity shunt w/scope","62201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Brain cavity shunt w/scope","62201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Brain cavity shunt w/scope","62201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62223","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Establish brain cavity shunt","62223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3399.75","11793.9",""
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3399.75","11793.9",""
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3399.75","11793.9",""
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","11793.9","APC 277.30"
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","11793.9","APC 296.56"
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","11793.9","APC 308.91"
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","11793.9","APC"
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","11793.9","APC"
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","11793.9","APC"
"Replace/irrigate catheter","62225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","11793.9","APC"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Replace/revise brain shunt","62230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.66","3408",""
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.66","3408",""
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.66","3408",""
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.86","","","","","","","fee schedule","305.66","3408","APC 277.30"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.97","","","","","","","fee schedule","305.66","3408","APC 296.56"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1060.36","","","","","","","fee schedule","305.66","3408","APC 308.91"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.9","","","","","","","fee schedule","305.66","3408","APC"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.66","","","","","","","fee schedule","305.66","3408","APC"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.66","","","","","","","fee schedule","305.66","3408","APC"
"Csf Shunt Reprogram","62252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.65","","","","","","","fee schedule","305.66","3408","APC"
"Remove brain cavity shunt","62256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove brain cavity shunt","62256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove brain cavity shunt","62256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Replace brain cavity shunt","62258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Replace brain cavity shunt","62258","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Replace brain cavity shunt","62258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis mult sessions","62263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Epidural lysis on single day","62264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","3880",""
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","704.73","3880",""
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","3880",""
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","3880","APC 277.30"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","3880","APC 296.56"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","3880","APC 308.91"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","3880","APC"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","3880","APC"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","3880","APC"
"Interdiscal perq aspir dx","62267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","3880","APC"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Drain spinal cord cyst","62268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Needle biopsy spinal cord","62269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Spinal fluid tap diagnostic","62270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Drain cerebro spinal fluid","62272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Inject epidural patch","62273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal cord lesion","62281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Treat spinal canal lesion","62282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Injection for myelogram","62284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for myelogram","62284","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for myelogram","62284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1943.35","19040",""
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","1943.35","19040",""
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1943.35","19040",""
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","19040","APC 277.30"
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","19040","APC 296.56"
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","19040","APC 308.91"
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","19040","APC"
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","19040","APC"
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","19040","APC"
"Percutaneous diskectomy","62287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","19040","APC"
"Inject for spine disk x-ray","62290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Inject for spine disk x-ray","62290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Inject for spine disk x-ray","62290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Inject for spine disk x-ray","62291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Inject for spine disk x-ray","62291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Inject for spine disk x-ray","62291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Injection into disk lesion","62292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","5220",""
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","880.23","5220",""
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","5220",""
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","5220","APC 277.30"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","5220","APC 296.56"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","5220","APC 308.91"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","5220","APC"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","5220","APC"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","5220","APC"
"Injection into spinal artery","62294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","5220","APC"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","5220","APC 277.30"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","5220","APC 296.56"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","5220","APC 308.91"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","5220","APC 277.30"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","5220","APC 296.56"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","5220","APC 308.91"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","5220","APC 277.30"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","5220","APC 296.56"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","5220","APC 308.91"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","780.16","5220",""
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","5220","APC 277.30"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","5220","APC 296.56"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","5220","APC 308.91"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","5220","APC"
"Myelography lumbar injection","62305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","5220","APC"
"Inject spine c/t","62310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Inject spine l/s (cd)","62311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Inject spine w/cath, c/t","62318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Inject spine w/cath l/s (cd)","62319","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","5220","APC 277.30"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","5220","APC 296.56"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","5220","APC 308.91"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar lmbr/sac","62323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","5220","APC 277.30"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","5220","APC 296.56"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","5220","APC 308.91"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","5220","APC 277.30"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","5220","APC 296.56"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","5220","APC 308.91"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar crv/thrc","62325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","5220","APC 277.30"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","5220","APC 296.56"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","5220","APC 308.91"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","5220",""
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","5220","APC 277.30"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","5220","APC 296.56"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","5220","APC 308.91"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","5220","APC"
"Njx interlaminar lmbr/sac","62327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","5220","APC"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Dx lmbr spi pnxr w/fluor/ct","62328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Ther spi pnxr csf fluor/ct","62329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Dcmprn prq rmv lig flv 1lmbr","62330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Implant spinal canal cath","62350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Implant spinal canal cath","62351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spinal canal catheter","62355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","62225.49",""
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","62225.49",""
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","62225.49",""
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55858.11","","","","","","","fee schedule","4564","62225.49","APC 277.30"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59737.76","","","","","","","fee schedule","4564","62225.49","APC 296.56"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62225.49","","","","","","","fee schedule","4564","62225.49","APC 308.91"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18420.92","","","","","","","fee schedule","4564","62225.49","APC"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18113.17","","","","","","","fee schedule","4564","62225.49","APC"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17937.31","","","","","","","fee schedule","4564","62225.49","APC"
"Insert spine infusion device","62360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18464.88","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","4564","62225.49",""
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","62225.49",""
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","4564","62225.49",""
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55858.11","","","","","","","fee schedule","4564","62225.49","APC 277.30"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59737.76","","","","","","","fee schedule","4564","62225.49","APC 296.56"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62225.49","","","","","","","fee schedule","4564","62225.49","APC 308.91"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18420.92","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18113.17","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17937.31","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18464.88","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","4564","62225.49",""
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","62225.49",""
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","4564","62225.49",""
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55858.11","","","","","","","fee schedule","4564","62225.49","APC 277.30"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59737.76","","","","","","","fee schedule","4564","62225.49","APC 296.56"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62225.49","","","","","","","fee schedule","4564","62225.49","APC 308.91"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18420.92","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18113.17","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17937.31","","","","","","","fee schedule","4564","62225.49","APC"
"Implant spine infusion pump","62362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18464.88","","","","","","","fee schedule","4564","62225.49","APC"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3399.75","29398",""
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3399.75","29398",""
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3399.75","29398",""
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","29398","APC 277.30"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","29398","APC 296.56"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","29398","APC 308.91"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","29398","APC"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","29398","APC"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","29398","APC"
"Remove spine infusion device","62365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","29398","APC"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.66","4564",""
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","305.66","4564",""
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.66","4564",""
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.86","","","","","","","fee schedule","305.66","4564","APC 277.30"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.97","","","","","","","fee schedule","305.66","4564","APC 296.56"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1060.36","","","","","","","fee schedule","305.66","4564","APC 308.91"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.9","","","","","","","fee schedule","305.66","4564","APC"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.66","","","","","","","fee schedule","305.66","4564","APC"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.66","","","","","","","fee schedule","305.66","4564","APC"
"Analyze spine infus pump","62367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.65","","","","","","","fee schedule","305.66","4564","APC"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.66","4564",""
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","305.66","4564",""
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.66","4564",""
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.86","","","","","","","fee schedule","305.66","4564","APC 277.30"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.97","","","","","","","fee schedule","305.66","4564","APC 296.56"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1060.36","","","","","","","fee schedule","305.66","4564","APC 308.91"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.9","","","","","","","fee schedule","305.66","4564","APC"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.66","","","","","","","fee schedule","305.66","4564","APC"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.66","","","","","","","fee schedule","305.66","4564","APC"
"Analyze sp inf pump w/reprog","62368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.65","","","","","","","fee schedule","305.66","4564","APC"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.66","5220",""
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.66","5220",""
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.66","5220",""
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.86","","","","","","","fee schedule","305.66","5220","APC 277.30"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.97","","","","","","","fee schedule","305.66","5220","APC 296.56"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1060.36","","","","","","","fee schedule","305.66","5220","APC 308.91"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.9","","","","","","","fee schedule","305.66","5220","APC"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.66","","","","","","","fee schedule","305.66","5220","APC"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.66","","","","","","","fee schedule","305.66","5220","APC"
"Anal sp inf pmp w/reprg&fill","62369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.65","","","","","","","fee schedule","305.66","5220","APC"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.66","5220",""
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.66","5220",""
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.66","5220",""
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.86","","","","","","","fee schedule","305.66","5220","APC 277.30"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.97","","","","","","","fee schedule","305.66","5220","APC 296.56"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1060.36","","","","","","","fee schedule","305.66","5220","APC 308.91"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.9","","","","","","","fee schedule","305.66","5220","APC"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.66","","","","","","","fee schedule","305.66","5220","APC"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.66","","","","","","","fee schedule","305.66","5220","APC"
"Anl sp inf pmp w/mdreprg&fil","62370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.65","","","","","","","fee schedule","305.66","5220","APC"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Ndsc dcmprn 1 ntrspc lumbar","62380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 crvl","63001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 thrc","63003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 lmbr","63005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1/2 scrl","63011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove lamina/facets lumbar","63012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 crvcl","63015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 thrc","63016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina >2 lmbr","63017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Low back disk surgery","63030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Spinal disk surgery add-on","63035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Spinal disk surgery add-on","63035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Spinal disk surgery add-on","63035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single cervical","63040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy single lumbar","63042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Laminotomy addl cervical","63043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Laminotomy addl cervical","63043","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Laminotomy addl cervical","63043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Laminotomy addl lumbar","63044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Laminotomy addl lumbar","63044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Laminotomy addl lumbar","63044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 crvl","63045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 thrc","63046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Remove spine lamina 1 lmbr","63047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Remove spinal lamina add-on","63048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Remove spinal lamina add-on","63048","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Remove spinal lamina add-on","63048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Cervical laminoplsty 2/> seg","63050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Cervical laminoplsty 2/> seg","63050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Cervical laminoplsty 2/> seg","63050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"C-laminoplasty w/graft/plate","63051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"C-laminoplasty w/graft/plate","63051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"C-laminoplasty w/graft/plate","63051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Lam facetc/frmt arthrd lum 1","63052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Lam facetc/frmt arthrd lum 1","63052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Lam factc/frmt arthrd lum ea","63053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Lam factc/frmt arthrd lum ea","63053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord thrc","63055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord lmbr","63056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spine cord add-on","63057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Decompress spine cord add-on","63057","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Decompress spine cord add-on","63057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","7221.37","29398",""
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","29398","APC 277.30"
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","29398","APC 296.56"
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","29398","APC 308.91"
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spinal cord thrc","63064","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","29398","APC"
"Decompress spine cord add-on","63066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","13700",""
"Decompress spine cord add-on","63066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","2375","13700",""
"Decompress spine cord add-on","63066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","13700",""
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Neck spine disk surgery","63076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Neck spine disk surgery","63076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Neck spine disk surgery","63076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Spine disk surgery thorax","63077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Spine disk surgery thorax","63077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Spine disk surgery thorax","63077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Spine disk surgery thorax","63078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Spine disk surgery thorax","63078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Spine disk surgery thorax","63078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn crvl","63081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Remove vert body dcmprn crvl","63081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Remove vert body dcmprn crvl","63081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Remove vertebral body add-on","63082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63082","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn thrc","63085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn thrc","63085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn thrc","63085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remov vertbr dcmprn thrclmbr","63087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remov vertbr dcmprn thrclmbr","63087","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remov vertbr dcmprn thrclmbr","63087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63088","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn lmbr","63090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn lmbr","63090","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn lmbr","63090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63091","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn thrc","63101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn thrc","63101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn thrc","63101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn lmbr","63102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn lmbr","63102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert body dcmprn lmbr","63102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise spinal cord tract(s)","63170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise spinal cord tract(s)","63170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise spinal cord tract(s)","63170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drainage of spinal cyst","63172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drainage of spinal cyst","63172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drainage of spinal cyst","63172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Drainage of spinal cyst","63173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Drainage of spinal cyst","63173","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Drainage of spinal cyst","63173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise spinal cord ligaments","63180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Revise spinal cord ligaments","63182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Incise spine nrv half segmnt","63185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Incise spine nrv half segmnt","63185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Incise spine nrv half segmnt","63185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Incise spine nrv >2 segmnts","63190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Incise spine nrv >2 segmnts","63190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Incise spine nrv >2 segmnts","63190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Incise spine accessory nerve","63191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Incise spine accessory nerve","63191","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Incise spine accessory nerve","63191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Incise spine & cord cervical","63194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Incise spine & cord thoracic","63195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Incise spine&cord 2 trx crvl","63196","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Incise spine&cord 2 trx thrc","63197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise spine&cord 2 trx thrc","63197","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise spine&cord 2 trx thrc","63197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise spin&cord 2 stgs crvl","63198","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Incise spin&cord 2 stgs thrc","63199","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Release spinal cord lumbar","63200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Release spinal cord lumbar","63200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Release spinal cord lumbar","63200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Revise spinal cord vsls crvl","63250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise spinal cord vsls crvl","63250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise spinal cord vsls crvl","63250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise spinal cord vsls thrc","63251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Revise spinal cord vsls thrc","63251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Revise spinal cord vsls thrc","63251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Revise spine cord vsl thrlmb","63252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Revise spine cord vsl thrlmb","63252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Revise spine cord vsl thrlmb","63252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Excise intraspinl lesion crv","63265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion thrc","63266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","25051.33",""
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","25051.33",""
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Excise intrspinl lesion lmbr","63267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion scrl","63268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Excise intrspinl lesion crvl","63270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion crvl","63270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion crvl","63270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion thrc","63271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion thrc","63271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion thrc","63271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion lmbr","63272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Excise intrspinl lesion lmbr","63272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Excise intrspinl lesion lmbr","63272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Excise intrspinl lesion scrl","63273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion scrl","63273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Excise intrspinl lesion scrl","63273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn crvl","63275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn crvl","63275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn crvl","63275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn thrc","63276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn thrc","63276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn thrc","63276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn lmbr","63277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Bx/exc xdrl spine lesn lmbr","63277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Bx/exc xdrl spine lesn lmbr","63277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Bx/exc xdrl spine lesn scrl","63278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn scrl","63278","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bx/exc xdrl spine lesn scrl","63278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
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"Bx/exc idrl spine lesn crvl","63280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
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"Bx/exc idrl spine lesn scrl","63283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn cervl","63285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn cervl","63285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn cervl","63285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn thrc","63286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn thrc","63286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn thrc","63286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Bx/exc idrl imed lesn thrlmb","63287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Bx/exc idrl imed lesn thrlmb","63287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Bx/exc idrl imed lesn thrlmb","63287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Bx/exc xdrl/idrl lsn any lvl","63290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
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"Bx/exc xdrl/idrl lsn any lvl","63290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Repair laminectomy defect","63295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair laminectomy defect","63295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair laminectomy defect","63295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body crvcl","63300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body crvcl","63300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body crvcl","63300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body thrc","63301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body thrc","63301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body thrc","63301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body thrlmb","63302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body thrlmb","63302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert xdrl body thrlmb","63302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remov vert xdrl bdy lmbr/sac","63303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remov vert xdrl bdy lmbr/sac","63303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remov vert xdrl bdy lmbr/sac","63303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert idrl body crvcl","63304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert idrl body crvcl","63304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert idrl body crvcl","63304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vert idrl body thrc","63305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vert idrl body thrc","63305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vert idrl body thrc","63305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remov vert idrl bdy thrclmbr","63306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remov vert idrl bdy thrclmbr","63306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remov vert idrl bdy thrclmbr","63306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remov vert idrl bdy lmbr/sac","63307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remov vert idrl bdy lmbr/sac","63307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remov vert idrl bdy lmbr/sac","63307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove vertebral body add-on","63308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1943.35","14111",""
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spinal cord lesion","63600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","6741.58",""
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Stimulation of spinal cord","63610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Remove lesion of spinal cord","63615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Srs spinal lesion","63620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Srs spinal lesion","63620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Srs spinal lesion","63620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Srs spinal lesion addl","63621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Srs spinal lesion addl","63621","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Srs spinal lesion addl","63621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6342.39","29398",""
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","6342.39","29398",""
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6342.39","29398",""
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19750.68","","","","","","","fee schedule","6342.39","29398","APC 277.30"
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21122.48","","","","","","","fee schedule","6342.39","29398","APC 296.56"
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22002.1","","","","","","","fee schedule","6342.39","29398","APC 308.91"
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6513.39","","","","","","","fee schedule","6342.39","29398","APC"
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6404.57","","","","","","","fee schedule","6342.39","29398","APC"
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6342.39","","","","","","","fee schedule","6342.39","29398","APC"
"Implant neuroelectrodes","63650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6528.94","","","","","","","fee schedule","6342.39","29398","APC"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","66976.89",""
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","66976.89",""
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","66976.89",""
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","5220","66976.89","APC 277.30"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","5220","66976.89","APC 296.56"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","5220","66976.89","APC 308.91"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","5220","66976.89","APC"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","5220","66976.89","APC"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","5220","66976.89","APC"
"Implant neuroelectrodes","63655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","5220","66976.89","APC"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","1943.35","14111",""
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spine eltrd perq aray","63661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3479.32","19040",""
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Remove spine eltrd plate","63662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","6342.39","29398",""
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","6342.39","29398",""
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","6342.39","29398",""
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19750.68","","","","","","","fee schedule","6342.39","29398","APC 277.30"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21122.48","","","","","","","fee schedule","6342.39","29398","APC 296.56"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22002.1","","","","","","","fee schedule","6342.39","29398","APC 308.91"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6513.39","","","","","","","fee schedule","6342.39","29398","APC"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6404.57","","","","","","","fee schedule","6342.39","29398","APC"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6342.39","","","","","","","fee schedule","6342.39","29398","APC"
"Revise spine eltrd perq aray","63663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6528.94","","","","","","","fee schedule","6342.39","29398","APC"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10181","38469",""
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","38469",""
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10181","38469",""
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","10181","38469","APC 277.30"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","10181","38469","APC 296.56"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","10181","38469","APC 308.91"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","10181","38469","APC"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","10181","38469","APC"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","10181","38469","APC"
"Revise spine eltrd plate","63664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","10181","38469","APC"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","4564","106533.01",""
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","106533.01",""
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","4564","106533.01",""
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","4564","106533.01","APC 277.30"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","4564","106533.01","APC 296.56"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","4564","106533.01","APC 308.91"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","4564","106533.01","APC"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","4564","106533.01","APC"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","4564","106533.01","APC"
"Insrt/redo spine n generator","63685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","4564","106533.01","APC"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3408","19040","APC 277.30"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3408","19040","APC 296.56"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3408","19040","APC 308.91"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3408","19040","APC"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3408","19040","APC"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3408","19040","APC"
"Revise/remove neuroreceiver","63688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3408","19040","APC"
"Repair of spinal herniation","63700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of spinal herniation","63706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair spinal fluid leakage","63707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair spinal fluid leakage","63707","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair spinal fluid leakage","63707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair spinal fluid leakage","63709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair spinal fluid leakage","63709","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair spinal fluid leakage","63709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Graft repair of spine defect","63710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Graft repair of spine defect","63710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Graft repair of spine defect","63710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Install spinal shunt","63740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Install spinal shunt","63740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Install spinal shunt","63740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Install spinal shunt","63741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3399.75","23971",""
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Revision of spinal shunt","63744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of spinal shunt","63746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"N block inj trigeminal","64400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"N block inj facial","64402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"N block inj occipital","64405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"N block inj vagus","64408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"N block inj phrenic","64410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Injection for nerve block","64412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"N block inj cervical plexus","64413","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj brachial plexus","64415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block cont infuse b plex","64416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj axillary","64417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block inj suprascapular","64418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block inj intercost sng","64420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj intercost mlt","64421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block inj ilio-ing/hypogi","64425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj pudendal","64430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block inj paracervical","64435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block inj sciatic sng","64445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N blk inj sciatic cont inf","64446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block inj fem single","64447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj fem cont inf","64448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj lumbar plexus","64449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"N block other peripheral","64450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd nrv nrvtg si jt","64451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Njx aa&/strd gnclr nrv brnch","64454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"N block inj plantar digit","64455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic single inj site","64461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic 2nd+ inj site","64462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Pvb thoracic 2nd+ inj site","64462","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Pvb thoracic 2nd+ inj site","64462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Pvb thoracic cont infusion","64463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Thrc fascial pln blk uni njx","64466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk uni njx","64466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk uni nfs","64467","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk uni nfs","64467","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk bi njx","64468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk bi njx","64468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk bi nfs","64469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Thrc fascial pln blk bi nfs","64469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Lwr xtr fscl pln blk uni njx","64473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Lwr xtr fscl pln blk uni njx","64473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Lwr xtr fscl pln blk uni nfs","64474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Lwr xtr fscl pln blk uni nfs","64474","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural c/t","64479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural add-on","64480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Inj foramen epidural add-on","64480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Inj foramen epidural add-on","64480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural l/s","64483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Inj foramen epidural add-on","64484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Inj foramen epidural add-on","64484","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Inj foramen epidural add-on","64484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Tap block unil by injection","64486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Tap block unil by injection","64486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Tap block unil by injection","64486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Tap block uni by infusion","64487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Tap block uni by infusion","64487","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Tap block uni by infusion","64487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Tap block bi injection","64488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Tap block bi injection","64488","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Tap block bi injection","64488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Tap block bi by infusion","64489","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Tap block bi by infusion","64489","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Tap block bi by infusion","64489","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt c/t 1 lev","64490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt c/t 2 lev","64491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt c/t 2 lev","64491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt c/t 2 lev","64491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt c/t 3 lev","64492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt c/t 3 lev","64492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt c/t 3 lev","64492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt l/s 1 lev","64493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Inj paravert f jnt l/s 2 lev","64494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt l/s 2 lev","64494","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt l/s 2 lev","64494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt l/s 3 lev","64495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt l/s 3 lev","64495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Inj paravert f jnt l/s 3 lev","64495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"N block spenopalatine gangl","64505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"N block carotid sinus s/p","64508","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block stellate ganglion","64510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","4564",""
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","880.23","4564",""
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","4564",""
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","4564","APC 277.30"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","4564","APC 296.56"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","4564","APC 308.91"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","4564","APC"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","4564","APC"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","4564","APC"
"N block inj hypogas plxs","64517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","4564","APC"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block lumbar/thoracic","64520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"N block inj celiac pelus","64530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Apply neurostimulator","64550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3408","38469",""
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","38469",""
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3408","38469",""
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","3408","38469","APC 277.30"
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","3408","38469","APC 296.56"
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","3408","38469","APC 308.91"
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19750.68","","","","","","","fee schedule","5220","29398","APC 277.30"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21122.48","","","","","","","fee schedule","5220","29398","APC 296.56"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22002.1","","","","","","","fee schedule","5220","29398","APC 308.91"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6513.39","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6404.57","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6342.39","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6528.94","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19750.68","","","","","","","fee schedule","5220","29398","APC 277.30"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21122.48","","","","","","","fee schedule","5220","29398","APC 296.56"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22002.1","","","","","","","fee schedule","5220","29398","APC 308.91"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6513.39","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6404.57","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6342.39","","","","","","","fee schedule","5220","29398","APC"
"Implant neuroelectrodes","64561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6528.94","","","","","","","fee schedule","5220","29398","APC"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Neuroeltrd stim post tibial","64566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","3131.27","APC 277.30"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","3131.27","APC 296.56"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","3131.27","APC 308.91"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","3131.27","APC"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","3131.27","APC"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","3131.27","APC"
"Perq elec nrv field stimj cn","64567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","3131.27","APC"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","5220","152065.9",""
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","152065.9",""
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","5220","152065.9",""
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","136505.37","","","","","","","fee schedule","5220","152065.9","APC 277.30"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","145986.42","","","","","","","fee schedule","5220","152065.9","APC 296.56"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","152065.9","","","","","","","fee schedule","5220","152065.9","APC 308.91"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45016.81","","","","","","","fee schedule","5220","152065.9","APC"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44264.74","","","","","","","fee schedule","5220","152065.9","APC"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43834.99","","","","","","","fee schedule","5220","152065.9","APC"
"Inc for vagus n elect impl","64568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45124.25","","","","","","","fee schedule","5220","152065.9","APC"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10181","38469",""
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","38469",""
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10181","38469",""
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","10181","38469","APC 277.30"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","10181","38469","APC 296.56"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","10181","38469","APC 308.91"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","10181","38469","APC"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","10181","38469","APC"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","10181","38469","APC"
"Revise/repl vagus n eltrd","64569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","10181","38469","APC"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3399.75","29398",""
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","3399.75","29398",""
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3399.75","29398",""
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","29398","APC 277.30"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","29398","APC 296.56"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","29398","APC 308.91"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","29398","APC"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","29398","APC"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","29398","APC"
"Remove vagus n eltrd","64570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","29398","APC"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","3408","38469",""
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","38469",""
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","3408","38469",""
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","3408","38469","APC 277.30"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","3408","38469","APC 296.56"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","3408","38469","APC 308.91"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","3408","38469","APC"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","3408","66976.89",""
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","66976.89",""
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","3408","66976.89",""
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","3408","66976.89","APC 277.30"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","3408","66976.89","APC 296.56"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","3408","66976.89","APC 308.91"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","3408","66976.89","APC"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","3408","66976.89","APC"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","3408","66976.89","APC"
"Implant neuroelectrodes","64580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","3408","66976.89","APC"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","35289",""
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","35289",""
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","35289",""
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19750.68","","","","","","","fee schedule","5220","35289","APC 277.30"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21122.48","","","","","","","fee schedule","5220","35289","APC 296.56"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22002.1","","","","","","","fee schedule","5220","35289","APC 308.91"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6513.39","","","","","","","fee schedule","5220","35289","APC"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6404.57","","","","","","","fee schedule","5220","35289","APC"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6342.39","","","","","","","fee schedule","5220","35289","APC"
"Implant neuroelectrodes","64581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6528.94","","","","","","","fee schedule","5220","35289","APC"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","30709.54","106533.01",""
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","30709.54","106533.01",""
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","30709.54","106533.01","APC 277.30"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","30709.54","106533.01","APC 296.56"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","30709.54","106533.01","APC 308.91"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","30709.54","106533.01","APC"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","30709.54","106533.01","APC"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","30709.54","106533.01","APC"
"Opn mpltj hpglsl nstm ary pg","64582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Rev/rplct hpglsl nstm ary pg","64583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3399.75","29398",""
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3399.75","29398",""
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","29398","APC 277.30"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","29398","APC 296.56"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","29398","APC 308.91"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","29398","APC"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","29398","APC"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","29398","APC"
"Rmvl hpglsl nstim ary pg","64584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","29398","APC"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3408","19040","APC 277.30"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3408","19040","APC 296.56"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3408","19040","APC 308.91"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3408","19040","APC"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3408","19040","APC"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3408","19040","APC"
"Revise/remove neuroelectrode","64585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3408","19040","APC"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","4564","66976.89",""
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","66976.89",""
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","4564","66976.89",""
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60123.31","","","","","","","fee schedule","4564","66976.89","APC 277.30"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64299.2","","","","","","","fee schedule","4564","66976.89","APC 296.56"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66976.89","","","","","","","fee schedule","4564","66976.89","APC 308.91"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19827.49","","","","","","","fee schedule","4564","66976.89","APC"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19496.25","","","","","","","fee schedule","4564","66976.89","APC"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19306.96","","","","","","","fee schedule","4564","66976.89","APC"
"Insrt/redo pn/gastr stimul","64590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19874.82","","","","","","","fee schedule","4564","66976.89","APC"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3408","19040","APC 277.30"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3408","19040","APC 296.56"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3408","19040","APC 308.91"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3408","19040","APC"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3408","19040","APC"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3408","19040","APC"
"Revise/rmv pn/gastr stimul","64595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3408","19040","APC"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11089.19","38469",""
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11089.19","38469",""
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34532.56","","","","","","","fee schedule","11089.19","38469","APC 277.30"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36931.04","","","","","","","fee schedule","11089.19","38469","APC 296.56"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38469","","","","","","","fee schedule","11089.19","38469","APC 308.91"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11388.17","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11197.91","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11089.19","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplcmt prq eltrd ra pn 1","64596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11415.35","","","","","","","fee schedule","11089.19","38469","APC"
"Ins/rplcm prq eltrd ra pn ea","64597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Ins/rplcm prq eltrd ra pn ea","64597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3479.32","19040",""
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","19040","APC 277.30"
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","19040","APC 296.56"
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","19040","APC 308.91"
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","19040","APC"
"Revj/rmvl nea pn w/int nstim","64598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","19040","APC"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Injection treatment of nerve","64610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv saliv glands","64611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Destroy nerve face muscle","64612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Destroy nerve, spine muscle","64613","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Destroy Nerve, Extrem Musc","64614","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc migraine","64615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Chemodenerv musc neck dyston","64616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Chemodener muscle larynx emg","64617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Dstrj nulyt agt gnclr nrv","64624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Rf abltj nrv nrvtg si jt","64625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Trml dstrj ios bvn 1st 2 l/s","64628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Trml dstrj ios bvn ea addl","64629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Trml dstrj ios bvn ea addl","64629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","4564","APC 277.30"
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","4564","APC 296.56"
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","4564","APC 308.91"
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","4564","APC"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"N block inj common digit","64632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy cerv/thor facet jnt","64633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy c/th facet jnt addl","64634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Destroy c/th facet jnt addl","64634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Destroy c/th facet jnt addl","64634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1943.35","14111",""
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy lumb/sac facet jnt","64635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Destroy l/s facet jnt addl","64636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Destroy l/s facet jnt addl","64636","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Destroy l/s facet jnt addl","64636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","3880",""
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","3880","APC 277.30"
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","3880","APC 296.56"
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","3880","APC 308.91"
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","3880","APC"
"Injection treatment of nerve","64640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","3880","APC"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extremity 1-4","64642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extrem 1-4 ea","64643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Chemodenerv 1 extrem 1-4 ea","64643","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Chemodenerv 1 extrem 1-4 ea","64643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extrem 5/> mus","64644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv 1 extrem 5/> ea","64645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Chemodenerv 1 extrem 5/> ea","64645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Chemodenerv 1 extrem 5/> ea","64645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 1-5","64646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","5220",""
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","5220","APC 277.30"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","5220","APC 296.56"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","5220","APC 308.91"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv trunk musc 6/>","64647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","5220","APC"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","3408",""
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","305.48","3408",""
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","3408",""
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","3408","APC 277.30"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","3408","APC 296.56"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","3408","APC 308.91"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","3408","APC"
"Chemodenerv eccrine glands","64653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","3408","APC"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","12069.94","APC 277.30"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","12069.94","APC 296.56"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","12069.94","APC 308.91"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rplcmt bat mod sys lead","64655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","12069.94","APC"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95631.75","","","","","","","fee schedule","30709.54","106533.01","APC 277.30"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102273.9","","","","","","","fee schedule","30709.54","106533.01","APC 296.56"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106533.01","","","","","","","fee schedule","30709.54","106533.01","APC 308.91"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31537.49","","","","","","","fee schedule","30709.54","106533.01","APC"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31010.61","","","","","","","fee schedule","30709.54","106533.01","APC"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30709.54","","","","","","","fee schedule","30709.54","106533.01","APC"
"Revj/rplcmt bat mod sys pg","64656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31612.76","","","","","","","fee schedule","30709.54","106533.01","APC"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","11793.9","APC 277.30"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","11793.9","APC 296.56"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","11793.9","APC 308.91"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","11793.9","APC"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","11793.9","APC"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","11793.9","APC"
"Rmvl bat modulj sys tot sys","64657","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","11793.9","APC"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","12069.94","APC 277.30"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","12069.94","APC 296.56"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","12069.94","APC 308.91"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modul sys lead only","64658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10834.86","","","","","","","fee schedule","3479.32","12069.94","APC 277.30"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11587.4","","","","","","","fee schedule","3479.32","12069.94","APC 296.56"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12069.94","","","","","","","fee schedule","3479.32","12069.94","APC 308.91"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3573.12","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3513.43","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3479.32","","","","","","","fee schedule","3479.32","12069.94","APC"
"Rmvl bat modulj sys pg only","64659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3581.65","","","","","","","fee schedule","3479.32","12069.94","APC"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","4564","APC 277.30"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","4564","APC 296.56"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","4564","APC 308.91"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","880.23","4564",""
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2741.09","","","","","","","fee schedule","880.23","4564","APC 277.30"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2931.47","","","","","","","fee schedule","880.23","4564","APC 296.56"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3053.55","","","","","","","fee schedule","880.23","4564","APC 308.91"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","903.96","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","888.86","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","880.23","","","","","","","fee schedule","880.23","4564","APC"
"Injection treatment of nerve","64681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","906.11","","","","","","","fee schedule","880.23","4564","APC"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revise finger/toe nerve","64702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revise hand/foot nerve","64704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revise arm/leg nerve","64708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of sciatic nerve","64712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of arm nerve(s)","64713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revise low back nerve(s)","64714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revision of cranial nerve","64716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at elbow","64718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Revise ulnar nerve at wrist","64719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Carpal tunnel surgery","64721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Relieve pressure on nerve(s)","64722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1943.35","14111",""
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Release foot/toe nerve","64726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Internal nerve revision","64727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Internal nerve revision","64727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Internal nerve revision","64727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Dcmprn median nrv carpl tunl","64728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of brow nerve","64732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of cheek nerve","64734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of chin nerve","64736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of jaw nerve","64738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of tongue nerve","64740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of facial nerve","64742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Incise nerve back of head","64744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise diaphragm nerve","64746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incision of stomach nerves","64755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of stomach nerves","64755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of stomach nerves","64755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incision of vagus nerve","64760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incision of vagus nerve","64760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incision of vagus nerve","64760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise hip/thigh nerve","64763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1943.35","19040",""
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","19040",""
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1943.35","19040",""
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","19040","APC 277.30"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","19040","APC 296.56"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","19040","APC 308.91"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","19040","APC"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","19040","APC"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","19040","APC"
"Incise hip/thigh nerve","64766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","19040","APC"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Sever cranial nerve","64771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Incision of spinal nerve","64772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove digit nerve lesion","64776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Digit nerve surgery add-on","64778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Digit nerve surgery add-on","64778","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Digit nerve surgery add-on","64778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove limb nerve lesion","64782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Limb nerve surgery add-on","64783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Limb nerve surgery add-on","64783","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Limb nerve surgery add-on","64783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove nerve lesion","64784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3399.75","23971",""
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Remove sciatic nerve lesion","64786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Implant nerve end","64787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Implant nerve end","64787","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Implant nerve end","64787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Remove skin nerve lesion","64788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of nerve lesion","64790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3399.75","23971",""
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Removal of nerve lesion","64792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","14111",""
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Biopsy of nerve","64795","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","6741.58",""
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Sympathectomy cervical","64802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1943.35","6741.58",""
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","6741.58",""
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1943.35","6741.58",""
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Remove sympathetic nerves","64804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"Remove sympathetic nerves","64809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove sympathetic nerves","64809","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove sympathetic nerves","64809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove sympathetic nerves","64818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove sympathetic nerves","64818","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove sympathetic nerves","64818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1943.35","14111",""
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","14111",""
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1943.35","14111",""
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","14111","APC 277.30"
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","14111","APC 296.56"
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","14111","APC 308.91"
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","14111","APC"
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","14111","APC"
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","14111","APC"
"Sympathectomy digital artery","64820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","14111","APC"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3256.29","19040",""
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","19040",""
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Remove sympathetic nerves","64822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3256.29","19040",""
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Sympathectomy supfc palmar","64823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1943.35","19040",""
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","1943.35","19040",""
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1943.35","19040",""
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","19040","APC 277.30"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","19040","APC 296.56"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","19040","APC 308.91"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of digit nerve","64831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","19040","APC"
"Repair nerve add-on","64832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Repair nerve add-on","64832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Repair nerve add-on","64832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of hand or foot nerve","64836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Repair nerve add-on","64837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Repair nerve add-on","64837","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Repair nerve add-on","64837","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Repair of leg nerve","64840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Repair/transpose nerve","64856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3399.75","23971",""
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Repair arm/leg nerve","64857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1943.35","19040",""
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","1943.35","19040",""
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1943.35","19040",""
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","19040","APC 277.30"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","19040","APC 296.56"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","19040","APC 308.91"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","19040","APC"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","19040","APC"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","19040","APC"
"Repair sciatic nerve","64858","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","19040","APC"
"Nerve surgery","64859","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Nerve surgery","64859","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Nerve surgery","64859","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","1943.35","19040",""
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1943.35","19040",""
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","1943.35","19040",""
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","19040","APC 277.30"
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","19040","APC 296.56"
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","19040","APC 308.91"
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of arm nerves","64861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","19040","APC"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3399.75","23971",""
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of low back nerves","64862","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Repair of facial nerve","64864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3399.75","23971",""
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Repair of facial nerve","64865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Fusion of facial/other nerve","64866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of facial/other nerve","64866","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of facial/other nerve","64866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of facial/other nerve","64868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Fusion of facial/other nerve","64868","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Fusion of facial/other nerve","64868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Fusion of facial/other nerve","64870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Subsequent repair of nerve","64872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Subsequent repair of nerve","64872","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Subsequent repair of nerve","64872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Repair & revise nerve add-on","64874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Repair & revise nerve add-on","64874","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Repair & revise nerve add-on","64874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Repair nerve/shorten bone","64876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Repair nerve/shorten bone","64876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Repair nerve/shorten bone","64876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck <=4 cm","64885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft head/neck >4 cm","64886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft hand/foot >4 cm","64891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft arm/leg <4 cm","64892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3399.75","23971",""
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3399.75","23971",""
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3399.75","23971",""
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10587.06","","","","","","","fee schedule","3399.75","23971","APC 277.30"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11322.39","","","","","","","fee schedule","3399.75","23971","APC 296.56"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11793.9","","","","","","","fee schedule","3399.75","23971","APC 308.91"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3491.41","","","","","","","fee schedule","3399.75","23971","APC"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3433.08","","","","","","","fee schedule","3399.75","23971","APC"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3399.75","","","","","","","fee schedule","3399.75","23971","APC"
"Nerve graft arm/leg >4 cm","64893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3499.74","","","","","","","fee schedule","3399.75","23971","APC"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot <=4 cm","64895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft hand/foot >4 cm","64896","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg <=4 cm","64897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft arm/leg >4 cm","64898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Nerve graft add-on","64901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Nerve graft add-on","64901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Nerve graft add-on","64901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Nerve graft add-on","64902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","4564",""
"Nerve graft add-on","64902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2375","4564",""
"Nerve graft add-on","64902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","4564",""
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4564","30297.71",""
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","30297.71",""
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4564","30297.71",""
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","4564","30297.71","APC 277.30"
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","4564","30297.71","APC 296.56"
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","4564","30297.71","APC 308.91"
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve pedicle transfer","64905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","4564","30297.71","APC"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3408","30297.71",""
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","30297.71",""
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3408","30297.71",""
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","3408","30297.71","APC 277.30"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","3408","30297.71","APC 296.56"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","3408","30297.71","APC 308.91"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","3408","30297.71","APC"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","3408","30297.71","APC"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","3408","30297.71","APC"
"Nerve pedicle transfer","64907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","3408","30297.71","APC"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","30297.71",""
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","30297.71",""
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","30297.71",""
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","7337","30297.71","APC 277.30"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","7337","30297.71","APC 296.56"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","7337","30297.71","APC 308.91"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","7337","30297.71","APC"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","7337","30297.71","APC"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","7337","30297.71","APC"
"Nerve repair w/allograft","64910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","7337","30297.71","APC"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","7337","30297.71",""
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","30297.71",""
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","7337","30297.71",""
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","7337","30297.71","APC 277.30"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","7337","30297.71","APC 296.56"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","7337","30297.71","APC 308.91"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","7337","30297.71","APC"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","7337","30297.71","APC"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","7337","30297.71","APC"
"Neurorraphy w/vein autograft","64911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","7337","30297.71","APC"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","30297.71",""
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","30297.71",""
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","30297.71",""
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27197.42","","","","","","","fee schedule","5220","30297.71","APC 277.30"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29086.43","","","","","","","fee schedule","5220","30297.71","APC 296.56"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30297.71","","","","","","","fee schedule","5220","30297.71","APC 308.91"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8969.18","","","","","","","fee schedule","5220","30297.71","APC"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8819.34","","","","","","","fee schedule","5220","30297.71","APC"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.71","","","","","","","fee schedule","5220","30297.71","APC"
"Nrv rpr w/nrv algrft 1st","64912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.59","","","","","","","fee schedule","5220","30297.71","APC"
"Nrv rpr w/nrv algrft ea addl","64913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Nrv rpr w/nrv algrft ea addl","64913","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Nrv rpr w/nrv algrft ea addl","64913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","5220",""
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","305.48","5220",""
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","5220",""
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","5220","APC 277.30"
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","5220","APC 296.56"
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","5220","APC 308.91"
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","5220","APC"
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","5220","APC"
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","5220","APC"
"Nervous system surgery","64999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","5220","APC"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye","65091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye with implant","65093","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/insert implant","65103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/attach implant","65105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye","65110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Remove eye/revise socket","65114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise ocular implant","65125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3912.52","19040",""
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Insert ocular implant","65135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Attach ocular implant","65140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3912.52","19040",""
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise ocular implant","65150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Reinsert ocular implant","65155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3408","19040","APC 277.30"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3408","19040","APC 296.56"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3408","19040","APC 308.91"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3408","19040","APC"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3408","19040","APC"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3408","19040","APC"
"Removal of ocular implant","65175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3408","19040","APC"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2296.74","7967.52",""
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","7967.52",""
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2296.74","7967.52",""
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Remove foreign body from eye","65260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Remove foreign body from eye","65265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair of eye wound","65273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Repair of eye wound","65273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Repair of eye wound","65273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye wound","65275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5295.75","18371.25",""
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5295.75","18371.25",""
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5295.75","18371.25",""
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","18371.25","APC 277.30"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","18371.25","APC 296.56"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","18371.25","APC 308.91"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5295.75","18371.25",""
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5295.75","18371.25",""
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5295.75","18371.25",""
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","18371.25","APC 277.30"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","18371.25","APC 296.56"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","18371.25","APC 308.91"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Repair of eye wound","65286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Repair of eye socket wound","65290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Removal of eye lesion","65400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2366.07","8208.02",""
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","8208.02",""
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2366.07","8208.02",""
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","8208.02","APC 277.30"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","8208.02","APC 296.56"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","8208.02","APC 308.91"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","8208.02","APC"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","8208.02","APC"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","8208.02","APC"
"Biopsy of cornea","65410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","8208.02","APC"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of eye lesion","65426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Corneal smear","65430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Curette/treat cornea","65435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Curette/treat cornea","65436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Treatment of corneal lesion","65450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of cornea","65600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5295.75","23971",""
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4113.58","23971",""
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5295.75","23971",""
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4113.58","23971",""
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal transplant","65755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4113.58","23971",""
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Corneal trnspl endothelial","65756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Prep corneal endo allograft","65757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Prep corneal endo allograft","65757","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Prep corneal endo allograft","65757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Revision of cornea","65760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Revision of cornea","65760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Revision of cornea","65760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Revision of cornea","65765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Revision of cornea","65765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Revision of cornea","65765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Corneal tissue transplant","65767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Corneal tissue transplant","65767","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Corneal tissue transplant","65767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","50080.83",""
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","50080.83",""
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","50080.83",""
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44956.18","","","","","","","fee schedule","5220","50080.83","APC 277.30"
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","48078.63","","","","","","","fee schedule","5220","50080.83","APC 296.56"
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","50080.83","","","","","","","fee schedule","5220","50080.83","APC 308.91"
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14825.67","","","","","","","fee schedule","5220","50080.83","APC"
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14577.99","","","","","","","fee schedule","5220","50080.83","APC"
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14436.45","","","","","","","fee schedule","5220","50080.83","APC"
"Revise cornea with implant","65770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14861.06","","","","","","","fee schedule","5220","50080.83","APC"
"Radial keratotomy","65771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","14111",""
"Radial keratotomy","65771","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","14111",""
"Radial keratotomy","65771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","14111",""
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","6448",""
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","992.09","6448",""
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","6448",""
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","6448","APC 277.30"
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","6448","APC 296.56"
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","6448","APC 308.91"
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","6448","APC"
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","6448","APC"
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","6448","APC"
"Correction of astigmatism","65772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","6448","APC"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Correction of astigmatism","65775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","992.09","5790",""
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Cover eye w/membrane","65778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3912.52","19040",""
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Cover eye w/membrane suture","65779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5295.75","23971",""
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Ocular reconst transplant","65781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Ocular reconst transplant","65782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4113.58","23971",""
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Impltj ntrstrml crnl rng seg","65785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2296.74","7967.52",""
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2296.74","7967.52",""
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Drainage of eye","65800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","14111",""
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Drainage of eye","65815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3408","14270.21",""
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","14270.21",""
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3408","14270.21",""
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","3408","14270.21","APC 277.30"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","3408","14270.21","APC 296.56"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","3408","14270.21","APC 308.91"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","3408","14270.21","APC"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","3408","14270.21","APC"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","3408","14270.21","APC"
"Relieve inner eye pressure","65820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","3408","14270.21","APC"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","65850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Trabeculoplasty laser surg","65855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Incise inner eye adhesions","65860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","4113.58","14270.21",""
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Incise inner eye adhesions","65880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2296.74","14111",""
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye lesion","65900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2296.74","14111",""
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Remove implant of eye","65920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2296.74","14111",""
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Remove blood clot from eye","65930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Injection treatment of eye","66030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2366.07","14111",""
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eye lesion","66130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","4113.58","14270.21",""
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","4113.58","14270.21",""
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66165","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","6448",""
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Glaucoma surgery","66170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Incision of eye","66172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4113.58","23971",""
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Translum dil eye canal","66174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5295.75","23971",""
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Trnslum dil eye canal w/stnt","66175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5220","23971","APC 277.30"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5220","23971","APC 296.56"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5220","23971","APC 308.91"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5220","23971","APC"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5220","23971","APC"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5220","23971","APC"
"Aqueous shunt eye w/o graft","66179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5220","23971","APC"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5295.75","23971",""
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Aqueous shunt eye w/graft","66180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4113.58","23971",""
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Insert ant drainage device","66183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","14111",""
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Revision of aqueous shunt","66184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Revise aqueous shunt eye","66185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Repair eye lesion","66220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5295.75","18371.25",""
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","5295.75","18371.25",""
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5295.75","18371.25",""
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","18371.25","APC 277.30"
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","18371.25","APC 296.56"
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","18371.25","APC 308.91"
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","18371.25","APC"
"Repair/graft eye lesion","66225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","18371.25","APC"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Follow-up surgery of eye","66250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2296.74","7967.52",""
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2296.74","7967.52",""
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision of iris","66505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4113.58","14270.21",""
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Remove iris and lesion","66600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","2296.74","23971",""
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","23971",""
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","2296.74","23971",""
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","23971","APC 277.30"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","23971","APC 296.56"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","23971","APC 308.91"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","23971","APC"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","23971","APC"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","23971","APC"
"Removal of iris","66605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","23971","APC"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","7967.52",""
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","7967.52",""
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","14111",""
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of iris","66635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","14111",""
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Repair iris & ciliary body","66682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","16381.79","56829.3",""
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","16381.79","56829.3",""
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51014.1","","","","","","","fee schedule","16381.79","56829.3","APC 277.30"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","54557.31","","","","","","","fee schedule","16381.79","56829.3","APC 296.56"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","56829.3","","","","","","","fee schedule","16381.79","56829.3","APC 308.91"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16823.46","","","","","","","fee schedule","16381.79","56829.3","APC"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16542.4","","","","","","","fee schedule","16381.79","56829.3","APC"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16381.79","","","","","","","fee schedule","16381.79","56829.3","APC"
"Implantation iris prosthesis","66683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16863.61","","","","","","","fee schedule","16381.79","56829.3","APC"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","7967.52",""
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Destruction ciliary body","66700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Ciliary transsleral therapy","66710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Ciliary endoscopic ablation","66711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Destruction ciliary body","66740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Revision of iris","66762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Removal of inner eye lesion","66770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2296.74","7967.52",""
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","7967.52",""
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2296.74","7967.52",""
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Incision secondary cataract","66820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","4564",""
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","547.36","4564",""
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","4564",""
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","4564","APC 277.30"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","4564","APC 296.56"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","4564","APC 308.91"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","4564","APC"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","4564","APC"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","4564","APC"
"After cataract laser surgery","66821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","4564","APC"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Reposition intraocular lens","66825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens lesion","66830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","4113.58","23971",""
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Removal of lens material","66852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Extraction of lens","66920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4113.58","14270.21",""
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Extraction of lens","66930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2296.74","7967.52",""
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Extraction of lens","66940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","9956","","","","","","","fee schedule","2296.74","14111",""
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surgery complex","66982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","9956","","","","","","","fee schedule","2296.74","14111",""
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","9956","","","","","","","fee schedule","2296.74","14111",""
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Cataract surg w/iol 1 stage","66984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8575","","","","","","","fee schedule","2296.74","14111",""
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Insert lens prosthesis","66985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8575","","","","","","","fee schedule","2296.74","14111",""
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Exchange lens prosthesis","66986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4113.58","23971",""
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl cplx w/ecp","66987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4113.58","23971",""
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Xcapsl ctrc rmvl w/ecp","66988","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Xcpsl ctrc rmvl cplx insj 1+","66989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Ophthalmic endoscope add-on","66990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Ophthalmic endoscope add-on","66990","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Ophthalmic endoscope add-on","66990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Xcapsl ctrc rmvl insj 1+","66991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","7967.52",""
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Eye surgery procedure","66999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Partial removal of eye fluid","67010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","14111",""
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Release of eye fluid","67015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","14111",""
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Replace eye fluid","67025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","6448","48171.14",""
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","6448","48171.14",""
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","6448","48171.14",""
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43241.9","","","","","","","fee schedule","6448","48171.14","APC 277.30"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46245.29","","","","","","","fee schedule","6448","48171.14","APC 296.56"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","48171.14","","","","","","","fee schedule","6448","48171.14","APC 308.91"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14260.34","","","","","","","fee schedule","6448","48171.14","APC"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14022.1","","","","","","","fee schedule","6448","48171.14","APC"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13885.96","","","","","","","fee schedule","6448","48171.14","APC"
"Implant eye drug system","67027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14294.37","","","","","","","fee schedule","6448","48171.14","APC"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","328.72","3408",""
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","328.72","3408",""
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","328.72","3408",""
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","3408","APC 277.30"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","3408","APC 296.56"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","3408","APC 308.91"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","3408","APC"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","3408","APC"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","3408","APC"
"Injection eye drug","67028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","3408","APC"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Incise inner eye strands","67030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","4564",""
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","547.36","4564",""
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","4564",""
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","4564","APC 277.30"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","4564","APC 296.56"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","4564","APC 308.91"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","4564","APC"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","4564","APC"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","4564","APC"
"Laser surgery eye strands","67031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","4564","APC"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","4113.58","23971",""
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Removal of inner eye fluid","67036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4113.58","23971",""
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4113.58","23971",""
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Laser treatment of retina","67040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4113.58","23971",""
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular pucker","67041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4113.58","23971",""
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for macular hole","67042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","4113.58","23971",""
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Vit for membrane dissect","67043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2296.74","14111",""
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina crtx","67101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Repair detached retina pc","67105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","4113.58","23971",""
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","4113.58","23971",""
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","4113.58","23971",""
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","4113.58","23971",""
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","23971","APC 277.30"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","23971","APC 296.56"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","23971","APC 308.91"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","23971","APC"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","14111",""
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Repair detached retina","67110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Rerepair detached retina","67112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","10181",""
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5295.75","23971",""
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","5295.75","23971",""
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5295.75","23971",""
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16491.36","","","","","","","fee schedule","5295.75","23971","APC 277.30"
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17636.78","","","","","","","fee schedule","5295.75","23971","APC 296.56"
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18371.25","","","","","","","fee schedule","5295.75","23971","APC 308.91"
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5438.53","","","","","","","fee schedule","5295.75","23971","APC"
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5347.67","","","","","","","fee schedule","5295.75","23971","APC"
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5295.75","","","","","","","fee schedule","5295.75","23971","APC"
"Repair retinal detach cplx","67113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5451.51","","","","","","","fee schedule","5295.75","23971","APC"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4113.58","14270.21",""
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Release encircling material","67115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","14111",""
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye implant material","67120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","2296.74","19040",""
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2296.74","19040",""
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","2296.74","19040",""
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","19040","APC 277.30"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","19040","APC 296.56"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","19040","APC 308.91"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","19040","APC"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","19040","APC"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","19040","APC"
"Remove eye implant material","67121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","19040","APC"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","4564",""
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","315.88","4564",""
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","4564",""
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","4564","APC 277.30"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","4564","APC 296.56"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","4564","APC 308.91"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","4564","APC"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","4564","APC"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","4564","APC"
"Treatment of retina","67141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","4564","APC"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retina","67145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Treatment of retinal lesion","67208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retinal lesion","67210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Treatment of retinal lesion","67218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Treatment of choroid lesion","67220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Ocular Photodynamic Ther","67221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Eye photodynamic ther add-on","67225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","3408",""
"Eye photodynamic ther add-on","67225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2375","3408",""
"Eye photodynamic ther add-on","67225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","3408",""
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3408","19040","APC 277.30"
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3408","19040","APC 296.56"
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3408","19040","APC 308.91"
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3408","19040","APC"
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3408","19040","APC"
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3408","19040","APC"
"Dstrj extensive retinopathy","67227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3408","19040","APC"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Treatment x10sv retinopathy","67228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","5220",""
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","547.36","5220",""
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","5220",""
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","5220","APC 277.30"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","5220","APC 296.56"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","5220","APC 308.91"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","5220","APC"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","5220","APC"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","5220","APC"
"Tr retinal les preterm inf","67229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","5220","APC"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Reinforce eye wall","67250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4113.58","14270.21",""
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","4113.58","14270.21",""
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4113.58","14270.21",""
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12809.98","","","","","","","fee schedule","4113.58","14270.21","APC 277.30"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13699.7","","","","","","","fee schedule","4113.58","14270.21","APC 296.56"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14270.21","","","","","","","fee schedule","4113.58","14270.21","APC 308.91"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4224.48","","","","","","","fee schedule","4113.58","14270.21","APC"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4153.9","","","","","","","fee schedule","4113.58","14270.21","APC"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4113.58","","","","","","","fee schedule","4113.58","14270.21","APC"
"Reinforce/graft eye wall","67255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4234.56","","","","","","","fee schedule","4113.58","14270.21","APC"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2296.74","7967.52",""
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2296.74","7967.52",""
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2296.74","7967.52",""
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","7967.52","APC 277.30"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","7967.52","APC 296.56"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","7967.52","APC 308.91"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","7967.52","APC"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","7967.52","APC"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","7967.52","APC"
"Eye surgery procedure","67299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","7967.52","APC"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle","67311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise two eye muscles","67312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle","67314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise two eye muscles","67316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle(s)","67318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eye muscle(s) add-on","67320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle(s) add-on","67320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle(s) add-on","67320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Eye surgery follow-up add-on","67331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Eye surgery follow-up add-on","67331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Eye surgery follow-up add-on","67331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Rerevise eye muscles add-on","67332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Rerevise eye muscles add-on","67332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Rerevise eye muscles add-on","67332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle w/suture","67334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle w/suture","67334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle w/suture","67334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Eye suture during surgery","67335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Eye suture during surgery","67335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Eye suture during surgery","67335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle add-on","67340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle add-on","67340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2375","6448",""
"Revise eye muscle add-on","67340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","6448",""
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","2366.07","14111",""
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Release eye tissue","67343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Destroy nerve of eye muscle","67345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3408","19040",""
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","19040",""
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3408","19040",""
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3408","19040","APC 277.30"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3408","19040","APC 296.56"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3408","19040","APC 308.91"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3408","19040","APC"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3408","19040","APC"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3408","19040","APC"
"Biopsy eye muscle","67346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3408","19040","APC"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Unlisted px extraocular musc","67399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/drain eye socket","67405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Aspiration orbital contents","67415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/treat eye socket","67430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/drain eye socket","67440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explr/decompress eye socket","67445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Explore/biopsy eye socket","67450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Inject/treat eye socket","67500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Inject/treat eye socket","67515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","328.72","2633",""
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","328.72","2633",""
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","2633","APC 277.30"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","2633","APC 296.56"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","2633","APC 308.91"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","2633","APC"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","2633","APC"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","2633","APC"
"Sprchoroidal spc njx rx agt","67516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","2633","APC"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Insert eye socket implant","67550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3912.52","19040",""
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eye socket implant","67560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Decompress optic nerve","67570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Orbit surgery procedure","67599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Drainage of eyelid abscess","67700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Incision of eyelid","67710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Incision of eyelid fold","67715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesion","67800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesions","67801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesions","67805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lesion(s)","67808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Biopsy eyelid & lid margin","67810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Revise eyelashes","67820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Revise eyelashes","67825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","992.09","5790",""
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Revise eyelashes","67830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelashes","67835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Remove eyelid lesion","67840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Treat eyelid lesion","67850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Closure of eyelid by suture","67875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair brow defect","67900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","3912.52","19040",""
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid defect","67909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid defect","67911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid defect","67911","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
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"Correction eyelid w/implant","67912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Correction eyelid w/implant","67912","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
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"Correction eyelid w/implant","67912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
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"Correction eyelid w/implant","67912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
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"Correction eyelid w/implant","67912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Correction eyelid w/implant","67912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid defect","67924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair eyelid wound","67935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Remove eyelid foreign body","67938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67966","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Reconstruction of eyelid","67974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Reconstruction of eyelid","67975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Revision of eyelid","67999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","992.09","5790",""
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain eyelid lining","68020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Treatment of eyelid lesions","68040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2366.07","8208.02",""
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","8208.02",""
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2366.07","8208.02",""
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","8208.02","APC 277.30"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","8208.02","APC 296.56"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","8208.02","APC 308.91"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","8208.02","APC"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","8208.02","APC"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","8208.02","APC"
"Biopsy of eyelid lining","68100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","8208.02","APC"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove eyelid lining lesion","68135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Treat eyelid by injection","68200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise/graft eyelid lining","68328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2296.74","14111",""
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2296.74","14111",""
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2296.74","14111",""
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7152.23","","","","","","","fee schedule","2296.74","14111","APC 277.30"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7648.99","","","","","","","fee schedule","2296.74","14111","APC 296.56"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7967.52","","","","","","","fee schedule","2296.74","14111","APC 308.91"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2358.66","","","","","","","fee schedule","2296.74","14111","APC"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2319.26","","","","","","","fee schedule","2296.74","14111","APC"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2296.74","","","","","","","fee schedule","2296.74","14111","APC"
"Revise eyelid lining","68330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2364.29","","","","","","","fee schedule","2296.74","14111","APC"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise/graft eyelid lining","68335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","14111",""
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Separate eyelid adhesions","68340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3912.52","19040",""
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eyelid lining","68360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Revise eyelid lining","68362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Harvest eye tissue alograft","68371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Eyelid lining surgery","68399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","992.09","5790",""
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","992.09","5790",""
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","992.09","5790",""
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3089.45","","","","","","","fee schedule","992.09","5790","APC 277.30"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3304.03","","","","","","","fee schedule","992.09","5790","APC 296.56"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3441.62","","","","","","","fee schedule","992.09","5790","APC 308.91"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.84","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.82","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","992.09","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain tear gland","68400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1021.27","","","","","","","fee schedule","992.09","5790","APC"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2366.07","8208.02",""
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","8208.02",""
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2366.07","8208.02",""
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","8208.02","APC 277.30"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","8208.02","APC 296.56"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","8208.02","APC 308.91"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","8208.02","APC"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","8208.02","APC"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","8208.02","APC"
"Incise/drain tear sac","68420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","8208.02","APC"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Incise tear duct opening","68440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of tear gland","68500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Partial removal tear gland","68505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy of tear gland","68510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Removal of tear sac","68520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2366.07","14111",""
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Biopsy of tear sac","68525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Clearance of tear duct","68530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2366.07","14111",""
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Remove tear gland lesion","68540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3912.52","19040",""
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Remove tear gland lesion","68550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Repair tear ducts","68700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Revise tear duct opening","68705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear sac drain","68720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3912.52","19040",""
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3912.52","19040",""
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3912.52","19040",""
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12183.88","","","","","","","fee schedule","3912.52","19040","APC 277.30"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13030.12","","","","","","","fee schedule","3912.52","19040","APC 296.56"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13572.74","","","","","","","fee schedule","3912.52","19040","APC 308.91"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4018.01","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3950.88","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3912.52","","","","","","","fee schedule","3912.52","19040","APC"
"Create tear duct drain","68750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4027.6","","","","","","","fee schedule","3912.52","19040","APC"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Close tear duct opening","68761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","2366.07","8208.02",""
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","2366.07","8208.02",""
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","2366.07","8208.02",""
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","8208.02","APC 277.30"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","8208.02","APC 296.56"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","8208.02","APC 308.91"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","8208.02","APC"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","8208.02","APC"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","8208.02","APC"
"Close tear system fistula","68770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","8208.02","APC"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Dilate tear duct opening","68801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","3408",""
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","315.88","3408",""
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","3408",""
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","3408","APC 277.30"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","3408","APC 296.56"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","3408","APC 308.91"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","3408","APC"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","3408","APC"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","3408","APC"
"Probe nasolacrimal duct","68810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","3408","APC"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2366.07","14111",""
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nasolacrimal duct","68815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","2366.07","14111",""
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Probe nl duct w/balloon","68816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Explore/irrigate tear ducts","68840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Insj rx elut implt lac canal","68841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Injection for tear sac x-ray","68850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Injection for tear sac x-ray","68850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Injection for tear sac x-ray","68850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","315.88","5220",""
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","315.88","5220",""
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","315.88","5220",""
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","983.68","","","","","","","fee schedule","315.88","5220","APC 277.30"
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1052","","","","","","","fee schedule","315.88","5220","APC 296.56"
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1095.81","","","","","","","fee schedule","315.88","5220","APC 308.91"
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.4","","","","","","","fee schedule","315.88","5220","APC"
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.98","","","","","","","fee schedule","315.88","5220","APC"
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.88","","","","","","","fee schedule","315.88","5220","APC"
"Tear duct system surgery","68899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.17","","","","","","","fee schedule","315.88","5220","APC"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Drain external ear lesion","69000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1643.67","5790",""
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Drain external ear lesion","69005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","704.73","5220",""
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","704.73","5220",""
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Drain outer ear canal lesion","69020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Pierce earlobes","69090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Pierce earlobes","69090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Biopsy of external ear","69100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Biopsy of external ear canal","69105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","2890.77","10028.23",""
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove external ear partial","69110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Removal of external ear","69120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4564","20437.6",""
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","4564","20437.6",""
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4564","20437.6",""
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","4564","20437.6","APC 277.30"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","4564","20437.6","APC 296.56"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","4564","20437.6","APC 308.91"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","4564","20437.6","APC"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","4564","20437.6","APC"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","4564","20437.6","APC"
"Remove ear canal lesion(s)","69140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","4564","20437.6","APC"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","2890.77","10028.23",""
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","2890.77","10028.23",""
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","2890.77","10028.23",""
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9002.07","","","","","","","fee schedule","2890.77","10028.23","APC 277.30"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9627.31","","","","","","","fee schedule","2890.77","10028.23","APC 296.56"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10028.23","","","","","","","fee schedule","2890.77","10028.23","APC 308.91"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2968.71","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2919.11","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2890.77","","","","","","","fee schedule","2890.77","10028.23","APC"
"Remove ear canal lesion(s)","69145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2975.79","","","","","","","fee schedule","2890.77","10028.23","APC"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5220","20437.6",""
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5220","20437.6",""
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive ear canal surgery","69150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Extensive ear/neck surgery","69155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Extensive ear/neck surgery","69155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Extensive ear/neck surgery","69155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","5220",""
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","132.41","5220",""
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","5220",""
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","5220","APC 277.30"
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","5220","APC 296.56"
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","5220","APC 308.91"
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","5220","APC"
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","5220","APC"
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","5220","APC"
"Clear outer ear canal","69200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","5220","APC"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1643.67","5790",""
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","1643.67","5790",""
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1643.67","5790",""
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5118.5","","","","","","","fee schedule","1643.67","5790","APC 277.30"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5474.01","","","","","","","fee schedule","1643.67","5790","APC 296.56"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5701.97","","","","","","","fee schedule","1643.67","5790","APC 308.91"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1687.98","","","","","","","fee schedule","1643.67","5790","APC"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1659.78","","","","","","","fee schedule","1643.67","5790","APC"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1643.67","","","","","","","fee schedule","1643.67","5790","APC"
"Clear outer ear canal","69205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1692.01","","","","","","","fee schedule","1643.67","5790","APC"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Remove impacted ear wax uni","69210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","5220",""
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","5220",""
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Clean out mastoid cavity","69220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","5220",""
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","536.74","5220",""
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","5220",""
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","5220","APC 277.30"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","5220","APC 296.56"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","5220","APC 308.91"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","5220","APC"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","5220","APC"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","5220","APC"
"Clean out mastoid cavity","69222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","5220","APC"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Revise external ear","69300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Rebuild outer ear canal","69310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Rebuild outer ear canal","69320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Outer ear surgery procedure","69399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Inflate middle ear canal","69400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Inflate middle ear canal","69401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Catheterize middle ear canal","69405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","3408",""
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","235.71","3408",""
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","3408",""
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","3408","APC 277.30"
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","3408","APC 296.56"
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","3408","APC 308.91"
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","3408","APC"
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","3408","APC"
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","3408","APC"
"Incision of eardrum","69420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","3408","APC"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Incision of eardrum","69421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3299.54","19040",""
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","19040",""
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3299.54","19040",""
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","19040","APC 277.30"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","19040","APC 296.56"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","19040","APC 308.91"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","19040","APC"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","19040","APC"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","19040","APC"
"Remove ventilating tube","69424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","19040","APC"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","3408",""
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","536.74","3408",""
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","3408",""
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","3408","APC 277.30"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","3408","APC 296.56"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","3408","APC 308.91"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","3408","APC"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","3408","APC"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","3408","APC"
"Create eardrum opening","69433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","3408","APC"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Create eardrum opening","69436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Exploration of middle ear","69440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","23971",""
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Eardrum revision","69450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoidectomy","69501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5891.41","20437.6",""
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","20437.6",""
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5891.41","20437.6",""
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","20437.6","APC 277.30"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","20437.6","APC 296.56"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","20437.6","APC 308.91"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","20437.6","APC"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","20437.6","APC"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","20437.6","APC"
"Mastoidectomy","69502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","20437.6","APC"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Remove mastoid structures","69505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Extensive mastoid surgery","69530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Remove part of temporal bone","69535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove part of temporal bone","69535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove part of temporal bone","69535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Remove ear lesion","69540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Remove ear lesion","69554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Remove ear lesion","69554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Remove ear lesion","69554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Mastoid surgery revision","69605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","10181",""
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1544.13","14111",""
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","14111",""
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1544.13","14111",""
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","14111","APC 277.30"
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","14111","APC 296.56"
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","14111","APC 308.91"
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","14111","APC"
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","14111","APC"
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","14111","APC"
"Repair of eardrum","69610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","14111","APC"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","3299.54","14111",""
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair of eardrum","69620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair eardrum structures","69631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair eardrum structures","69631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair eardrum structures","69631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair eardrum structures","69631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair eardrum structures","69631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair eardrum structures","69631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
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"Revise middle ear & mastoid","69641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
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"Revise middle ear & mastoid","69641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
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"Revise middle ear & mastoid","69642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69642","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
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"Revise middle ear & mastoid","69642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69643","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
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"Revise middle ear & mastoid","69643","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
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"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear & mastoid","69646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","14111",""
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Release middle ear bone","69650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Revise middle ear bone","69662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6448","","","","","","","fee schedule","3299.54","14111",""
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Repair middle ear structures","69667","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Remove mastoid air cells","69670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3299.54","14111",""
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","14111",""
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3299.54","14111",""
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","14111","APC 277.30"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","14111","APC 296.56"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","14111","APC 308.91"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","14111","APC"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","14111","APC"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","14111","APC"
"Remove middle ear nerve","69676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","14111","APC"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Close mastoid fistula","69700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube uni","69705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Nps surg dilat eust tube bi","69706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Implant/replace hearing aid","69710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Implant/replace hearing aid","69710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Implant/replace hearing aid","69710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3299.54","23971",""
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Remove/repair hearing aid","69711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","44324.22",""
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","44324.22",""
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Implant Temple Bone W/Stimul","69714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Temple Bne Implnt W/Stimulat","69715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Impltj oi implt skl tc esp","69716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","25051.33",""
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","25051.33",""
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","25051.33",""
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","25051.33","APC 277.30"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","25051.33","APC 296.56"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","25051.33","APC 308.91"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","25051.33","APC"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","25051.33","APC"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","25051.33","APC"
"Temple Bone Implant Revision","69717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","25051.33","APC"
"Revise Temple Bone Implant","69718","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Revj/rplcmt oi implt tc esp","69719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Release facial nerve","69720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Release facial nerve","69725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl perq esp","69726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Rmvl oi implt skl tc esp","69727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3256.29","19040",""
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3256.29","19040",""
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","19040","APC 277.30"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","19040","APC 296.56"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","19040","APC 308.91"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","19040","APC"
"Rmv ntr oi imp sktc esp>=100","69728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","19040","APC"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Impl oi implt sk tc esp>=100","69729","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Rplc oi implt sk tc esp>=100","69730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","5891.41","23971",""
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Repair facial nerve","69745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Middle ear surgery procedure","69799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","7337",""
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","1544.13","7337",""
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","7337",""
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","7337","APC 277.30"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","7337","APC 296.56"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","7337","APC 308.91"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","7337","APC"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","7337","APC"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","7337","APC"
"Incise inner ear","69801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","7337","APC"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Explore inner ear","69806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Establish inner ear window","69820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Revise inner ear window","69840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7337","","","","","","","fee schedule","7337","7337",""
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear","69905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5891.41","23971",""
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","5891.41","23971",""
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5891.41","23971",""
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5891.41","23971","APC 277.30"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5891.41","23971","APC 296.56"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5891.41","23971","APC 308.91"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5891.41","23971","APC"
"Remove inner ear & mastoid","69910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5891.41","23971","APC"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3299.54","23971",""
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","3299.54","23971",""
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3299.54","23971",""
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","23971","APC 277.30"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","23971","APC 296.56"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","23971","APC 308.91"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","23971","APC"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","23971","APC"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","23971","APC"
"Incise inner ear nerve","69915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","23971","APC"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","10181","113832.84",""
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10181","","","","","","","fee schedule","10181","113832.84",""
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","10181","113832.84",""
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","102184.6","","","","","","","fee schedule","10181","113832.84","APC 277.30"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","109281.88","","","","","","","fee schedule","10181","113832.84","APC 296.56"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","113832.84","","","","","","","fee schedule","10181","113832.84","APC 308.91"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33698.49","","","","","","","fee schedule","10181","113832.84","APC"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33135.51","","","","","","","fee schedule","10181","113832.84","APC"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32813.81","","","","","","","fee schedule","10181","113832.84","APC"
"Implant cochlear device","69930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33778.92","","","","","","","fee schedule","10181","113832.84","APC"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Inner ear surgery procedure","69949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Incise inner ear nerve","69950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Incise inner ear nerve","69950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Incise inner ear nerve","69950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Release facial nerve","69955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Release inner ear canal","69960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","5220","23971",""
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","23971",""
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","5220","23971",""
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","23971","APC 277.30"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","23971","APC 296.56"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","23971","APC 308.91"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","23971","APC"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","23971","APC"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","23971","APC"
"Remove inner ear lesion","69970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","23971","APC"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","235.71","5220",""
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","235.71","5220",""
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","235.71","5220",""
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","5220","APC 277.30"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","5220","APC 296.56"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","5220","APC 308.91"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","5220","APC"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","5220","APC"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","5220","APC"
"Temporal bone surgery","69979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","5220","APC"
"Microsurgery add-on","69990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Microsurgery add-on","69990","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Microsurgery add-on","69990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of brain","70010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Contrast x-ray of brain","70015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray eye for foreign body","70030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw <4views","70100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of jaw 4/> views","70110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of mastoids","70130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of middle ear","70134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of facial bones","70140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of facial bones","70150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of nasal bones","70160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of tear duct","70170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of eye sockets","70190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of eye sockets","70200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","269","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","277","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","270","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of sinuses","70220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam pituitary saddle","70240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of skull","70250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","437","","","","","","","fee schedule","104.04","449",""
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","449","","","","","","","fee schedule","104.04","449",""
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","438","","","","","","","fee schedule","104.04","449",""
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","449","APC 277.30"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","449","APC 296.56"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","449","APC 308.91"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","449","APC"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","449","APC"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","449","APC"
"X-ray exam of skull","70260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","449","APC"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of teeth","70300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of teeth","70310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Full mouth x-ray of teeth","70320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joint","70328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joints","70330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of jaw joint","70332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1591","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1637","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1599","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Magnetic image jaw joint","70336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray head for orthodontia","70350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Panoramic x-ray of jaws","70355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of neck","70360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Throat x-ray & fluoroscopy","70370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Speech evaluation complex","70371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of salivary gland","70380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of salivary duct","70390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct head/brain w/o dye","70450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","4714.07",""
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","4714.07",""
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","4714.07",""
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct head/brain w/dye","70460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct head/brain w/o & w/dye","70470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Cta h&n c+ w/noncontrast img","70471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Ct cere prfu aly c+wo ct/cta","70473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct orbit/ear/fossa w/o dye","70480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","4714.07",""
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","4714.07",""
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","4714.07",""
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct orbit/ear/fossa w/dye","70481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct orbit/ear/fossa w/o&w/dye","70482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","713","","","","","","","fee schedule","104.04","2753.72",""
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","734","","","","","","","fee schedule","104.04","2753.72",""
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","716","","","","","","","fee schedule","104.04","2753.72",""
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct maxillofacial w/o dye","70486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","713","","","","","","","fee schedule","174.56","4714.07",""
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","734","","","","","","","fee schedule","174.56","4714.07",""
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","716","","","","","","","fee schedule","174.56","4714.07",""
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct maxillofacial w/dye","70487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","713","","","","","","","fee schedule","174.56","5224.75",""
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","734","","","","","","","fee schedule","174.56","5224.75",""
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","716","","","","","","","fee schedule","174.56","5224.75",""
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct maxillofacial w/o & w/dye","70488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct soft tissue neck w/o dye","70490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","4714.07",""
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","4714.07",""
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","4714.07",""
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct soft tissue neck w/dye","70491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct sft tsue nck w/o & w/dye","70492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1693","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1742","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1700","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography head","70496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2671","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2749","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2682","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography neck","70498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1631","","","","","","","fee schedule","237.46","5369.86",""
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1679","","","","","","","fee schedule","237.46","5369.86",""
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1638","","","","","","","fee schedule","237.46","5369.86",""
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri orbit/face/neck w/o dye","70540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1631","","","","","","","fee schedule","347.2","7211.2",""
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1679","","","","","","","fee schedule","347.2","7211.2",""
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1638","","","","","","","fee schedule","347.2","7211.2",""
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Orbit/Face/Neck W/Dye","70542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1631","","","","","","","fee schedule","347.2","8716.76",""
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1679","","","","","","","fee schedule","347.2","8716.76",""
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1638","","","","","","","fee schedule","347.2","8716.76",""
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri orbt/fac/nck w/o &w/dye","70543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2163","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2225","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2172","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Head W/O Dye","70544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2163","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2225","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2172","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr Angiography Head W/Dye","70545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2163","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2225","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2172","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angiograph head w/o&w/dye","70546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1803","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1855","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1810","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Neck W/O Dye","70547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1803","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1855","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1810","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr Angiography Neck W/Dye","70548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1803","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1855","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1810","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angiograph neck w/o&w/dye","70549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1849","","","","","","","fee schedule","237.46","5369.86",""
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1903","","","","","","","fee schedule","237.46","5369.86",""
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1856","","","","","","","fee schedule","237.46","5369.86",""
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri brain stem w/o dye","70551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1849","","","","","","","fee schedule","347.2","7211.2",""
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1903","","","","","","","fee schedule","347.2","7211.2",""
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1856","","","","","","","fee schedule","347.2","7211.2",""
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri brain stem w/dye","70552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1849","","","","","","","fee schedule","347.2","8716.76",""
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1903","","","","","","","fee schedule","347.2","8716.76",""
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1856","","","","","","","fee schedule","347.2","8716.76",""
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri brain stem w/o & w/dye","70553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1490","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1533","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1496","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by tech","70554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1490","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1533","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1496","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Fmri brain by phys/psych","70555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3077","","","","","","","fee schedule","543.79","5369.86",""
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3165","","","","","","","fee schedule","543.79","5369.86",""
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3087","","","","","","","fee schedule","543.79","5369.86",""
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","543.79","5369.86",""
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","5369.86","APC 277.30"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","5369.86","APC 296.56"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","5369.86","APC 308.91"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","5369.86","APC"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","5369.86","APC"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","5369.86","APC"
"Mri brain w/o dye","70557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","5369.86","APC"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3077","","","","","","","fee schedule","174.56","7211.2",""
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3165","","","","","","","fee schedule","174.56","7211.2",""
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3087","","","","","","","fee schedule","174.56","7211.2",""
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","174.56","7211.2",""
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","7211.2","APC 277.30"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","7211.2","APC 296.56"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","7211.2","APC 308.91"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri brain w/dye","70558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3077","","","","","","","fee schedule","174.56","8716.76",""
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3165","","","","","","","fee schedule","174.56","8716.76",""
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3087","","","","","","","fee schedule","174.56","8716.76",""
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","174.56","8716.76",""
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","8716.76","APC 277.30"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","8716.76","APC 296.56"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","8716.76","APC 308.91"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","8716.76","APC"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","8716.76","APC"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","8716.76","APC"
"Mri brain w/o & w/dye","70559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","8716.76","APC"
"Chest x-ray 1 view frontal","71010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","248","","","","","","","fee schedule","248","254",""
"Chest x-ray 1 view frontal","71010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","254","","","","","","","fee schedule","248","254",""
"Chest x-ray 1 view frontal","71010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","249","","","","","","","fee schedule","248","254",""
"Chest x-ray 2vw frontal&latl","71020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","248","","","","","","","fee schedule","248","254",""
"Chest x-ray 2vw frontal&latl","71020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","254","","","","","","","fee schedule","248","254",""
"Chest x-ray 2vw frontal&latl","71020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","249","","","","","","","fee schedule","248","254",""
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","277","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","285","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","278","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 1 view","71045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","277","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","285","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","278","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 2 views","71046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","277","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","285","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","278","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 3 views","71047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","277","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","285","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","278","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam chest 4+ views","71048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","308","","","","","","","fee schedule","86.61","316",""
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","316","","","","","","","fee schedule","86.61","316",""
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","310","","","","","","","fee schedule","86.61","316",""
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","316","APC 277.30"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","316","APC 296.56"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","316","APC 308.91"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","316","APC"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","316","APC"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","316","APC"
"X-ray exam ribs uni 2 views","71100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","316","APC"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","443","","","","","","","fee schedule","104.04","456",""
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","456","","","","","","","fee schedule","104.04","456",""
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","445","","","","","","","fee schedule","104.04","456",""
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","456","APC 277.30"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","456","APC 296.56"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","456","APC 308.91"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","456","APC"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","456","APC"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","456","APC"
"X-ray exam unilat ribs/chest","71101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","456","APC"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","308","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","316","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","310","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs bil 3 views","71110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","308","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","316","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","310","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam ribs/chest4/> vws","71111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam breastbone 2/>vws","71120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray strenoclavic jt 3/>vws","71130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1166","","","","","","","fee schedule","104.04","2753.72",""
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1200","","","","","","","fee schedule","104.04","2753.72",""
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1170","","","","","","","fee schedule","104.04","2753.72",""
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct thorax w/o dye","71250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1166","","","","","","","fee schedule","174.56","4714.07",""
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1200","","","","","","","fee schedule","174.56","4714.07",""
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1170","","","","","","","fee schedule","174.56","4714.07",""
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct thorax w/dye","71260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1166","","","","","","","fee schedule","174.56","5224.75",""
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1200","","","","","","","fee schedule","174.56","5224.75",""
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1170","","","","","","","fee schedule","174.56","5224.75",""
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct thorax w/o & w/dye","71270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","350","","","","","","","fee schedule","104.04","360.93",""
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","350","","","","","","","fee schedule","104.04","360.93",""
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","350","","","","","","","fee schedule","104.04","360.93",""
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Ct thorax lung cancer scr c-","71271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1607","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1653","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1614","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiography chest","71275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1276","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1314","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1283","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest w/o dye","71550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1276","","","","","","","fee schedule","780.16","7211.2",""
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1314","","","","","","","fee schedule","780.16","7211.2",""
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1283","","","","","","","fee schedule","780.16","7211.2",""
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","780.16","7211.2",""
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","7211.2","APC 277.30"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","7211.2","APC 296.56"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","7211.2","APC 308.91"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri Chest W/Dye","71551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1276","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1314","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1283","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest w/o & w/dye","71552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri angio chest w or w/o dye","71555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2392","","","","","","","fee schedule","2392","6189.1",""
"Mri angio chest w or w/o dye","71555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2460","","","","","","","fee schedule","2392","6189.1",""
"Mri angio chest w or w/o dye","71555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2401","","","","","","","fee schedule","2392","6189.1",""
"Mri angio chest w or w/o dye","71555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6189.1","","","","","","","fee schedule","2392","6189.1",""
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of spine 1 view","72020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","166","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","170","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","167","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam neck spine 2-3 vw","72040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","359","","","","","","","fee schedule","104.04","369",""
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","369","","","","","","","fee schedule","104.04","369",""
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","361","","","","","","","fee schedule","104.04","369",""
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","369","APC 277.30"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","369","APC 296.56"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","369","APC 308.91"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","369","APC"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","369","APC"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","369","APC"
"X-ray exam neck spine 4/5vws","72050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","369","APC"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","477","","","","","","","fee schedule","104.04","490",""
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","490","","","","","","","fee schedule","104.04","490",""
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","478","","","","","","","fee schedule","104.04","490",""
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","490","APC 277.30"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","490","APC 296.56"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","490","APC 308.91"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","490","APC"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","490","APC"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","490","APC"
"X-ray exam neck spine 6/>vws","72052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","490","APC"
"X-ray exam of trunk spine","72069","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","88","","","","","","","fee schedule","88","90",""
"X-ray exam of trunk spine","72069","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","90","","","","","","","fee schedule","88","90",""
"X-ray exam of trunk spine","72069","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","89","","","","","","","fee schedule","88","90",""
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","526","","","","","","","fee schedule","104.04","541",""
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","541","","","","","","","fee schedule","104.04","541",""
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","528","","","","","","","fee schedule","104.04","541",""
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","541","APC 277.30"
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","541","APC 296.56"
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","541","APC 308.91"
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","541","APC"
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","541","APC"
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","541","APC"
"X-ray exam thorac spine 2vws","72070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","541","APC"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","232","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","238","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","233","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine 3vws","72072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","314","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","323","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","315","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thorac spine4/>vw","72074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","400","","","","","","","fee schedule","86.61","412",""
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","412","","","","","","","fee schedule","86.61","412",""
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","402","","","","","","","fee schedule","86.61","412",""
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","412","APC 277.30"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","412","APC 296.56"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","412","APC 308.91"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","412","APC"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","412","APC"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","412","APC"
"X-ray exam thoracolmb 2/> vw","72080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","412","APC"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam entire spi 1 vw","72081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 2/3 vw","72082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 4/5 vw","72083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam entire spi 6/> vw","72084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","302","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","311","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","303","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam l-s spine 2/3 vws","72100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","449","","","","","","","fee schedule","104.04","462",""
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","462","","","","","","","fee schedule","104.04","462",""
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","450","","","","","","","fee schedule","104.04","462",""
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","462","APC 277.30"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","462","APC 296.56"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","462","APC 308.91"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","462","APC"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","462","APC"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","462","APC"
"X-ray exam l-2 spine 4/>vws","72110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","462","APC"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","515","","","","","","","fee schedule","104.04","530",""
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","530","","","","","","","fee schedule","104.04","530",""
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","516","","","","","","","fee schedule","104.04","530",""
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","530","APC 277.30"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","530","APC 296.56"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","530","APC 308.91"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","530","APC"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","530","APC"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","530","APC"
"X-ray exam l-s spine bending","72114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","530","APC"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","402","","","","","","","fee schedule","104.04","414",""
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","414","","","","","","","fee schedule","104.04","414",""
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","404","","","","","","","fee schedule","104.04","414",""
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","414","APC 277.30"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","414","APC 296.56"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","414","APC 308.91"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","414","APC"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","414","APC"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","414","APC"
"X-ray bend only l-s spine","72120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","414","APC"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct neck spine w/o dye","72125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","347.2","4714.07",""
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","347.2","4714.07",""
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","347.2","4714.07",""
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","347.2","4714.07",""
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","4714.07","APC 277.30"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","4714.07","APC 296.56"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","4714.07","APC 308.91"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct neck spine w/dye","72126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct neck spine w/o & w/dye","72127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1022","","","","","","","fee schedule","104.04","2753.72",""
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1052","","","","","","","fee schedule","104.04","2753.72",""
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1026","","","","","","","fee schedule","104.04","2753.72",""
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct chest spine w/o dye","72128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1022","","","","","","","fee schedule","174.56","4714.07",""
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1052","","","","","","","fee schedule","174.56","4714.07",""
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1026","","","","","","","fee schedule","174.56","4714.07",""
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct chest spine w/dye","72129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1022","","","","","","","fee schedule","174.56","5224.75",""
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1052","","","","","","","fee schedule","174.56","5224.75",""
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1026","","","","","","","fee schedule","174.56","5224.75",""
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct chest spine w/o & w/dye","72130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","984","","","","","","","fee schedule","104.04","2753.72",""
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1012","","","","","","","fee schedule","104.04","2753.72",""
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","987","","","","","","","fee schedule","104.04","2753.72",""
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lumbar spine w/o dye","72131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","984","","","","","","","fee schedule","347.2","4714.07",""
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1012","","","","","","","fee schedule","347.2","4714.07",""
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","987","","","","","","","fee schedule","347.2","4714.07",""
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","347.2","4714.07",""
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","4714.07","APC 277.30"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","4714.07","APC 296.56"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","4714.07","APC 308.91"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct lumbar spine w/dye","72132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","984","","","","","","","fee schedule","174.56","5224.75",""
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1012","","","","","","","fee schedule","174.56","5224.75",""
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","987","","","","","","","fee schedule","174.56","5224.75",""
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lumbar spine w/o & w/dye","72133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1400","","","","","","","fee schedule","237.46","5369.86",""
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1440","","","","","","","fee schedule","237.46","5369.86",""
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1407","","","","","","","fee schedule","237.46","5369.86",""
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri neck spine w/o dye","72141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1400","","","","","","","fee schedule","347.2","7211.2",""
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1440","","","","","","","fee schedule","347.2","7211.2",""
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1407","","","","","","","fee schedule","347.2","7211.2",""
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri neck spine w/dye","72142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1284","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1320","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1288","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest spine w/o dye","72146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1284","","","","","","","fee schedule","347.2","7211.2",""
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1320","","","","","","","fee schedule","347.2","7211.2",""
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1288","","","","","","","fee schedule","347.2","7211.2",""
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri chest spine w/dye","72147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1553","","","","","","","fee schedule","237.46","5369.86",""
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1598","","","","","","","fee schedule","237.46","5369.86",""
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1560","","","","","","","fee schedule","237.46","5369.86",""
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri lumbar spine w/o dye","72148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1553","","","","","","","fee schedule","347.2","7211.2",""
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1598","","","","","","","fee schedule","347.2","7211.2",""
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1560","","","","","","","fee schedule","347.2","7211.2",""
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri lumbar spine w/dye","72149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2006","","","","","","","fee schedule","347.2","8716.76",""
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2064","","","","","","","fee schedule","347.2","8716.76",""
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2015","","","","","","","fee schedule","347.2","8716.76",""
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri neck spine w/o & w/dye","72156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2006","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2064","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2015","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri chest spine w/o & w/dye","72157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2006","","","","","","","fee schedule","347.2","8716.76",""
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2064","","","","","","","fee schedule","347.2","8716.76",""
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2015","","","","","","","fee schedule","347.2","8716.76",""
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lumbar spine w/o & w/dye","72158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angio spine w/o&w/dye","72159","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1648","","","","","","","fee schedule","1648","6386.71",""
"Mr angio spine w/o&w/dye","72159","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1696","","","","","","","fee schedule","1648","6386.71",""
"Mr angio spine w/o&w/dye","72159","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1655","","","","","","","fee schedule","1648","6386.71",""
"Mr angio spine w/o&w/dye","72159","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6386.71","","","","","","","fee schedule","1648","6386.71",""
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","290","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","298","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","291","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","278","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","286","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","279","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of pelvis","72190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1593","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1638","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1600","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angiograph pelv w/o&w/dye","72191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct pelvis w/o dye","72192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","4714.07",""
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","4714.07",""
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","4714.07",""
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct pelvis w/dye","72193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct pelvis w/o & w/dye","72194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1555","","","","","","","fee schedule","237.46","5369.86",""
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1599","","","","","","","fee schedule","237.46","5369.86",""
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1561","","","","","","","fee schedule","237.46","5369.86",""
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Pelvis W/O Dye","72195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1555","","","","","","","fee schedule","347.2","7211.2",""
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1599","","","","","","","fee schedule","347.2","7211.2",""
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1561","","","","","","","fee schedule","347.2","7211.2",""
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri pelvis w/dye","72196","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1555","","","","","","","fee schedule","347.2","8716.76",""
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1599","","","","","","","fee schedule","347.2","8716.76",""
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1561","","","","","","","fee schedule","347.2","8716.76",""
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri pelvis w/o & w/dye","72197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angio pelvis w/o & w/dye","72198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2120","","","","","","","fee schedule","2120","6265.83",""
"Mr angio pelvis w/o & w/dye","72198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2181","","","","","","","fee schedule","2120","6265.83",""
"Mr angio pelvis w/o & w/dye","72198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2128","","","","","","","fee schedule","2120","6265.83",""
"Mr angio pelvis w/o & w/dye","72198","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6265.83","","","","","","","fee schedule","2120","6265.83",""
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","440","","","","","","","fee schedule","104.04","452",""
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","452","","","","","","","fee schedule","104.04","452",""
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","442","","","","","","","fee schedule","104.04","452",""
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","452","APC 277.30"
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","452","APC 296.56"
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","452","APC 308.91"
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","452","APC"
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","452","APC"
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","452","APC"
"X-ray exam si joints","72200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","452","APC"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","492","","","","","","","fee schedule","104.04","506",""
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","506","","","","","","","fee schedule","104.04","506",""
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","494","","","","","","","fee schedule","104.04","506",""
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","506","APC 277.30"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","506","APC 296.56"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","506","APC 308.91"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","506","APC"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","506","APC"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","506","APC"
"X-ray exam si joints 3/> vws","72202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","506","APC"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","265","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","271","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","266","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam sacrum tailbone","72220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography neck spine","72240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography thoracic spine","72255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelography l-s spine","72265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Myelogphy 2/> spine regions","72270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"Discography cerv/thor spine","72285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6051.73","","","","","","","fee schedule","1943.35","6741.58","APC 277.30"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6472.06","","","","","","","fee schedule","1943.35","6741.58","APC 296.56"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6741.58","","","","","","","fee schedule","1943.35","6741.58","APC 308.91"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.74","","","","","","","fee schedule","1943.35","6741.58","APC"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.4","","","","","","","fee schedule","1943.35","6741.58","APC"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.35","","","","","","","fee schedule","1943.35","6741.58","APC"
"X-ray of lower spine disk","72295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.51","","","","","","","fee schedule","1943.35","6741.58","APC"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","209","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","215","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","210","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of collar bone","73000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of shoulder blade","73010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","209","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","215","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","210","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","216","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","223","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","217","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulder","73030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of shoulder","73040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of shoulders","73050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","269","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","277","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","270","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of humerus","73060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","170","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","175","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","171","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","230","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","236","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","231","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of elbow","73080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of elbow","73085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","147","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","151","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","147","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of forearm","73090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of arm infant","73092","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","115","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","118","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","117","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","190","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","196","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","191","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of wrist","73110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of wrist","73115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","219","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","225","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","220","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of hand","73120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","192","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","198","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","193","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of hand","73130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","106","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","110","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","106","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of finger(s)","73140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct upper extremity w/o dye","73200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","347.2","4714.07",""
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","347.2","4714.07",""
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","347.2","4714.07",""
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","347.2","4714.07",""
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","4714.07","APC 277.30"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","4714.07","APC 296.56"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","4714.07","APC 308.91"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct upper extremity w/dye","73201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","4714.07","APC"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct uppr extremity w/o&w/dye","73202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1143","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1175","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1147","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio upr extrm w/o&w/dye","73206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1232","","","","","","","fee schedule","237.46","5369.86",""
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1268","","","","","","","fee schedule","237.46","5369.86",""
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1236","","","","","","","fee schedule","237.46","5369.86",""
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Upper Extremity W/O Dye","73218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1232","","","","","","","fee schedule","347.2","7211.2",""
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1268","","","","","","","fee schedule","347.2","7211.2",""
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1236","","","","","","","fee schedule","347.2","7211.2",""
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Upper Extremity W/Dye","73219","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1232","","","","","","","fee schedule","347.2","8716.76",""
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1268","","","","","","","fee schedule","347.2","8716.76",""
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1236","","","","","","","fee schedule","347.2","8716.76",""
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri uppr extremity w/o&w/dye","73220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1848","","","","","","","fee schedule","237.46","5369.86",""
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1901","","","","","","","fee schedule","237.46","5369.86",""
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1855","","","","","","","fee schedule","237.46","5369.86",""
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri joint upr extrem w/o dye","73221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1848","","","","","","","fee schedule","780.16","7211.2",""
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1901","","","","","","","fee schedule","780.16","7211.2",""
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1855","","","","","","","fee schedule","780.16","7211.2",""
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","780.16","7211.2",""
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","7211.2","APC 277.30"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","7211.2","APC 296.56"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","7211.2","APC 308.91"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri joint upr extrem w/dye","73222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1848","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1901","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1855","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint upr extr w/o&w/dye","73223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr angio upr extr w/o&w/dye","73225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2605","","","","","","","fee schedule","2605","6458.03",""
"Mr angio upr extr w/o&w/dye","73225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2681","","","","","","","fee schedule","2605","6458.03",""
"Mr angio upr extr w/o&w/dye","73225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2616","","","","","","","fee schedule","2605","6458.03",""
"Mr angio upr extr w/o&w/dye","73225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6458.03","","","","","","","fee schedule","2605","6458.03",""
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","463","","","","","","","fee schedule","86.61","477",""
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","477","","","","","","","fee schedule","86.61","477",""
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","464","","","","","","","fee schedule","86.61","477",""
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","477","APC 277.30"
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","477","APC 296.56"
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","477","APC 308.91"
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 1 view","73501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","463","","","","","","","fee schedule","86.61","477",""
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","477","","","","","","","fee schedule","86.61","477",""
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","464","","","","","","","fee schedule","86.61","477",""
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","477","APC 277.30"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","477","APC 296.56"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","477","APC 308.91"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 2-3 views","73502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","477","APC"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam hip uni 4/> views","73503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of hip","73510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","237","","","","","","","fee schedule","237","245",""
"X-ray exam of hip","73510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","245","","","","","","","fee schedule","237","245",""
"X-ray exam of hip","73510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","238","","","","","","","fee schedule","237","245",""
"X-ray exam of hips","73520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","436","","","","","","","fee schedule","436","448",""
"X-ray exam of hips","73520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","448","","","","","","","fee schedule","436","448",""
"X-ray exam of hips","73520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","437","","","","","","","fee schedule","436","448",""
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","999","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1028","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1002","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","1028","APC 277.30"
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","1028","APC 296.56"
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","1028","APC 308.91"
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 2 views","73521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","999","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1028","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1002","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","1028","APC 277.30"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","1028","APC 296.56"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","1028","APC 308.91"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 3-4 views","73522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","999","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1028","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1002","","","","","","","fee schedule","104.04","1028",""
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","1028","APC 277.30"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","1028","APC 296.56"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","1028","APC 308.91"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","1028","APC"
"X-ray exam hips bi 5/> views","73523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","1028","APC"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of hip","73525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray exam of thigh","73550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","366","","","","","","","fee schedule","366","377",""
"X-ray exam of thigh","73550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","377","","","","","","","fee schedule","366","377",""
"X-ray exam of thigh","73550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","367","","","","","","","fee schedule","366","377",""
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","566","","","","","","","fee schedule","86.61","582",""
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","582","","","","","","","fee schedule","86.61","582",""
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","568","","","","","","","fee schedule","86.61","582",""
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","582","APC 277.30"
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","582","APC 296.56"
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","582","APC 308.91"
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 1","73551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","566","","","","","","","fee schedule","86.61","582",""
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","582","","","","","","","fee schedule","86.61","582",""
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","568","","","","","","","fee schedule","86.61","582",""
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","582","APC 277.30"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","582","APC 296.56"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","582","APC 308.91"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of femur 2/>","73552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","582","APC"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","136","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","139","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","136","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 1 or 2","73560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","175","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","181","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","175","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knee 3","73562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","274","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","282","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","275","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam knee 4 or more","73564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","274","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","282","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","275","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of knees","73565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of knee joint","73580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","209","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","215","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","210","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of lower leg","73590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of leg infant","73592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","715","","","","","","","fee schedule","86.61","736",""
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","736","","","","","","","fee schedule","86.61","736",""
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","719","","","","","","","fee schedule","86.61","736",""
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","736","APC 277.30"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","736","APC 296.56"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","736","APC 308.91"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","736","APC"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","736","APC"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","736","APC"
"X-ray exam of ankle","73600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","736","APC"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","255","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","263","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","256","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of ankle","73610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray of ankle","73615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","194","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","200","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","195","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","186","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","191","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","186","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of foot","73630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","206","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","212","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","207","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of heel","73650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","169","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","174","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","170","","","","","","","fee schedule","86.61","300.45",""
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray exam of toe(s)","73660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lower extremity w/o dye","73700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","4714.07",""
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","4714.07",""
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","4714.07",""
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct lower extremity w/dye","73701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","5224.75",""
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","5224.75",""
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","5224.75",""
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct lwr extremity w/o&w/dye","73702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1256","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1292","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1262","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio lwr extr w/o&w/dye","73706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1333","","","","","","","fee schedule","237.46","5369.86",""
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1371","","","","","","","fee schedule","237.46","5369.86",""
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1338","","","","","","","fee schedule","237.46","5369.86",""
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Lower Extremity W/O Dye","73718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1333","","","","","","","fee schedule","347.2","7211.2",""
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1371","","","","","","","fee schedule","347.2","7211.2",""
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1338","","","","","","","fee schedule","347.2","7211.2",""
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Lower Extremity W/Dye","73719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1333","","","","","","","fee schedule","347.2","8716.76",""
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1371","","","","","","","fee schedule","347.2","8716.76",""
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1338","","","","","","","fee schedule","347.2","8716.76",""
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri lwr extremity w/o&w/dye","73720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1412","","","","","","","fee schedule","237.46","5369.86",""
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1452","","","","","","","fee schedule","237.46","5369.86",""
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1417","","","","","","","fee schedule","237.46","5369.86",""
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri jnt of lwr extre w/o dye","73721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1412","","","","","","","fee schedule","780.16","7211.2",""
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1452","","","","","","","fee schedule","780.16","7211.2",""
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1417","","","","","","","fee schedule","780.16","7211.2",""
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","780.16","7211.2",""
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","7211.2","APC 277.30"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","7211.2","APC 296.56"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","7211.2","APC 308.91"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri Joint Of Lwr Extr W/Dye","73722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","7211.2","APC"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1412","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1452","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1417","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri joint lwr extr w/o&w/dye","73723","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mr ang lwr ext w or w/o dye","73725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1844","","","","","","","fee schedule","1844","6298.87",""
"Mr ang lwr ext w or w/o dye","73725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1897","","","","","","","fee schedule","1844","6298.87",""
"Mr ang lwr ext w or w/o dye","73725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1851","","","","","","","fee schedule","1844","6298.87",""
"Mr ang lwr ext w or w/o dye","73725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6298.87","","","","","","","fee schedule","1844","6298.87",""
"X-ray exam of abdomen","74000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","165","","","","","","","fee schedule","165","169",""
"X-ray exam of abdomen","74000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","169","","","","","","","fee schedule","165","169",""
"X-ray exam of abdomen","74000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","166","","","","","","","fee schedule","165","169",""
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","470","","","","","","","fee schedule","86.61","483",""
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","483","","","","","","","fee schedule","86.61","483",""
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","472","","","","","","","fee schedule","86.61","483",""
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","483","APC 277.30"
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","483","APC 296.56"
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","483","APC 308.91"
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","483","APC"
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","483","APC"
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","483","APC"
"X-ray exam abdomen 1 view","74018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","483","APC"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","470","","","","","","","fee schedule","104.04","483",""
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","483","","","","","","","fee schedule","104.04","483",""
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","472","","","","","","","fee schedule","104.04","483",""
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","483","APC 277.30"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","483","APC 296.56"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","483","APC 308.91"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam abdomen 2 views","74019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam of abdomen","74020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","178","","","","","","","fee schedule","178","183",""
"X-ray exam of abdomen","74020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","183","","","","","","","fee schedule","178","183",""
"X-ray exam of abdomen","74020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","179","","","","","","","fee schedule","178","183",""
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","470","","","","","","","fee schedule","104.04","483",""
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","483","","","","","","","fee schedule","104.04","483",""
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","472","","","","","","","fee schedule","104.04","483",""
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","483","APC 277.30"
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","483","APC 296.56"
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","483","APC 308.91"
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam abdomen 3+ views","74021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","483","APC"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","233","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","240","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","234","","","","","","","fee schedule","104.04","360.93",""
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam series abdomen","74022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","939","","","","","","","fee schedule","104.04","2753.72",""
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","967","","","","","","","fee schedule","104.04","2753.72",""
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","943","","","","","","","fee schedule","104.04","2753.72",""
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct abdomen w/o dye","74150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","939","","","","","","","fee schedule","174.56","4714.07",""
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","967","","","","","","","fee schedule","174.56","4714.07",""
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","943","","","","","","","fee schedule","174.56","4714.07",""
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct abdomen w/dye","74160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","939","","","","","","","fee schedule","174.56","5224.75",""
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","967","","","","","","","fee schedule","174.56","5224.75",""
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","943","","","","","","","fee schedule","174.56","5224.75",""
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5224.75","","","","","","","fee schedule","174.56","5224.75",""
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5224.75","APC 277.30"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5224.75","APC 296.56"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5224.75","APC 308.91"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct abdomen w/o & w/dye","74170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5224.75","APC"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","4367","","","","","","","fee schedule","347.2","7655.69",""
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","4492","","","","","","","fee schedule","347.2","7655.69",""
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","4383","","","","","","","fee schedule","347.2","7655.69",""
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7655.69","","","","","","","fee schedule","347.2","7655.69",""
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7655.69","APC 277.30"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7655.69","APC 296.56"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7655.69","APC 308.91"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct angio abd&pelv w/o&w/dye","74174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1974","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2031","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1982","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct angio abdom w/o & w/dye","74175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3639","","","","","","","fee schedule","237.46","4855.24",""
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3743","","","","","","","fee schedule","237.46","4855.24",""
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3653","","","","","","","fee schedule","237.46","4855.24",""
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4855.24","","","","","","","fee schedule","237.46","4855.24",""
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","4855.24","APC 277.30"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","4855.24","APC 296.56"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","4855.24","APC 308.91"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","4855.24","APC"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","4855.24","APC"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","4855.24","APC"
"Ct abd & pelvis w/o contrast","74176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","4855.24","APC"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3639","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3743","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3653","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7655.69","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7655.69","APC 277.30"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7655.69","APC 296.56"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7655.69","APC 308.91"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv w/contrast","74177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3639","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3743","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3653","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7655.69","","","","","","","fee schedule","347.2","7655.69",""
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7655.69","APC 277.30"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7655.69","APC 296.56"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7655.69","APC 308.91"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7655.69","APC"
"Ct abd & pelv 1/> regns","74178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7655.69","APC"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1757","","","","","","","fee schedule","237.46","5369.86",""
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1808","","","","","","","fee schedule","237.46","5369.86",""
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1766","","","","","","","fee schedule","237.46","5369.86",""
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri abdomen w/o dye","74181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1757","","","","","","","fee schedule","347.2","7211.2",""
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1808","","","","","","","fee schedule","347.2","7211.2",""
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1766","","","","","","","fee schedule","347.2","7211.2",""
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri Abdomen W/Dye","74182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1757","","","","","","","fee schedule","347.2","8716.76",""
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1808","","","","","","","fee schedule","347.2","8716.76",""
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1766","","","","","","","fee schedule","347.2","8716.76",""
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri abdomen w/o & w/dye","74183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri angio abdom w orw/o dye","74185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2392","","","","","","","fee schedule","2392","6260.42",""
"Mri angio abdom w orw/o dye","74185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2460","","","","","","","fee schedule","2392","6260.42",""
"Mri angio abdom w orw/o dye","74185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2401","","","","","","","fee schedule","2392","6260.42",""
"Mri angio abdom w orw/o dye","74185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6260.42","","","","","","","fee schedule","2392","6260.42",""
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of peritoneum","74190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray exam of throat","74210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","308","","","","","","","fee schedule","174.56","605.55",""
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","316","","","","","","","fee schedule","174.56","605.55",""
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","310","","","","","","","fee schedule","174.56","605.55",""
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray esophagus","74220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray xm esophagus 2cntrst","74221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","632","","","","","","","fee schedule","174.56","650",""
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","650","","","","","","","fee schedule","174.56","650",""
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","634","","","","","","","fee schedule","174.56","650",""
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","650","APC 277.30"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","650","APC 296.56"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","650","APC 308.91"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","650","APC"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","650","APC"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","650","APC"
"Cine/vid x-ray throat/esoph","74230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","650","APC"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","442","","","","","","","fee schedule","174.56","605.55",""
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","455","","","","","","","fee schedule","174.56","605.55",""
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","444","","","","","","","fee schedule","174.56","605.55",""
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray upper gi delay w/o kub","74240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray upper gi delay w/kub","74241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","442","","","","","","","fee schedule","442","455",""
"X-ray upper gi delay w/kub","74241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","455","","","","","","","fee schedule","442","455",""
"X-ray upper gi delay w/kub","74241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","444","","","","","","","fee schedule","442","455",""
"X-ray upper gi&small intest","74245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","600","","","","","","","fee schedule","600","617",""
"X-ray upper gi&small intest","74245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","617","","","","","","","fee schedule","600","617",""
"X-ray upper gi&small intest","74245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","602","","","","","","","fee schedule","600","617",""
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray uppr gi tract","74246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray uppr gi tract","74247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","873","","","","","","","fee schedule","873","899",""
"Contrst x-ray uppr gi tract","74247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","899","","","","","","","fee schedule","873","899",""
"Contrst x-ray uppr gi tract","74247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","876","","","","","","","fee schedule","873","899",""
"Contrst x-ray uppr gi tract","74249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","674","","","","","","","fee schedule","674","694",""
"Contrst x-ray uppr gi tract","74249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","694","","","","","","","fee schedule","674","694",""
"Contrst x-ray uppr gi tract","74249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","678","","","","","","","fee schedule","674","694",""
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","299","","","","","","","fee schedule","174.56","605.55",""
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","308","","","","","","","fee schedule","174.56","605.55",""
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","300","","","","","","","fee schedule","174.56","605.55",""
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"X-ray exam of small bowel","74251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","104.04","2753.72",""
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","104.04","2753.72",""
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","104.04","2753.72",""
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2753.72","","","","","","","fee schedule","104.04","2753.72",""
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","2753.72","APC 277.30"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","2753.72","APC 296.56"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","2753.72","APC 308.91"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct colonography dx","74261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","2753.72","APC"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","174.56","4714.07",""
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","174.56","4714.07",""
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","174.56","4714.07",""
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4714.07","","","","","","","fee schedule","174.56","4714.07",""
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","4714.07","APC 277.30"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","4714.07","APC 296.56"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","4714.07","APC 308.91"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct colonography dx w/dye","74262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","4714.07","APC"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","10870.34","","","","","","","fee schedule","237.46","10870.34",""
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","10870.34","APC 277.30"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","10870.34","APC 296.56"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","10870.34","APC 308.91"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","10870.34","APC"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","10870.34","APC"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","10870.34","APC"
"Ct colonography screening","74263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","10870.34","APC"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","838","","","","","","","fee schedule","174.56","862",""
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","862","","","","","","","fee schedule","174.56","862",""
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","841","","","","","","","fee schedule","174.56","862",""
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","862","APC 277.30"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","862","APC 296.56"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","862","APC 308.91"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","862","APC"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","862","APC"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","862","APC"
"Contrast x-ray exam of colon","74270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","862","APC"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","590","","","","","","","fee schedule","174.56","607",""
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","607","","","","","","","fee schedule","174.56","607",""
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","592","","","","","","","fee schedule","174.56","607",""
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","607","APC 277.30"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","607","APC 296.56"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","607","APC 308.91"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","607","APC"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","607","APC"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","607","APC"
"Contrast x-ray exam of colon","74280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","607","APC"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray exam of colon","74283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrast x-ray gallbladder","74290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","605.55","APC 277.30"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","605.55","APC 296.56"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","605.55","APC 308.91"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","605.55","APC"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrst x-ray urinary tract","74425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Contrast x-ray bladder","74430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray male genital tract","74440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of penis","74445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray urethra/bladder","74455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of kidney lesion","74470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6478.35","","","","","","","fee schedule","2080.35","7216.83","APC 277.30"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6928.31","","","","","","","fee schedule","2080.35","7216.83","APC 296.56"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7216.83","","","","","","","fee schedule","2080.35","7216.83","APC 308.91"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.43","","","","","","","fee schedule","2080.35","7216.83","APC"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.74","","","","","","","fee schedule","2080.35","7216.83","APC"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.35","","","","","","","fee schedule","2080.35","7216.83","APC"
"X-ray guide gu dilation","74485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.53","","","","","","","fee schedule","2080.35","7216.83","APC"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mri fetal sngl/1st gestation","74712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray female genital tract","74740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray exam of perineum","74775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","237.46","5369.86",""
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","237.46","5369.86",""
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","237.46","5369.86",""
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Cardiac mri for morph","75557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","876","","","","","","","fee schedule","543.79","5369.86",""
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","902","","","","","","","fee schedule","543.79","5369.86",""
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","880","","","","","","","fee schedule","543.79","5369.86",""
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","543.79","5369.86",""
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","5369.86","APC 277.30"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","5369.86","APC 296.56"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","5369.86","APC 308.91"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","5369.86","APC"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","5369.86","APC"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","5369.86","APC"
"Cardiac mri w/stress img","75559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","5369.86","APC"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","972","","","","","","","fee schedule","347.2","8716.76",""
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1000","","","","","","","fee schedule","347.2","8716.76",""
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","975","","","","","","","fee schedule","347.2","8716.76",""
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Cardiac mri for morph w/dye","75561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","972","","","","","","","fee schedule","780.16","8716.76",""
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1000","","","","","","","fee schedule","780.16","8716.76",""
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","975","","","","","","","fee schedule","780.16","8716.76",""
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","780.16","8716.76",""
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","8716.76","APC 277.30"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","8716.76","APC 296.56"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","8716.76","APC 308.91"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","8716.76","APC"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","8716.76","APC"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","8716.76","APC"
"Card mri w/stress img & dye","75563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","8716.76","APC"
"Card mri veloc flow mapping","75565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","838.27","","","","","","","fee schedule","838.27","838.27",""
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","787.52","","","","","","","fee schedule","86.61","787.52",""
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","787.52","APC 277.30"
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","787.52","APC 296.56"
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","787.52","APC 308.91"
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","787.52","APC"
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","787.52","APC"
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","787.52","APC"
"Ct hrt w/o dye w/ca test","75571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","787.52","APC"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1616","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1663","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1623","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4238.98","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","4238.98","APC 277.30"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","4238.98","APC 296.56"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","4238.98","APC 308.91"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image","75572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1616","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1663","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1623","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4238.98","","","","","","","fee schedule","347.2","4238.98",""
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","4238.98","APC 277.30"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","4238.98","APC 296.56"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","4238.98","APC 308.91"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct hrt w/3d image congen","75573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","903","","","","","","","fee schedule","347.2","4238.98",""
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","929","","","","","","","fee schedule","347.2","4238.98",""
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","907","","","","","","","fee schedule","347.2","4238.98",""
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4238.98","","","","","","","fee schedule","347.2","4238.98",""
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","4238.98","APC 277.30"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","4238.98","APC 296.56"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","4238.98","APC 308.91"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","4238.98","APC"
"Ct angio hrt w/3d image","75574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","4238.98","APC"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"N-invas est c ffr sw aly cta","75580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam thoracic aorta","75600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","19210.81","APC 277.30"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","19210.81","APC 296.56"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","19210.81","APC 308.91"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","19210.81","APC"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","19210.81","APC"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","19210.81","APC"
"Contrast exam thoracic aorta","75605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","19210.81","APC"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Contrast exam abdominl aorta","75625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"X-ray aorta leg arteries","75630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2065","","","","","","","fee schedule","174.56","5381.8",""
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2124","","","","","","","fee schedule","174.56","5381.8",""
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2073","","","","","","","fee schedule","174.56","5381.8",""
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5381.8","","","","","","","fee schedule","174.56","5381.8",""
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","5381.8","APC 277.30"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","5381.8","APC 296.56"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","5381.8","APC 308.91"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","5381.8","APC"
"Ct Angio Abdominal Arteries","75635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","5381.8","APC"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","19210.81","APC 277.30"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","19210.81","APC 296.56"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","19210.81","APC 308.91"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays spine","75705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arm/leg","75710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays arms/legs","75716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","19210.81","APC 277.30"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","19210.81","APC 296.56"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","19210.81","APC 308.91"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays abdomen","75726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenal gland","75731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays adrenals","75733","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","19210.81","APC 277.30"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","19210.81","APC 296.56"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","19210.81","APC 308.91"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays pelvis","75736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","19210.81","APC"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lungs","75743","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays lung","75746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Artery x-rays chest","75756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","2165.7","APC 277.30"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","2165.7","APC 296.56"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","2165.7","APC 308.91"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","2165.7","APC"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","2165.7","APC"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","2165.7","APC"
"Lymph vessel x-ray arm/leg","75801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","2165.7","APC"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Lymph vessel x-ray arms/legs","75803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Lymph vessel x-ray trunk","75807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Nonvascular shunt x-ray","75809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray spleen/liver","75810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arm/leg","75820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray arms/legs","75822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray trunk","75825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray chest","75827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidney","75831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray kidneys","75833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray adrenal gland","75840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray neck","75860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray skull","75870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","2165.7","APC 277.30"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","2165.7","APC 296.56"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","2165.7","APC 308.91"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray skull epidural","75872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1944.09","","","","","","","fee schedule","624.29","2165.7","APC 277.30"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2079.12","","","","","","","fee schedule","624.29","2165.7","APC 296.56"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2165.7","","","","","","","fee schedule","624.29","2165.7","APC 308.91"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","641.12","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","630.41","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","624.29","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray eye socket","75880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.65","","","","","","","fee schedule","624.29","2165.7","APC"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/o hemodyn","75887","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver w/hemodynam","75889","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Vein x-ray liver","75891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17245.02","","","","","","","fee schedule","5537.77","19210.81","APC 277.30"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18442.78","","","","","","","fee schedule","5537.77","19210.81","APC 296.56"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19210.81","","","","","","","fee schedule","5537.77","19210.81","APC 308.91"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5687.07","","","","","","","fee schedule","5537.77","19210.81","APC"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5592.06","","","","","","","fee schedule","5537.77","19210.81","APC"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5537.77","","","","","","","fee schedule","5537.77","19210.81","APC"
"Venous sampling by catheter","75893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5700.64","","","","","","","fee schedule","5537.77","19210.81","APC"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","10900.88","APC 277.30"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","10900.88","APC 296.56"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","10900.88","APC 308.91"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","10900.88","APC"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","10900.88","APC"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","10900.88","APC"
"Follow-up angiography","75898","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","10900.88","APC"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Fluoroscope examination","76000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-ray nose to rectum","76010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Mr sfty implt&/fb asmt stf 1","76014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Mr safety deter phys/qhp","76016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mr sfty med physics xm cstmz","76017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Mr safety implt pos&/immoblj","76019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam of fistula","76080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","421","","","","","","","fee schedule","421","1886.44",""
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","433","","","","","","","fee schedule","421","1886.44",""
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","422","","","","","","","fee schedule","421","1886.44",""
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","421","1886.44","APC 277.30"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","421","1886.44","APC 296.56"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","421","1886.44","APC 308.91"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","421","1886.44","APC"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","421","1886.44","APC"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","421","1886.44","APC"
"X-ray exam breast specimen","76098","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","421","1886.44","APC"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-ray exam of body section","76100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cine/video x-rays","76120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Med physic dos eval rad exps","76145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","535","","","","","","","fee schedule","86.61","1568.48",""
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","550","","","","","","","fee schedule","86.61","1568.48",""
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","537","","","","","","","fee schedule","86.61","1568.48",""
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1568.48","","","","","","","fee schedule","86.61","1568.48",""
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","1568.48","APC 277.30"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","1568.48","APC 296.56"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","1568.48","APC 308.91"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","1568.48","APC"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","1568.48","APC"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","1568.48","APC"
"CAT scan follow-up study","76380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","1568.48","APC"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6397.61","","","","","","","fee schedule","86.61","6397.61",""
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","6397.61","APC 277.30"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","6397.61","APC 296.56"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","6397.61","APC 308.91"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","6397.61","APC"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","6397.61","APC"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","6397.61","APC"
"Mr spectroscopy","76390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","6397.61","APC"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mr elastography","76391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Fluoroscopic procedure","76496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1568.48","","","","","","","fee schedule","86.61","1568.48",""
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","1568.48","APC 277.30"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","1568.48","APC 296.56"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","1568.48","APC 308.91"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","1568.48","APC"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","1568.48","APC"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","1568.48","APC"
"Ct procedure","76497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","1568.48","APC"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","86.61","5369.86",""
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","5369.86","APC 277.30"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","5369.86","APC 296.56"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","5369.86","APC 308.91"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","5369.86","APC"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","5369.86","APC"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","5369.86","APC"
"Mri procedure","76498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","5369.86","APC"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Radiographic procedure","76499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of head","76506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ophth us b & quant a","76510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us quant a only","76511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Ophth us b w/non-quant a","76512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye water bath","76513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Echo exam of eye thickness","76514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Echo exam of eye","76529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","352","","","","","","","fee schedule","104.04","362",""
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","362","","","","","","","fee schedule","104.04","362",""
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","353","","","","","","","fee schedule","104.04","362",""
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","362","APC 277.30"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","362","APC 296.56"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","362","APC 308.91"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","362","APC"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","362","APC"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","362","APC"
"Us exam of head and neck","76536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","362","APC"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","214","","","","","","","fee schedule","104.04","360.93",""
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","220","","","","","","","fee schedule","104.04","360.93",""
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","214","","","","","","","fee schedule","104.04","360.93",""
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam chest","76604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","887","","","","","","","fee schedule","104.04","912",""
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","912","","","","","","","fee schedule","104.04","912",""
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","890","","","","","","","fee schedule","104.04","912",""
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","912","APC 277.30"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","912","APC 296.56"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","912","APC 308.91"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","912","APC"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","912","APC"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","912","APC"
"Ultrasound breast complete","76641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","912","APC"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","674","","","","","","","fee schedule","86.61","694",""
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","694","","","","","","","fee schedule","86.61","694",""
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","678","","","","","","","fee schedule","86.61","694",""
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","694","APC 277.30"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","694","APC 296.56"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","694","APC 308.91"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","694","APC"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","694","APC"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","694","APC"
"Ultrasound breast limited","76642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","694","APC"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","521","","","","","","","fee schedule","104.04","536",""
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","536","","","","","","","fee schedule","104.04","536",""
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","523","","","","","","","fee schedule","104.04","536",""
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","536","APC 277.30"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","536","APC 296.56"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","536","APC 308.91"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","536","APC"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","536","APC"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","536","APC"
"Us exam abdom complete","76700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","536","APC"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","416","","","","","","","fee schedule","104.04","428",""
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","428","","","","","","","fee schedule","104.04","428",""
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","418","","","","","","","fee schedule","104.04","428",""
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","428","APC 277.30"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","428","APC 296.56"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","428","APC 308.91"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","428","APC"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","428","APC"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","428","APC"
"Echo exam of abdomen","76705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","428","APC"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","845","","","","","","","fee schedule","104.04","869",""
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","869","","","","","","","fee schedule","104.04","869",""
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","848","","","","","","","fee schedule","104.04","869",""
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","869","APC 277.30"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","869","APC 296.56"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","869","APC 308.91"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","869","APC"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","869","APC"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","869","APC"
"Us abdl aorta screen aaa","76706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","869","APC"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","449","","","","","","","fee schedule","104.04","462",""
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","462","","","","","","","fee schedule","104.04","462",""
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","450","","","","","","","fee schedule","104.04","462",""
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","462","APC 277.30"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","462","APC 296.56"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","462","APC 308.91"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","462","APC"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","462","APC"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","462","APC"
"Us exam abdo back wall comp","76770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","462","APC"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","327","","","","","","","fee schedule","104.04","360.93",""
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","336","","","","","","","fee schedule","104.04","360.93",""
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","329","","","","","","","fee schedule","104.04","360.93",""
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam abdo back wall lim","76775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam k transpl w/doppler","76776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam spinal canal","76800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","833","","","","","","","fee schedule","104.04","857",""
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","857","","","","","","","fee schedule","104.04","857",""
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","837","","","","","","","fee schedule","104.04","857",""
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","857","APC 277.30"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","857","APC 296.56"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","857","APC 308.91"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","857","APC"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","857","APC"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","857","APC"
"Ob us < 14 wks single fetus","76801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","857","APC"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","570","","","","","","","fee schedule","104.04","587",""
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","587","","","","","","","fee schedule","104.04","587",""
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","573","","","","","","","fee schedule","104.04","587",""
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","587","APC 277.30"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","587","APC 296.56"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","587","APC 308.91"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","587","APC"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","587","APC"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","587","APC"
"Ob us >/= 14 wks sngl fetus","76805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","587","APC"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1475","","","","","","","fee schedule","237.46","1517",""
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1517","","","","","","","fee schedule","237.46","1517",""
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1480","","","","","","","fee schedule","237.46","1517",""
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","1517","APC 277.30"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","1517","APC 296.56"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","1517","APC 308.91"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","1517","APC"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","1517","APC"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","1517","APC"
"Ob us detailed sngl fetus","76811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","1517","APC"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Ob us nuchal meas 1 gest","76813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","413","","","","","","","fee schedule","104.04","424",""
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","424","","","","","","","fee schedule","104.04","424",""
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","415","","","","","","","fee schedule","104.04","424",""
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","424","APC 277.30"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","424","APC 296.56"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","424","APC 308.91"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","424","APC"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","424","APC"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","424","APC"
"Ob us limited fetus(s)","76815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","424","APC"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","536","","","","","","","fee schedule","104.04","551",""
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","551","","","","","","","fee schedule","104.04","551",""
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","538","","","","","","","fee schedule","104.04","551",""
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","551","APC 277.30"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","551","APC 296.56"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","551","APC 308.91"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","551","APC"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","551","APC"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","551","APC"
"Ob us follow-up per fetus","76816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","551","APC"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","409","","","","","","","fee schedule","104.04","421",""
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","421","","","","","","","fee schedule","104.04","421",""
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","410","","","","","","","fee schedule","104.04","421",""
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","421","APC 277.30"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","421","APC 296.56"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","421","APC 308.91"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","421","APC"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","421","APC"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","421","APC"
"Transvaginal us obstetric","76817","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","421","APC"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1663","","","","","","","fee schedule","104.04","1710",""
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1710","","","","","","","fee schedule","104.04","1710",""
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1669","","","","","","","fee schedule","104.04","1710",""
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","1710","APC 277.30"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","1710","APC 296.56"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","1710","APC 308.91"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","1710","APC"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","1710","APC"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","1710","APC"
"Fetal biophys profile w/nst","76818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","1710","APC"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Fetal biophys profil w/o nst","76819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Umbilical artery echo","76820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Middle cerebral artery echo","76821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo exam of fetal heart","76825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam of fetal heart","76826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echo exam of fetal heart","76828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","365","","","","","","","fee schedule","104.04","375",""
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","375","","","","","","","fee schedule","104.04","375",""
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","366","","","","","","","fee schedule","104.04","375",""
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","375","APC 277.30"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","375","APC 296.56"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","375","APC 308.91"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","375","APC"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","375","APC"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","375","APC"
"Transvaginal us non-ob","76830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","375","APC"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Echo exam uterus","76831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","730","","","","","","","fee schedule","104.04","751",""
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","751","","","","","","","fee schedule","104.04","751",""
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","733","","","","","","","fee schedule","104.04","751",""
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","751","APC 277.30"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","751","APC 296.56"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","751","APC 308.91"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","751","APC"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","751","APC"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","751","APC"
"Us exam pelvic complete","76856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","751","APC"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","338","","","","","","","fee schedule","104.04","360.93",""
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","348","","","","","","","fee schedule","104.04","360.93",""
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","339","","","","","","","fee schedule","104.04","360.93",""
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam pelvic limited","76857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","430","","","","","","","fee schedule","104.04","442",""
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","442","","","","","","","fee schedule","104.04","442",""
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","432","","","","","","","fee schedule","104.04","442",""
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","442","APC 277.30"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","442","APC 296.56"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","442","APC 308.91"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","442","APC"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","442","APC"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","442","APC"
"Us exam scrotum","76870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","442","APC"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us transrectal","76872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Echograp trans r pros study","76873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","365","","","","","","","fee schedule","104.04","375",""
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","375","","","","","","","fee schedule","104.04","375",""
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","366","","","","","","","fee schedule","104.04","375",""
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","375","APC 277.30"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","375","APC 296.56"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","375","APC 308.91"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","375","APC"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","375","APC"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","375","APC"
"Us xtr non-vasc complete","76881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","375","APC"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","492","","","","","","","fee schedule","104.04","506",""
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","506","","","","","","","fee schedule","104.04","506",""
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","494","","","","","","","fee schedule","104.04","506",""
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","506","APC 277.30"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","506","APC 296.56"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","506","APC 308.91"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","506","APC"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","506","APC"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","506","APC"
"Us xtr non-vasc lmtd","76882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","506","APC"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us nrv&acc strux 1xtr compre","76883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips dynamic","76885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Us exam infant hips static","76886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Echo guide for artery repair","76936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Echo guide for biopsy","76942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","715","","","","","","","fee schedule","715","736",""
"Echo guide for biopsy","76942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","736","","","","","","","fee schedule","715","736",""
"Echo guide for biopsy","76942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","719","","","","","","","fee schedule","715","736",""
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"GI endoscopic ultrasound","76975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Us bone density measure","76977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Us trgt dyn mbubb 1st les","76978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Use parenchyma","76981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Use 1st target lesion","76982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Echo examination procedure","76999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"CT Scan for Therapy Guide","77014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2510","","","","","","","fee schedule","2510","2582",""
"CT Scan for Therapy Guide","77014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2582","","","","","","","fee schedule","2510","2582",""
"CT Scan for Therapy Guide","77014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2519","","","","","","","fee schedule","2510","2582",""
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- unilateral","77046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Mri breast c- bilateral","77047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-Ray of Mammary Duct","77053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"X-ray of mammary ducts","77054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Mammogram, One Breast","77055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","397","","","","","","","fee schedule","397","408",""
"Mammogram, One Breast","77055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","408","","","","","","","fee schedule","397","408",""
"Mammogram, One Breast","77055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","398","","","","","","","fee schedule","397","408",""
"Mammogram, Both Breasts","77056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","494","","","","","","","fee schedule","494","508",""
"Mammogram, Both Breasts","77056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","508","","","","","","","fee schedule","494","508",""
"Mammogram, Both Breasts","77056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","496","","","","","","","fee schedule","494","508",""
"Mammogram, Screening","77057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","252","","","","","","","fee schedule","252","260",""
"Mammogram, Screening","77057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","260","","","","","","","fee schedule","252","260",""
"Mammogram, Screening","77057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","253","","","","","","","fee schedule","252","260",""
"Mri one breast","77058","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1324","","","","","","","fee schedule","1324","8905.65",""
"Mri one breast","77058","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1362","","","","","","","fee schedule","1324","8905.65",""
"Mri one breast","77058","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1328","","","","","","","fee schedule","1324","8905.65",""
"Mri one breast","77058","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8905.65","","","","","","","fee schedule","1324","8905.65",""
"Mri both breasts","77059","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3534","","","","","","","fee schedule","3534","8828.83",""
"Mri both breasts","77059","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3636","","","","","","","fee schedule","3534","8828.83",""
"Mri both breasts","77059","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3547","","","","","","","fee schedule","3534","8828.83",""
"Mri both breasts","77059","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8828.83","","","","","","","fee schedule","3534","8828.83",""
"Breast tomosynthesis bi","77063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.07","","","","","","","fee schedule","23.44","24.13","APC"
"Breast tomosynthesis bi","77063","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.67","","","","","","","fee schedule","23.44","24.13","APC"
"Breast tomosynthesis bi","77063","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.44","","","","","","","fee schedule","23.44","24.13","APC"
"Breast tomosynthesis bi","77063","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.13","","","","","","","fee schedule","23.44","24.13","APC"
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","397","","","","","","","fee schedule","86.31","408",""
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","408","","","","","","","fee schedule","86.31","408",""
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","398","","","","","","","fee schedule","86.31","408",""
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.64","","","","","","","fee schedule","86.31","408","APC"
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.16","","","","","","","fee schedule","86.31","408","APC"
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.31","","","","","","","fee schedule","86.31","408","APC"
"Dx mammo incl cad uni","77065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","88.85","","","","","","","fee schedule","86.31","408","APC"
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","494","","","","","","","fee schedule","110.66","508",""
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","508","","","","","","","fee schedule","110.66","508",""
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","496","","","","","","","fee schedule","110.66","508",""
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","113.64","","","","","","","fee schedule","110.66","508","APC"
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","111.74","","","","","","","fee schedule","110.66","508","APC"
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","110.66","","","","","","","fee schedule","110.66","508","APC"
"Dx mammo incl cad bi","77066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","113.91","","","","","","","fee schedule","110.66","508","APC"
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","252","","","","","","","fee schedule","91.33","260",""
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","260","","","","","","","fee schedule","91.33","260",""
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","253","","","","","","","fee schedule","91.33","260",""
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","93.79","","","","","","","fee schedule","91.33","260","APC"
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","92.23","","","","","","","fee schedule","91.33","260","APC"
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","91.33","","","","","","","fee schedule","91.33","260","APC"
"Scr mammo bi incl cad","77067","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","94.02","","","","","","","fee schedule","91.33","260","APC"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"X-Ray Stress View","77071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-Rays for Bone Age","77072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","88","","","","","","","fee schedule","88","360.93",""
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","90","","","","","","","fee schedule","88","360.93",""
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","89","","","","","","","fee schedule","88","360.93",""
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","88","360.93","APC 277.30"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","88","360.93","APC 296.56"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","88","360.93","APC 308.91"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","88","360.93","APC"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","88","360.93","APC"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","88","360.93","APC"
"X-rays bone length studies","77073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","88","360.93","APC"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey limited","77074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","493","","","","","","","fee schedule","104.04","507",""
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","507","","","","","","","fee schedule","104.04","507",""
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","495","","","","","","","fee schedule","104.04","507",""
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","507","APC 277.30"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","507","APC 296.56"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","507","APC 308.91"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","507","APC"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","507","APC"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","507","APC"
"X-rays bone survey complete","77075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","507","APC"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"X-rays bone survey infant","77076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Joint survey single view","77077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","485","","","","","","","fee schedule","86.61","1171.87",""
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","499","","","","","","","fee schedule","86.61","1171.87",""
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","487","","","","","","","fee schedule","86.61","1171.87",""
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1171.87","","","","","","","fee schedule","86.61","1171.87",""
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","1171.87","APC 277.30"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","1171.87","APC 296.56"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","1171.87","APC 308.91"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","1171.87","APC"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","1171.87","APC"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","1171.87","APC"
"Ct bone density axial","77078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","1171.87","APC"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","402","","","","","","","fee schedule","104.04","414",""
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","414","","","","","","","fee schedule","104.04","414",""
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","404","","","","","","","fee schedule","104.04","414",""
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","414","APC 277.30"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","414","APC 296.56"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","414","APC 308.91"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","414","APC"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","414","APC"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","414","APC"
"Dxa bone density axial","77080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","414","APC"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Dxa bone density/peripheral","77081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2169","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2231","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2178","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Magnetic image bone marrow","77084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Dxa bone density study","77085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture assessment via dxa","77086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl prep&transmis data","77090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Tbs techl calculation only","77091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1278","","","","","","","fee schedule","133.76","1316",""
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1316","","","","","","","fee schedule","133.76","1316",""
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1285","","","","","","","fee schedule","133.76","1316",""
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","1316","APC 277.30"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","1316","APC 296.56"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","1316","APC 308.91"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","1316","APC"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","1316","APC"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","1316","APC"
"Set radiation therapy field","77280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","1316","APC"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","1292.68","APC 277.30"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","1292.68","APC 296.56"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","1292.68","APC 308.91"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","1292.68","APC"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","1292.68","APC"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","1292.68","APC"
"Set radiation therapy field","77285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","1292.68","APC"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2001","","","","","","","fee schedule","372.63","2058",""
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2058","","","","","","","fee schedule","372.63","2058",""
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2009","","","","","","","fee schedule","372.63","2058",""
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","2058","APC 277.30"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","2058","APC 296.56"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","2058","APC 308.91"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","2058","APC"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","2058","APC"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","2058","APC"
"Set radiation therapy field","77290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","2058","APC"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","5072","","","","","","","fee schedule","1377.48","5218",""
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","5218","","","","","","","fee schedule","1377.48","5218",""
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","5092","","","","","","","fee schedule","1377.48","5218",""
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4289.59","","","","","","","fee schedule","1377.48","5218","APC 277.30"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4587.52","","","","","","","fee schedule","1377.48","5218","APC 296.56"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4778.57","","","","","","","fee schedule","1377.48","5218","APC 308.91"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.62","","","","","","","fee schedule","1377.48","5218","APC"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.99","","","","","","","fee schedule","1377.48","5218","APC"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.48","","","","","","","fee schedule","1377.48","5218","APC"
"3-d radiotherapy plan","77295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1418","","","","","","","fee schedule","1377.48","5218","APC"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation therapy planning","77299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2014","","","","","","","fee schedule","133.76","2072",""
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2072","","","","","","","fee schedule","133.76","2072",""
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2022","","","","","","","fee schedule","133.76","2072",""
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","2072","APC 277.30"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","2072","APC 296.56"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","2072","APC 308.91"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","2072","APC"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","2072","APC"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","2072","APC"
"Radiation therapy dose plan","77300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","2072","APC"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","8010","","","","","","","fee schedule","1377.48","8240",""
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","8240","","","","","","","fee schedule","1377.48","8240",""
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","8040","","","","","","","fee schedule","1377.48","8240",""
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4289.59","","","","","","","fee schedule","1377.48","8240","APC 277.30"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4587.52","","","","","","","fee schedule","1377.48","8240","APC 296.56"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4778.57","","","","","","","fee schedule","1377.48","8240","APC 308.91"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.62","","","","","","","fee schedule","1377.48","8240","APC"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.99","","","","","","","fee schedule","1377.48","8240","APC"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.48","","","","","","","fee schedule","1377.48","8240","APC"
"Radiotherapy dose plan imrt","77301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1418","","","","","","","fee schedule","1377.48","8240","APC"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","1292.68","APC 277.30"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","1292.68","APC 296.56"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","1292.68","APC 308.91"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","1292.68","APC"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","1292.68","APC"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","1292.68","APC"
"Telethx isodose plan simple","77306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","1292.68","APC"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2663","","","","","","","fee schedule","372.63","2739",""
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2739","","","","","","","fee schedule","372.63","2739",""
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2673","","","","","","","fee schedule","372.63","2739",""
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","2739","APC 277.30"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","2739","APC 296.56"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","2739","APC 308.91"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","2739","APC"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","2739","APC"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","2739","APC"
"Telethx isodose plan cplx","77307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","2739","APC"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","1292.68","APC 277.30"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","1292.68","APC 296.56"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","1292.68","APC 308.91"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose plan simple","77316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","1292.68","APC 277.30"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","1292.68","APC 296.56"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","1292.68","APC 308.91"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose intermed","77317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","1292.68","APC 277.30"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","1292.68","APC 296.56"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","1292.68","APC 308.91"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","1292.68","APC"
"Brachytx isodose complex","77318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","1292.68","APC"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","1292.68","APC 277.30"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","1292.68","APC 296.56"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","1292.68","APC 308.91"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","1292.68","APC"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","1292.68","APC"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","1292.68","APC"
"Special teletx port plan","77321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","1292.68","APC"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"Special radiation dosimetry","77331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3101","","","","","","","fee schedule","372.63","3190",""
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3190","","","","","","","fee schedule","372.63","3190",""
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3113","","","","","","","fee schedule","372.63","3190",""
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","3190","APC 277.30"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","3190","APC 296.56"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","3190","APC 308.91"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","3190","APC"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","3190","APC"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","3190","APC"
"Radiation treatment aid(s)","77334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","3190","APC"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","520","","","","","","","fee schedule","133.76","534",""
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","534","","","","","","","fee schedule","133.76","534",""
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","522","","","","","","","fee schedule","133.76","534",""
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","534","APC 277.30"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","534","APC 296.56"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","534","APC 308.91"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","534","APC"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","534","APC"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","534","APC"
"Radiation physics consult","77336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","534","APC"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","7848","","","","","","","fee schedule","372.63","8074",""
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","8074","","","","","","","fee schedule","372.63","8074",""
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","7879","","","","","","","fee schedule","372.63","8074",""
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160.4","","","","","","","fee schedule","372.63","8074","APC 277.30"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1241","","","","","","","fee schedule","372.63","8074","APC 296.56"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1292.68","","","","","","","fee schedule","372.63","8074","APC 308.91"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.68","","","","","","","fee schedule","372.63","8074","APC"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.29","","","","","","","fee schedule","372.63","8074","APC"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.63","","","","","","","fee schedule","372.63","8074","APC"
"Design mlc device for imrt","77338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.59","","","","","","","fee schedule","372.63","8074","APC"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","446","","","","","","","fee schedule","133.76","464.03",""
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","460","","","","","","","fee schedule","133.76","464.03",""
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","448","","","","","","","fee schedule","133.76","464.03",""
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation physics consult","77370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22825.93","","","","","","","fee schedule","7329.93","25427.91","APC 277.30"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24411.32","","","","","","","fee schedule","7329.93","25427.91","APC 296.56"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25427.91","","","","","","","fee schedule","7329.93","25427.91","APC 308.91"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7527.55","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7401.79","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7329.93","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs multisource","77371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7545.51","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","10090","","","","","","","fee schedule","7329.93","25427.91",""
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","10380","","","","","","","fee schedule","7329.93","25427.91",""
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","10129","","","","","","","fee schedule","7329.93","25427.91",""
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22825.93","","","","","","","fee schedule","7329.93","25427.91","APC 277.30"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24411.32","","","","","","","fee schedule","7329.93","25427.91","APC 296.56"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25427.91","","","","","","","fee schedule","7329.93","25427.91","APC 308.91"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7527.55","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7401.79","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7329.93","","","","","","","fee schedule","7329.93","25427.91","APC"
"Srs linear based","77372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7545.51","","","","","","","fee schedule","7329.93","25427.91","APC"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","10142","","","","","","","fee schedule","1779.47","10434",""
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","10434","","","","","","","fee schedule","1779.47","10434",""
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","10182","","","","","","","fee schedule","1779.47","10434",""
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5541.39","","","","","","","fee schedule","1779.47","10434","APC 277.30"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5926.27","","","","","","","fee schedule","1779.47","10434","APC 296.56"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6173.06","","","","","","","fee schedule","1779.47","10434","APC 308.91"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1827.44","","","","","","","fee schedule","1779.47","10434","APC"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1796.91","","","","","","","fee schedule","1779.47","10434","APC"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1779.47","","","","","","","fee schedule","1779.47","10434","APC"
"SBRT Delivery","77373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1831.8","","","","","","","fee schedule","1779.47","10434","APC"
"Ntsty modul rad tx dlvr smpl","77385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","4819","","","","","","","fee schedule","4819","4957",""
"Ntsty modul rad tx dlvr smpl","77385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","4957","","","","","","","fee schedule","4819","4957",""
"Ntsty modul rad tx dlvr smpl","77385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","4837","","","","","","","fee schedule","4819","4957",""
"Ntsty modul rad tx dlvr cplx","77386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3807","","","","","","","fee schedule","3807","3917",""
"Ntsty modul rad tx dlvr cplx","77386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3917","","","","","","","fee schedule","3807","3917",""
"Ntsty modul rad tx dlvr cplx","77386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3822","","","","","","","fee schedule","3807","3917",""
"Guidance for radiaj tx dlvr","77387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1408","","","","","","","fee schedule","1408","1448",""
"Guidance for radiaj tx dlvr","77387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1448","","","","","","","fee schedule","1408","1448",""
"Guidance for radiaj tx dlvr","77387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1413","","","","","","","fee schedule","1408","1448",""
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.55","","","","","","","fee schedule","133.76","464.03","APC 277.30"
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.48","","","","","","","fee schedule","133.76","464.03","APC 296.56"
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.03","","","","","","","fee schedule","133.76","464.03","APC 308.91"
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.37","","","","","","","fee schedule","133.76","464.03","APC"
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.07","","","","","","","fee schedule","133.76","464.03","APC"
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.76","","","","","","","fee schedule","133.76","464.03","APC"
"External radiation dosimetry","77399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.7","","","","","","","fee schedule","133.76","464.03","APC"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","438","","","","","","","fee schedule","101.54","450",""
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","450","","","","","","","fee schedule","101.54","450",""
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","439","","","","","","","fee schedule","101.54","450",""
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","316.2","","","","","","","fee schedule","101.54","450","APC 277.30"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","338.17","","","","","","","fee schedule","101.54","450","APC 296.56"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","352.25","","","","","","","fee schedule","101.54","450","APC 308.91"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.28","","","","","","","fee schedule","101.54","450","APC"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.54","","","","","","","fee schedule","101.54","450","APC"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.54","","","","","","","fee schedule","101.54","450","APC"
"Radiation treatment delivery","77402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.53","","","","","","","fee schedule","101.54","450","APC"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1195.32","","","","","","","fee schedule","383.84","1331.58","APC 277.30"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1278.34","","","","","","","fee schedule","383.84","1331.58","APC 296.56"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1331.58","","","","","","","fee schedule","383.84","1331.58","APC 308.91"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.19","","","","","","","fee schedule","383.84","1331.58","APC"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","387.61","","","","","","","fee schedule","383.84","1331.58","APC"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","383.84","","","","","","","fee schedule","383.84","1331.58","APC"
"Radiation treatment delivery","77407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.13","","","","","","","fee schedule","383.84","1331.58","APC"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","865","","","","","","","fee schedule","549.89","1907.59",""
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","889","","","","","","","fee schedule","549.89","1907.59",""
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","868","","","","","","","fee schedule","549.89","1907.59",""
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Radiation treatment delivery","77412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Radiology port images(s)","77417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","936","","","","","","","fee schedule","936","964",""
"Radiology port images(s)","77417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","964","","","","","","","fee schedule","936","964",""
"Radiology port images(s)","77417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","940","","","","","","","fee schedule","936","964",""
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Neutron beam tx complex","77423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22825.93","","","","","","","fee schedule","7329.93","25427.91","APC 277.30"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24411.32","","","","","","","fee schedule","7329.93","25427.91","APC 296.56"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25427.91","","","","","","","fee schedule","7329.93","25427.91","APC 308.91"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7527.55","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7401.79","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7329.93","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx delivery by x-ray","77424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7545.51","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22825.93","","","","","","","fee schedule","7329.93","25427.91","APC 277.30"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24411.32","","","","","","","fee schedule","7329.93","25427.91","APC 296.56"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25427.91","","","","","","","fee schedule","7329.93","25427.91","APC 308.91"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7527.55","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7401.79","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7329.93","","","","","","","fee schedule","7329.93","25427.91","APC"
"Io rad tx deliver by elctrns","77425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7545.51","","","","","","","fee schedule","7329.93","25427.91","APC"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Surf radj ther tx planning","77436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","316.2","","","","","","","fee schedule","101.54","352.25","APC 277.30"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","338.17","","","","","","","fee schedule","101.54","352.25","APC 296.56"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","352.25","","","","","","","fee schedule","101.54","352.25","APC 308.91"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.28","","","","","","","fee schedule","101.54","352.25","APC"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.54","","","","","","","fee schedule","101.54","352.25","APC"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.54","","","","","","","fee schedule","101.54","352.25","APC"
"Surf radj ther supfc<=150kv","77437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.53","","","","","","","fee schedule","101.54","352.25","APC"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","316.2","","","","","","","fee schedule","101.54","352.25","APC 277.30"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","338.17","","","","","","","fee schedule","101.54","352.25","APC 296.56"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","352.25","","","","","","","fee schedule","101.54","352.25","APC 308.91"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.28","","","","","","","fee schedule","101.54","352.25","APC"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.54","","","","","","","fee schedule","101.54","352.25","APC"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.54","","","","","","","fee schedule","101.54","352.25","APC"
"Surf rad thr orthvlt>150-500","77438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.53","","","","","","","fee schedule","101.54","352.25","APC"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3539","","","","","","","fee schedule","549.89","3641",""
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3641","","","","","","","fee schedule","549.89","3641",""
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3554","","","","","","","fee schedule","549.89","3641",""
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","3641","APC 277.30"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","3641","APC 296.56"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","3641","APC 308.91"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","3641","APC"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","3641","APC"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","3641","APC"
"Special radiation treatment","77470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","3641","APC"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Proton trmt simple w/o comp","77520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1195.32","","","","","","","fee schedule","383.84","1331.58","APC 277.30"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1278.34","","","","","","","fee schedule","383.84","1331.58","APC 296.56"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1331.58","","","","","","","fee schedule","383.84","1331.58","APC 308.91"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.19","","","","","","","fee schedule","383.84","1331.58","APC"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","387.61","","","","","","","fee schedule","383.84","1331.58","APC"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","383.84","","","","","","","fee schedule","383.84","1331.58","APC"
"Hyperthermia treatment","77600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.13","","","","","","","fee schedule","383.84","1331.58","APC"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","2404.51","APC 277.30"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","2404.51","APC 296.56"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","2404.51","APC 308.91"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","2404.51","APC"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","2404.51","APC"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","2404.51","APC"
"Hyperthermia treatment","77605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","2404.51","APC"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Hyperthermia treatment","77620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1195.32","","","","","","","fee schedule","383.84","1331.58","APC 277.30"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1278.34","","","","","","","fee schedule","383.84","1331.58","APC 296.56"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1331.58","","","","","","","fee schedule","383.84","1331.58","APC 308.91"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.19","","","","","","","fee schedule","383.84","1331.58","APC"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","387.61","","","","","","","fee schedule","383.84","1331.58","APC"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","383.84","","","","","","","fee schedule","383.84","1331.58","APC"
"Infuse radioactive materials","77750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.13","","","","","","","fee schedule","383.84","1331.58","APC"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat simple","77761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1712.4","","","","","","","fee schedule","549.89","1907.59","APC 277.30"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1831.33","","","","","","","fee schedule","549.89","1907.59","APC 296.56"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1907.59","","","","","","","fee schedule","549.89","1907.59","APC 308.91"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","564.71","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","555.28","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","549.89","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat interm","77762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.06","","","","","","","fee schedule","549.89","1907.59","APC"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","2404.51","APC 277.30"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","2404.51","APC 296.56"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","2404.51","APC 308.91"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply intrcav radiat compl","77763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1195.32","","","","","","","fee schedule","383.84","1331.58","APC 277.30"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1278.34","","","","","","","fee schedule","383.84","1331.58","APC 296.56"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1331.58","","","","","","","fee schedule","383.84","1331.58","APC 308.91"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.19","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","387.61","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","383.84","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.13","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1195.32","","","","","","","fee schedule","383.84","1331.58","APC 277.30"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1278.34","","","","","","","fee schedule","383.84","1331.58","APC 296.56"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1331.58","","","","","","","fee schedule","383.84","1331.58","APC 308.91"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.19","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","387.61","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","383.84","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl skn surf brachytx","77768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.13","","","","","","","fee schedule","383.84","1331.58","APC"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3700","","","","","","","fee schedule","693.13","3806",""
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3806","","","","","","","fee schedule","693.13","3806",""
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3714","","","","","","","fee schedule","693.13","3806",""
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","3806","APC 277.30"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","3806","APC 296.56"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","3806","APC 308.91"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","3806","APC"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","3806","APC"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","3806","APC"
"Hdr rdncl ntrstl/icav brchtx","77770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","3806","APC"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","6620","","","","","","","fee schedule","693.13","6811",""
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","6811","","","","","","","fee schedule","693.13","6811",""
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","6646","","","","","","","fee schedule","693.13","6811",""
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","6811","APC 277.30"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","6811","APC 296.56"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","6811","APC 308.91"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","6811","APC"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","6811","APC"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","6811","APC"
"Hdr rdncl ntrstl/icav brchtx","77771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","6811","APC"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","2404.51","APC 277.30"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","2404.51","APC 296.56"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","2404.51","APC 308.91"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr rdncl ntrstl/icav brchtx","77772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2158.46","","","","","","","fee schedule","693.13","2404.51","APC 277.30"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2308.38","","","","","","","fee schedule","693.13","2404.51","APC 296.56"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2404.51","","","","","","","fee schedule","693.13","2404.51","APC 308.91"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.82","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.93","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.13","","","","","","","fee schedule","693.13","2404.51","APC"
"Apply interstit radiat compl","77778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.52","","","","","","","fee schedule","693.13","2404.51","APC"
"Hdr brachytx, 2-12 channel","77786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","6071","","","","","","","fee schedule","6071","6245",""
"Hdr brachytx, 2-12 channel","77786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","6245","","","","","","","fee schedule","6071","6245",""
"Hdr brachytx, 2-12 channel","77786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","6095","","","","","","","fee schedule","6071","6245",""
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","316.2","","","","","","","fee schedule","101.54","352.25","APC 277.30"
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","338.17","","","","","","","fee schedule","101.54","352.25","APC 296.56"
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","352.25","","","","","","","fee schedule","101.54","352.25","APC 308.91"
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.28","","","","","","","fee schedule","101.54","352.25","APC"
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.54","","","","","","","fee schedule","101.54","352.25","APC"
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.54","","","","","","","fee schedule","101.54","352.25","APC"
"Apply surf ldr radionuclide","77789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.53","","","","","","","fee schedule","101.54","352.25","APC"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","316.2","","","","","","","fee schedule","101.54","352.25","APC 277.30"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","338.17","","","","","","","fee schedule","101.54","352.25","APC 296.56"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","352.25","","","","","","","fee schedule","101.54","352.25","APC 308.91"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.28","","","","","","","fee schedule","101.54","352.25","APC"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.54","","","","","","","fee schedule","101.54","352.25","APC"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.54","","","","","","","fee schedule","101.54","352.25","APC"
"Radium/radioisotope therapy","77799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.53","","","","","","","fee schedule","101.54","352.25","APC"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid uptake measurement","78012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid imaging w/blood flow","78013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1757","","","","","","","fee schedule","397.85","1808",""
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1808","","","","","","","fee schedule","397.85","1808",""
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1766","","","","","","","fee schedule","397.85","1808",""
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1808","APC 277.30"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1808","APC 296.56"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1808","APC 308.91"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1808","APC"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1808","APC"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1808","APC"
"Thyroid imaging w/blood flow","78014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1808","APC"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging","78015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging/studies","78016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1238","","","","","","","fee schedule","540.36","1874.55",""
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1273","","","","","","","fee schedule","540.36","1874.55",""
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1244","","","","","","","fee schedule","540.36","1874.55",""
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Thyroid met imaging body","78018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyroid planar imaging","78070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyrd planar w/wo subtrj","78071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Parathyrd planar w/spect&ct","78072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Adrenal cortex & medulla img","78075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Endocrine nuclear procedure","78099","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging ltd","78102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging mult","78103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone marrow imaging body","78104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume single","78110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Plasma volume multiple","78111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell mass single","78120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Red cell mass multiple","78121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Blood volume","78122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell survival study","78130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Red cell sequestration","78140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Spleen imaging","78185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Platelet survival","78191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","931","","","","","","","fee schedule","540.36","1874.55",""
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","957","","","","","","","fee schedule","540.36","1874.55",""
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","934","","","","","","","fee schedule","540.36","1874.55",""
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Lymph system imaging","78195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Blood/lymph nuclear exam","78199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging","78201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver imaging with flow","78202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver and spleen imaging","78215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Liver & spleen image/flow","78216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2482","","","","","","","fee schedule","397.85","2554",""
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2554","","","","","","","fee schedule","397.85","2554",""
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2493","","","","","","","fee schedule","397.85","2554",""
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","2554","APC 277.30"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","2554","APC 296.56"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","2554","APC 308.91"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","2554","APC"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","2554","APC"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","2554","APC"
"Hepatobiliary system imaging","78226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","2554","APC"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2893","","","","","","","fee schedule","540.36","2976",""
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2976","","","","","","","fee schedule","540.36","2976",""
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2904","","","","","","","fee schedule","540.36","2976",""
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","2976","APC 277.30"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","2976","APC 296.56"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","2976","APC 308.91"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","2976","APC"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","2976","APC"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","2976","APC"
"Hepatobil syst image w/drug","78227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","2976","APC"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland imaging","78230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Serial salivary imaging","78231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Salivary gland function exam","78232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Esophageal motility study","78258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric mucosa imaging","78261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastroesophageal reflux exam","78262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1734","","","","","","","fee schedule","397.85","1784",""
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1784","","","","","","","fee schedule","397.85","1784",""
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1741","","","","","","","fee schedule","397.85","1784",""
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1784","APC 277.30"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1784","APC 296.56"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1784","APC 308.91"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1784","APC"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1784","APC"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1784","APC"
"Gastric emptying imag study","78264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1784","APC"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric emptying imag study","78265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Gastric emptying imag study","78266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.06","","","","","","","fee schedule","11.06","11.61",""
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.06","","","","","","","fee schedule","11.06","11.61",""
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.06","","","","","","","fee schedule","11.06","11.61",""
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.59","","","","","","","fee schedule","11.06","11.61","APC"
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.39","","","","","","","fee schedule","11.06","11.61","APC"
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.28","","","","","","","fee schedule","11.06","11.61","APC"
"Breath tst attain/anal c-14","78267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.61","","","","","","","fee schedule","11.06","11.61","APC"
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","94.41","","","","","","","fee schedule","94.41","99.13",""
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","94.41","","","","","","","fee schedule","94.41","99.13",""
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","94.41","","","","","","","fee schedule","94.41","99.13",""
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","98.89","","","","","","","fee schedule","94.41","99.13","APC"
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","97.24","","","","","","","fee schedule","94.41","99.13","APC"
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96.3","","","","","","","fee schedule","94.41","99.13","APC"
"Breath test analysis c-14","78268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99.13","","","","","","","fee schedule","94.41","99.13","APC"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Acute GI blood loss imaging","78278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"GI protein loss exam","78282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Meckels divert exam","78290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Leveen/shunt patency exam","78291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"GI nuclear procedure","78299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging limited area","78300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging multiple areas","78305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","931","","","","","","","fee schedule","397.85","1380.17",""
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","957","","","","","","","fee schedule","397.85","1380.17",""
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","934","","","","","","","fee schedule","397.85","1380.17",""
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging whole body","78306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1326","","","","","","","fee schedule","397.85","1380.17",""
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1364","","","","","","","fee schedule","397.85","1380.17",""
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1330","","","","","","","fee schedule","397.85","1380.17",""
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging 3 phase","78315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Bone imaging (3D)","78320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1504","","","","","","","fee schedule","1504","1548",""
"Bone imaging (3D)","78320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1548","","","","","","","fee schedule","1504","1548",""
"Bone imaging (3D)","78320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1510","","","","","","","fee schedule","1504","1548",""
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Musculoskeletal nuclear exam","78399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Non-imaging heart function","78414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiac shunt imaging","78428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet 1 std w/ct","78429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Myocrd img pet rst/strs w/ct","78430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Vascular flow imaging","78445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect sing","78451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3670","","","","","","","fee schedule","1288.43","4469.64",""
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3775","","","","","","","fee schedule","1288.43","4469.64",""
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3684","","","","","","","fee schedule","1288.43","4469.64",""
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image spect mult","78452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht muscle image planar sing","78453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Ht musc image planar mult","78454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Acute venous thrombus image","78456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Venous thrombosis imaging","78457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Ven thrombosis images bilat","78458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart muscle imaging (PET)","78459","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart infarct image","78466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (ef)","78468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart infarct image (3D)","78469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1288","","","","","","","fee schedule","397.85","1380.17",""
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1324","","","","","","","fee schedule","397.85","1380.17",""
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1293","","","","","","","fee schedule","397.85","1380.17",""
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart planar single","78472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Gated heart multiple","78473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass single","78481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart first pass multiple","78483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) single","78491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image (pet) multiple","78492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Heart image spect","78494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Cardiovascular nuclear exam","78499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung ventilation imaging","78579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion imaging","78580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2087","","","","","","","fee schedule","540.36","2147",""
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2147","","","","","","","fee schedule","540.36","2147",""
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2096","","","","","","","fee schedule","540.36","2147",""
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","2147","APC 277.30"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","2147","APC 296.56"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","2147","APC 308.91"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","2147","APC"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","2147","APC"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","2147","APC"
"Lung ventilat&perfus imaging","78582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","2147","APC"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perfusion differential","78597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Lung perf&ventilat diferentl","78598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Respiratory nuclear exam","78599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image < 4 views","78600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image w/flow < 4 views","78601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image 4+ views","78605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain image w/flow 4 + views","78606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Brain imaging (PET)","78608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Brain flow imaging only","78610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Cerebrospinal fluid scan","78630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF ventriculography","78635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF shunt evaluation","78645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"CSF leakage imaging","78650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear exam of tear flow","78660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Nervous system nuclear exam","78699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging morphol","78700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney imaging with flow","78701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/o drug","78707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image w/drug","78708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1180","","","","","","","fee schedule","540.36","1874.55",""
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1214","","","","","","","fee schedule","540.36","1874.55",""
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1184","","","","","","","fee schedule","540.36","1874.55",""
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"K flow/funct image multiple","78709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Kidney function study","78725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Ureteral reflux study","78740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Testicular imaging w/flow","78761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Genitourinary nuclear exam","78799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging limited area","78800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging mult areas","78801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging whole body","78802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2313","","","","","","","fee schedule","540.36","2381",""
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2381","","","","","","","fee schedule","540.36","2381",""
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2323","","","","","","","fee schedule","540.36","2381",""
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","2381","APC 277.30"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","2381","APC 296.56"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","2381","APC 308.91"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","2381","APC"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","2381","APC"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","2381","APC"
"Tumor imaging (3D)","78803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","2381","APC"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1682.73","","","","","","","fee schedule","540.36","1874.55","APC 277.30"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.6","","","","","","","fee schedule","540.36","1874.55","APC 296.56"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.55","","","","","","","fee schedule","540.36","1874.55","APC 308.91"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.93","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.66","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.36","","","","","","","fee schedule","540.36","1874.55","APC"
"Tumor imaging whole body","78804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.26","","","","","","","fee schedule","540.36","1874.55","APC"
"Abscess imaging ltd area","78805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3394","","","","","","","fee schedule","3394","3491",""
"Abscess imaging ltd area","78805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","3491","","","","","","","fee schedule","3394","3491",""
"Abscess imaging ltd area","78805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3407","","","","","","","fee schedule","3394","3491",""
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Iv inj ra drug dx study","78808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Pet image ltd area","78811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image skull-thigh","78812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image full body","78813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct lmtd","78814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","4263","","","","","","","fee schedule","1423.08","4936.75",""
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","4385","","","","","","","fee schedule","1423.08","4936.75",""
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","4279","","","","","","","fee schedule","1423.08","4936.75",""
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct skull-thigh","78815","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","3956","","","","","","","fee schedule","1423.08","4936.75",""
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","4070","","","","","","","fee schedule","1423.08","4936.75",""
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","3972","","","","","","","fee schedule","1423.08","4936.75",""
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Pet image w/ct full body","78816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect w/ct 1","78830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4012.27","","","","","","","fee schedule","1288.43","4469.64","APC 277.30"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4290.95","","","","","","","fee schedule","1288.43","4469.64","APC 296.56"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4469.64","","","","","","","fee schedule","1288.43","4469.64","APC 308.91"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.17","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.06","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.43","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect 2 areas","78831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.33","","","","","","","fee schedule","1288.43","4469.64","APC"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4431.58","","","","","","","fee schedule","1423.08","4936.75","APC 277.30"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4739.38","","","","","","","fee schedule","1423.08","4936.75","APC 296.56"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4936.75","","","","","","","fee schedule","1423.08","4936.75","APC 308.91"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1461.45","","","","","","","fee schedule","1423.08","4936.75","APC"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1437.03","","","","","","","fee schedule","1423.08","4936.75","APC"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1423.08","","","","","","","fee schedule","1423.08","4936.75","APC"
"Rp loclzj tum spect w/ct 2","78832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1464.94","","","","","","","fee schedule","1423.08","4936.75","APC"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear diagnostic exam","78999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2524","","","","","","","fee schedule","232.22","2598",""
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2598","","","","","","","fee schedule","232.22","2598",""
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2535","","","","","","","fee schedule","232.22","2598",""
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","2598","APC 277.30"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","2598","APC 296.56"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","2598","APC 308.91"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","2598","APC"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","2598","APC"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","2598","APC"
"Nuclear rx oral admin","79005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","2598","APC"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx iv admin","79101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intracav admin","79200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclr rx interstit colloid","79300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Hematopoietic nuclear tx","79403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-articular","79440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear rx intra-arterial","79445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","723.14","","","","","","","fee schedule","232.22","805.57","APC 277.30"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","773.36","","","","","","","fee schedule","232.22","805.57","APC 296.56"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","805.57","","","","","","","fee schedule","232.22","805.57","APC 308.91"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.48","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.49","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.22","","","","","","","fee schedule","232.22","805.57","APC"
"Nuclear medicine therapy","79999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.05","","","","","","","fee schedule","232.22","805.57","APC"
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.73","","","","","","","fee schedule","13.73","61.68",""
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.73","","","","","","","fee schedule","13.73","61.68",""
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.73","","","","","","","fee schedule","13.73","61.68",""
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.54","","","","","","","fee schedule","13.73","61.68",""
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","61.68","","","","","","","fee schedule","13.73","61.68",""
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.54","","","","","","","fee schedule","13.73","61.68",""
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.38","","","","","","","fee schedule","13.73","61.68","APC"
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.14","","","","","","","fee schedule","13.73","61.68","APC"
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14","","","","","","","fee schedule","13.73","61.68","APC"
"Metabolic panel ionized ca","80047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.42","","","","","","","fee schedule","13.73","61.68","APC"
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.46","","","","","","","fee schedule","8.46","61.68",""
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.46","","","","","","","fee schedule","8.46","61.68",""
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.46","","","","","","","fee schedule","8.46","61.68",""
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.54","","","","","","","fee schedule","8.46","61.68",""
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","61.68","","","","","","","fee schedule","8.46","61.68",""
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.54","","","","","","","fee schedule","8.46","61.68",""
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.86","","","","","","","fee schedule","8.46","61.68","APC"
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.71","","","","","","","fee schedule","8.46","61.68","APC"
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.63","","","","","","","fee schedule","8.46","61.68","APC"
"Metabolic panel total ca","80048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.88","","","","","","","fee schedule","8.46","61.68","APC"
"General health panel","80050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","49.37","","","","","","","fee schedule","49.37","223.34",""
"General health panel","80050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","223.34","","","","","","","fee schedule","49.37","223.34",""
"General health panel","80050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","49.37","","","","","","","fee schedule","49.37","223.34",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.01","","","","","","","fee schedule","7.01","50.41",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.01","","","","","","","fee schedule","7.01","50.41",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.01","","","","","","","fee schedule","7.01","50.41",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.06","","","","","","","fee schedule","7.01","50.41",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.41","","","","","","","fee schedule","7.01","50.41",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.06","","","","","","","fee schedule","7.01","50.41",""
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.34","","","","","","","fee schedule","7.01","50.41","APC"
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.22","","","","","","","fee schedule","7.01","50.41","APC"
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.15","","","","","","","fee schedule","7.01","50.41","APC"
"Electrolyte panel","80051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.36","","","","","","","fee schedule","7.01","50.41","APC"
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.56","","","","","","","fee schedule","10.56","77.84",""
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.56","","","","","","","fee schedule","10.56","77.84",""
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.56","","","","","","","fee schedule","10.56","77.84",""
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.17","","","","","","","fee schedule","10.56","77.84",""
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","77.84","","","","","","","fee schedule","10.56","77.84",""
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.17","","","","","","","fee schedule","10.56","77.84",""
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.56","77.84","APC"
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.88","","","","","","","fee schedule","10.56","77.84","APC"
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.77","","","","","","","fee schedule","10.56","77.84","APC"
"Comprehen metabolic panel","80053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.09","","","","","","","fee schedule","10.56","77.84","APC"
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.81","","","","","","","fee schedule","47.81","325.63",""
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.81","","","","","","","fee schedule","47.81","325.63",""
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.81","","","","","","","fee schedule","47.81","325.63",""
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.88","","","","","","","fee schedule","47.81","325.63",""
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","325.63","","","","","","","fee schedule","47.81","325.63",""
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.88","","","","","","","fee schedule","47.81","325.63",""
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50.08","","","","","","","fee schedule","47.81","325.63","APC"
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49.24","","","","","","","fee schedule","47.81","325.63","APC"
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.77","","","","","","","fee schedule","47.81","325.63","APC"
"Obstetric panel","80055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50.2","","","","","","","fee schedule","47.81","325.63","APC"
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.39","","","","","","","fee schedule","13.39","97.95",""
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.39","","","","","","","fee schedule","13.39","97.95",""
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.39","","","","","","","fee schedule","13.39","97.95",""
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.03","","","","","","","fee schedule","13.39","97.95",""
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.95","","","","","","","fee schedule","13.39","97.95",""
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.03","","","","","","","fee schedule","13.39","97.95",""
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.03","","","","","","","fee schedule","13.39","97.95","APC"
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.79","","","","","","","fee schedule","13.39","97.95","APC"
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.66","","","","","","","fee schedule","13.39","97.95","APC"
"Lipid panel","80061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.39","97.95","APC"
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.68","","","","","","","fee schedule","8.68","64.3",""
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.68","","","","","","","fee schedule","8.68","64.3",""
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.68","","","","","","","fee schedule","8.68","64.3",""
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.92","","","","","","","fee schedule","8.68","64.3",""
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.3","","","","","","","fee schedule","8.68","64.3",""
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.92","","","","","","","fee schedule","8.68","64.3",""
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.09","","","","","","","fee schedule","8.68","64.3","APC"
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.94","","","","","","","fee schedule","8.68","64.3","APC"
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.85","","","","","","","fee schedule","8.68","64.3","APC"
"Renal function panel","80069","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.11","","","","","","","fee schedule","8.68","64.3","APC"
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.63","","","","","","","fee schedule","47.63","351",""
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.63","","","","","","","fee schedule","47.63","351",""
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.63","","","","","","","fee schedule","47.63","351",""
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","81.85","","","","","","","fee schedule","47.63","351",""
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","351","","","","","","","fee schedule","47.63","351",""
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","81.85","","","","","","","fee schedule","47.63","351",""
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.89","","","","","","","fee schedule","47.63","351","APC"
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49.06","","","","","","","fee schedule","47.63","351","APC"
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.58","","","","","","","fee schedule","47.63","351","APC"
"Acute hepatitis panel","80074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50.01","","","","","","","fee schedule","47.63","351","APC"
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.17","","","","","","","fee schedule","8.17","59.36",""
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.17","","","","","","","fee schedule","8.17","59.36",""
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.17","","","","","","","fee schedule","8.17","59.36",""
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.04","","","","","","","fee schedule","8.17","59.36",""
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.36","","","","","","","fee schedule","8.17","59.36",""
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.04","","","","","","","fee schedule","8.17","59.36",""
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.56","","","","","","","fee schedule","8.17","59.36","APC"
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.42","","","","","","","fee schedule","8.17","59.36","APC"
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.33","","","","","","","fee schedule","8.17","59.36","APC"
"Hepatic function panel","80076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.17","59.36","APC"
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","74.86","","","","","","","fee schedule","74.86","122.36",""
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","74.86","","","","","","","fee schedule","74.86","122.36",""
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.86","","","","","","","fee schedule","74.86","122.36",""
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","122.36","","","","","","","fee schedule","74.86","122.36",""
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","122.36","","","","","","","fee schedule","74.86","122.36",""
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.42","","","","","","","fee schedule","74.86","122.36","APC"
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.11","","","","","","","fee schedule","74.86","122.36","APC"
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.36","","","","","","","fee schedule","74.86","122.36","APC"
"Obstetric panel","80081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.6","","","","","","","fee schedule","74.86","122.36","APC"
"Drug screen","80100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","184.23","","","","","","","fee schedule","184.23","184.23",""
"Drug screen","80101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","154.5","","","","","","","fee schedule","154.5","154.5",""
"Drug confirmation","80102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.27","","","","","","","fee schedule","97.27","97.27",""
"Drug analysis, tissue prep","80103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","134.05","","","","","","","fee schedule","134.05","134.05",""
"Drug scrn 1+ class nonchromo","80104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","195.42","","","","","","","fee schedule","195.42","195.42",""
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay acetaminophen","80143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay adalimumab","80145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","46.28","APC"
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.08","","","","","","","fee schedule","15.08","110.82",""
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.08","","","","","","","fee schedule","15.08","110.82",""
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.08","","","","","","","fee schedule","15.08","110.82",""
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.91","","","","","","","fee schedule","15.08","110.82",""
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","110.82","","","","","","","fee schedule","15.08","110.82",""
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.91","","","","","","","fee schedule","15.08","110.82",""
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.08","110.82","APC"
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.53","","","","","","","fee schedule","15.08","110.82","APC"
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.38","","","","","","","fee schedule","15.08","110.82","APC"
"Assay of amikacin","80150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.83","","","","","","","fee schedule","15.08","110.82","APC"
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay amiodarone","80151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Assay of amitriptyline","80152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.4","","","","","","","fee schedule","132.4","132.4",""
"Assay of benzodiazepines","80154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","136.41","","","","","","","fee schedule","136.41","136.41",""
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","23.16","40.5",""
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","23.16","40.5",""
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","23.16","40.5",""
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.16","","","","","","","fee schedule","23.16","40.5",""
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.16","","","","","","","fee schedule","23.16","40.5",""
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","23.16","40.5","APC"
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","23.16","40.5","APC"
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","23.16","40.5","APC"
"Drug assay caffeine","80155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","23.16","40.5","APC"
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.57","","","","","","","fee schedule","14.57","107.32",""
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.57","","","","","","","fee schedule","14.57","107.32",""
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.57","","","","","","","fee schedule","14.57","107.32",""
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.02","","","","","","","fee schedule","14.57","107.32",""
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.32","","","","","","","fee schedule","14.57","107.32",""
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.02","","","","","","","fee schedule","14.57","107.32",""
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.26","","","","","","","fee schedule","14.57","107.32","APC"
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.01","","","","","","","fee schedule","14.57","107.32","APC"
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.86","","","","","","","fee schedule","14.57","107.32","APC"
"Assay carbamazepine total","80156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.3","","","","","","","fee schedule","14.57","107.32","APC"
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","99.63",""
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","99.63",""
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","99.63",""
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.79","","","","","","","fee schedule","13.25","99.63",""
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.63","","","","","","","fee schedule","13.25","99.63",""
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.79","","","","","","","fee schedule","13.25","99.63",""
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","99.63","APC"
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","99.63","APC"
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","99.63","APC"
"Assay carbamazepine free","80157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","99.63","APC"
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.05","","","","","","","fee schedule","18.05","128.51",""
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.05","","","","","","","fee schedule","18.05","128.51",""
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.05","","","","","","","fee schedule","18.05","128.51",""
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","18.05","128.51",""
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.51","","","","","","","fee schedule","18.05","128.51",""
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","18.05","128.51",""
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.05","128.51","APC"
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.59","","","","","","","fee schedule","18.05","128.51","APC"
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.41","","","","","","","fee schedule","18.05","128.51","APC"
"Drug assay cyclosporine","80158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.05","128.51","APC"
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.15","","","","","","","fee schedule","20.15","30.28",""
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.15","","","","","","","fee schedule","20.15","30.28",""
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.15","","","","","","","fee schedule","20.15","30.28",""
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.28","","","","","","","fee schedule","20.15","30.28",""
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.28","","","","","","","fee schedule","20.15","30.28",""
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.11","","","","","","","fee schedule","20.15","30.28","APC"
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.75","","","","","","","fee schedule","20.15","30.28","APC"
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.55","","","","","","","fee schedule","20.15","30.28","APC"
"Drug assay clozapine","80159","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.16","","","","","","","fee schedule","20.15","30.28","APC"
"Assay of desipramine","80160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.55","","","","","","","fee schedule","126.55","126.55",""
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Asy carbamazepin 10,11-epxid","80161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.28","","","","","","","fee schedule","13.28","99.8",""
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.28","","","","","","","fee schedule","13.28","99.8",""
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.28","","","","","","","fee schedule","13.28","99.8",""
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.82","","","","","","","fee schedule","13.28","99.8",""
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.8","","","","","","","fee schedule","13.28","99.8",""
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.82","","","","","","","fee schedule","13.28","99.8",""
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.28","99.8","APC"
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.68","","","","","","","fee schedule","13.28","99.8","APC"
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.55","","","","","","","fee schedule","13.28","99.8","APC"
"Assay of digoxin total","80162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.94","","","","","","","fee schedule","13.28","99.8","APC"
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.28","","","","","","","fee schedule","13.28","21.68",""
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.28","","","","","","","fee schedule","13.28","21.68",""
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.28","","","","","","","fee schedule","13.28","21.68",""
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.68","","","","","","","fee schedule","13.28","21.68",""
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.68","","","","","","","fee schedule","13.28","21.68",""
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.28","21.68","APC"
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.68","","","","","","","fee schedule","13.28","21.68","APC"
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.55","","","","","","","fee schedule","13.28","21.68","APC"
"Assay of digoxin free","80163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.94","","","","","","","fee schedule","13.28","21.68","APC"
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.54","","","","","","","fee schedule","13.54","99.06",""
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.54","","","","","","","fee schedule","13.54","99.06",""
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.54","","","","","","","fee schedule","13.54","99.06",""
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.28","","","","","","","fee schedule","13.54","99.06",""
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.06","","","","","","","fee schedule","13.54","99.06",""
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.28","","","","","","","fee schedule","13.54","99.06",""
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.18","","","","","","","fee schedule","13.54","99.06","APC"
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.95","","","","","","","fee schedule","13.54","99.06","APC"
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.81","","","","","","","fee schedule","13.54","99.06","APC"
"Assay dipropylacetic acd tot","80164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.22","","","","","","","fee schedule","13.54","99.06","APC"
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.54","","","","","","","fee schedule","13.54","22.13",""
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.54","","","","","","","fee schedule","13.54","22.13",""
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.54","","","","","","","fee schedule","13.54","22.13",""
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.13","","","","","","","fee schedule","13.54","22.13",""
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.13","","","","","","","fee schedule","13.54","22.13",""
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.18","","","","","","","fee schedule","13.54","22.13","APC"
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.95","","","","","","","fee schedule","13.54","22.13","APC"
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.81","","","","","","","fee schedule","13.54","22.13","APC"
"Dipropylacetic acid free","80165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.22","","","","","","","fee schedule","13.54","22.13","APC"
"Assay of doxepin","80166","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","113.37","","","","","","","fee schedule","113.37","113.37",""
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay felbamate","80167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.34","","","","","","","fee schedule","16.34","119.11",""
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.34","","","","","","","fee schedule","16.34","119.11",""
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.34","","","","","","","fee schedule","16.34","119.11",""
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.09","","","","","","","fee schedule","16.34","119.11",""
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.11","","","","","","","fee schedule","16.34","119.11",""
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.09","","","","","","","fee schedule","16.34","119.11",""
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.12","","","","","","","fee schedule","16.34","119.11","APC"
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.83","","","","","","","fee schedule","16.34","119.11","APC"
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.67","","","","","","","fee schedule","16.34","119.11","APC"
"Assay of ethosuximide","80168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.16","","","","","","","fee schedule","16.34","119.11","APC"
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.73","","","","","","","fee schedule","13.73","22.48",""
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.73","","","","","","","fee schedule","13.73","22.48",""
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.73","","","","","","","fee schedule","13.73","22.48",""
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.48","","","","","","","fee schedule","13.73","22.48",""
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.48","","","","","","","fee schedule","13.73","22.48",""
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.38","","","","","","","fee schedule","13.73","22.48","APC"
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.14","","","","","","","fee schedule","13.73","22.48","APC"
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14","","","","","","","fee schedule","13.73","22.48","APC"
"Drug assay everolimus","80169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.42","","","","","","","fee schedule","13.73","22.48","APC"
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.38","","","","","","","fee schedule","16.38","119.34",""
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.38","","","","","","","fee schedule","16.38","119.34",""
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.38","","","","","","","fee schedule","16.38","119.34",""
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.18","","","","","","","fee schedule","16.38","119.34",""
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.34","","","","","","","fee schedule","16.38","119.34",""
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.18","","","","","","","fee schedule","16.38","119.34",""
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.16","","","","","","","fee schedule","16.38","119.34","APC"
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.87","","","","","","","fee schedule","16.38","119.34","APC"
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.71","","","","","","","fee schedule","16.38","119.34","APC"
"Assay of gentamicin","80170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.2","","","","","","","fee schedule","16.38","119.34","APC"
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.67","","","","","","","fee schedule","21.67","22.75",""
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.67","","","","","","","fee schedule","21.67","22.75",""
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.67","","","","","","","fee schedule","21.67","22.75",""
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.71","","","","","","","fee schedule","21.67","22.75",""
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.71","","","","","","","fee schedule","21.67","22.75",""
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.7","","","","","","","fee schedule","21.67","22.75","APC"
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.32","","","","","","","fee schedule","21.67","22.75","APC"
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.1","","","","","","","fee schedule","21.67","22.75","APC"
"Drug screen quant gabapentin","80171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.75","","","","","","","fee schedule","21.67","22.75","APC"
"Assay of gold","80172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.93","","","","","","","fee schedule","119.93","119.93",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.78","","","","","","","fee schedule","15.78","107.32",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.78","","","","","","","fee schedule","15.78","107.32",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.78","","","","","","","fee schedule","15.78","107.32",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.02","","","","","","","fee schedule","15.78","107.32",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.32","","","","","","","fee schedule","15.78","107.32",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.02","","","","","","","fee schedule","15.78","107.32",""
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.53","","","","","","","fee schedule","15.78","107.32","APC"
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.25","","","","","","","fee schedule","15.78","107.32","APC"
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.1","","","","","","","fee schedule","15.78","107.32","APC"
"Assay Of Haloperidol","80173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.57","","","","","","","fee schedule","15.78","107.32","APC"
"Assay of imipramine","80174","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.17","","","","","","","fee schedule","128.17","128.17",""
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","21.71","APC"
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","21.71","APC"
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","21.71","APC"
"Drug screen quan lamotrigine","80175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","21.71","APC"
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.69","","","","","","","fee schedule","14.69","108.89",""
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.69","","","","","","","fee schedule","14.69","108.89",""
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.69","","","","","","","fee schedule","14.69","108.89",""
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.25","","","","","","","fee schedule","14.69","108.89",""
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","108.89","","","","","","","fee schedule","14.69","108.89",""
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.25","","","","","","","fee schedule","14.69","108.89",""
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.39","","","","","","","fee schedule","14.69","108.89","APC"
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.13","","","","","","","fee schedule","14.69","108.89","APC"
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.98","","","","","","","fee schedule","14.69","108.89","APC"
"Assay of lidocaine","80176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.42","","","","","","","fee schedule","14.69","108.89","APC"
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","21.71","APC"
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","21.71","APC"
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","21.71","APC"
"Drug scrn quan levetiracetam","80177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","21.71","APC"
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.61","","","","","","","fee schedule","6.61","49.56",""
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.61","","","","","","","fee schedule","6.61","49.56",""
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.61","","","","","","","fee schedule","6.61","49.56",""
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.35","","","","","","","fee schedule","6.61","49.56",""
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","49.56","","","","","","","fee schedule","6.61","49.56",""
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.35","","","","","","","fee schedule","6.61","49.56",""
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.92","","","","","","","fee schedule","6.61","49.56","APC"
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.81","","","","","","","fee schedule","6.61","49.56","APC"
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.74","","","","","","","fee schedule","6.61","49.56","APC"
"Assay of lithium","80178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.94","","","","","","","fee schedule","6.61","49.56","APC"
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay salicylate","80179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.05","","","","","","","fee schedule","18.05","29.56",""
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.05","","","","","","","fee schedule","18.05","29.56",""
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.05","","","","","","","fee schedule","18.05","29.56",""
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.56","","","","","","","fee schedule","18.05","29.56",""
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.56","","","","","","","fee schedule","18.05","29.56",""
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.05","29.56","APC"
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.59","","","","","","","fee schedule","18.05","29.56","APC"
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.41","","","","","","","fee schedule","18.05","29.56","APC"
"Drug scrn quan mycophenolate","80180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.05","29.56","APC"
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay flecainide","80181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Assay of nortriptyline","80182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.06","","","","","","","fee schedule","99.06","99.06",""
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","21.71","APC"
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","21.71","APC"
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","21.71","APC"
"Drug scrn quant oxcarbazepin","80183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","21.71","APC"
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.3","","","","","","","fee schedule","15.3","85",""
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.3","","","","","","","fee schedule","15.3","85",""
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.3","","","","","","","fee schedule","15.3","85",""
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.69","","","","","","","fee schedule","15.3","85",""
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85","","","","","","","fee schedule","15.3","85",""
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.69","","","","","","","fee schedule","15.3","85",""
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.03","","","","","","","fee schedule","15.3","85","APC"
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.3","85","APC"
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.61","","","","","","","fee schedule","15.3","85","APC"
"Assay of phenobarbital","80184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.07","","","","","","","fee schedule","15.3","85","APC"
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","99.63",""
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","99.63",""
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","99.63",""
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.79","","","","","","","fee schedule","13.25","99.63",""
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.63","","","","","","","fee schedule","13.25","99.63",""
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.79","","","","","","","fee schedule","13.25","99.63",""
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","99.63","APC"
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","99.63","APC"
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","99.63","APC"
"Assay of phenytoin total","80185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","99.63","APC"
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.76","","","","","","","fee schedule","13.76","102.58",""
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.76","","","","","","","fee schedule","13.76","102.58",""
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.76","","","","","","","fee schedule","13.76","102.58",""
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.65","","","","","","","fee schedule","13.76","102.58",""
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.58","","","","","","","fee schedule","13.76","102.58",""
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.65","","","","","","","fee schedule","13.76","102.58",""
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.41","","","","","","","fee schedule","13.76","102.58","APC"
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.17","","","","","","","fee schedule","13.76","102.58","APC"
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.04","","","","","","","fee schedule","13.76","102.58","APC"
"Assay of phenytoin free","80186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.45","","","","","","","fee schedule","13.76","102.58","APC"
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay posaconazole","80187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","32.53","APC"
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.59","","","","","","","fee schedule","16.59","123.51",""
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.59","","","","","","","fee schedule","16.59","123.51",""
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.59","","","","","","","fee schedule","16.59","123.51",""
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.52","","","","","","","fee schedule","16.59","123.51",""
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","123.51","","","","","","","fee schedule","16.59","123.51",""
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.52","","","","","","","fee schedule","16.59","123.51",""
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.59","123.51","APC"
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.09","","","","","","","fee schedule","16.59","123.51","APC"
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.92","","","","","","","fee schedule","16.59","123.51","APC"
"Assay of primidone","80188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.42","","","","","","","fee schedule","16.59","123.51","APC"
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay itraconzaole","80189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","32.53","APC"
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60","","","","","","","fee schedule","28.79","125.5",""
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60","","","","","","","fee schedule","28.79","125.5",""
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60","","","","","","","fee schedule","28.79","125.5",""
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.79","","","","","","","fee schedule","28.79","125.5",""
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","125.5","","","","","","","fee schedule","28.79","125.5",""
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.79","","","","","","","fee schedule","28.79","125.5",""
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.85","","","","","","","fee schedule","28.79","125.5","APC"
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.8","","","","","","","fee schedule","28.79","125.5","APC"
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61.2","","","","","","","fee schedule","28.79","125.5","APC"
"Assay of procainamide","80190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63","","","","","","","fee schedule","28.79","125.5","APC"
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.75","","","","","","","fee schedule","16.75","125.5",""
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.75","","","","","","","fee schedule","16.75","125.5",""
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.75","","","","","","","fee schedule","16.75","125.5",""
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.79","","","","","","","fee schedule","16.75","125.5",""
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","125.5","","","","","","","fee schedule","16.75","125.5",""
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.79","","","","","","","fee schedule","16.75","125.5",""
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.55","","","","","","","fee schedule","16.75","125.5","APC"
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.25","","","","","","","fee schedule","16.75","125.5","APC"
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.08","","","","","","","fee schedule","16.75","125.5","APC"
"Assay of procainamide","80192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.59","","","","","","","fee schedule","16.75","125.5","APC"
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay leflunomide","80193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","46.28","APC"
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.6","","","","","","","fee schedule","14.6","109.31",""
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.6","","","","","","","fee schedule","14.6","109.31",""
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.6","","","","","","","fee schedule","14.6","109.31",""
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.09","","","","","","","fee schedule","14.6","109.31",""
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.31","","","","","","","fee schedule","14.6","109.31",""
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.09","","","","","","","fee schedule","14.6","109.31",""
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.29","","","","","","","fee schedule","14.6","109.31","APC"
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.04","","","","","","","fee schedule","14.6","109.31","APC"
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.6","109.31","APC"
"Assay of quinidine","80194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.33","","","","","","","fee schedule","14.6","109.31","APC"
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.73","","","","","","","fee schedule","13.73","97.27",""
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.73","","","","","","","fee schedule","13.73","97.27",""
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.73","","","","","","","fee schedule","13.73","97.27",""
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.59","","","","","","","fee schedule","13.73","97.27",""
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.27","","","","","","","fee schedule","13.73","97.27",""
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.59","","","","","","","fee schedule","13.73","97.27",""
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.38","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.14","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of sirolimus","80195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.42","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of salicylate","80196","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","53.36","","","","","","","fee schedule","53.36","53.36",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.73","","","","","","","fee schedule","13.73","97.27",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.73","","","","","","","fee schedule","13.73","97.27",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.73","","","","","","","fee schedule","13.73","97.27",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.59","","","","","","","fee schedule","13.73","97.27",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.27","","","","","","","fee schedule","13.73","97.27",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.59","","","","","","","fee schedule","13.73","97.27",""
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.38","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.14","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of tacrolimus","80197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.42","","","","","","","fee schedule","13.73","97.27","APC"
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.14","","","","","","","fee schedule","14.14","105.62",""
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.14","","","","","","","fee schedule","14.14","105.62",""
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.14","","","","","","","fee schedule","14.14","105.62",""
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.32","","","","","","","fee schedule","14.14","105.62",""
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.62","","","","","","","fee schedule","14.14","105.62",""
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.32","","","","","","","fee schedule","14.14","105.62",""
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.81","","","","","","","fee schedule","14.14","105.62","APC"
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.56","","","","","","","fee schedule","14.14","105.62","APC"
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.42","","","","","","","fee schedule","14.14","105.62","APC"
"Assay of theophylline","80198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.85","","","","","","","fee schedule","14.14","105.62","APC"
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","29.56",""
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","29.56",""
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","29.56",""
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.56","","","","","","","fee schedule","27.11","29.56",""
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.56","","","","","","","fee schedule","27.11","29.56",""
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","29.56","APC"
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","29.56","APC"
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","29.56","APC"
"Drug screen quant tiagabine","80199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","29.56","APC"
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.13","","","","","","","fee schedule","16.13","117.46",""
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.13","","","","","","","fee schedule","16.13","117.46",""
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.13","","","","","","","fee schedule","16.13","117.46",""
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.71","","","","","","","fee schedule","16.13","117.46",""
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","117.46","","","","","","","fee schedule","16.13","117.46",""
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.71","","","","","","","fee schedule","16.13","117.46",""
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.9","","","","","","","fee schedule","16.13","117.46","APC"
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.61","","","","","","","fee schedule","16.13","117.46","APC"
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.45","","","","","","","fee schedule","16.13","117.46","APC"
"Assay of tobramycin","80200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.94","","","","","","","fee schedule","16.13","117.46","APC"
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.92","","","","","","","fee schedule","11.92","89.63",""
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.92","","","","","","","fee schedule","11.92","89.63",""
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.92","","","","","","","fee schedule","11.92","89.63",""
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.48","","","","","","","fee schedule","11.92","89.63",""
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.63","","","","","","","fee schedule","11.92","89.63",""
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.48","","","","","","","fee schedule","11.92","89.63",""
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.49","","","","","","","fee schedule","11.92","89.63","APC"
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.28","","","","","","","fee schedule","11.92","89.63","APC"
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.16","","","","","","","fee schedule","11.92","89.63","APC"
"Assay of topiramate","80201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.52","","","","","","","fee schedule","11.92","89.63","APC"
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.54","","","","","","","fee schedule","13.54","99.06",""
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.54","","","","","","","fee schedule","13.54","99.06",""
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.54","","","","","","","fee schedule","13.54","99.06",""
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.28","","","","","","","fee schedule","13.54","99.06",""
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.06","","","","","","","fee schedule","13.54","99.06",""
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.28","","","","","","","fee schedule","13.54","99.06",""
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.18","","","","","","","fee schedule","13.54","99.06","APC"
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.95","","","","","","","fee schedule","13.54","99.06","APC"
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.81","","","","","","","fee schedule","13.54","99.06","APC"
"Assay of vancomycin","80202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.22","","","","","","","fee schedule","13.54","99.06","APC"
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.71","","","","","","","fee schedule","13.25","21.71",""
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","21.71","APC"
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","21.71","APC"
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","21.71","APC"
"Drug screen quant zonisamide","80203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","21.71","APC"
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay methotrexate","80204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay rufinamide","80210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","32.53","APC"
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","22.37",""
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.37","","","","","","","fee schedule","18.64","22.37",""
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","22.37","APC"
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","22.37","APC"
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","22.37","APC"
"Drug asy hydroxychloroquine","80220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","22.37","APC"
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay infliximab","80230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay lacosamide","80235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.57","","","","","","","fee schedule","38.57","46.28",""
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.28","","","","","","","fee schedule","38.57","46.28",""
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.4","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.73","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.34","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay vedolizumab","80280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.5","","","","","","","fee schedule","38.57","46.28","APC"
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.11","","","","","","","fee schedule","27.11","32.53",""
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.53","","","","","","","fee schedule","27.11","32.53",""
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.92","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.65","","","","","","","fee schedule","27.11","32.53","APC"
"Drug assay voriconazole","80285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.47","","","","","","","fee schedule","27.11","32.53","APC"
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.64","","","","","","","fee schedule","18.64","100.73",""
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.64","","","","","","","fee schedule","18.64","100.73",""
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.64","","","","","","","fee schedule","18.64","100.73",""
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.53","","","","","","","fee schedule","18.64","100.73",""
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","100.73","","","","","","","fee schedule","18.64","100.73",""
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.53","","","","","","","fee schedule","18.64","100.73",""
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.64","100.73","APC"
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.64","100.73","APC"
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.64","100.73","APC"
"Quantitative assay drug","80299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.64","100.73","APC"
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.6","","","","","","","fee schedule","12.6","17.95",""
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.6","","","","","","","fee schedule","12.6","17.95",""
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.6","","","","","","","fee schedule","12.6","17.95",""
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.95","","","","","","","fee schedule","12.6","17.95",""
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.95","","","","","","","fee schedule","12.6","17.95",""
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.2","","","","","","","fee schedule","12.6","17.95","APC"
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.98","","","","","","","fee schedule","12.6","17.95","APC"
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.85","","","","","","","fee schedule","12.6","17.95","APC"
"Drug test prsmv dir opt obs","80305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.23","","","","","","","fee schedule","12.6","17.95","APC"
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.14","","","","","","","fee schedule","17.14","23.94",""
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.14","","","","","","","fee schedule","17.14","23.94",""
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.14","","","","","","","fee schedule","17.14","23.94",""
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.94","","","","","","","fee schedule","17.14","23.94",""
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.94","","","","","","","fee schedule","17.14","23.94",""
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.95","","","","","","","fee schedule","17.14","23.94","APC"
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.65","","","","","","","fee schedule","17.14","23.94","APC"
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.48","","","","","","","fee schedule","17.14","23.94","APC"
"Drug test prsmv instrmnt","80306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18","","","","","","","fee schedule","17.14","23.94","APC"
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.14","","","","","","","fee schedule","62.14","95.77",""
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.14","","","","","","","fee schedule","62.14","95.77",""
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62.14","","","","","","","fee schedule","62.14","95.77",""
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","95.77","","","","","","","fee schedule","62.14","95.77",""
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","95.77","","","","","","","fee schedule","62.14","95.77",""
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.09","","","","","","","fee schedule","62.14","95.77","APC"
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64","","","","","","","fee schedule","62.14","95.77","APC"
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.38","","","","","","","fee schedule","62.14","95.77","APC"
"Drug test prsmv chem anlyzr","80307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.25","","","","","","","fee schedule","62.14","95.77","APC"
"Drug screen quantalcohols","80320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.22","","","","","","","fee schedule","28.22","28.22",""
"Drug screen quantalcohols","80320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.22","","","","","","","fee schedule","28.22","28.22",""
"Alcohols biomarkers 1or 2","80321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.64","","","","","","","fee schedule","17.64","17.64",""
"Alcohols biomarkers 1or 2","80321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.64","","","","","","","fee schedule","17.64","17.64",""
"Alcohols biomarkers 3/more","80322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.64","","","","","","","fee schedule","17.64","17.64",""
"Alcohols biomarkers 3/more","80322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.64","","","","","","","fee schedule","17.64","17.64",""
"Alkaloids nos","80323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","49.02","","","","","","","fee schedule","49.02","49.02",""
"Alkaloids nos","80323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","49.02","","","","","","","fee schedule","49.02","49.02",""
"Drug screen amphetamines 1/2","80324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.38","","","","","","","fee schedule","25.38","25.38",""
"Drug screen amphetamines 1/2","80324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.38","","","","","","","fee schedule","25.38","25.38",""
"Amphetamines 3or 4","80325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.38","","","","","","","fee schedule","25.38","25.38",""
"Amphetamines 3or 4","80325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.38","","","","","","","fee schedule","25.38","25.38",""
"Amphetamines 5 or more","80326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.38","","","","","","","fee schedule","25.38","25.38",""
"Amphetamines 5 or more","80326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.38","","","","","","","fee schedule","25.38","25.38",""
"Anabolic steroid 1 or 2","80327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.16","","","","","","","fee schedule","42.16","42.16",""
"Anabolic steroid 1 or 2","80327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.16","","","","","","","fee schedule","42.16","42.16",""
"Anabolic steroid 3 or more","80328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.16","","","","","","","fee schedule","42.16","42.16",""
"Anabolic steroid 3 or more","80328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.16","","","","","","","fee schedule","42.16","42.16",""
"Analgesics non-opioid 1 or 2","80329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.05","","","","","","","fee schedule","33.05","33.05",""
"Analgesics non-opioid 1 or 2","80329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.05","","","","","","","fee schedule","33.05","33.05",""
"Analgesics non-opioid 3-5","80330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.05","","","","","","","fee schedule","33.05","33.05",""
"Analgesics non-opioid 3-5","80330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.05","","","","","","","fee schedule","33.05","33.05",""
"Analgesics non-opioid 6/more","80331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.05","","","","","","","fee schedule","33.05","33.05",""
"Analgesics non-opioid 6/more","80331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.05","","","","","","","fee schedule","33.05","33.05",""
"Antidepressants class 1 or 2","80332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.32","","","","","","","fee schedule","29.32","29.32",""
"Antidepressants class 1 or 2","80332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.32","","","","","","","fee schedule","29.32","29.32",""
"Antidepressants class 3-5","80333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.71","","","","","","","fee schedule","17.71","17.71",""
"Antidepressants class 3-5","80333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.71","","","","","","","fee schedule","17.71","17.71",""
"Antidepressants class 6/more","80334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.66","","","","","","","fee schedule","11.66","11.66",""
"Antidepressants class 6/more","80334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.66","","","","","","","fee schedule","11.66","11.66",""
"Antidepressant tricyclic 1/2","80335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.23","","","","","","","fee schedule","29.23","29.23",""
"Antidepressant tricyclic 1/2","80335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.23","","","","","","","fee schedule","29.23","29.23",""
"Antidepressant tricyclic 3-5","80336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.23","","","","","","","fee schedule","29.23","29.23",""
"Antidepressant tricyclic 3-5","80336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.23","","","","","","","fee schedule","29.23","29.23",""
"Tricyclic & cyclicals 6/more","80337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.23","","","","","","","fee schedule","29.23","29.23",""
"Tricyclic & cyclicals 6/more","80337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.23","","","","","","","fee schedule","29.23","29.23",""
"Antidepressant not specified","80338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.12","","","","","","","fee schedule","15.12","15.12",""
"Antidepressant not specified","80338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.12","","","","","","","fee schedule","15.12","15.12",""
"Antiepileptics nos 1-3","80339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.19","","","","","","","fee schedule","24.19","24.19",""
"Antiepileptics nos 1-3","80339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.19","","","","","","","fee schedule","24.19","24.19",""
"Antiepileptics nos 4-6","80340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.19","","","","","","","fee schedule","24.19","24.19",""
"Antiepileptics nos 4-6","80340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.19","","","","","","","fee schedule","24.19","24.19",""
"Antiepileptics nos 7/more","80341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.19","","","","","","","fee schedule","24.19","24.19",""
"Antiepileptics nos 7/more","80341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.19","","","","","","","fee schedule","24.19","24.19",""
"Antipsychotics nos 1-3","80342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.43","","","","","","","fee schedule","25.43","25.43",""
"Antipsychotics nos 1-3","80342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.43","","","","","","","fee schedule","25.43","25.43",""
"Antipsychotics nos 4-6","80343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.43","","","","","","","fee schedule","25.43","25.43",""
"Antipsychotics nos 4-6","80343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.43","","","","","","","fee schedule","25.43","25.43",""
"Antipsychotics nos 7/more","80344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.43","","","","","","","fee schedule","25.43","25.43",""
"Antipsychotics nos 7/more","80344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.43","","","","","","","fee schedule","25.43","25.43",""
"Drug screening barbiturates","80345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.7","","","","","","","fee schedule","18.7","18.7",""
"Drug screening barbiturates","80345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.7","","","","","","","fee schedule","18.7","18.7",""
"Benzodiazepines1-12","80346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.33","","","","","","","fee schedule","32.33","32.33",""
"Benzodiazepines1-12","80346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.33","","","","","","","fee schedule","32.33","32.33",""
"Benzodiazepines 13 or more","80347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.33","","","","","","","fee schedule","32.33","32.33",""
"Benzodiazepines 13 or more","80347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.33","","","","","","","fee schedule","32.33","32.33",""
"Drug screening buprenorphine","80348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.44","","","","","","","fee schedule","19.44","19.44",""
"Drug screening buprenorphine","80348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.44","","","","","","","fee schedule","19.44","19.44",""
"Cannabinoids natural","80349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.32","","","","","","","fee schedule","29.32","29.32",""
"Cannabinoids natural","80349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.32","","","","","","","fee schedule","29.32","29.32",""
"Cannabinoids synthetic 1-3","80350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.32","","","","","","","fee schedule","29.32","29.32",""
"Cannabinoids synthetic 1-3","80350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.32","","","","","","","fee schedule","29.32","29.32",""
"Cannabinoids synthetic 4-6","80351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.87","","","","","","","fee schedule","19.87","19.87",""
"Cannabinoids synthetic 4-6","80351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.87","","","","","","","fee schedule","19.87","19.87",""
"Cannabinoid synthetic 7/more","80352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.44","","","","","","","fee schedule","19.44","19.44",""
"Cannabinoid synthetic 7/more","80352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.44","","","","","","","fee schedule","19.44","19.44",""
"Drug screening cocaine","80353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.74","","","","","","","fee schedule","24.74","24.74",""
"Drug screening cocaine","80353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.74","","","","","","","fee schedule","24.74","24.74",""
"Drug screening fentanyl","80354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.32","","","","","","","fee schedule","29.32","29.32",""
"Drug screening fentanyl","80354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.32","","","","","","","fee schedule","29.32","29.32",""
"Gabapentin non-blood","80355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.56","","","","","","","fee schedule","21.56","21.56",""
"Gabapentin non-blood","80355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.56","","","","","","","fee schedule","21.56","21.56",""
"Heroin metabolite","80356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.91","","","","","","","fee schedule","31.91","31.91",""
"Heroin metabolite","80356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.91","","","","","","","fee schedule","31.91","31.91",""
"Ketamine and norketamine","80357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","25.87","25.87",""
"Ketamine and norketamine","80357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","25.87","25.87",""
"Drug screening methadone","80358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.66","","","","","","","fee schedule","26.66","26.66",""
"Drug screening methadone","80358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.66","","","","","","","fee schedule","26.66","26.66",""
"Methylenedioxyamphetamines","80359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.44","","","","","","","fee schedule","25.44","25.44",""
"Methylenedioxyamphetamines","80359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.44","","","","","","","fee schedule","25.44","25.44",""
"Methylphenidate","80360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","25.87","25.87",""
"Methylphenidate","80360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","25.87","25.87",""
"Opiates 1 or more","80361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","41.98","","","","","","","fee schedule","41.98","41.98",""
"Opiates 1 or more","80361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41.98","","","","","","","fee schedule","41.98","41.98",""
"Opioids & opiate analogs 1/2","80362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.78","","","","","","","fee schedule","35.78","35.78",""
"Opioids & opiate analogs 1/2","80362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.78","","","","","","","fee schedule","35.78","35.78",""
"Opioids & opiate analogs 3/4","80363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.49","","","","","","","fee schedule","25.49","25.49",""
"Opioids & opiate analogs 3/4","80363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.49","","","","","","","fee schedule","25.49","25.49",""
"Opioid &opiate analog 5/more","80364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.01","","","","","","","fee schedule","19.01","19.01",""
"Opioid &opiate analog 5/more","80364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.01","","","","","","","fee schedule","19.01","19.01",""
"Drug screening oxycodone","80365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.91","","","","","","","fee schedule","31.91","31.91",""
"Drug screening oxycodone","80365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.91","","","","","","","fee schedule","31.91","31.91",""
"Drug screening pregabalin","80366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","25.87","25.87",""
"Drug screening pregabalin","80366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","25.87","25.87",""
"Drug screening propoxyphene","80367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.32","","","","","","","fee schedule","29.32","29.32",""
"Drug screening propoxyphene","80367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.32","","","","","","","fee schedule","29.32","29.32",""
"Sedative hypnotics","80368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.03","","","","","","","fee schedule","28.03","28.03",""
"Sedative hypnotics","80368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.03","","","","","","","fee schedule","28.03","28.03",""
"Skeletal muscle relaxant 1/2","80369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.78","","","","","","","fee schedule","28.78","28.78",""
"Skeletal muscle relaxant 1/2","80369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.78","","","","","","","fee schedule","28.78","28.78",""
"Skel musc relaxant 3 or more","80370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.78","","","","","","","fee schedule","28.78","28.78",""
"Skel musc relaxant 3 or more","80370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.78","","","","","","","fee schedule","28.78","28.78",""
"Stimulants synthetic","80371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.32","","","","","","","fee schedule","29.32","29.32",""
"Stimulants synthetic","80371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.32","","","","","","","fee schedule","29.32","29.32",""
"Drug screening tapentadol","80372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","25.87","25.87",""
"Drug screening tapentadol","80372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","25.87","25.87",""
"Drug screening tramadol","80373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","25.87","25.87",""
"Drug screening tramadol","80373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","25.87","25.87",""
"Stereoisomer analysis","80374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.44","","","","","","","fee schedule","25.44","25.44",""
"Stereoisomer analysis","80374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.44","","","","","","","fee schedule","25.44","25.44",""
"Drug/substance nos 1-3","80375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.59","","","","","","","fee schedule","26.59","26.59",""
"Drug/substance nos 1-3","80375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.59","","","","","","","fee schedule","26.59","26.59",""
"Drug/substance nos 4-6","80376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.66","","","","","","","fee schedule","29.66","29.66",""
"Drug/substance nos 4-6","80376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.66","","","","","","","fee schedule","29.66","29.66",""
"Drug/substance nos 7/more","80377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.66","","","","","","","fee schedule","29.66","29.66",""
"Drug/substance nos 7/more","80377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.66","","","","","","","fee schedule","29.66","29.66",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.62","","","","","","","fee schedule","32.62","242.62",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","32.62","","","","","","","fee schedule","32.62","242.62",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.62","","","","","","","fee schedule","32.62","242.62",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","56.04","","","","","","","fee schedule","32.62","242.62",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","242.62","","","","","","","fee schedule","32.62","242.62",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","56.04","","","","","","","fee schedule","32.62","242.62",""
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34.17","","","","","","","fee schedule","32.62","242.62","APC"
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.6","","","","","","","fee schedule","32.62","242.62","APC"
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.27","","","","","","","fee schedule","32.62","242.62","APC"
"Acth stimulation panel","80400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34.25","","","","","","","fee schedule","32.62","242.62","APC"
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","86.96","","","","","","","fee schedule","86.96","642.38",""
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","86.96","","","","","","","fee schedule","86.96","642.38",""
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","86.96","","","","","","","fee schedule","86.96","642.38",""
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","149.42","","","","","","","fee schedule","86.96","642.38",""
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","642.38","","","","","","","fee schedule","86.96","642.38",""
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","149.42","","","","","","","fee schedule","86.96","642.38",""
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","91.09","","","","","","","fee schedule","86.96","642.38","APC"
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","89.57","","","","","","","fee schedule","86.96","642.38","APC"
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","88.7","","","","","","","fee schedule","86.96","642.38","APC"
"Acth stimulation panel","80402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","91.31","","","","","","","fee schedule","86.96","642.38","APC"
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","78.26","","","","","","","fee schedule","78.26","559.37",""
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","78.26","","","","","","","fee schedule","78.26","559.37",""
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","78.26","","","","","","","fee schedule","78.26","559.37",""
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","134.5","","","","","","","fee schedule","78.26","559.37",""
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","559.37","","","","","","","fee schedule","78.26","559.37",""
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","134.5","","","","","","","fee schedule","78.26","559.37",""
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","81.98","","","","","","","fee schedule","78.26","559.37","APC"
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.61","","","","","","","fee schedule","78.26","559.37","APC"
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.83","","","","","","","fee schedule","78.26","559.37","APC"
"Acth stimulation panel","80406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.17","","","","","","","fee schedule","78.26","559.37","APC"
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","125.5","","","","","","","fee schedule","125.5","934.67",""
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","125.5","","","","","","","fee schedule","125.5","934.67",""
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","125.5","","","","","","","fee schedule","125.5","934.67",""
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","215.71","","","","","","","fee schedule","125.5","934.67",""
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","934.67","","","","","","","fee schedule","125.5","934.67",""
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","215.71","","","","","","","fee schedule","125.5","934.67",""
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.46","","","","","","","fee schedule","125.5","934.67","APC"
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.27","","","","","","","fee schedule","125.5","934.67","APC"
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.01","","","","","","","fee schedule","125.5","934.67","APC"
"Aldosterone suppression eval","80408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.78","","","","","","","fee schedule","125.5","934.67","APC"
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","80.37","","","","","","","fee schedule","80.37","588.99",""
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","80.37","","","","","","","fee schedule","80.37","588.99",""
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","80.37","","","","","","","fee schedule","80.37","588.99",""
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138.1","","","","","","","fee schedule","80.37","588.99",""
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","588.99","","","","","","","fee schedule","80.37","588.99",""
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","138.1","","","","","","","fee schedule","80.37","588.99",""
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","84.19","","","","","","","fee schedule","80.37","588.99","APC"
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","82.78","","","","","","","fee schedule","80.37","588.99","APC"
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","81.98","","","","","","","fee schedule","80.37","588.99","APC"
"Calcitonin stimul panel","80410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","84.39","","","","","","","fee schedule","80.37","588.99","APC"
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","801.62","","","","","","","fee schedule","566.42","2443.82",""
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","801.62","","","","","","","fee schedule","566.42","2443.82",""
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","801.62","","","","","","","fee schedule","566.42","2443.82",""
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","566.42","","","","","","","fee schedule","566.42","2443.82",""
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2443.82","","","","","","","fee schedule","566.42","2443.82",""
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","566.42","","","","","","","fee schedule","566.42","2443.82",""
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","839.7","","","","","","","fee schedule","566.42","2443.82","APC"
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","825.67","","","","","","","fee schedule","566.42","2443.82","APC"
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","817.65","","","","","","","fee schedule","566.42","2443.82","APC"
"CRH stimulation panel","80412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","841.7","","","","","","","fee schedule","566.42","2443.82","APC"
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.64","","","","","","","fee schedule","51.64","384.25",""
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.64","","","","","","","fee schedule","51.64","384.25",""
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.64","","","","","","","fee schedule","51.64","384.25",""
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","88.75","","","","","","","fee schedule","51.64","384.25",""
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","384.25","","","","","","","fee schedule","51.64","384.25",""
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","88.75","","","","","","","fee schedule","51.64","384.25",""
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.09","","","","","","","fee schedule","51.64","384.25","APC"
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.19","","","","","","","fee schedule","51.64","384.25","APC"
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.67","","","","","","","fee schedule","51.64","384.25","APC"
"Testosterone response","80414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.22","","","","","","","fee schedule","51.64","384.25","APC"
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.89","","","","","","","fee schedule","55.89","414.19",""
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","55.89","","","","","","","fee schedule","55.89","414.19",""
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","55.89","","","","","","","fee schedule","55.89","414.19",""
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","96.05","","","","","","","fee schedule","55.89","414.19",""
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","414.19","","","","","","","fee schedule","55.89","414.19",""
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","96.05","","","","","","","fee schedule","55.89","414.19",""
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.54","","","","","","","fee schedule","55.89","414.19","APC"
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.57","","","","","","","fee schedule","55.89","414.19","APC"
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.01","","","","","","","fee schedule","55.89","414.19","APC"
"Estradiol response panel","80415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.68","","","","","","","fee schedule","55.89","414.19","APC"
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","209.32","","","","","","","fee schedule","209.32","986.84",""
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","209.32","","","","","","","fee schedule","209.32","986.84",""
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","209.32","","","","","","","fee schedule","209.32","986.84",""
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","226.87","","","","","","","fee schedule","209.32","986.84",""
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","986.84","","","","","","","fee schedule","209.32","986.84",""
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","226.87","","","","","","","fee schedule","209.32","986.84",""
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","219.26","","","","","","","fee schedule","209.32","986.84","APC"
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","215.6","","","","","","","fee schedule","209.32","986.84","APC"
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","213.51","","","","","","","fee schedule","209.32","986.84","APC"
"Renin stimulation panel","80416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","219.79","","","","","","","fee schedule","209.32","986.84","APC"
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.99","","","","","","","fee schedule","43.99","328.96",""
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.99","","","","","","","fee schedule","43.99","328.96",""
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.99","","","","","","","fee schedule","43.99","328.96",""
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","75.62","","","","","","","fee schedule","43.99","328.96",""
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","328.96","","","","","","","fee schedule","43.99","328.96",""
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","75.62","","","","","","","fee schedule","43.99","328.96",""
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.08","","","","","","","fee schedule","43.99","328.96","APC"
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.31","","","","","","","fee schedule","43.99","328.96","APC"
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.87","","","","","","","fee schedule","43.99","328.96","APC"
"Renin stimulation panel","80417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.19","","","","","","","fee schedule","43.99","328.96","APC"
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","579.48","","","","","","","fee schedule","579.48","4322.71",""
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","579.48","","","","","","","fee schedule","579.48","4322.71",""
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","579.48","","","","","","","fee schedule","579.48","4322.71",""
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","996.1","","","","","","","fee schedule","579.48","4322.71",""
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4322.71","","","","","","","fee schedule","579.48","4322.71",""
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","996.1","","","","","","","fee schedule","579.48","4322.71",""
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","607.01","","","","","","","fee schedule","579.48","4322.71","APC"
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","596.86","","","","","","","fee schedule","579.48","4322.71","APC"
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","591.07","","","","","","","fee schedule","579.48","4322.71","APC"
"Pituitary evaluation panel","80418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","608.45","","","","","","","fee schedule","579.48","4322.71","APC"
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.88","","","","","","","fee schedule","123.79","536.7",""
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","161.88","","","","","","","fee schedule","123.79","536.7",""
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.88","","","","","","","fee schedule","123.79","536.7",""
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","123.79","","","","","","","fee schedule","123.79","536.7",""
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","536.7","","","","","","","fee schedule","123.79","536.7",""
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","123.79","","","","","","","fee schedule","123.79","536.7",""
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","169.57","","","","","","","fee schedule","123.79","536.7","APC"
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","166.74","","","","","","","fee schedule","123.79","536.7","APC"
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","165.12","","","","","","","fee schedule","123.79","536.7","APC"
"Dexamethasone panel","80420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","169.97","","","","","","","fee schedule","123.79","536.7","APC"
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.07","","","","","","","fee schedule","46.07","342.67",""
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46.07","","","","","","","fee schedule","46.07","342.67",""
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.07","","","","","","","fee schedule","46.07","342.67",""
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","79.2","","","","","","","fee schedule","46.07","342.67",""
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","342.67","","","","","","","fee schedule","46.07","342.67",""
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","79.2","","","","","","","fee schedule","46.07","342.67",""
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48.26","","","","","","","fee schedule","46.07","342.67","APC"
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.45","","","","","","","fee schedule","46.07","342.67","APC"
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.99","","","","","","","fee schedule","46.07","342.67","APC"
"Glucagon tolerance panel","80422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.37","","","","","","","fee schedule","46.07","342.67","APC"
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","50.5","","","","","","","fee schedule","50.5","367.41",""
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.5","","","","","","","fee schedule","50.5","367.41",""
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","50.5","","","","","","","fee schedule","50.5","367.41",""
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","86.81","","","","","","","fee schedule","50.5","367.41",""
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","367.41","","","","","","","fee schedule","50.5","367.41",""
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","86.81","","","","","","","fee schedule","50.5","367.41",""
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52.9","","","","","","","fee schedule","50.5","367.41","APC"
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.02","","","","","","","fee schedule","50.5","367.41","APC"
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.51","","","","","","","fee schedule","50.5","367.41","APC"
"Glucagon tolerance panel","80424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.03","","","","","","","fee schedule","50.5","367.41","APC"
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","148.41","","","","","","","fee schedule","148.41","1108.37",""
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","148.41","","","","","","","fee schedule","148.41","1108.37",""
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","148.41","","","","","","","fee schedule","148.41","1108.37",""
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","255.12","","","","","","","fee schedule","148.41","1108.37",""
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1108.37","","","","","","","fee schedule","148.41","1108.37",""
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","255.12","","","","","","","fee schedule","148.41","1108.37",""
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","155.46","","","","","","","fee schedule","148.41","1108.37","APC"
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","152.86","","","","","","","fee schedule","148.41","1108.37","APC"
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","151.38","","","","","","","fee schedule","148.41","1108.37","APC"
"Gonadotropin hormone panel","80426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","155.83","","","","","","","fee schedule","148.41","1108.37","APC"
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.7","","","","","","","fee schedule","66.7","498.28",""
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","66.7","","","","","","","fee schedule","66.7","498.28",""
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66.7","","","","","","","fee schedule","66.7","498.28",""
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","114.62","","","","","","","fee schedule","66.7","498.28",""
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","498.28","","","","","","","fee schedule","66.7","498.28",""
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","114.62","","","","","","","fee schedule","66.7","498.28",""
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","69.87","","","","","","","fee schedule","66.7","498.28","APC"
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","68.7","","","","","","","fee schedule","66.7","498.28","APC"
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","68.03","","","","","","","fee schedule","66.7","498.28","APC"
"Growth hormone panel","80428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70.04","","","","","","","fee schedule","66.7","498.28","APC"
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","129.33","","","","","","","fee schedule","129.33","586.52",""
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","129.33","","","","","","","fee schedule","129.33","586.52",""
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.33","","","","","","","fee schedule","129.33","586.52",""
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","134.86","","","","","","","fee schedule","129.33","586.52",""
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","586.52","","","","","","","fee schedule","129.33","586.52",""
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","134.86","","","","","","","fee schedule","129.33","586.52",""
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.47","","","","","","","fee schedule","129.33","586.52","APC"
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.21","","","","","","","fee schedule","129.33","586.52","APC"
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.92","","","","","","","fee schedule","129.33","586.52","APC"
"Growth hormone panel","80430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.8","","","","","","","fee schedule","129.33","586.52","APC"
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","165.61","","","","","","","fee schedule","165.61","971.59",""
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","165.61","","","","","","","fee schedule","165.61","971.59",""
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","165.61","","","","","","","fee schedule","165.61","971.59",""
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","232.18","","","","","","","fee schedule","165.61","971.59",""
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","971.59","","","","","","","fee schedule","165.61","971.59",""
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","232.18","","","","","","","fee schedule","165.61","971.59",""
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","173.48","","","","","","","fee schedule","165.61","971.59","APC"
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","170.58","","","","","","","fee schedule","165.61","971.59","APC"
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","168.92","","","","","","","fee schedule","165.61","971.59","APC"
"Insulin suppression panel","80432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","173.89","","","","","","","fee schedule","165.61","971.59","APC"
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","285.03","","","","","","","fee schedule","173.82","753.59",""
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","285.03","","","","","","","fee schedule","173.82","753.59",""
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","285.03","","","","","","","fee schedule","173.82","753.59",""
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","173.82","","","","","","","fee schedule","173.82","753.59",""
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","753.59","","","","","","","fee schedule","173.82","753.59",""
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","173.82","","","","","","","fee schedule","173.82","753.59",""
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","298.57","","","","","","","fee schedule","173.82","753.59","APC"
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","293.58","","","","","","","fee schedule","173.82","753.59","APC"
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","290.73","","","","","","","fee schedule","173.82","753.59","APC"
"Insulin tolerance panel","80434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","299.28","","","","","","","fee schedule","173.82","753.59","APC"
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","103","","","","","","","fee schedule","103","769.9",""
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","103","","","","","","","fee schedule","103","769.9",""
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","103","","","","","","","fee schedule","103","769.9",""
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","177","","","","","","","fee schedule","103","769.9",""
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","769.9","","","","","","","fee schedule","103","769.9",""
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","177","","","","","","","fee schedule","103","769.9",""
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.89","","","","","","","fee schedule","103","769.9","APC"
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.09","","","","","","","fee schedule","103","769.9","APC"
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","103","769.9","APC"
"Insulin tolerance panel","80435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.15","","","","","","","fee schedule","103","769.9","APC"
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.16","","","","","","","fee schedule","91.16","668.25",""
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","91.16","","","","","","","fee schedule","91.16","668.25",""
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","91.16","","","","","","","fee schedule","91.16","668.25",""
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","156.67","","","","","","","fee schedule","91.16","668.25",""
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","668.25","","","","","","","fee schedule","91.16","668.25",""
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","156.67","","","","","","","fee schedule","91.16","668.25",""
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.49","","","","","","","fee schedule","91.16","668.25","APC"
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","93.89","","","","","","","fee schedule","91.16","668.25","APC"
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","92.98","","","","","","","fee schedule","91.16","668.25","APC"
"Metyrapone panel","80436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","95.72","","","","","","","fee schedule","91.16","668.25","APC"
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","50.41","","","","","","","fee schedule","50.41","378",""
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.41","","","","","","","fee schedule","50.41","378",""
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","50.41","","","","","","","fee schedule","50.41","378",""
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","86.62","","","","","","","fee schedule","50.41","378",""
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","378","","","","","","","fee schedule","50.41","378",""
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","86.62","","","","","","","fee schedule","50.41","378",""
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52.8","","","","","","","fee schedule","50.41","378","APC"
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.92","","","","","","","fee schedule","50.41","378","APC"
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.42","","","","","","","fee schedule","50.41","378","APC"
"TRH stimulation panel","80438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.93","","","","","","","fee schedule","50.41","378","APC"
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","67.21","","","","","","","fee schedule","67.21","504.07",""
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.21","","","","","","","fee schedule","67.21","504.07",""
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","67.21","","","","","","","fee schedule","67.21","504.07",""
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","115.49","","","","","","","fee schedule","67.21","504.07",""
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","504.07","","","","","","","fee schedule","67.21","504.07",""
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","115.49","","","","","","","fee schedule","67.21","504.07",""
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","70.4","","","","","","","fee schedule","67.21","504.07","APC"
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","69.23","","","","","","","fee schedule","67.21","504.07","APC"
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","68.55","","","","","","","fee schedule","67.21","504.07","APC"
"TRH stimulation panel","80439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70.57","","","","","","","fee schedule","67.21","504.07","APC"
"TRH stimulation panel","80440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","437.16","","","","","","","fee schedule","437.16","437.16",""
"Lab pathology consultation","80500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","98.63","","","","","","","fee schedule","98.63","98.63",""
"Lab pathology consultation","80502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","344.26","","","","","","","fee schedule","344.26","344.26",""
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.9","","","","","","","fee schedule","51.86","179.91",""
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.9","","","","","","","fee schedule","51.86","179.91",""
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","179.91","APC 277.30"
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","179.91","APC 296.56"
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","179.91","APC 308.91"
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","179.91","APC"
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","179.91","APC"
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","179.91","APC"
"Path clin consltj sf 5-20","80503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","179.91","APC"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","182.78","","","","","","","fee schedule","169.55","588.18",""
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","182.78","","","","","","","fee schedule","169.55","588.18",""
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","169.55","588.18","APC 277.30"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","169.55","588.18","APC 296.56"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","169.55","588.18","APC 308.91"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj mod 21-40","80504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","182.78","","","","","","","fee schedule","169.55","588.18",""
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","182.78","","","","","","","fee schedule","169.55","588.18",""
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","169.55","588.18","APC 277.30"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","169.55","588.18","APC 296.56"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","169.55","588.18","APC 308.91"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj high 41-60","80505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","169.55","588.18","APC"
"Path clin consltj prolng svc","80506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","51.91","","","","","","","fee schedule","51.91","51.91",""
"Path clin consltj prolng svc","80506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","51.91","","","","","","","fee schedule","51.91","51.91",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.02","","","","","","","fee schedule","4.02","23.66",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.02","","","","","","","fee schedule","4.02","23.66",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.02","","","","","","","fee schedule","4.02","23.66",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.45","","","","","","","fee schedule","4.02","23.66",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","23.66","","","","","","","fee schedule","4.02","23.66",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.45","","","","","","","fee schedule","4.02","23.66",""
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.21","","","","","","","fee schedule","4.02","23.66","APC"
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.14","","","","","","","fee schedule","4.02","23.66","APC"
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.1","","","","","","","fee schedule","4.02","23.66","APC"
"Urinalysis nonauto w/scope","81000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.22","","","","","","","fee schedule","4.02","23.66","APC"
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.17","","","","","","","fee schedule","3.17","23.66",""
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.17","","","","","","","fee schedule","3.17","23.66",""
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.17","","","","","","","fee schedule","3.17","23.66",""
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.45","","","","","","","fee schedule","3.17","23.66",""
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","23.66","","","","","","","fee schedule","3.17","23.66",""
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.45","","","","","","","fee schedule","3.17","23.66",""
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.32","","","","","","","fee schedule","3.17","23.66","APC"
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.27","","","","","","","fee schedule","3.17","23.66","APC"
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.23","","","","","","","fee schedule","3.17","23.66","APC"
"Urinalysis auto w/scope","81001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.33","","","","","","","fee schedule","3.17","23.66","APC"
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.48","","","","","","","fee schedule","3.48","18.94",""
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.48","","","","","","","fee schedule","3.48","18.94",""
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.48","","","","","","","fee schedule","3.48","18.94",""
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.39","","","","","","","fee schedule","3.48","18.94",""
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","18.94","","","","","","","fee schedule","3.48","18.94",""
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.39","","","","","","","fee schedule","3.48","18.94",""
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.65","","","","","","","fee schedule","3.48","18.94","APC"
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.58","","","","","","","fee schedule","3.48","18.94","APC"
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.55","","","","","","","fee schedule","3.48","18.94","APC"
"Urinalysis nonauto w/o scope","81002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.65","","","","","","","fee schedule","3.48","18.94","APC"
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.25","","","","","","","fee schedule","2.25","16.93",""
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.25","","","","","","","fee schedule","2.25","16.93",""
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.25","","","","","","","fee schedule","2.25","16.93",""
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3.86","","","","","","","fee schedule","2.25","16.93",""
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","16.93","","","","","","","fee schedule","2.25","16.93",""
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3.86","","","","","","","fee schedule","2.25","16.93",""
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.36","","","","","","","fee schedule","2.25","16.93","APC"
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.32","","","","","","","fee schedule","2.25","16.93","APC"
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.3","","","","","","","fee schedule","2.25","16.93","APC"
"Urinalysis auto w/o scope","81003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.36","","","","","","","fee schedule","2.25","16.93","APC"
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.17","","","","","","","fee schedule","2.17","16.33",""
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.17","","","","","","","fee schedule","2.17","16.33",""
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.17","","","","","","","fee schedule","2.17","16.33",""
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3.72","","","","","","","fee schedule","2.17","16.33",""
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","16.33","","","","","","","fee schedule","2.17","16.33",""
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3.72","","","","","","","fee schedule","2.17","16.33",""
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.27","","","","","","","fee schedule","2.17","16.33","APC"
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.24","","","","","","","fee schedule","2.17","16.33","APC"
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.21","","","","","","","fee schedule","2.17","16.33","APC"
"Urinalysis","81005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.28","","","","","","","fee schedule","2.17","16.33","APC"
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.98","","","","","","","fee schedule","4.42","31.48",""
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.98","","","","","","","fee schedule","4.42","31.48",""
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.98","","","","","","","fee schedule","4.42","31.48",""
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.42","","","","","","","fee schedule","4.42","31.48",""
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","18.77","","","","","","","fee schedule","4.42","31.48",""
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.42","","","","","","","fee schedule","4.42","31.48",""
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.4","","","","","","","fee schedule","4.42","31.48","APC"
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.88","","","","","","","fee schedule","4.42","31.48","APC"
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.58","","","","","","","fee schedule","4.42","31.48","APC"
"Urine screen for bacteria","81007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.48","","","","","","","fee schedule","4.42","31.48","APC"
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.05","","","","","","","fee schedule","3.05","22.49",""
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.05","","","","","","","fee schedule","3.05","22.49",""
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.05","","","","","","","fee schedule","3.05","22.49",""
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.22","","","","","","","fee schedule","3.05","22.49",""
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","22.49","","","","","","","fee schedule","3.05","22.49",""
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.22","","","","","","","fee schedule","3.05","22.49",""
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.19","","","","","","","fee schedule","3.05","22.49","APC"
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.14","","","","","","","fee schedule","3.05","22.49","APC"
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.11","","","","","","","fee schedule","3.05","22.49","APC"
"Microscopic exam of urine","81015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.2","","","","","","","fee schedule","3.05","22.49","APC"
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.7","","","","","","","fee schedule","4.7","26.87",""
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.7","","","","","","","fee schedule","4.7","26.87",""
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.7","","","","","","","fee schedule","4.7","26.87",""
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.34","","","","","","","fee schedule","4.7","26.87",""
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.87","","","","","","","fee schedule","4.7","26.87",""
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.34","","","","","","","fee schedule","4.7","26.87",""
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.92","","","","","","","fee schedule","4.7","26.87","APC"
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.84","","","","","","","fee schedule","4.7","26.87","APC"
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.79","","","","","","","fee schedule","4.7","26.87","APC"
"Urinalysis glass test","81020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.94","","","","","","","fee schedule","4.7","26.87","APC"
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.61","","","","","","","fee schedule","8.61","45.1",""
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.61","","","","","","","fee schedule","8.61","45.1",""
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.61","","","","","","","fee schedule","8.61","45.1",""
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.87","","","","","","","fee schedule","8.61","45.1",""
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","45.1","","","","","","","fee schedule","8.61","45.1",""
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.87","","","","","","","fee schedule","8.61","45.1",""
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.02","","","","","","","fee schedule","8.61","45.1","APC"
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.87","","","","","","","fee schedule","8.61","45.1","APC"
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.78","","","","","","","fee schedule","8.61","45.1","APC"
"Urine pregnancy test","81025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.04","","","","","","","fee schedule","8.61","45.1","APC"
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.64","","","","","","","fee schedule","3.64","22.32",""
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.64","","","","","","","fee schedule","3.64","22.32",""
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.64","","","","","","","fee schedule","3.64","22.32",""
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.15","","","","","","","fee schedule","3.64","22.32",""
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","22.32","","","","","","","fee schedule","3.64","22.32",""
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.15","","","","","","","fee schedule","3.64","22.32",""
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.81","","","","","","","fee schedule","3.64","22.32","APC"
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.75","","","","","","","fee schedule","3.64","22.32","APC"
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.71","","","","","","","fee schedule","3.64","22.32","APC"
"Urinalysis volume measure","81050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.82","","","","","","","fee schedule","3.64","22.32","APC"
"Urinalysis test procedure","81099","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-1 genotyping","81105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-2 genotyping","81106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-3 genotyping","81107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-4 genotyping","81108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-5 genotyping","81109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-6 genotyping","81110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-9 genotyping","81111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","181.07",""
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","181.07","","","","","","","fee schedule","122.22","181.07",""
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","181.07","APC"
"Hpa-15 genotyping","81112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","181.07","APC"
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","193.25","","","","","","","fee schedule","193.25","231.9",""
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.25","","","","","","","fee schedule","193.25","231.9",""
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.25","","","","","","","fee schedule","193.25","231.9",""
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","231.9","","","","","","","fee schedule","193.25","231.9",""
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","231.9","","","","","","","fee schedule","193.25","231.9",""
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.43","","","","","","","fee schedule","193.25","231.9","APC"
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.05","","","","","","","fee schedule","193.25","231.9","APC"
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.12","","","","","","","fee schedule","193.25","231.9","APC"
"Idh1 common variants","81120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202.91","","","","","","","fee schedule","193.25","231.9","APC"
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","295.79","","","","","","","fee schedule","295.79","354.95",""
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","295.79","","","","","","","fee schedule","295.79","354.95",""
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","295.79","","","","","","","fee schedule","295.79","354.95",""
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","354.95","","","","","","","fee schedule","295.79","354.95",""
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","354.95","","","","","","","fee schedule","295.79","354.95",""
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","309.84","","","","","","","fee schedule","295.79","354.95","APC"
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","304.66","","","","","","","fee schedule","295.79","354.95","APC"
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","301.71","","","","","","","fee schedule","295.79","354.95","APC"
"Idh2 common variants","81121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","310.58","","","","","","","fee schedule","295.79","354.95","APC"
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","279","","","","","","","fee schedule","37.32","292.95",""
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","279","","","","","","","fee schedule","37.32","292.95",""
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","279","","","","","","","fee schedule","37.32","292.95",""
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","292.95",""
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","168.17","","","","","","","fee schedule","37.32","292.95",""
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","168.17","","","","","","","fee schedule","37.32","292.95",""
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","292.25","","","","","","","fee schedule","37.32","292.95","APC"
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","287.37","","","","","","","fee schedule","37.32","292.95","APC"
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","284.58","","","","","","","fee schedule","37.32","292.95","APC"
"DMD dup/delet analysis","81161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","292.95","","","","","","","fee schedule","37.32","292.95","APC"
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1824.88","","","","","","","fee schedule","1824.88","2983.03",""
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1824.88","","","","","","","fee schedule","1824.88","2983.03",""
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1824.88","","","","","","","fee schedule","1824.88","2983.03",""
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2983.03","","","","","","","fee schedule","1824.88","2983.03",""
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2983.03","","","","","","","fee schedule","1824.88","2983.03",""
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1911.56","","","","","","","fee schedule","1824.88","2983.03","APC"
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1879.63","","","","","","","fee schedule","1824.88","2983.03","APC"
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1861.38","","","","","","","fee schedule","1824.88","2983.03","APC"
"Brca1&2 seq & full dup/del","81162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1916.12","","","","","","","fee schedule","1824.88","2983.03","APC"
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","468","","","","","","","fee schedule","468","561.6",""
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","468","","","","","","","fee schedule","468","561.6",""
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","468","","","","","","","fee schedule","468","561.6",""
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","561.6","","","","","","","fee schedule","468","561.6",""
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","561.6","","","","","","","fee schedule","468","561.6",""
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","490.23","","","","","","","fee schedule","468","561.6","APC"
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","482.04","","","","","","","fee schedule","468","561.6","APC"
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","477.36","","","","","","","fee schedule","468","561.6","APC"
"Brca1&2 gene full seq alys","81163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","491.4","","","","","","","fee schedule","468","561.6","APC"
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.23","","","","","","","fee schedule","584.23","701.08",""
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.23","","","","","","","fee schedule","584.23","701.08",""
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.23","","","","","","","fee schedule","584.23","701.08",""
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","701.08","","","","","","","fee schedule","584.23","701.08",""
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","701.08","","","","","","","fee schedule","584.23","701.08",""
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","611.98","","","","","","","fee schedule","584.23","701.08","APC"
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","601.76","","","","","","","fee schedule","584.23","701.08","APC"
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","595.91","","","","","","","fee schedule","584.23","701.08","APC"
"Brca1&2 gen ful dup/del alys","81164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","613.44","","","","","","","fee schedule","584.23","701.08","APC"
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Brca1 gene full seq alys","81165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Brca1 gene full dup/del alys","81166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Brca2 gene full dup/del alys","81167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","248.77","APC"
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","248.77","APC"
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","248.77","APC"
"Ccnd1/igh translocation alys","81168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","248.77","APC"
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","300","","","","","","","fee schedule","300","395.41",""
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","300","","","","","","","fee schedule","300","395.41",""
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300","","","","","","","fee schedule","300","395.41",""
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","395.41","","","","","","","fee schedule","300","395.41",""
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","395.41","","","","","","","fee schedule","300","395.41",""
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","314.25","","","","","","","fee schedule","300","395.41","APC"
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","309","","","","","","","fee schedule","300","395.41","APC"
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","306","","","","","","","fee schedule","300","395.41","APC"
"Abl1 gene","81170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","315","","","","","","","fee schedule","300","395.41","APC"
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Aff2 gene detc abnor alleles","81171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Aff2 gene charac alleles","81172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Ar gene full gene sequence","81173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Ar gene known famil variant","81174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","676.5","","","","","","","fee schedule","676.5","848.42",""
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","676.5","","","","","","","fee schedule","676.5","848.42",""
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","676.5","","","","","","","fee schedule","676.5","848.42",""
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","848.42","","","","","","","fee schedule","676.5","848.42",""
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","848.42","","","","","","","fee schedule","676.5","848.42",""
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","708.63","","","","","","","fee schedule","676.5","848.42","APC"
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","696.8","","","","","","","fee schedule","676.5","848.42","APC"
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","690.03","","","","","","","fee schedule","676.5","848.42","APC"
"Asxl1 full gene sequence","81175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","710.32","","","","","","","fee schedule","676.5","848.42","APC"
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","241.9","","","","","","","fee schedule","241.9","358.37",""
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","241.9","","","","","","","fee schedule","241.9","358.37",""
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","241.9","","","","","","","fee schedule","241.9","358.37",""
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","358.37","","","","","","","fee schedule","241.9","358.37",""
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","358.37","","","","","","","fee schedule","241.9","358.37",""
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","253.39","","","","","","","fee schedule","241.9","358.37","APC"
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","249.16","","","","","","","fee schedule","241.9","358.37","APC"
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","246.74","","","","","","","fee schedule","241.9","358.37","APC"
"Asxl1 gene target seq alys","81176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","254","","","","","","","fee schedule","241.9","358.37","APC"
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atn1 gene detc abnor alleles","81177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atxn1 gene detc abnor allele","81178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atxn2 gene detc abnor allele","81179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atxn3 gene detc abnor allele","81180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atxn7 gene detc abnor allele","81181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atxn8os gen detc abnor allel","81182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Atxn10 gene detc abnor allel","81183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Cacna1a gen detc abnor allel","81184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1015.52","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1015.52","","","","","","","fee schedule","846.27","1015.52",""
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","886.47","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","871.66","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","863.2","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a gene full gene seq","81185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","888.58","","","","","","","fee schedule","846.27","1015.52","APC"
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Cacna1a gen known famil vrnt","81186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Cnbp gene detc abnor allele","81187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Cstb gene detc abnor allele","81188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb gene full gene sequence","81189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Cstb gene known famil vrnt","81190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk1 translocation analysis","81191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk2 translocation analysis","81192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","248.77","","","","","","","fee schedule","207.31","248.77",""
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk3 translocation analysis","81193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","248.77","APC"
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","518.28","","","","","","","fee schedule","518.28","621.94",""
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","518.28","","","","","","","fee schedule","518.28","621.94",""
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","518.28","","","","","","","fee schedule","518.28","621.94",""
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","621.94","","","","","","","fee schedule","518.28","621.94",""
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","621.94","","","","","","","fee schedule","518.28","621.94",""
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","542.9","","","","","","","fee schedule","518.28","621.94","APC"
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","533.83","","","","","","","fee schedule","518.28","621.94","APC"
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","528.65","","","","","","","fee schedule","518.28","621.94","APC"
"Ntrk translocation analysis","81194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","544.19","","","","","","","fee schedule","518.28","621.94","APC"
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1263.53","","","","","","","fee schedule","1263.53","1956.38",""
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1263.53","","","","","","","fee schedule","1263.53","1956.38",""
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1263.53","","","","","","","fee schedule","1263.53","1956.38",""
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1951.72","","","","","","","fee schedule","1263.53","1956.38","APC"
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1919.12","","","","","","","fee schedule","1263.53","1956.38","APC"
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1900.48","","","","","","","fee schedule","1263.53","1956.38","APC"
"Cytog genom-wid alys hem mal","81195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1956.38","","","","","","","fee schedule","1263.53","1956.38","APC"
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.25","","","","","","","fee schedule","47.25","56.7",""
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.25","","","","","","","fee schedule","47.25","56.7",""
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.25","","","","","","","fee schedule","47.25","56.7",""
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","56.7","","","","","","","fee schedule","47.25","56.7",""
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","56.7","","","","","","","fee schedule","47.25","56.7",""
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.49","","","","","","","fee schedule","47.25","56.7","APC"
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.67","","","","","","","fee schedule","47.25","56.7","APC"
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.2","","","","","","","fee schedule","47.25","56.7","APC"
"Aspa gene","81200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.61","","","","","","","fee schedule","47.25","56.7","APC"
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","780","","","","","","","fee schedule","780","936",""
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","780","","","","","","","fee schedule","780","936",""
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","780","","","","","","","fee schedule","780","936",""
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","936","","","","","","","fee schedule","780","936",""
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","936","","","","","","","fee schedule","780","936",""
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","817.05","","","","","","","fee schedule","780","936","APC"
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","803.4","","","","","","","fee schedule","780","936","APC"
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","795.6","","","","","","","fee schedule","780","936","APC"
"Apc gene full sequence","81201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","819","","","","","","","fee schedule","780","936","APC"
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","280","","","","","","","fee schedule","280","336",""
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","280","","","","","","","fee schedule","280","336",""
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","280","","","","","","","fee schedule","280","336",""
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","336","","","","","","","fee schedule","280","336",""
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","336","","","","","","","fee schedule","280","336",""
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","293.3","","","","","","","fee schedule","280","336","APC"
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","288.4","","","","","","","fee schedule","280","336","APC"
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","285.6","","","","","","","fee schedule","280","336","APC"
"Apc gene known fam variants","81202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","294","","","","","","","fee schedule","280","336","APC"
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","200","","","","","","","fee schedule","200","240",""
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","200","","","","","","","fee schedule","200","240",""
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","200","","","","","","","fee schedule","200","240",""
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","240","","","","","","","fee schedule","200","240",""
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","240","","","","","","","fee schedule","200","240",""
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","209.5","","","","","","","fee schedule","200","240","APC"
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","206","","","","","","","fee schedule","200","240","APC"
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","204","","","","","","","fee schedule","200","240","APC"
"Apc gene dup/delet variants","81203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","210","","","","","","","fee schedule","200","240","APC"
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Ar gene charac alleles","81204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","94.99","","","","","","","fee schedule","94.99","113.99",""
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","94.99","","","","","","","fee schedule","94.99","113.99",""
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","94.99","","","","","","","fee schedule","94.99","113.99",""
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","113.99","","","","","","","fee schedule","94.99","113.99",""
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","113.99","","","","","","","fee schedule","94.99","113.99",""
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","99.5","","","","","","","fee schedule","94.99","113.99","APC"
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","97.84","","","","","","","fee schedule","94.99","113.99","APC"
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96.89","","","","","","","fee schedule","94.99","113.99","APC"
"Bckdhb gene","81205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99.74","","","","","","","fee schedule","94.99","113.99","APC"
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","163.96","","","","","","","fee schedule","163.96","268.43",""
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","163.96","","","","","","","fee schedule","163.96","268.43",""
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","163.96","","","","","","","fee schedule","163.96","268.43",""
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","268.43","","","","","","","fee schedule","163.96","268.43",""
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","268.43","","","","","","","fee schedule","163.96","268.43",""
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","171.75","","","","","","","fee schedule","163.96","268.43","APC"
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","168.88","","","","","","","fee schedule","163.96","268.43","APC"
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","167.24","","","","","","","fee schedule","163.96","268.43","APC"
"Bcr/abl1 gene major bp","81206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","172.16","","","","","","","fee schedule","163.96","268.43","APC"
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","144.84","","","","","","","fee schedule","144.84","237.11",""
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","144.84","","","","","","","fee schedule","144.84","237.11",""
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","144.84","","","","","","","fee schedule","144.84","237.11",""
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","237.11","","","","","","","fee schedule","144.84","237.11",""
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","237.11","","","","","","","fee schedule","144.84","237.11",""
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","151.72","","","","","","","fee schedule","144.84","237.11","APC"
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","149.19","","","","","","","fee schedule","144.84","237.11","APC"
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","147.74","","","","","","","fee schedule","144.84","237.11","APC"
"Bcr/abl1 gene minor bp","81207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","152.08","","","","","","","fee schedule","144.84","237.11","APC"
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","214.62","","","","","","","fee schedule","214.62","263.32",""
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","214.62","","","","","","","fee schedule","214.62","263.32",""
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","214.62","","","","","","","fee schedule","214.62","263.32",""
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","263.32","","","","","","","fee schedule","214.62","263.32",""
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","263.32","","","","","","","fee schedule","214.62","263.32",""
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","224.81","","","","","","","fee schedule","214.62","263.32","APC"
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","221.06","","","","","","","fee schedule","214.62","263.32","APC"
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","218.91","","","","","","","fee schedule","214.62","263.32","APC"
"Bcr/abl1 gene other bp","81208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","225.35","","","","","","","fee schedule","214.62","263.32","APC"
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.31","","","","","","","fee schedule","39.31","47.17",""
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.31","","","","","","","fee schedule","39.31","47.17",""
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.31","","","","","","","fee schedule","39.31","47.17",""
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","47.17","","","","","","","fee schedule","39.31","47.17",""
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","47.17","","","","","","","fee schedule","39.31","47.17",""
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.18","","","","","","","fee schedule","39.31","47.17","APC"
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.49","","","","","","","fee schedule","39.31","47.17","APC"
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.1","","","","","","","fee schedule","39.31","47.17","APC"
"Blm gene","81209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.28","","","","","","","fee schedule","39.31","47.17","APC"
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.4","","","","","","","fee schedule","175.4","215.1",""
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","175.4","","","","","","","fee schedule","175.4","215.1",""
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.4","","","","","","","fee schedule","175.4","215.1",""
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","215.1","","","","","","","fee schedule","175.4","215.1",""
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","215.1","","","","","","","fee schedule","175.4","215.1",""
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.73","","","","","","","fee schedule","175.4","215.1","APC"
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.66","","","","","","","fee schedule","175.4","215.1","APC"
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.91","","","","","","","fee schedule","175.4","215.1","APC"
"Braf gene","81210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.17","","","","","","","fee schedule","175.4","215.1","APC"
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","440","","","","","","","fee schedule","212.04","462",""
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440","","","","","","","fee schedule","212.04","462",""
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","440","","","","","","","fee schedule","212.04","462",""
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","212.04","","","","","","","fee schedule","212.04","462",""
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","212.04","","","","","","","fee schedule","212.04","462",""
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","460.9","","","","","","","fee schedule","212.04","462","APC"
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","453.2","","","","","","","fee schedule","212.04","462","APC"
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","448.8","","","","","","","fee schedule","212.04","462","APC"
"Brca1&2 185&5385&6174 var","81212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","462","","","","","","","fee schedule","212.04","462","APC"
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375.25","","","","","","","fee schedule","111.89","394.01",""
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375.25","","","","","","","fee schedule","111.89","394.01",""
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375.25","","","","","","","fee schedule","111.89","394.01",""
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","111.89","","","","","","","fee schedule","111.89","394.01",""
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","111.89","","","","","","","fee schedule","111.89","394.01",""
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","393.07","","","","","","","fee schedule","111.89","394.01","APC"
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.51","","","","","","","fee schedule","111.89","394.01","APC"
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.76","","","","","","","fee schedule","111.89","394.01","APC"
"Brca1 gene known fam variant","81215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","394.01","","","","","","","fee schedule","111.89","394.01","APC"
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.12","","","","","","","fee schedule","185.12","222.14",""
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.12","","","","","","","fee schedule","185.12","222.14",""
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.12","","","","","","","fee schedule","185.12","222.14",""
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.14","","","","","","","fee schedule","185.12","222.14",""
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.14","","","","","","","fee schedule","185.12","222.14",""
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","193.91","","","","","","","fee schedule","185.12","222.14","APC"
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.67","","","","","","","fee schedule","185.12","222.14","APC"
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.82","","","","","","","fee schedule","185.12","222.14","APC"
"Brca2 gene full sequence","81216","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.38","","","","","","","fee schedule","185.12","222.14","APC"
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375.25","","","","","","","fee schedule","111.89","394.01",""
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375.25","","","","","","","fee schedule","111.89","394.01",""
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375.25","","","","","","","fee schedule","111.89","394.01",""
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","111.89","","","","","","","fee schedule","111.89","394.01",""
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","111.89","","","","","","","fee schedule","111.89","394.01",""
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","393.07","","","","","","","fee schedule","111.89","394.01","APC"
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.51","","","","","","","fee schedule","111.89","394.01","APC"
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.76","","","","","","","fee schedule","111.89","394.01","APC"
"Brca2 gene known fam variant","81217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","394.01","","","","","","","fee schedule","111.89","394.01","APC"
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","241.9","","","","","","","fee schedule","241.9","395.41",""
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","241.9","","","","","","","fee schedule","241.9","395.41",""
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","241.9","","","","","","","fee schedule","241.9","395.41",""
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","395.41","","","","","","","fee schedule","241.9","395.41",""
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","395.41","","","","","","","fee schedule","241.9","395.41",""
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","253.39","","","","","","","fee schedule","241.9","395.41","APC"
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","249.16","","","","","","","fee schedule","241.9","395.41","APC"
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","246.74","","","","","","","fee schedule","241.9","395.41","APC"
"Cebpa gene full sequence","81218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","254","","","","","","","fee schedule","241.9","395.41","APC"
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","121.63","","","","","","","fee schedule","121.63","198.82",""
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","121.63","","","","","","","fee schedule","121.63","198.82",""
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","121.63","","","","","","","fee schedule","121.63","198.82",""
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","198.82","","","","","","","fee schedule","121.63","198.82",""
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","198.82","","","","","","","fee schedule","121.63","198.82",""
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","127.41","","","","","","","fee schedule","121.63","198.82","APC"
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.28","","","","","","","fee schedule","121.63","198.82","APC"
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.06","","","","","","","fee schedule","121.63","198.82","APC"
"Calr gene com variants","81219","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","127.71","","","","","","","fee schedule","121.63","198.82","APC"
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","556.6","","","","","","","fee schedule","556.6","667.92",""
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","556.6","","","","","","","fee schedule","556.6","667.92",""
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","556.6","","","","","","","fee schedule","556.6","667.92",""
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","667.92","","","","","","","fee schedule","556.6","667.92",""
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","667.92","","","","","","","fee schedule","556.6","667.92",""
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","583.04","","","","","","","fee schedule","556.6","667.92","APC"
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","573.3","","","","","","","fee schedule","556.6","667.92","APC"
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","567.73","","","","","","","fee schedule","556.6","667.92","APC"
"Cftr gene com variants","81220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","584.43","","","","","","","fee schedule","556.6","667.92","APC"
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97.22","","","","","","","fee schedule","97.22","116.66",""
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","97.22","","","","","","","fee schedule","97.22","116.66",""
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","97.22","","","","","","","fee schedule","97.22","116.66",""
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","116.66","","","","","","","fee schedule","97.22","116.66",""
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","116.66","","","","","","","fee schedule","97.22","116.66",""
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","101.84","","","","","","","fee schedule","97.22","116.66","APC"
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","100.14","","","","","","","fee schedule","97.22","116.66","APC"
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","99.16","","","","","","","fee schedule","97.22","116.66","APC"
"Cftr gene known fam variants","81221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","102.08","","","","","","","fee schedule","97.22","116.66","APC"
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","435.07","","","","","","","fee schedule","435.07","522.08",""
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","435.07","","","","","","","fee schedule","435.07","522.08",""
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","435.07","","","","","","","fee schedule","435.07","522.08",""
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","522.08","","","","","","","fee schedule","435.07","522.08",""
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","522.08","","","","","","","fee schedule","435.07","522.08",""
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","455.74","","","","","","","fee schedule","435.07","522.08","APC"
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.12","","","","","","","fee schedule","435.07","522.08","APC"
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","443.77","","","","","","","fee schedule","435.07","522.08","APC"
"Cftr gene dup/delet variants","81222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","456.82","","","","","","","fee schedule","435.07","522.08","APC"
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","499","","","","","","","fee schedule","499","598.8",""
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","499","","","","","","","fee schedule","499","598.8",""
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","499","","","","","","","fee schedule","499","598.8",""
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","598.8","","","","","","","fee schedule","499","598.8",""
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","598.8","","","","","","","fee schedule","499","598.8",""
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","522.7","","","","","","","fee schedule","499","598.8","APC"
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","513.97","","","","","","","fee schedule","499","598.8","APC"
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","508.98","","","","","","","fee schedule","499","598.8","APC"
"Cftr gene full sequence","81223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","523.95","","","","","","","fee schedule","499","598.8","APC"
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","168.75","","","","","","","fee schedule","168.75","202.5",""
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","168.75","","","","","","","fee schedule","168.75","202.5",""
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","168.75","","","","","","","fee schedule","168.75","202.5",""
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","202.5","","","","","","","fee schedule","168.75","202.5",""
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","202.5","","","","","","","fee schedule","168.75","202.5",""
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","176.77","","","","","","","fee schedule","168.75","202.5","APC"
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","173.81","","","","","","","fee schedule","168.75","202.5","APC"
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","172.12","","","","","","","fee schedule","168.75","202.5","APC"
"Cftr gene intron poly t","81224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","177.19","","","","","","","fee schedule","168.75","202.5","APC"
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","291.36","","","","","","","fee schedule","291.36","350.16",""
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","291.36","","","","","","","fee schedule","291.36","350.16",""
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","291.36","","","","","","","fee schedule","291.36","350.16",""
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","350.16","","","","","","","fee schedule","291.36","350.16",""
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","350.16","","","","","","","fee schedule","291.36","350.16",""
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","305.2","","","","","","","fee schedule","291.36","350.16","APC"
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","300.1","","","","","","","fee schedule","291.36","350.16","APC"
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","297.19","","","","","","","fee schedule","291.36","350.16","APC"
"Cyp2c19 gene com variants","81225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","305.93","","","","","","","fee schedule","291.36","350.16","APC"
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.91","","","","","","","fee schedule","450.91","541.91",""
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","450.91","","","","","","","fee schedule","450.91","541.91",""
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","450.91","","","","","","","fee schedule","450.91","541.91",""
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","541.91","","","","","","","fee schedule","450.91","541.91",""
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","541.91","","","","","","","fee schedule","450.91","541.91",""
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","472.33","","","","","","","fee schedule","450.91","541.91","APC"
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","464.44","","","","","","","fee schedule","450.91","541.91","APC"
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","459.93","","","","","","","fee schedule","450.91","541.91","APC"
"Cyp2d6 gene com variants","81226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","473.46","","","","","","","fee schedule","450.91","541.91","APC"
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","210.1",""
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","210.1",""
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","210.1",""
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","210.1","","","","","","","fee schedule","174.81","210.1",""
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","210.1","","","","","","","fee schedule","174.81","210.1",""
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","210.1","APC"
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","210.1","APC"
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","210.1","APC"
"Cyp2c9 gene com variants","81227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","210.1","APC"
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","900","","","","","","","fee schedule","900","1080",""
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","900","","","","","","","fee schedule","900","1080",""
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","900","","","","","","","fee schedule","900","1080",""
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1080","","","","","","","fee schedule","900","1080",""
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1080","","","","","","","fee schedule","900","1080",""
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","942.75","","","","","","","fee schedule","900","1080","APC"
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","927","","","","","","","fee schedule","900","1080","APC"
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","918","","","","","","","fee schedule","900","1080","APC"
"Cytogen micrarray copy nmbr","81228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","945","","","","","","","fee schedule","900","1080","APC"
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160","","","","","","","fee schedule","1160","1392",""
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1160","","","","","","","fee schedule","1160","1392",""
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1160","","","","","","","fee schedule","1160","1392",""
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1392","","","","","","","fee schedule","1160","1392",""
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1392","","","","","","","fee schedule","1160","1392",""
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1215.1","","","","","","","fee schedule","1160","1392","APC"
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1194.8","","","","","","","fee schedule","1160","1392","APC"
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1183.2","","","","","","","fee schedule","1160","1392","APC"
"Cytogen m array copy no&snp","81229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1218","","","","","","","fee schedule","1160","1392","APC"
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a4 gene common variants","81230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Cyp3a5 gene common variants","81231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Dpyd gene common variants","81232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.4","","","","","","","fee schedule","175.4","210.48",""
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","210.48","","","","","","","fee schedule","175.4","210.48",""
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","210.48","","","","","","","fee schedule","175.4","210.48",""
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.73","","","","","","","fee schedule","175.4","210.48","APC"
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.66","","","","","","","fee schedule","175.4","210.48","APC"
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.91","","","","","","","fee schedule","175.4","210.48","APC"
"Btk gene common variants","81233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.17","","","","","","","fee schedule","175.4","210.48","APC"
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Dmpk gene detc abnor allele","81234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324.58","","","","","","","fee schedule","324.58","396.01",""
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","324.58","","","","","","","fee schedule","324.58","396.01",""
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","324.58","","","","","","","fee schedule","324.58","396.01",""
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","396.01","","","","","","","fee schedule","324.58","396.01",""
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","396.01","","","","","","","fee schedule","324.58","396.01",""
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","340","","","","","","","fee schedule","324.58","396.01","APC"
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","334.32","","","","","","","fee schedule","324.58","396.01","APC"
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","331.07","","","","","","","fee schedule","324.58","396.01","APC"
"Egfr gene com variants","81235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","340.81","","","","","","","fee schedule","324.58","396.01","APC"
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Ezh2 gene full gene sequence","81236","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.4","","","","","","","fee schedule","175.4","210.48",""
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","210.48","","","","","","","fee schedule","175.4","210.48",""
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","210.48","","","","","","","fee schedule","175.4","210.48",""
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.73","","","","","","","fee schedule","175.4","210.48","APC"
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.66","","","","","","","fee schedule","175.4","210.48","APC"
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.91","","","","","","","fee schedule","175.4","210.48","APC"
"Ezh2 gene common variants","81237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.17","","","","","","","fee schedule","175.4","210.48","APC"
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","600","","","","","","","fee schedule","600","720",""
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","600","","","","","","","fee schedule","600","720",""
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","600","","","","","","","fee schedule","600","720",""
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","720","","","","","","","fee schedule","600","720",""
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","720","","","","","","","fee schedule","600","720",""
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","628.5","","","","","","","fee schedule","600","720","APC"
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","618","","","","","","","fee schedule","600","720","APC"
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","612","","","","","","","fee schedule","600","720","APC"
"F9 full gene sequence","81238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","630","","","","","","","fee schedule","600","720","APC"
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Dmpk gene charac alleles","81239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","65.69","","","","","","","fee schedule","65.69","80.56",""
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","65.69","","","","","","","fee schedule","65.69","80.56",""
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","65.69","","","","","","","fee schedule","65.69","80.56",""
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","80.56","","","","","","","fee schedule","65.69","80.56",""
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","80.56","","","","","","","fee schedule","65.69","80.56",""
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.81","","","","","","","fee schedule","65.69","80.56","APC"
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.66","","","","","","","fee schedule","65.69","80.56","APC"
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","67","","","","","","","fee schedule","65.69","80.56","APC"
"F2 gene","81240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.97","","","","","","","fee schedule","65.69","80.56","APC"
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","73.37","","","","","","","fee schedule","73.37","100.04",""
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73.37","","","","","","","fee schedule","73.37","100.04",""
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","73.37","","","","","","","fee schedule","73.37","100.04",""
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","100.04","","","","","","","fee schedule","73.37","100.04",""
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","100.04","","","","","","","fee schedule","73.37","100.04",""
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.86","","","","","","","fee schedule","73.37","100.04","APC"
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.57","","","","","","","fee schedule","73.37","100.04","APC"
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.84","","","","","","","fee schedule","73.37","100.04","APC"
"F5 gene","81241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","77.04","","","","","","","fee schedule","73.37","100.04","APC"
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.62","","","","","","","fee schedule","36.62","43.94",""
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.62","","","","","","","fee schedule","36.62","43.94",""
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.62","","","","","","","fee schedule","36.62","43.94",""
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.94","","","","","","","fee schedule","36.62","43.94",""
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.94","","","","","","","fee schedule","36.62","43.94",""
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.36","","","","","","","fee schedule","36.62","43.94","APC"
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.72","","","","","","","fee schedule","36.62","43.94","APC"
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.35","","","","","","","fee schedule","36.62","43.94","APC"
"Fancc gene","81242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.45","","","","","","","fee schedule","36.62","43.94","APC"
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","57.04","","","","","","","fee schedule","57.04","68.45",""
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","57.04","","","","","","","fee schedule","57.04","68.45",""
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","57.04","","","","","","","fee schedule","57.04","68.45",""
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","68.45","","","","","","","fee schedule","57.04","68.45",""
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","68.45","","","","","","","fee schedule","57.04","68.45",""
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59.75","","","","","","","fee schedule","57.04","68.45","APC"
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","58.75","","","","","","","fee schedule","57.04","68.45","APC"
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.18","","","","","","","fee schedule","57.04","68.45","APC"
"Fmr1 gene detection","81243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59.89","","","","","","","fee schedule","57.04","68.45","APC"
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44.89","","","","","","","fee schedule","44.89","53.87",""
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.89","","","","","","","fee schedule","44.89","53.87",""
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44.89","","","","","","","fee schedule","44.89","53.87",""
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","53.87","","","","","","","fee schedule","44.89","53.87",""
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","53.87","","","","","","","fee schedule","44.89","53.87",""
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.02","","","","","","","fee schedule","44.89","53.87","APC"
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46.24","","","","","","","fee schedule","44.89","53.87","APC"
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45.79","","","","","","","fee schedule","44.89","53.87","APC"
"Fmr1 gene characterization","81244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.13","","","","","","","fee schedule","44.89","53.87","APC"
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","165.51","","","","","","","fee schedule","165.51","199.1",""
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","165.51","","","","","","","fee schedule","165.51","199.1",""
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","165.51","","","","","","","fee schedule","165.51","199.1",""
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","199.1","","","","","","","fee schedule","165.51","199.1",""
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","199.1","","","","","","","fee schedule","165.51","199.1",""
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","173.37","","","","","","","fee schedule","165.51","199.1","APC"
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","170.48","","","","","","","fee schedule","165.51","199.1","APC"
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","168.82","","","","","","","fee schedule","165.51","199.1","APC"
"Flt3 gene","81245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","173.79","","","","","","","fee schedule","165.51","199.1","APC"
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","83","","","","","","","fee schedule","83","99.61",""
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","83","","","","","","","fee schedule","83","99.61",""
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","83","","","","","","","fee schedule","83","99.61",""
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","99.61","","","","","","","fee schedule","83","99.61",""
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","99.61","","","","","","","fee schedule","83","99.61",""
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","86.94","","","","","","","fee schedule","83","99.61","APC"
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","85.49","","","","","","","fee schedule","83","99.61","APC"
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","84.66","","","","","","","fee schedule","83","99.61","APC"
"Flt3 gene analysis","81246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","87.15","","","","","","","fee schedule","83","99.61","APC"
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"G6pd gene alys cmn variant","81247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375.25","","","","","","","fee schedule","375.25","450.3",""
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375.25","","","","","","","fee schedule","375.25","450.3",""
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375.25","","","","","","","fee schedule","375.25","450.3",""
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","450.3","","","","","","","fee schedule","375.25","450.3",""
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","450.3","","","","","","","fee schedule","375.25","450.3",""
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","393.07","","","","","","","fee schedule","375.25","450.3","APC"
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.51","","","","","","","fee schedule","375.25","450.3","APC"
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.76","","","","","","","fee schedule","375.25","450.3","APC"
"G6pd known familial variant","81248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","394.01","","","","","","","fee schedule","375.25","450.3","APC"
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","600","","","","","","","fee schedule","600","720",""
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","600","","","","","","","fee schedule","600","720",""
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","600","","","","","","","fee schedule","600","720",""
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","720","","","","","","","fee schedule","600","720",""
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","720","","","","","","","fee schedule","600","720",""
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","628.5","","","","","","","fee schedule","600","720","APC"
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","618","","","","","","","fee schedule","600","720","APC"
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","612","","","","","","","fee schedule","600","720","APC"
"G6pd full gene sequence","81249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","630","","","","","","","fee schedule","600","720","APC"
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.49","","","","","","","fee schedule","58.49","70.19",""
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58.49","","","","","","","fee schedule","58.49","70.19",""
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","58.49","","","","","","","fee schedule","58.49","70.19",""
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","70.19","","","","","","","fee schedule","58.49","70.19",""
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","70.19","","","","","","","fee schedule","58.49","70.19",""
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","61.27","","","","","","","fee schedule","58.49","70.19","APC"
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","60.24","","","","","","","fee schedule","58.49","70.19","APC"
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.66","","","","","","","fee schedule","58.49","70.19","APC"
"G6pc gene","81250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","61.41","","","","","","","fee schedule","58.49","70.19","APC"
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.25","","","","","","","fee schedule","47.25","56.7",""
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.25","","","","","","","fee schedule","47.25","56.7",""
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.25","","","","","","","fee schedule","47.25","56.7",""
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","56.7","","","","","","","fee schedule","47.25","56.7",""
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","56.7","","","","","","","fee schedule","47.25","56.7",""
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.49","","","","","","","fee schedule","47.25","56.7","APC"
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.67","","","","","","","fee schedule","47.25","56.7","APC"
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.2","","","","","","","fee schedule","47.25","56.7","APC"
"Gba gene","81251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.61","","","","","","","fee schedule","47.25","56.7","APC"
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","101.12","","","","","","","fee schedule","101.12","121.34",""
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","101.12","","","","","","","fee schedule","101.12","121.34",""
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","101.12","","","","","","","fee schedule","101.12","121.34",""
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","121.34","","","","","","","fee schedule","101.12","121.34",""
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","121.34","","","","","","","fee schedule","101.12","121.34",""
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","105.92","","","","","","","fee schedule","101.12","121.34","APC"
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","104.15","","","","","","","fee schedule","101.12","121.34","APC"
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","103.14","","","","","","","fee schedule","101.12","121.34","APC"
"Gjb2 gene full sequence","81252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","106.18","","","","","","","fee schedule","101.12","121.34","APC"
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","61.52","","","","","","","fee schedule","61.52","73.82",""
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.52","","","","","","","fee schedule","61.52","73.82",""
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.52","","","","","","","fee schedule","61.52","73.82",""
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.82","","","","","","","fee schedule","61.52","73.82",""
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.82","","","","","","","fee schedule","61.52","73.82",""
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.44","","","","","","","fee schedule","61.52","73.82","APC"
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.37","","","","","","","fee schedule","61.52","73.82","APC"
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.75","","","","","","","fee schedule","61.52","73.82","APC"
"Gjb2 gene known fam variants","81253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.6","","","","","","","fee schedule","61.52","73.82","APC"
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35","","","","","","","fee schedule","35","42",""
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35","","","","","","","fee schedule","35","42",""
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35","","","","","","","fee schedule","35","42",""
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42","","","","","","","fee schedule","35","42",""
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42","","","","","","","fee schedule","35","42",""
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.66","","","","","","","fee schedule","35","42","APC"
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.05","","","","","","","fee schedule","35","42","APC"
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.7","","","","","","","fee schedule","35","42","APC"
"Gjb6 gene com variants","81254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.75","","","","","","","fee schedule","35","42","APC"
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.45","","","","","","","fee schedule","51.45","61.74",""
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.45","","","","","","","fee schedule","51.45","61.74",""
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.45","","","","","","","fee schedule","51.45","61.74",""
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","61.74","","","","","","","fee schedule","51.45","61.74",""
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","61.74","","","","","","","fee schedule","51.45","61.74",""
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.89","","","","","","","fee schedule","51.45","61.74","APC"
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.99","","","","","","","fee schedule","51.45","61.74","APC"
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.48","","","","","","","fee schedule","51.45","61.74","APC"
"Hexa gene","81255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.02","","","","","","","fee schedule","51.45","61.74","APC"
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","65.36","","","","","","","fee schedule","65.36","107",""
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","65.36","","","","","","","fee schedule","65.36","107",""
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","65.36","","","","","","","fee schedule","65.36","107",""
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","107","","","","","","","fee schedule","65.36","107",""
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","107","","","","","","","fee schedule","65.36","107",""
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.46","","","","","","","fee schedule","65.36","107","APC"
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.32","","","","","","","fee schedule","65.36","107","APC"
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.67","","","","","","","fee schedule","65.36","107","APC"
"Hfe gene","81256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.63","","","","","","","fee schedule","65.36","107","APC"
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","102.26","","","","","","","fee schedule","102.26","122.71",""
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102.26","","","","","","","fee schedule","102.26","122.71",""
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","102.26","","","","","","","fee schedule","102.26","122.71",""
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","122.71","","","","","","","fee schedule","102.26","122.71",""
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","122.71","","","","","","","fee schedule","102.26","122.71",""
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.12","","","","","","","fee schedule","102.26","122.71","APC"
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.33","","","","","","","fee schedule","102.26","122.71","APC"
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.31","","","","","","","fee schedule","102.26","122.71","APC"
"Hba1/hba2 gene","81257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.37","","","","","","","fee schedule","102.26","122.71","APC"
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375.25","","","","","","","fee schedule","375.25","450.3",""
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375.25","","","","","","","fee schedule","375.25","450.3",""
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375.25","","","","","","","fee schedule","375.25","450.3",""
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","450.3","","","","","","","fee schedule","375.25","450.3",""
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","450.3","","","","","","","fee schedule","375.25","450.3",""
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","393.07","","","","","","","fee schedule","375.25","450.3","APC"
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.51","","","","","","","fee schedule","375.25","450.3","APC"
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.76","","","","","","","fee schedule","375.25","450.3","APC"
"Hba1/hba2 gene fam vrnt","81258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","394.01","","","","","","","fee schedule","375.25","450.3","APC"
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","600","","","","","","","fee schedule","600","720",""
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","600","","","","","","","fee schedule","600","720",""
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","600","","","","","","","fee schedule","600","720",""
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","720","","","","","","","fee schedule","600","720",""
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","720","","","","","","","fee schedule","600","720",""
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","628.5","","","","","","","fee schedule","600","720","APC"
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","618","","","","","","","fee schedule","600","720","APC"
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","612","","","","","","","fee schedule","600","720","APC"
"Hba1/hba2 full gene sequence","81259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","630","","","","","","","fee schedule","600","720","APC"
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.31","","","","","","","fee schedule","39.31","47.17",""
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.31","","","","","","","fee schedule","39.31","47.17",""
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.31","","","","","","","fee schedule","39.31","47.17",""
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","47.17","","","","","","","fee schedule","39.31","47.17",""
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","47.17","","","","","","","fee schedule","39.31","47.17",""
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.18","","","","","","","fee schedule","39.31","47.17","APC"
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.49","","","","","","","fee schedule","39.31","47.17","APC"
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.1","","","","","","","fee schedule","39.31","47.17","APC"
"Ikbkap gene","81260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.28","","","","","","","fee schedule","39.31","47.17","APC"
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","197.99","","","","","","","fee schedule","197.99","324.13",""
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","197.99","","","","","","","fee schedule","197.99","324.13",""
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","197.99","","","","","","","fee schedule","197.99","324.13",""
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","324.13","","","","","","","fee schedule","197.99","324.13",""
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","324.13","","","","","","","fee schedule","197.99","324.13",""
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","207.39","","","","","","","fee schedule","197.99","324.13","APC"
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.93","","","","","","","fee schedule","197.99","324.13","APC"
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.95","","","","","","","fee schedule","197.99","324.13","APC"
"Igh gene rearrange amp meth","81261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.89","","","","","","","fee schedule","197.99","324.13","APC"
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68.55","","","","","","","fee schedule","68.55","71.98",""
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68.55","","","","","","","fee schedule","68.55","71.98",""
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","68.55","","","","","","","fee schedule","68.55","71.98",""
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.46","","","","","","","fee schedule","68.55","71.98",""
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.46","","","","","","","fee schedule","68.55","71.98",""
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","71.81","","","","","","","fee schedule","68.55","71.98","APC"
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","70.61","","","","","","","fee schedule","68.55","71.98","APC"
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","69.92","","","","","","","fee schedule","68.55","71.98","APC"
"Igh gene rearrang dir probe","81262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","71.98","","","","","","","fee schedule","68.55","71.98","APC"
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","294.52","","","","","","","fee schedule","294.52","482.15",""
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","294.52","","","","","","","fee schedule","294.52","482.15",""
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","294.52","","","","","","","fee schedule","294.52","482.15",""
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","482.15","","","","","","","fee schedule","294.52","482.15",""
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","482.15","","","","","","","fee schedule","294.52","482.15",""
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","308.51","","","","","","","fee schedule","294.52","482.15","APC"
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","303.36","","","","","","","fee schedule","294.52","482.15","APC"
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","300.41","","","","","","","fee schedule","294.52","482.15","APC"
"Igh vari regional mutation","81263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","309.25","","","","","","","fee schedule","294.52","482.15","APC"
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","172.73","","","","","","","fee schedule","172.73","244.46",""
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.73","","","","","","","fee schedule","172.73","244.46",""
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","172.73","","","","","","","fee schedule","172.73","244.46",""
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","244.46","","","","","","","fee schedule","172.73","244.46",""
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","244.46","","","","","","","fee schedule","172.73","244.46",""
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","180.93","","","","","","","fee schedule","172.73","244.46","APC"
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","177.91","","","","","","","fee schedule","172.73","244.46","APC"
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","176.18","","","","","","","fee schedule","172.73","244.46","APC"
"Igk rearrangeabn clonal pop","81264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","181.37","","","","","","","fee schedule","172.73","244.46","APC"
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","233.07","","","","","","","fee schedule","233.07","352.06",""
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","233.07","","","","","","","fee schedule","233.07","352.06",""
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","233.07","","","","","","","fee schedule","233.07","352.06",""
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","352.06","","","","","","","fee schedule","233.07","352.06",""
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","352.06","","","","","","","fee schedule","233.07","352.06",""
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","244.14","","","","","","","fee schedule","233.07","352.06","APC"
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","240.06","","","","","","","fee schedule","233.07","352.06","APC"
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.73","","","","","","","fee schedule","233.07","352.06","APC"
"Str markers specimen anal","81265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.72","","","","","","","fee schedule","233.07","352.06","APC"
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","304.81","","","","","","","fee schedule","304.81","365.77",""
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","304.81","","","","","","","fee schedule","304.81","365.77",""
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","304.81","","","","","","","fee schedule","304.81","365.77",""
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","365.77","","","","","","","fee schedule","304.81","365.77",""
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","365.77","","","","","","","fee schedule","304.81","365.77",""
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","319.29","","","","","","","fee schedule","304.81","365.77","APC"
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","313.95","","","","","","","fee schedule","304.81","365.77","APC"
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","310.91","","","","","","","fee schedule","304.81","365.77","APC"
"Str markers spec anal addl","81266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","320.05","","","","","","","fee schedule","304.81","365.77","APC"
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.46","","","","","","","fee schedule","207.46","339.64",""
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.46","","","","","","","fee schedule","207.46","339.64",""
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.46","","","","","","","fee schedule","207.46","339.64",""
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.64","","","","","","","fee schedule","207.46","339.64",""
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.64","","","","","","","fee schedule","207.46","339.64",""
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.31","","","","","","","fee schedule","207.46","339.64","APC"
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.68","","","","","","","fee schedule","207.46","339.64","APC"
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.61","","","","","","","fee schedule","207.46","339.64","APC"
"Chimerism anal no cell selec","81267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.83","","","","","","","fee schedule","207.46","339.64","APC"
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.79","","","","","","","fee schedule","260.79","426.94",""
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.79","","","","","","","fee schedule","260.79","426.94",""
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.79","","","","","","","fee schedule","260.79","426.94",""
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","426.94","","","","","","","fee schedule","260.79","426.94",""
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","426.94","","","","","","","fee schedule","260.79","426.94",""
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","273.18","","","","","","","fee schedule","260.79","426.94","APC"
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.61","","","","","","","fee schedule","260.79","426.94","APC"
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","266.01","","","","","","","fee schedule","260.79","426.94","APC"
"Chimerism anal w/cell select","81268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.83","","","","","","","fee schedule","260.79","426.94","APC"
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","202.4","","","","","","","fee schedule","202.4","242.88",""
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","202.4","","","","","","","fee schedule","202.4","242.88",""
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","202.4","","","","","","","fee schedule","202.4","242.88",""
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","242.88","","","","","","","fee schedule","202.4","242.88",""
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","242.88","","","","","","","fee schedule","202.4","242.88",""
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","212.01","","","","","","","fee schedule","202.4","242.88","APC"
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","208.47","","","","","","","fee schedule","202.4","242.88","APC"
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","206.45","","","","","","","fee schedule","202.4","242.88","APC"
"Hba1/hba2 gene dup/del vrnts","81269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","212.52","","","","","","","fee schedule","202.4","242.88","APC"
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.66","","","","","","","fee schedule","91.66","150.07",""
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","91.66","","","","","","","fee schedule","91.66","150.07",""
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","91.66","","","","","","","fee schedule","91.66","150.07",""
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","150.07","","","","","","","fee schedule","91.66","150.07",""
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","150.07","","","","","","","fee schedule","91.66","150.07",""
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","96.01","","","","","","","fee schedule","91.66","150.07","APC"
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.41","","","","","","","fee schedule","91.66","150.07","APC"
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.49","","","","","","","fee schedule","91.66","150.07","APC"
"Jak2 gene","81270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.24","","","","","","","fee schedule","91.66","150.07","APC"
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Htt gene detc abnor alleles","81271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","329.51","","","","","","","fee schedule","329.51","395.41",""
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","395.41","","","","","","","fee schedule","329.51","395.41",""
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","395.41","","","","","","","fee schedule","329.51","395.41",""
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","345.16","","","","","","","fee schedule","329.51","395.41","APC"
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","339.4","","","","","","","fee schedule","329.51","395.41","APC"
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","336.1","","","","","","","fee schedule","329.51","395.41","APC"
"Kit gene targeted seq analys","81272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","345.99","","","","","","","fee schedule","329.51","395.41","APC"
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","124.87","","","","","","","fee schedule","124.87","149.84",""
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.87","","","","","","","fee schedule","124.87","149.84",""
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","124.87","","","","","","","fee schedule","124.87","149.84",""
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","149.84","","","","","","","fee schedule","124.87","149.84",""
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","149.84","","","","","","","fee schedule","124.87","149.84",""
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","130.8","","","","","","","fee schedule","124.87","149.84","APC"
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","128.62","","","","","","","fee schedule","124.87","149.84","APC"
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","127.37","","","","","","","fee schedule","124.87","149.84","APC"
"Kit gene analys d816 variant","81273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.11","","","","","","","fee schedule","124.87","149.84","APC"
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Htt gene charac alleles","81274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","193.25","","","","","","","fee schedule","193.25","236.98",""
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.25","","","","","","","fee schedule","193.25","236.98",""
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.25","","","","","","","fee schedule","193.25","236.98",""
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","236.98","","","","","","","fee schedule","193.25","236.98",""
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","236.98","","","","","","","fee schedule","193.25","236.98",""
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.43","","","","","","","fee schedule","193.25","236.98","APC"
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.05","","","","","","","fee schedule","193.25","236.98","APC"
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.12","","","","","","","fee schedule","193.25","236.98","APC"
"Kras gene variants exon 2","81275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202.91","","","","","","","fee schedule","193.25","236.98","APC"
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","193.25","","","","","","","fee schedule","193.25","236.63",""
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.25","","","","","","","fee schedule","193.25","236.63",""
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.25","","","","","","","fee schedule","193.25","236.63",""
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","236.63","","","","","","","fee schedule","193.25","236.63",""
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","236.63","","","","","","","fee schedule","193.25","236.63",""
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.43","","","","","","","fee schedule","193.25","236.63","APC"
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.05","","","","","","","fee schedule","193.25","236.63","APC"
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.12","","","","","","","fee schedule","193.25","236.63","APC"
"Kras gene addl variants","81276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202.91","","","","","","","fee schedule","193.25","236.63","APC"
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1160","","","","","","","fee schedule","1160","1392",""
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1160","","","","","","","fee schedule","1160","1392",""
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1160","","","","","","","fee schedule","1160","1392",""
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1392","","","","","","","fee schedule","1160","1392",""
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1392","","","","","","","fee schedule","1160","1392",""
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1215.1","","","","","","","fee schedule","1160","1392","APC"
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1194.8","","","","","","","fee schedule","1160","1392","APC"
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1183.2","","","","","","","fee schedule","1160","1392","APC"
"Cytogenomic neo microra alys","81277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1218","","","","","","","fee schedule","1160","1392","APC"
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","248.77",""
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","248.77",""
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","248.77","","","","","","","fee schedule","207.31","248.77",""
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","248.77","","","","","","","fee schedule","207.31","248.77",""
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","248.77","APC"
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","248.77","APC"
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","248.77","APC"
"Igh@/bcl2 translocation alys","81278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","248.77","APC"
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Jak2 gene trgt sequence alys","81279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","73.37","","","","","","","fee schedule","73.37","90.53",""
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","73.37","","","","","","","fee schedule","73.37","90.53",""
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","73.37","","","","","","","fee schedule","73.37","90.53",""
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","90.53","","","","","","","fee schedule","73.37","90.53",""
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","90.53","","","","","","","fee schedule","73.37","90.53",""
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.86","","","","","","","fee schedule","73.37","90.53","APC"
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.57","","","","","","","fee schedule","73.37","90.53","APC"
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.84","","","","","","","fee schedule","73.37","90.53","APC"
"Ifnl3 gene","81283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","77.04","","","","","","","fee schedule","73.37","90.53","APC"
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Fxn gene detc abnor alleles","81284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene charac alleles","81285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Fxn gene full gene sequence","81286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","124.64","","","","","","","fee schedule","99.61","130.87",""
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.64","","","","","","","fee schedule","99.61","130.87",""
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","124.64","","","","","","","fee schedule","99.61","130.87",""
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","99.61","","","","","","","fee schedule","99.61","130.87",""
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","99.61","","","","","","","fee schedule","99.61","130.87",""
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","130.56","","","","","","","fee schedule","99.61","130.87","APC"
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","128.38","","","","","","","fee schedule","99.61","130.87","APC"
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","127.13","","","","","","","fee schedule","99.61","130.87","APC"
"Mgmt gene methylation anal","81287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","130.87","","","","","","","fee schedule","99.61","130.87","APC"
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","192.32","","","","","","","fee schedule","192.32","228.11",""
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","192.32","","","","","","","fee schedule","192.32","228.11",""
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","192.32","","","","","","","fee schedule","192.32","228.11",""
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","228.11","","","","","","","fee schedule","192.32","228.11",""
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","228.11","","","","","","","fee schedule","192.32","228.11",""
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.46","","","","","","","fee schedule","192.32","228.11","APC"
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","198.09","","","","","","","fee schedule","192.32","228.11","APC"
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","196.17","","","","","","","fee schedule","192.32","228.11","APC"
"Mlh1 gene","81288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.94","","","","","","","fee schedule","192.32","228.11","APC"
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Fxn gene known famil variant","81289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.31","","","","","","","fee schedule","39.31","47.17",""
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.31","","","","","","","fee schedule","39.31","47.17",""
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.31","","","","","","","fee schedule","39.31","47.17",""
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","47.17","","","","","","","fee schedule","39.31","47.17",""
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","47.17","","","","","","","fee schedule","39.31","47.17",""
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.18","","","","","","","fee schedule","39.31","47.17","APC"
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.49","","","","","","","fee schedule","39.31","47.17","APC"
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.1","","","","","","","fee schedule","39.31","47.17","APC"
"Mcoln1 gene","81290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.28","","","","","","","fee schedule","39.31","47.17","APC"
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","65.34","","","","","","","fee schedule","65.34","71.46",""
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","65.34","","","","","","","fee schedule","65.34","71.46",""
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","65.34","","","","","","","fee schedule","65.34","71.46",""
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.46","","","","","","","fee schedule","65.34","71.46",""
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.46","","","","","","","fee schedule","65.34","71.46",""
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.44","","","","","","","fee schedule","65.34","71.46","APC"
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.3","","","","","","","fee schedule","65.34","71.46","APC"
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.65","","","","","","","fee schedule","65.34","71.46","APC"
"Mthfr gene","81291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.61","","","","","","","fee schedule","65.34","71.46","APC"
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","675.4","","","","","","","fee schedule","675.4","775.49",""
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","675.4","","","","","","","fee schedule","675.4","775.49",""
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","675.4","","","","","","","fee schedule","675.4","775.49",""
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","775.49","","","","","","","fee schedule","675.4","775.49",""
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","775.49","","","","","","","fee schedule","675.4","775.49",""
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","707.48","","","","","","","fee schedule","675.4","775.49","APC"
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","695.66","","","","","","","fee schedule","675.4","775.49","APC"
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","688.91","","","","","","","fee schedule","675.4","775.49","APC"
"Mlh1 gene full seq","81292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","709.17","","","","","","","fee schedule","675.4","775.49","APC"
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","331","","","","","","","fee schedule","310.87","347.55",""
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","331","","","","","","","fee schedule","310.87","347.55",""
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","331","","","","","","","fee schedule","310.87","347.55",""
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","310.87","","","","","","","fee schedule","310.87","347.55",""
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","310.87","","","","","","","fee schedule","310.87","347.55",""
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","346.72","","","","","","","fee schedule","310.87","347.55","APC"
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","340.93","","","","","","","fee schedule","310.87","347.55","APC"
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","337.62","","","","","","","fee schedule","310.87","347.55","APC"
"Mlh1 gene known variants","81293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","347.55","","","","","","","fee schedule","310.87","347.55","APC"
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","202.4","","","","","","","fee schedule","202.4","228.82",""
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","202.4","","","","","","","fee schedule","202.4","228.82",""
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","202.4","","","","","","","fee schedule","202.4","228.82",""
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","228.82","","","","","","","fee schedule","202.4","228.82",""
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","228.82","","","","","","","fee schedule","202.4","228.82",""
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","212.01","","","","","","","fee schedule","202.4","228.82","APC"
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","208.47","","","","","","","fee schedule","202.4","228.82","APC"
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","206.45","","","","","","","fee schedule","202.4","228.82","APC"
"Mlh1 gene dup/delete variant","81294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","212.52","","","","","","","fee schedule","202.4","228.82","APC"
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","381.7","","","","","","","fee schedule","182.05","400.78",""
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","381.7","","","","","","","fee schedule","182.05","400.78",""
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","381.7","","","","","","","fee schedule","182.05","400.78",""
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","182.05","","","","","","","fee schedule","182.05","400.78",""
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","182.05","","","","","","","fee schedule","182.05","400.78",""
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.83","","","","","","","fee schedule","182.05","400.78","APC"
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","393.15","","","","","","","fee schedule","182.05","400.78","APC"
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","389.33","","","","","","","fee schedule","182.05","400.78","APC"
"Msh2 gene full seq","81295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.78","","","","","","","fee schedule","182.05","400.78","APC"
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","337.73","","","","","","","fee schedule","155.44","354.62",""
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","337.73","","","","","","","fee schedule","155.44","354.62",""
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","337.73","","","","","","","fee schedule","155.44","354.62",""
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","155.44","","","","","","","fee schedule","155.44","354.62",""
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","155.44","","","","","","","fee schedule","155.44","354.62",""
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","353.77","","","","","","","fee schedule","155.44","354.62","APC"
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","347.86","","","","","","","fee schedule","155.44","354.62","APC"
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","344.48","","","","","","","fee schedule","155.44","354.62","APC"
"Msh2 gene known variants","81296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","354.62","","","","","","","fee schedule","155.44","354.62","APC"
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","213.3","","","","","","","fee schedule","182.05","223.96",""
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","213.3","","","","","","","fee schedule","182.05","223.96",""
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","213.3","","","","","","","fee schedule","182.05","223.96",""
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","182.05","","","","","","","fee schedule","182.05","223.96",""
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","182.05","","","","","","","fee schedule","182.05","223.96",""
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.43","","","","","","","fee schedule","182.05","223.96","APC"
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","219.7","","","","","","","fee schedule","182.05","223.96","APC"
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.57","","","","","","","fee schedule","182.05","223.96","APC"
"Msh2 gene dup/delete variant","81297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","223.97","","","","","","","fee schedule","182.05","223.96","APC"
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","641.85","","","","","","","fee schedule","345.4","673.94",""
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","641.85","","","","","","","fee schedule","345.4","673.94",""
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","641.85","","","","","","","fee schedule","345.4","673.94",""
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","345.4","","","","","","","fee schedule","345.4","673.94",""
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","345.4","","","","","","","fee schedule","345.4","673.94",""
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","672.34","","","","","","","fee schedule","345.4","673.94","APC"
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","661.11","","","","","","","fee schedule","345.4","673.94","APC"
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","654.69","","","","","","","fee schedule","345.4","673.94","APC"
"Msh6 gene full seq","81298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","673.94","","","","","","","fee schedule","345.4","673.94","APC"
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","308","","","","","","","fee schedule","193.49","323.4",""
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","308","","","","","","","fee schedule","193.49","323.4",""
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","308","","","","","","","fee schedule","193.49","323.4",""
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","193.49","","","","","","","fee schedule","193.49","323.4",""
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","193.49","","","","","","","fee schedule","193.49","323.4",""
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","322.63","","","","","","","fee schedule","193.49","323.4","APC"
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","317.24","","","","","","","fee schedule","193.49","323.4","APC"
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","314.16","","","","","","","fee schedule","193.49","323.4","APC"
"Msh6 gene known variants","81299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","323.4","","","","","","","fee schedule","193.49","323.4","APC"
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","238","","","","","","","fee schedule","194.02","249.9",""
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238","","","","","","","fee schedule","194.02","249.9",""
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","238","","","","","","","fee schedule","194.02","249.9",""
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","194.02","","","","","","","fee schedule","194.02","249.9",""
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","194.02","","","","","","","fee schedule","194.02","249.9",""
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","249.31","","","","","","","fee schedule","194.02","249.9","APC"
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","245.14","","","","","","","fee schedule","194.02","249.9","APC"
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","242.76","","","","","","","fee schedule","194.02","249.9","APC"
"Msh6 gene dup/delete variant","81300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","249.9","","","","","","","fee schedule","194.02","249.9","APC"
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","348.56","","","","","","","fee schedule","348.56","474.05",""
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","348.56","","","","","","","fee schedule","348.56","474.05",""
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","348.56","","","","","","","fee schedule","348.56","474.05",""
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","474.05","","","","","","","fee schedule","348.56","474.05",""
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","474.05","","","","","","","fee schedule","348.56","474.05",""
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","365.12","","","","","","","fee schedule","348.56","474.05","APC"
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","359.02","","","","","","","fee schedule","348.56","474.05","APC"
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","355.53","","","","","","","fee schedule","348.56","474.05","APC"
"Microsatellite instability","81301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","365.99","","","","","","","fee schedule","348.56","474.05","APC"
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","527.87","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","527.87","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","527.87","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","633.44","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","633.44","","","","","","","fee schedule","527.87","633.44",""
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","552.94","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","543.71","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","538.43","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 gene full seq","81302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","554.26","","","","","","","fee schedule","527.87","633.44","APC"
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","120","","","","","","","fee schedule","120","144",""
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","120","","","","","","","fee schedule","120","144",""
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","120","","","","","","","fee schedule","120","144",""
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","144","","","","","","","fee schedule","120","144",""
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","144","","","","","","","fee schedule","120","144",""
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","125.7","","","","","","","fee schedule","120","144","APC"
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","123.6","","","","","","","fee schedule","120","144","APC"
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","122.4","","","","","","","fee schedule","120","144","APC"
"Mecp2 gene known variant","81303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","126","","","","","","","fee schedule","120","144","APC"
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150","","","","","","","fee schedule","150","180",""
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","150","","","","","","","fee schedule","150","180",""
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150","","","","","","","fee schedule","150","180",""
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","180","","","","","","","fee schedule","150","180",""
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","180","","","","","","","fee schedule","150","180",""
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.13","","","","","","","fee schedule","150","180","APC"
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.5","","","","","","","fee schedule","150","180","APC"
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153","","","","","","","fee schedule","150","180","APC"
"Mecp2 gene dup/delet variant","81304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.5","","","","","","","fee schedule","150","180","APC"
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.4","","","","","","","fee schedule","175.4","210.48",""
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","210.48","","","","","","","fee schedule","175.4","210.48",""
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","210.48","","","","","","","fee schedule","175.4","210.48",""
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.73","","","","","","","fee schedule","175.4","210.48","APC"
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.66","","","","","","","fee schedule","175.4","210.48","APC"
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.91","","","","","","","fee schedule","175.4","210.48","APC"
"Myd88 gene p.leu265pro vrnt","81305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.17","","","","","","","fee schedule","175.4","210.48","APC"
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","291.36","","","","","","","fee schedule","291.36","349.63",""
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","291.36","","","","","","","fee schedule","291.36","349.63",""
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","291.36","","","","","","","fee schedule","291.36","349.63",""
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","349.63","","","","","","","fee schedule","291.36","349.63",""
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","349.63","","","","","","","fee schedule","291.36","349.63",""
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","305.2","","","","","","","fee schedule","291.36","349.63","APC"
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","300.1","","","","","","","fee schedule","291.36","349.63","APC"
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","297.19","","","","","","","fee schedule","291.36","349.63","APC"
"Nudt15 gene common variants","81306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","305.93","","","","","","","fee schedule","291.36","349.63","APC"
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","676.5","","","","","","","fee schedule","339.46","710.32",""
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","676.5","","","","","","","fee schedule","339.46","710.32",""
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","676.5","","","","","","","fee schedule","339.46","710.32",""
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","339.46","710.32",""
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","339.46","710.32",""
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","708.63","","","","","","","fee schedule","339.46","710.32","APC"
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","696.8","","","","","","","fee schedule","339.46","710.32","APC"
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","690.03","","","","","","","fee schedule","339.46","710.32","APC"
"Palb2 gene full gene seq","81307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","710.32","","","","","","","fee schedule","339.46","710.32","APC"
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Palb2 gene known famil vrnt","81308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Pik3ca gene trgt seq alys","81309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.52","","","","","","","fee schedule","246.52","296.57",""
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.52","","","","","","","fee schedule","246.52","296.57",""
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.52","","","","","","","fee schedule","246.52","296.57",""
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","296.57","","","","","","","fee schedule","246.52","296.57",""
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","296.57","","","","","","","fee schedule","246.52","296.57",""
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.23","","","","","","","fee schedule","246.52","296.57","APC"
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","253.92","","","","","","","fee schedule","246.52","296.57","APC"
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.45","","","","","","","fee schedule","246.52","296.57","APC"
"Npm1 gene","81310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","258.85","","","","","","","fee schedule","246.52","296.57","APC"
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","295.79","","","","","","","fee schedule","295.79","354.95",""
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","295.79","","","","","","","fee schedule","295.79","354.95",""
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","295.79","","","","","","","fee schedule","295.79","354.95",""
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","354.95","","","","","","","fee schedule","295.79","354.95",""
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","354.95","","","","","","","fee schedule","295.79","354.95",""
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","309.84","","","","","","","fee schedule","295.79","354.95","APC"
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","304.66","","","","","","","fee schedule","295.79","354.95","APC"
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","301.71","","","","","","","fee schedule","295.79","354.95","APC"
"Nras gene variants exon 2&3","81311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","310.58","","","","","","","fee schedule","295.79","354.95","APC"
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Pabpn1 gene detc abnor allel","81312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","255.05","","","","","","","fee schedule","240.18","267.8",""
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","255.05","","","","","","","fee schedule","240.18","267.8",""
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","255.05","","","","","","","fee schedule","240.18","267.8",""
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","240.18","","","","","","","fee schedule","240.18","267.8",""
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","240.18","","","","","","","fee schedule","240.18","267.8",""
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","267.16","","","","","","","fee schedule","240.18","267.8","APC"
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","262.7","","","","","","","fee schedule","240.18","267.8","APC"
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","260.15","","","","","","","fee schedule","240.18","267.8","APC"
"Pca3/klk3 antigen","81313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","267.8","","","","","","","fee schedule","240.18","267.8","APC"
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","329.51","","","","","","","fee schedule","329.51","395.41",""
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","395.41","","","","","","","fee schedule","329.51","395.41",""
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","395.41","","","","","","","fee schedule","329.51","395.41",""
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","345.16","","","","","","","fee schedule","329.51","395.41","APC"
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","339.4","","","","","","","fee schedule","329.51","395.41","APC"
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","336.1","","","","","","","fee schedule","329.51","395.41","APC"
"Pdgfra gene","81314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","345.99","","","","","","","fee schedule","329.51","395.41","APC"
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","339.4",""
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","339.4",""
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","339.4",""
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.4","","","","","","","fee schedule","207.31","339.4",""
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.4","","","","","","","fee schedule","207.31","339.4",""
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","339.4","APC"
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","339.4","APC"
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","339.4","APC"
"Pml/raralpha com breakpoints","81315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","339.4","APC"
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.31","","","","","","","fee schedule","207.31","517.67",""
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","207.31","","","","","","","fee schedule","207.31","517.67",""
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.31","","","","","","","fee schedule","207.31","517.67",""
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","517.67","","","","","","","fee schedule","207.31","517.67",""
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","517.67","","","","","","","fee schedule","207.31","517.67",""
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.16","","","","","","","fee schedule","207.31","517.67","APC"
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.53","","","","","","","fee schedule","207.31","517.67","APC"
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.46","","","","","","","fee schedule","207.31","517.67","APC"
"Pml/raralpha 1 breakpoint","81316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.68","","","","","","","fee schedule","207.31","517.67","APC"
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","676.5","","","","","","","fee schedule","676.5","937.55",""
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","676.5","","","","","","","fee schedule","676.5","937.55",""
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","676.5","","","","","","","fee schedule","676.5","937.55",""
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","937.55","","","","","","","fee schedule","676.5","937.55",""
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","937.55","","","","","","","fee schedule","676.5","937.55",""
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","708.63","","","","","","","fee schedule","676.5","937.55","APC"
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","696.8","","","","","","","fee schedule","676.5","937.55","APC"
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","690.03","","","","","","","fee schedule","676.5","937.55","APC"
"Pms2 gene full seq analysis","81317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","710.32","","","","","","","fee schedule","676.5","937.55","APC"
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","331","","","","","","","fee schedule","221.53","347.55",""
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","331","","","","","","","fee schedule","221.53","347.55",""
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","331","","","","","","","fee schedule","221.53","347.55",""
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","221.53","","","","","","","fee schedule","221.53","347.55",""
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","221.53","","","","","","","fee schedule","221.53","347.55",""
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","346.72","","","","","","","fee schedule","221.53","347.55","APC"
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","340.93","","","","","","","fee schedule","221.53","347.55","APC"
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","337.62","","","","","","","fee schedule","221.53","347.55","APC"
"Pms2 known familial variants","81318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","347.55","","","","","","","fee schedule","221.53","347.55","APC"
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","203.5","","","","","","","fee schedule","203.5","265.99",""
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","203.5","","","","","","","fee schedule","203.5","265.99",""
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.5","","","","","","","fee schedule","203.5","265.99",""
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","265.99","","","","","","","fee schedule","203.5","265.99",""
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","265.99","","","","","","","fee schedule","203.5","265.99",""
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","213.17","","","","","","","fee schedule","203.5","265.99","APC"
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","209.6","","","","","","","fee schedule","203.5","265.99","APC"
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","207.57","","","","","","","fee schedule","203.5","265.99","APC"
"Pms2 gene dup/delet variants","81319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","213.68","","","","","","","fee schedule","203.5","265.99","APC"
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","291.36","","","","","","","fee schedule","291.36","349.63",""
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","291.36","","","","","","","fee schedule","291.36","349.63",""
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","291.36","","","","","","","fee schedule","291.36","349.63",""
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","349.63","","","","","","","fee schedule","291.36","349.63",""
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","349.63","","","","","","","fee schedule","291.36","349.63",""
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","305.2","","","","","","","fee schedule","291.36","349.63","APC"
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","300.1","","","","","","","fee schedule","291.36","349.63","APC"
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","297.19","","","","","","","fee schedule","291.36","349.63","APC"
"Plcg2 gene common variants","81320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","305.93","","","","","","","fee schedule","291.36","349.63","APC"
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","600","","","","","","","fee schedule","600","720.84",""
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","600","","","","","","","fee schedule","600","720.84",""
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","600","","","","","","","fee schedule","600","720.84",""
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","720.84","","","","","","","fee schedule","600","720.84",""
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","720.84","","","","","","","fee schedule","600","720.84",""
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","628.5","","","","","","","fee schedule","600","720.84","APC"
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","618","","","","","","","fee schedule","600","720.84","APC"
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","612","","","","","","","fee schedule","600","720.84","APC"
"Pten gene full sequence","81321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","630","","","","","","","fee schedule","600","720.84","APC"
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.6","","","","","","","fee schedule","46.6","70.08",""
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46.6","","","","","","","fee schedule","46.6","70.08",""
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.6","","","","","","","fee schedule","46.6","70.08",""
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","70.08","","","","","","","fee schedule","46.6","70.08",""
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","70.08","","","","","","","fee schedule","46.6","70.08",""
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48.81","","","","","","","fee schedule","46.6","70.08","APC"
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48","","","","","","","fee schedule","46.6","70.08","APC"
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.53","","","","","","","fee schedule","46.6","70.08","APC"
"Pten gene known fam variant","81322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.93","","","","","","","fee schedule","46.6","70.08","APC"
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","300","","","","","","","fee schedule","105.12","315",""
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","300","","","","","","","fee schedule","105.12","315",""
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300","","","","","","","fee schedule","105.12","315",""
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","105.12","","","","","","","fee schedule","105.12","315",""
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","105.12","","","","","","","fee schedule","105.12","315",""
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","314.25","","","","","","","fee schedule","105.12","315","APC"
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","309","","","","","","","fee schedule","105.12","315","APC"
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","306","","","","","","","fee schedule","105.12","315","APC"
"Pten gene dup/delet variant","81323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","315","","","","","","","fee schedule","105.12","315","APC"
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","758.36","","","","","","","fee schedule","758.36","910.03",""
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","758.36","","","","","","","fee schedule","758.36","910.03",""
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","758.36","","","","","","","fee schedule","758.36","910.03",""
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","910.03","","","","","","","fee schedule","758.36","910.03",""
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","910.03","","","","","","","fee schedule","758.36","910.03",""
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","794.38","","","","","","","fee schedule","758.36","910.03","APC"
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.11","","","","","","","fee schedule","758.36","910.03","APC"
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","773.53","","","","","","","fee schedule","758.36","910.03","APC"
"Pmp22 gene dup/delet","81324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","796.28","","","","","","","fee schedule","758.36","910.03","APC"
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","769.58","","","","","","","fee schedule","769.58","923.5",""
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","769.58","","","","","","","fee schedule","769.58","923.5",""
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","769.58","","","","","","","fee schedule","769.58","923.5",""
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","923.5","","","","","","","fee schedule","769.58","923.5",""
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","923.5","","","","","","","fee schedule","769.58","923.5",""
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","806.14","","","","","","","fee schedule","769.58","923.5","APC"
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","792.67","","","","","","","fee schedule","769.58","923.5","APC"
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","784.97","","","","","","","fee schedule","769.58","923.5","APC"
"Pmp22 gene full sequence","81325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","808.06","","","","","","","fee schedule","769.58","923.5","APC"
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.6","","","","","","","fee schedule","46.6","63.42",""
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46.6","","","","","","","fee schedule","46.6","63.42",""
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.6","","","","","","","fee schedule","46.6","63.42",""
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","63.42","","","","","","","fee schedule","46.6","63.42",""
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","63.42","","","","","","","fee schedule","46.6","63.42",""
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48.81","","","","","","","fee schedule","46.6","63.42","APC"
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48","","","","","","","fee schedule","46.6","63.42","APC"
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.53","","","","","","","fee schedule","46.6","63.42","APC"
"Pmp22 gene known fam variant","81326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.93","","","","","","","fee schedule","46.6","63.42","APC"
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","192","","","","","","","fee schedule","100.4","201.6",""
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","192","","","","","","","fee schedule","100.4","201.6",""
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","192","","","","","","","fee schedule","100.4","201.6",""
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","100.4","","","","","","","fee schedule","100.4","201.6",""
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","100.4","","","","","","","fee schedule","100.4","201.6",""
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.12","","","","","","","fee schedule","100.4","201.6","APC"
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","197.76","","","","","","","fee schedule","100.4","201.6","APC"
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","195.84","","","","","","","fee schedule","100.4","201.6","APC"
"Sept9 methylation analysis","81327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.6","","","","","","","fee schedule","100.4","201.6","APC"
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Slco1b1 gene com variants","81328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Smn1 gene dos/deletion alys","81329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47","","","","","","","fee schedule","47","56.4",""
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47","","","","","","","fee schedule","47","56.4",""
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47","","","","","","","fee schedule","47","56.4",""
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","56.4","","","","","","","fee schedule","47","56.4",""
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","56.4","","","","","","","fee schedule","47","56.4",""
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.23","","","","","","","fee schedule","47","56.4","APC"
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.41","","","","","","","fee schedule","47","56.4","APC"
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.94","","","","","","","fee schedule","47","56.4","APC"
"Smpd1 gene common variants","81330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.35","","","","","","","fee schedule","47","56.4","APC"
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.07","","","","","","","fee schedule","51.07","61.28",""
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.07","","","","","","","fee schedule","51.07","61.28",""
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.07","","","","","","","fee schedule","51.07","61.28",""
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","61.28","","","","","","","fee schedule","51.07","61.28",""
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","61.28","","","","","","","fee schedule","51.07","61.28",""
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.5","","","","","","","fee schedule","51.07","61.28","APC"
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.6","","","","","","","fee schedule","51.07","61.28","APC"
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.09","","","","","","","fee schedule","51.07","61.28","APC"
"Snrpn/ube3a gene","81331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.62","","","","","","","fee schedule","51.07","61.28","APC"
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.65","","","","","","","fee schedule","43.65","71.46",""
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.65","","","","","","","fee schedule","43.65","71.46",""
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.65","","","","","","","fee schedule","43.65","71.46",""
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.46","","","","","","","fee schedule","43.65","71.46",""
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.46","","","","","","","fee schedule","43.65","71.46",""
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45.72","","","","","","","fee schedule","43.65","71.46","APC"
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.96","","","","","","","fee schedule","43.65","71.46","APC"
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.52","","","","","","","fee schedule","43.65","71.46","APC"
"Serpina1 gene","81332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45.83","","","","","","","fee schedule","43.65","71.46","APC"
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Tgfbi gene common variants","81333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","329.51","","","","","","","fee schedule","329.51","395.41",""
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","395.41","","","","","","","fee schedule","329.51","395.41",""
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","395.41","","","","","","","fee schedule","329.51","395.41",""
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","345.16","","","","","","","fee schedule","329.51","395.41","APC"
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","339.4","","","","","","","fee schedule","329.51","395.41","APC"
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","336.1","","","","","","","fee schedule","329.51","395.41","APC"
"Runx1 gene targeted seq alys","81334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","345.99","","","","","","","fee schedule","329.51","395.41","APC"
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Tpmt gene com variants","81335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Smn1 gene full gene sequence","81336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Smn1 gen nown famil seq vrnt","81337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150.33","","","","","","","fee schedule","150.33","180.4",""
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","150.33","","","","","","","fee schedule","150.33","180.4",""
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150.33","","","","","","","fee schedule","150.33","180.4",""
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","180.4","","","","","","","fee schedule","150.33","180.4",""
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","180.4","","","","","","","fee schedule","150.33","180.4",""
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.47","","","","","","","fee schedule","150.33","180.4","APC"
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.84","","","","","","","fee schedule","150.33","180.4","APC"
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153.34","","","","","","","fee schedule","150.33","180.4","APC"
"Mpl gene common variants","81338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.85","","","","","","","fee schedule","150.33","180.4","APC"
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Mpl gene seq alys exon 10","81339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","208.92","","","","","","","fee schedule","208.92","342.02",""
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","208.92","","","","","","","fee schedule","208.92","342.02",""
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","208.92","","","","","","","fee schedule","208.92","342.02",""
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","342.02","","","","","","","fee schedule","208.92","342.02",""
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","342.02","","","","","","","fee schedule","208.92","342.02",""
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","218.84","","","","","","","fee schedule","208.92","342.02","APC"
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","215.19","","","","","","","fee schedule","208.92","342.02","APC"
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","213.1","","","","","","","fee schedule","208.92","342.02","APC"
"Trb@ gene rearrange amplify","81340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","219.37","","","","","","","fee schedule","208.92","342.02","APC"
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","49.59","","","","","","","fee schedule","49.59","81.18",""
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","49.59","","","","","","","fee schedule","49.59","81.18",""
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","49.59","","","","","","","fee schedule","49.59","81.18",""
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","81.18","","","","","","","fee schedule","49.59","81.18",""
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","81.18","","","","","","","fee schedule","49.59","81.18",""
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.95","","","","","","","fee schedule","49.59","81.18","APC"
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.08","","","","","","","fee schedule","49.59","81.18","APC"
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.58","","","","","","","fee schedule","49.59","81.18","APC"
"Trb@ gene rearrange dirprobe","81341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.07","","","","","","","fee schedule","49.59","81.18","APC"
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","201.5","","","","","","","fee schedule","201.5","329.88",""
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","201.5","","","","","","","fee schedule","201.5","329.88",""
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","201.5","","","","","","","fee schedule","201.5","329.88",""
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.88","","","","","","","fee schedule","201.5","329.88",""
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.88","","","","","","","fee schedule","201.5","329.88",""
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","211.07","","","","","","","fee schedule","201.5","329.88","APC"
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","207.54","","","","","","","fee schedule","201.5","329.88","APC"
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","205.53","","","","","","","fee schedule","201.5","329.88","APC"
"Trg gene rearrangement anal","81342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","211.58","","","","","","","fee schedule","201.5","329.88","APC"
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Ppp2r2b gen detc abnor allel","81343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Tbp gene detc abnor alleles","81344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Tert gene targeted seq alys","81345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Tyms gene com variants","81346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","193.25","","","","","","","fee schedule","193.25","231.9",""
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.25","","","","","","","fee schedule","193.25","231.9",""
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.25","","","","","","","fee schedule","193.25","231.9",""
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","231.9","","","","","","","fee schedule","193.25","231.9",""
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","231.9","","","","","","","fee schedule","193.25","231.9",""
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.43","","","","","","","fee schedule","193.25","231.9","APC"
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.05","","","","","","","fee schedule","193.25","231.9","APC"
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.12","","","","","","","fee schedule","193.25","231.9","APC"
"Sf3b1 gene common variants","81347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202.91","","","","","","","fee schedule","193.25","231.9","APC"
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.4","","","","","","","fee schedule","175.4","210.48",""
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.4","","","","","","","fee schedule","175.4","210.48",""
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","210.48","","","","","","","fee schedule","175.4","210.48",""
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","210.48","","","","","","","fee schedule","175.4","210.48",""
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.73","","","","","","","fee schedule","175.4","210.48","APC"
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.66","","","","","","","fee schedule","175.4","210.48","APC"
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.91","","","","","","","fee schedule","175.4","210.48","APC"
"Srsf2 gene common variants","81348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.17","","","","","","","fee schedule","175.4","210.48","APC"
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1197.94","","","","","","","fee schedule","1197.94","1392",""
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1197.94","","","","","","","fee schedule","1197.94","1392",""
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1197.94","","","","","","","fee schedule","1197.94","1392",""
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1392","","","","","","","fee schedule","1197.94","1392",""
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1392","","","","","","","fee schedule","1197.94","1392",""
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1254.84","","","","","","","fee schedule","1197.94","1392","APC"
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1233.88","","","","","","","fee schedule","1197.94","1392","APC"
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1221.9","","","","","","","fee schedule","1197.94","1392","APC"
"Cytog alys chrml abnr lw-ps","81349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1257.84","","","","","","","fee schedule","1197.94","1392","APC"
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","234","","","","","","","fee schedule","234","280.8",""
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","234","","","","","","","fee schedule","234","280.8",""
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","234","","","","","","","fee schedule","234","280.8",""
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","280.8","","","","","","","fee schedule","234","280.8",""
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","280.8","","","","","","","fee schedule","234","280.8",""
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","245.12","","","","","","","fee schedule","234","280.8","APC"
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","241.02","","","","","","","fee schedule","234","280.8","APC"
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","238.68","","","","","","","fee schedule","234","280.8","APC"
"Ugt1a1 gene","81350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","245.7","","","","","","","fee schedule","234","280.8","APC"
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","641.85","","","","","","","fee schedule","641.85","770.22",""
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","641.85","","","","","","","fee schedule","641.85","770.22",""
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","641.85","","","","","","","fee schedule","641.85","770.22",""
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","770.22","","","","","","","fee schedule","641.85","770.22",""
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","770.22","","","","","","","fee schedule","641.85","770.22",""
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","672.34","","","","","","","fee schedule","641.85","770.22","APC"
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","661.11","","","","","","","fee schedule","641.85","770.22","APC"
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","654.69","","","","","","","fee schedule","641.85","770.22","APC"
"Tp53 gene full gene sequence","81351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","673.94","","","","","","","fee schedule","641.85","770.22","APC"
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","329.51","","","","","","","fee schedule","329.51","395.41",""
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","329.51","","","","","","","fee schedule","329.51","395.41",""
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","395.41","","","","","","","fee schedule","329.51","395.41",""
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","395.41","","","","","","","fee schedule","329.51","395.41",""
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","345.16","","","","","","","fee schedule","329.51","395.41","APC"
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","339.4","","","","","","","fee schedule","329.51","395.41","APC"
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","336.1","","","","","","","fee schedule","329.51","395.41","APC"
"Tp53 gene trgt sequence alys","81352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","345.99","","","","","","","fee schedule","329.51","395.41","APC"
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","308","","","","","","","fee schedule","308","369.6",""
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","308","","","","","","","fee schedule","308","369.6",""
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","308","","","","","","","fee schedule","308","369.6",""
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","369.6","","","","","","","fee schedule","308","369.6",""
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","369.6","","","","","","","fee schedule","308","369.6",""
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","322.63","","","","","","","fee schedule","308","369.6","APC"
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","317.24","","","","","","","fee schedule","308","369.6","APC"
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","314.16","","","","","","","fee schedule","308","369.6","APC"
"Tp53 gene known famil vrnt","81353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","323.4","","","","","","","fee schedule","308","369.6","APC"
"Cytog alys chrml abnor ogm","81354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1323.55","","","","","","","fee schedule","1288.8","1326.71","APC"
"Cytog alys chrml abnor ogm","81354","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1301.44","","","","","","","fee schedule","1288.8","1326.71","APC"
"Cytog alys chrml abnor ogm","81354","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1288.8","","","","","","","fee schedule","1288.8","1326.71","APC"
"Cytog alys chrml abnor ogm","81354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1326.71","","","","","","","fee schedule","1288.8","1326.71","APC"
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","88.2","","","","","","","fee schedule","88.2","105.84",""
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","88.2","","","","","","","fee schedule","88.2","105.84",""
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","88.2","","","","","","","fee schedule","88.2","105.84",""
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","105.84","","","","","","","fee schedule","88.2","105.84",""
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","105.84","","","","","","","fee schedule","88.2","105.84",""
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","92.39","","","","","","","fee schedule","88.2","105.84","APC"
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","90.85","","","","","","","fee schedule","88.2","105.84","APC"
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","89.96","","","","","","","fee schedule","88.2","105.84","APC"
"Vkorc1 gene","81355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.61","","","","","","","fee schedule","88.2","105.84","APC"
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","193.25","","","","","","","fee schedule","193.25","231.9",""
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.25","","","","","","","fee schedule","193.25","231.9",""
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.25","","","","","","","fee schedule","193.25","231.9",""
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","231.9","","","","","","","fee schedule","193.25","231.9",""
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","231.9","","","","","","","fee schedule","193.25","231.9",""
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.43","","","","","","","fee schedule","193.25","231.9","APC"
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.05","","","","","","","fee schedule","193.25","231.9","APC"
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.12","","","","","","","fee schedule","193.25","231.9","APC"
"U2af1 gene common variants","81357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202.91","","","","","","","fee schedule","193.25","231.9","APC"
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","193.25","","","","","","","fee schedule","193.25","231.9",""
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.25","","","","","","","fee schedule","193.25","231.9",""
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.25","","","","","","","fee schedule","193.25","231.9",""
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","231.9","","","","","","","fee schedule","193.25","231.9",""
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","231.9","","","","","","","fee schedule","193.25","231.9",""
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.43","","","","","","","fee schedule","193.25","231.9","APC"
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.05","","","","","","","fee schedule","193.25","231.9","APC"
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.12","","","","","","","fee schedule","193.25","231.9","APC"
"Zrsr2 gene common variants","81360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202.91","","","","","","","fee schedule","193.25","231.9","APC"
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","174.81","","","","","","","fee schedule","174.81","209.77",""
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","174.81","","","","","","","fee schedule","174.81","209.77",""
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.77","","","","","","","fee schedule","174.81","209.77",""
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.77","","","","","","","fee schedule","174.81","209.77",""
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.11","","","","","","","fee schedule","174.81","209.77","APC"
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.05","","","","","","","fee schedule","174.81","209.77","APC"
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.31","","","","","","","fee schedule","174.81","209.77","APC"
"Hbb gene com variants","81361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","183.55","","","","","","","fee schedule","174.81","209.77","APC"
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","375.25","","","","","","","fee schedule","375.25","450.3",""
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","375.25","","","","","","","fee schedule","375.25","450.3",""
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","375.25","","","","","","","fee schedule","375.25","450.3",""
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","450.3","","","","","","","fee schedule","375.25","450.3",""
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","450.3","","","","","","","fee schedule","375.25","450.3",""
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","393.07","","","","","","","fee schedule","375.25","450.3","APC"
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","386.51","","","","","","","fee schedule","375.25","450.3","APC"
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","382.76","","","","","","","fee schedule","375.25","450.3","APC"
"Hbb gene known fam variant","81362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","394.01","","","","","","","fee schedule","375.25","450.3","APC"
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","202.4","","","","","","","fee schedule","202.4","242.88",""
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","202.4","","","","","","","fee schedule","202.4","242.88",""
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","202.4","","","","","","","fee schedule","202.4","242.88",""
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","242.88","","","","","","","fee schedule","202.4","242.88",""
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","242.88","","","","","","","fee schedule","202.4","242.88",""
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","212.01","","","","","","","fee schedule","202.4","242.88","APC"
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","208.47","","","","","","","fee schedule","202.4","242.88","APC"
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","206.45","","","","","","","fee schedule","202.4","242.88","APC"
"Hbb gene dup/del variants","81363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","212.52","","","","","","","fee schedule","202.4","242.88","APC"
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324.58","","","","","","","fee schedule","324.58","389.5",""
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","324.58","","","","","","","fee schedule","324.58","389.5",""
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","324.58","","","","","","","fee schedule","324.58","389.5",""
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","389.5","","","","","","","fee schedule","324.58","389.5",""
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","389.5","","","","","","","fee schedule","324.58","389.5",""
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","340","","","","","","","fee schedule","324.58","389.5","APC"
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","334.32","","","","","","","fee schedule","324.58","389.5","APC"
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","331.07","","","","","","","fee schedule","324.58","389.5","APC"
"Hbb full gene sequence","81364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","340.81","","","","","","","fee schedule","324.58","389.5","APC"
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","402.12","","","","","","","fee schedule","402.12","658.32",""
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","402.12","","","","","","","fee schedule","402.12","658.32",""
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","402.12","","","","","","","fee schedule","402.12","658.32",""
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","658.32","","","","","","","fee schedule","402.12","658.32",""
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","658.32","","","","","","","fee schedule","402.12","658.32",""
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","421.22","","","","","","","fee schedule","402.12","658.32","APC"
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","414.18","","","","","","","fee schedule","402.12","658.32","APC"
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","410.16","","","","","","","fee schedule","402.12","658.32","APC"
"Hla i & ii typing lr","81370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","422.23","","","","","","","fee schedule","402.12","658.32","APC"
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","404.52","","","","","","","fee schedule","394.03","424.75",""
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","404.52","","","","","","","fee schedule","394.03","424.75",""
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","404.52","","","","","","","fee schedule","394.03","424.75",""
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","394.03","","","","","","","fee schedule","394.03","424.75",""
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","394.03","","","","","","","fee schedule","394.03","424.75",""
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","423.73","","","","","","","fee schedule","394.03","424.75","APC"
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","416.66","","","","","","","fee schedule","394.03","424.75","APC"
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","412.61","","","","","","","fee schedule","394.03","424.75","APC"
"Hla i & ii type verify lr","81371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","424.75","","","","","","","fee schedule","394.03","424.75","APC"
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","403.59","","","","","","","fee schedule","361.63","423.77",""
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","403.59","","","","","","","fee schedule","361.63","423.77",""
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","403.59","","","","","","","fee schedule","361.63","423.77",""
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.63","","","","","","","fee schedule","361.63","423.77",""
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.63","","","","","","","fee schedule","361.63","423.77",""
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","422.76","","","","","","","fee schedule","361.63","423.77","APC"
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","415.7","","","","","","","fee schedule","361.63","423.77","APC"
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","411.66","","","","","","","fee schedule","361.63","423.77","APC"
"Hla i typing complete lr","81372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","423.77","","","","","","","fee schedule","361.63","423.77","APC"
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","127.43","","","","","","","fee schedule","127.43","182.32",""
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","127.43","","","","","","","fee schedule","127.43","182.32",""
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","127.43","","","","","","","fee schedule","127.43","182.32",""
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","182.32","","","","","","","fee schedule","127.43","182.32",""
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","182.32","","","","","","","fee schedule","127.43","182.32",""
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","133.48","","","","","","","fee schedule","127.43","182.32","APC"
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","131.25","","","","","","","fee schedule","127.43","182.32","APC"
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","129.98","","","","","","","fee schedule","127.43","182.32","APC"
"Hla i typing 1 locus lr","81373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","133.8","","","","","","","fee schedule","127.43","182.32","APC"
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","74.33","","","","","","","fee schedule","74.33","119.1",""
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","74.33","","","","","","","fee schedule","74.33","119.1",""
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.33","","","","","","","fee schedule","74.33","119.1",""
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","119.1","","","","","","","fee schedule","74.33","119.1",""
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","119.1","","","","","","","fee schedule","74.33","119.1",""
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","77.86","","","","","","","fee schedule","74.33","119.1","APC"
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.56","","","","","","","fee schedule","74.33","119.1","APC"
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","75.82","","","","","","","fee schedule","74.33","119.1","APC"
"Hla i typing 1 antigen lr","81374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.05","","","","","","","fee schedule","74.33","119.1","APC"
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","220.74","","","","","","","fee schedule","220.74","361.38",""
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","220.74","","","","","","","fee schedule","220.74","361.38",""
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","220.74","","","","","","","fee schedule","220.74","361.38",""
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.38","","","","","","","fee schedule","220.74","361.38",""
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.38","","","","","","","fee schedule","220.74","361.38",""
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","231.23","","","","","","","fee schedule","220.74","361.38","APC"
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","227.36","","","","","","","fee schedule","220.74","361.38","APC"
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","225.15","","","","","","","fee schedule","220.74","361.38","APC"
"Hla ii typing ag equiv lr","81375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","231.78","","","","","","","fee schedule","220.74","361.38","APC"
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","122.22","","","","","","","fee schedule","122.22","200.09",""
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.22","","","","","","","fee schedule","122.22","200.09",""
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.22","","","","","","","fee schedule","122.22","200.09",""
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","200.09","","","","","","","fee schedule","122.22","200.09",""
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","200.09","","","","","","","fee schedule","122.22","200.09",""
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","128.03","","","","","","","fee schedule","122.22","200.09","APC"
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.89","","","","","","","fee schedule","122.22","200.09","APC"
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","124.66","","","","","","","fee schedule","122.22","200.09","APC"
"Hla ii typing 1 locus lr","81376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","128.33","","","","","","","fee schedule","122.22","200.09","APC"
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","94.74","","","","","","","fee schedule","94.74","150.3",""
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","94.74","","","","","","","fee schedule","94.74","150.3",""
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","94.74","","","","","","","fee schedule","94.74","150.3",""
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","150.3","","","","","","","fee schedule","94.74","150.3",""
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","150.3","","","","","","","fee schedule","94.74","150.3",""
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","99.24","","","","","","","fee schedule","94.74","150.3","APC"
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","97.58","","","","","","","fee schedule","94.74","150.3","APC"
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96.63","","","","","","","fee schedule","94.74","150.3","APC"
"Hla ii type 1 ag equiv lr","81377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99.48","","","","","","","fee schedule","94.74","150.3","APC"
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","345.57","","","","","","","fee schedule","345.57","565.73",""
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","345.57","","","","","","","fee schedule","345.57","565.73",""
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","345.57","","","","","","","fee schedule","345.57","565.73",""
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","565.73","","","","","","","fee schedule","345.57","565.73",""
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","565.73","","","","","","","fee schedule","345.57","565.73",""
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","361.98","","","","","","","fee schedule","345.57","565.73","APC"
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","355.94","","","","","","","fee schedule","345.57","565.73","APC"
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","352.48","","","","","","","fee schedule","345.57","565.73","APC"
"Hla i & ii typing hr","81378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","362.85","","","","","","","fee schedule","345.57","565.73","APC"
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","335.38","","","","","","","fee schedule","335.38","549.05",""
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","335.38","","","","","","","fee schedule","335.38","549.05",""
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","335.38","","","","","","","fee schedule","335.38","549.05",""
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","549.05","","","","","","","fee schedule","335.38","549.05",""
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","549.05","","","","","","","fee schedule","335.38","549.05",""
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","351.31","","","","","","","fee schedule","335.38","549.05","APC"
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","345.44","","","","","","","fee schedule","335.38","549.05","APC"
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","342.09","","","","","","","fee schedule","335.38","549.05","APC"
"Hla i typing complete hr","81379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","352.15","","","","","","","fee schedule","335.38","549.05","APC"
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","177.25","","","","","","","fee schedule","177.25","290.17",""
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","177.25","","","","","","","fee schedule","177.25","290.17",""
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","177.25","","","","","","","fee schedule","177.25","290.17",""
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","290.17","","","","","","","fee schedule","177.25","290.17",""
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","290.17","","","","","","","fee schedule","177.25","290.17",""
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","185.67","","","","","","","fee schedule","177.25","290.17","APC"
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","182.57","","","","","","","fee schedule","177.25","290.17","APC"
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","180.8","","","","","","","fee schedule","177.25","290.17","APC"
"Hla i typing 1 locus hr","81380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","186.11","","","","","","","fee schedule","177.25","290.17","APC"
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","169.9","","","","","","","fee schedule","154.84","178.4",""
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","169.9","","","","","","","fee schedule","154.84","178.4",""
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","169.9","","","","","","","fee schedule","154.84","178.4",""
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","154.84","","","","","","","fee schedule","154.84","178.4",""
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","154.84","","","","","","","fee schedule","154.84","178.4",""
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","177.97","","","","","","","fee schedule","154.84","178.4","APC"
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","175","","","","","","","fee schedule","154.84","178.4","APC"
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","173.3","","","","","","","fee schedule","154.84","178.4","APC"
"Hla i typing 1 allele hr","81381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","178.4","","","","","","","fee schedule","154.84","178.4","APC"
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","123.68","","","","","","","fee schedule","123.68","202.48",""
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.68","","","","","","","fee schedule","123.68","202.48",""
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","123.68","","","","","","","fee schedule","123.68","202.48",""
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","202.48","","","","","","","fee schedule","123.68","202.48",""
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","202.48","","","","","","","fee schedule","123.68","202.48",""
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","129.55","","","","","","","fee schedule","123.68","202.48","APC"
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","127.39","","","","","","","fee schedule","123.68","202.48","APC"
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","126.15","","","","","","","fee schedule","123.68","202.48","APC"
"Hla ii typing 1 loc hr","81382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","129.86","","","","","","","fee schedule","123.68","202.48","APC"
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","109.13","","","","","","","fee schedule","109.13","178.66",""
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","109.13","","","","","","","fee schedule","109.13","178.66",""
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","109.13","","","","","","","fee schedule","109.13","178.66",""
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","178.66","","","","","","","fee schedule","109.13","178.66",""
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","178.66","","","","","","","fee schedule","109.13","178.66",""
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","114.31","","","","","","","fee schedule","109.13","178.66","APC"
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","112.4","","","","","","","fee schedule","109.13","178.66","APC"
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","111.31","","","","","","","fee schedule","109.13","178.66","APC"
"Hla ii typing 1 allele hr","81383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","114.59","","","","","","","fee schedule","109.13","178.66","APC"
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","63.96","","","","","","","fee schedule","63.96","76.75",""
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63.96","","","","","","","fee schedule","63.96","76.75",""
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63.96","","","","","","","fee schedule","63.96","76.75",""
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","76.75","","","","","","","fee schedule","63.96","76.75",""
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","76.75","","","","","","","fee schedule","63.96","76.75",""
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67","","","","","","","fee schedule","63.96","76.75","APC"
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65.88","","","","","","","fee schedule","63.96","76.75","APC"
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.24","","","","","","","fee schedule","63.96","76.75","APC"
"Mopath procedure level 1","81400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.16","","","","","","","fee schedule","63.96","76.75","APC"
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137","","","","","","","fee schedule","137","164.4",""
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137","","","","","","","fee schedule","137","164.4",""
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","137","","","","","","","fee schedule","137","164.4",""
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","164.4","","","","","","","fee schedule","137","164.4",""
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","164.4","","","","","","","fee schedule","137","164.4",""
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.51","","","","","","","fee schedule","137","164.4","APC"
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.11","","","","","","","fee schedule","137","164.4","APC"
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.74","","","","","","","fee schedule","137","164.4","APC"
"Mopath procedure level 2","81401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.85","","","","","","","fee schedule","137","164.4","APC"
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150.33","","","","","","","fee schedule","150.33","180.4",""
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","150.33","","","","","","","fee schedule","150.33","180.4",""
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150.33","","","","","","","fee schedule","150.33","180.4",""
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","180.4","","","","","","","fee schedule","150.33","180.4",""
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","180.4","","","","","","","fee schedule","150.33","180.4",""
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.47","","","","","","","fee schedule","150.33","180.4","APC"
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.84","","","","","","","fee schedule","150.33","180.4","APC"
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153.34","","","","","","","fee schedule","150.33","180.4","APC"
"Mopath procedure level 3","81402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.85","","","","","","","fee schedule","150.33","180.4","APC"
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.2","","","","","","","fee schedule","185.2","222.24",""
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.2","","","","","","","fee schedule","185.2","222.24",""
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","222.24","","","","","","","fee schedule","185.2","222.24",""
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","222.24","","","","","","","fee schedule","185.2","222.24",""
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","194","","","","","","","fee schedule","185.2","222.24","APC"
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.76","","","","","","","fee schedule","185.2","222.24","APC"
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.9","","","","","","","fee schedule","185.2","222.24","APC"
"Mopath procedure level 4","81403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.46","","","","","","","fee schedule","185.2","222.24","APC"
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","274.83","","","","","","","fee schedule","274.83","329.8",""
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.83","","","","","","","fee schedule","274.83","329.8",""
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","329.8","","","","","","","fee schedule","274.83","329.8",""
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","329.8","","","","","","","fee schedule","274.83","329.8",""
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","287.88","","","","","","","fee schedule","274.83","329.8","APC"
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","283.07","","","","","","","fee schedule","274.83","329.8","APC"
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","280.33","","","","","","","fee schedule","274.83","329.8","APC"
"Mopath procedure level 5","81404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","288.57","","","","","","","fee schedule","274.83","329.8","APC"
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","301.35","","","","","","","fee schedule","301.35","361.62",""
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.35","","","","","","","fee schedule","301.35","361.62",""
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","361.62","","","","","","","fee schedule","301.35","361.62",""
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","361.62","","","","","","","fee schedule","301.35","361.62",""
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","315.66","","","","","","","fee schedule","301.35","361.62","APC"
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","310.39","","","","","","","fee schedule","301.35","361.62","APC"
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","307.38","","","","","","","fee schedule","301.35","361.62","APC"
"Mopath procedure level 6","81405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","316.42","","","","","","","fee schedule","301.35","361.62","APC"
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","282.88","","","","","","","fee schedule","282.88","339.46",""
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","282.88","","","","","","","fee schedule","282.88","339.46",""
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","339.46","","","","","","","fee schedule","282.88","339.46",""
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","339.46","","","","","","","fee schedule","282.88","339.46",""
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","296.32","","","","","","","fee schedule","282.88","339.46","APC"
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","291.37","","","","","","","fee schedule","282.88","339.46","APC"
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","288.54","","","","","","","fee schedule","282.88","339.46","APC"
"Mopath procedure level 7","81406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","297.02","","","","","","","fee schedule","282.88","339.46","APC"
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","846.27","","","","","","","fee schedule","846.27","1015.52",""
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1015.52","","","","","","","fee schedule","846.27","1015.52",""
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1015.52","","","","","","","fee schedule","846.27","1015.52",""
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","886.47","","","","","","","fee schedule","846.27","1015.52","APC"
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","871.66","","","","","","","fee schedule","846.27","1015.52","APC"
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","863.2","","","","","","","fee schedule","846.27","1015.52","APC"
"Mopath procedure level 8","81407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","888.58","","","","","","","fee schedule","846.27","1015.52","APC"
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2000","","","","","","","fee schedule","2000","2400",""
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2000","","","","","","","fee schedule","2000","2400",""
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2000","","","","","","","fee schedule","2000","2400",""
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2400","","","","","","","fee schedule","2000","2400",""
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2400","","","","","","","fee schedule","2000","2400",""
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2095","","","","","","","fee schedule","2000","2400","APC"
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2060","","","","","","","fee schedule","2000","2400","APC"
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2040","","","","","","","fee schedule","2000","2400","APC"
"Mopath procedure level 9","81408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2100","","","","","","","fee schedule","2000","2400","APC"
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","504","","","","","","","fee schedule","504","604.8",""
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","504","","","","","","","fee schedule","504","604.8",""
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","504","","","","","","","fee schedule","504","604.8",""
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","604.8","","","","","","","fee schedule","504","604.8",""
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","604.8","","","","","","","fee schedule","504","604.8",""
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","527.94","","","","","","","fee schedule","504","604.8","APC"
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","519.12","","","","","","","fee schedule","504","604.8","APC"
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","514.08","","","","","","","fee schedule","504","604.8","APC"
"Aortic dysfunction/dilation","81410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","529.2","","","","","","","fee schedule","504","604.8","APC"
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1350.19","","","","","","","fee schedule","1350.19","1620.23",""
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1350.19","","","","","","","fee schedule","1350.19","1620.23",""
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1350.19","","","","","","","fee schedule","1350.19","1620.23",""
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1620.23","","","","","","","fee schedule","1350.19","1620.23",""
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1620.23","","","","","","","fee schedule","1350.19","1620.23",""
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.32","","","","","","","fee schedule","1350.19","1620.23","APC"
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.7","","","","","","","fee schedule","1350.19","1620.23","APC"
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.19","","","","","","","fee schedule","1350.19","1620.23","APC"
"Aortic dysfunction/dilation","81411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1417.7","","","","","","","fee schedule","1350.19","1620.23","APC"
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2448.56","","","","","","","fee schedule","722.52","2570.99",""
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2448.56","","","","","","","fee schedule","722.52","2570.99",""
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2448.56","","","","","","","fee schedule","722.52","2570.99",""
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","722.52","2570.99",""
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","722.52","2570.99",""
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2564.87","","","","","","","fee schedule","722.52","2570.99","APC"
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2522.02","","","","","","","fee schedule","722.52","2570.99","APC"
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2497.53","","","","","","","fee schedule","722.52","2570.99","APC"
"Ashkenazi jewish assoc dis","81412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2570.99","","","","","","","fee schedule","722.52","2570.99","APC"
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","962.8","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","962.8","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 10 gns","81413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","962.8","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","962.8","","","","","","","fee schedule","584.9","962.8",""
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","962.8","APC"
"Car ion chnnlpath inc 2 gns","81414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","962.8","APC"
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4780","","","","","","","fee schedule","4780","5736",""
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4780","","","","","","","fee schedule","4780","5736",""
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4780","","","","","","","fee schedule","4780","5736",""
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5736","","","","","","","fee schedule","4780","5736",""
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5736","","","","","","","fee schedule","4780","5736",""
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5007.05","","","","","","","fee schedule","4780","5736","APC"
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4923.4","","","","","","","fee schedule","4780","5736","APC"
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4875.6","","","","","","","fee schedule","4780","5736","APC"
"Exome sequence analysis","81415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5019","","","","","","","fee schedule","4780","5736","APC"
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12000","","","","","","","fee schedule","12000","14400",""
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12000","","","","","","","fee schedule","12000","14400",""
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12000","","","","","","","fee schedule","12000","14400",""
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14400","","","","","","","fee schedule","12000","14400",""
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14400","","","","","","","fee schedule","12000","14400",""
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12570","","","","","","","fee schedule","12000","14400","APC"
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12360","","","","","","","fee schedule","12000","14400","APC"
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12240","","","","","","","fee schedule","12000","14400","APC"
"Exome sequence analysis","81416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12600","","","","","","","fee schedule","12000","14400","APC"
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","320","","","","","","","fee schedule","320","384",""
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","320","","","","","","","fee schedule","320","384",""
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","320","","","","","","","fee schedule","320","384",""
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","384","","","","","","","fee schedule","320","384",""
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","384","","","","","","","fee schedule","320","384",""
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","335.2","","","","","","","fee schedule","320","384","APC"
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","329.6","","","","","","","fee schedule","320","384","APC"
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","326.4","","","","","","","fee schedule","320","384","APC"
"Exome re-evaluation","81417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","336","","","","","","","fee schedule","320","384","APC"
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","917.08","","","","","","","fee schedule","917.08","1100.5",""
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","917.08","","","","","","","fee schedule","917.08","1100.5",""
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","917.08","","","","","","","fee schedule","917.08","1100.5",""
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1100.5","","","","","","","fee schedule","917.08","1100.5",""
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1100.5","","","","","","","fee schedule","917.08","1100.5",""
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","960.64","","","","","","","fee schedule","917.08","1100.5","APC"
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","944.59","","","","","","","fee schedule","917.08","1100.5","APC"
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","935.42","","","","","","","fee schedule","917.08","1100.5","APC"
"Rx metab gen seq alys pnl 6","81418","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","962.93","","","","","","","fee schedule","917.08","1100.5","APC"
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2564.87","","","","","","","fee schedule","2448.56","2938.27","APC"
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2522.02","","","","","","","fee schedule","2448.56","2938.27","APC"
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2497.53","","","","","","","fee schedule","2448.56","2938.27","APC"
"Epilepsy gen seq alys panel","81419","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2570.99","","","","","","","fee schedule","2448.56","2938.27","APC"
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","962.8","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","962.8","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml aneuploidy","81420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.05","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.05","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.05","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","962.8","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","962.8","","","","","","","fee schedule","759.05","962.8",""
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.1","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","781.82","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.23","","","","","","","fee schedule","759.05","962.8","APC"
"Fetal chrmoml microdeltj","81422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797","","","","","","","fee schedule","759.05","962.8","APC"
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5031.2","","","","","","","fee schedule","5031.2","6037.44",""
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5031.2","","","","","","","fee schedule","5031.2","6037.44",""
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5031.2","","","","","","","fee schedule","5031.2","6037.44",""
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6037.44","","","","","","","fee schedule","5031.2","6037.44",""
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6037.44","","","","","","","fee schedule","5031.2","6037.44",""
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5270.18","","","","","","","fee schedule","5031.2","6037.44","APC"
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5182.14","","","","","","","fee schedule","5031.2","6037.44","APC"
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5131.82","","","","","","","fee schedule","5031.2","6037.44","APC"
"Genome sequence analysis","81425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5282.76","","","","","","","fee schedule","5031.2","6037.44","APC"
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2709.95","","","","","","","fee schedule","2709.95","3251.94",""
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2709.95","","","","","","","fee schedule","2709.95","3251.94",""
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2709.95","","","","","","","fee schedule","2709.95","3251.94",""
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3251.94","","","","","","","fee schedule","2709.95","3251.94",""
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3251.94","","","","","","","fee schedule","2709.95","3251.94",""
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2838.67","","","","","","","fee schedule","2709.95","3251.94","APC"
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2791.25","","","","","","","fee schedule","2709.95","3251.94","APC"
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2764.15","","","","","","","fee schedule","2709.95","3251.94","APC"
"Genome sequence analysis","81426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2845.45","","","","","","","fee schedule","2709.95","3251.94","APC"
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2337.65","","","","","","","fee schedule","2337.65","2805.18",""
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2337.65","","","","","","","fee schedule","2337.65","2805.18",""
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2337.65","","","","","","","fee schedule","2337.65","2805.18",""
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2805.18","","","","","","","fee schedule","2337.65","2805.18",""
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2805.18","","","","","","","fee schedule","2337.65","2805.18",""
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2448.69","","","","","","","fee schedule","2337.65","2805.18","APC"
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2407.78","","","","","","","fee schedule","2337.65","2805.18","APC"
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2384.4","","","","","","","fee schedule","2337.65","2805.18","APC"
"Genome re-evaluation","81427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2454.53","","","","","","","fee schedule","2337.65","2805.18","APC"
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1625","","","","","","","fee schedule","1625","1950",""
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1625","","","","","","","fee schedule","1625","1950",""
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1625","","","","","","","fee schedule","1625","1950",""
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1950","","","","","","","fee schedule","1625","1950",""
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1950","","","","","","","fee schedule","1625","1950",""
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1702.19","","","","","","","fee schedule","1625","1950","APC"
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1673.75","","","","","","","fee schedule","1625","1950","APC"
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1657.5","","","","","","","fee schedule","1625","1950","APC"
"Hearing loss sequence analys","81430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1706.25","","","","","","","fee schedule","1625","1950","APC"
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","679.57","","","","","","","fee schedule","679.57","815.48",""
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","679.57","","","","","","","fee schedule","679.57","815.48",""
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","679.57","","","","","","","fee schedule","679.57","815.48",""
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","815.48","","","","","","","fee schedule","679.57","815.48",""
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","815.48","","","","","","","fee schedule","679.57","815.48",""
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.85","","","","","","","fee schedule","679.57","815.48","APC"
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.96","","","","","","","fee schedule","679.57","815.48","APC"
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.16","","","","","","","fee schedule","679.57","815.48","APC"
"Hearing loss dup/del analys","81431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.55","","","","","","","fee schedule","679.57","815.48","APC"
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","1117.78","1369.15",""
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","1117.78","1369.15",""
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","1117.78","1369.15",""
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1117.78","","","","","","","fee schedule","1117.78","1369.15",""
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1117.78","","","","","","","fee schedule","1117.78","1369.15",""
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","1117.78","1369.15","APC"
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","1117.78","1369.15","APC"
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","1117.78","1369.15","APC"
"Hrdtry brst ca-rlatd dsordrs","81432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","1117.78","1369.15","APC"
"Hrdtry brst ca-rlatd dsordrs","81433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","438.93","","","","","","","fee schedule","438.93","722.52",""
"Hrdtry brst ca-rlatd dsordrs","81433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","438.93","","","","","","","fee schedule","438.93","722.52",""
"Hrdtry brst ca-rlatd dsordrs","81433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","438.93","","","","","","","fee schedule","438.93","722.52",""
"Hrdtry brst ca-rlatd dsordrs","81433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","438.93","722.52",""
"Hrdtry brst ca-rlatd dsordrs","81433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","438.93","722.52",""
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","597.91","","","","","","","fee schedule","597.91","722.52",""
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","597.91","","","","","","","fee schedule","597.91","722.52",""
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","597.91","","","","","","","fee schedule","597.91","722.52",""
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","597.91","722.52",""
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","597.91","722.52",""
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","597.91","722.52","APC"
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","597.91","722.52","APC"
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","597.91","722.52","APC"
"Hereditary retinal disorders","81434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","597.91","722.52","APC"
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","955.12","1369.15",""
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","955.12","1369.15",""
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","955.12","1369.15",""
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","955.12","","","","","","","fee schedule","955.12","1369.15",""
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","955.12","","","","","","","fee schedule","955.12","1369.15",""
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","955.12","1369.15","APC"
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","955.12","1369.15","APC"
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","955.12","1369.15","APC"
"Hereditary colon ca dsordrs","81435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","955.12","1369.15","APC"
"Hereditary colon ca dsordrs","81436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","955.12",""
"Hereditary colon ca dsordrs","81436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","955.12",""
"Hereditary colon ca dsordrs","81436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","955.12",""
"Hereditary colon ca dsordrs","81436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","955.12","","","","","","","fee schedule","584.9","955.12",""
"Hereditary colon ca dsordrs","81436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","955.12","","","","","","","fee schedule","584.9","955.12",""
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1303.95","","","","","","","fee schedule","722.52","1369.15",""
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1303.95","","","","","","","fee schedule","722.52","1369.15",""
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1303.95","","","","","","","fee schedule","722.52","1369.15",""
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","722.52","1369.15",""
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","722.52","1369.15",""
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1365.89","","","","","","","fee schedule","722.52","1369.15","APC"
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1343.07","","","","","","","fee schedule","722.52","1369.15","APC"
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1330.03","","","","","","","fee schedule","722.52","1369.15","APC"
"Heredtry nurondcrn tum dsrdr","81437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1369.15","","","","","","","fee schedule","722.52","1369.15","APC"
"Heredtry nurondcrn tum dsrdr","81438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","438.93","","","","","","","fee schedule","438.93","722.52",""
"Heredtry nurondcrn tum dsrdr","81438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","438.93","","","","","","","fee schedule","438.93","722.52",""
"Heredtry nurondcrn tum dsrdr","81438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","438.93","","","","","","","fee schedule","438.93","722.52",""
"Heredtry nurondcrn tum dsrdr","81438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","438.93","722.52",""
"Heredtry nurondcrn tum dsrdr","81438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","438.93","722.52",""
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","962.8",""
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","962.8",""
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","962.8",""
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","962.8","","","","","","","fee schedule","584.9","962.8",""
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","962.8","","","","","","","fee schedule","584.9","962.8",""
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","962.8","APC"
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","962.8","APC"
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","962.8","APC"
"Inherited cardmypthy 5 gns","81439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","962.8","APC"
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3324","","","","","","","fee schedule","3324","3988.8",""
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3324","","","","","","","fee schedule","3324","3988.8",""
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3324","","","","","","","fee schedule","3324","3988.8",""
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3988.8","","","","","","","fee schedule","3324","3988.8",""
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3988.8","","","","","","","fee schedule","3324","3988.8",""
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3481.89","","","","","","","fee schedule","3324","3988.8","APC"
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3423.72","","","","","","","fee schedule","3324","3988.8","APC"
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3390.48","","","","","","","fee schedule","3324","3988.8","APC"
"Mitochondrial gene","81440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3490.2","","","","","","","fee schedule","3324","3988.8","APC"
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2564.87","","","","","","","fee schedule","2448.56","2938.27","APC"
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2522.02","","","","","","","fee schedule","2448.56","2938.27","APC"
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2497.53","","","","","","","fee schedule","2448.56","2938.27","APC"
"Ibmfs seq alys pnl 30 genes","81441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2570.99","","","","","","","fee schedule","2448.56","2938.27","APC"
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2143.6","","","","","","","fee schedule","722.52","2250.78",""
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2143.6","","","","","","","fee schedule","722.52","2250.78",""
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2143.6","","","","","","","fee schedule","722.52","2250.78",""
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","722.52","2250.78",""
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","722.52","2250.78",""
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2245.42","","","","","","","fee schedule","722.52","2250.78","APC"
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2207.91","","","","","","","fee schedule","722.52","2250.78","APC"
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2186.47","","","","","","","fee schedule","722.52","2250.78","APC"
"Noonan spectrum disorders","81442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2250.78","","","","","","","fee schedule","722.52","2250.78","APC"
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2448.56","","","","","","","fee schedule","2448.56","2938.27",""
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2938.27","","","","","","","fee schedule","2448.56","2938.27",""
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2564.87","","","","","","","fee schedule","2448.56","2938.27","APC"
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2522.02","","","","","","","fee schedule","2448.56","2938.27","APC"
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2497.53","","","","","","","fee schedule","2448.56","2938.27","APC"
"Genetic tstg severe inh cond","81443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2570.99","","","","","","","fee schedule","2448.56","2938.27","APC"
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","597.91","","","","","","","fee schedule","107.8","627.81",""
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","597.91","","","","","","","fee schedule","107.8","627.81",""
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","597.91","","","","","","","fee schedule","107.8","627.81",""
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","107.8","","","","","","","fee schedule","107.8","627.81",""
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","107.8","","","","","","","fee schedule","107.8","627.81",""
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","107.8","627.81","APC"
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","107.8","627.81","APC"
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","107.8","627.81","APC"
"Targeted genomic seq analys","81445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","107.8","627.81","APC"
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","584.9","","","","","","","fee schedule","584.9","866.52",""
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.9","","","","","","","fee schedule","584.9","866.52",""
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","584.9","","","","","","","fee schedule","584.9","866.52",""
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","866.52","","","","","","","fee schedule","584.9","866.52",""
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","866.52","","","","","","","fee schedule","584.9","866.52",""
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","612.68","","","","","","","fee schedule","584.9","866.52","APC"
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","602.45","","","","","","","fee schedule","584.9","866.52","APC"
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","596.6","","","","","","","fee schedule","584.9","866.52","APC"
"Hrdtry perph neurphy panel","81448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","614.14","","","","","","","fee schedule","584.9","866.52","APC"
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","597.91","","","","","","","fee schedule","597.91","717.49",""
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","597.91","","","","","","","fee schedule","597.91","717.49",""
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","597.91","","","","","","","fee schedule","597.91","717.49",""
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","717.49","","","","","","","fee schedule","597.91","717.49",""
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","717.49","","","","","","","fee schedule","597.91","717.49",""
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.31","","","","","","","fee schedule","597.91","717.49","APC"
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.85","","","","","","","fee schedule","597.91","717.49","APC"
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.87","","","","","","","fee schedule","597.91","717.49","APC"
"Tgsap so neo 5-50 rna alys","81449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.81","","","","","","","fee schedule","597.91","717.49","APC"
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.53","","","","","","","fee schedule","107.8","797.51",""
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.53","","","","","","","fee schedule","107.8","797.51",""
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.53","","","","","","","fee schedule","107.8","797.51",""
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","107.8","","","","","","","fee schedule","107.8","797.51",""
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","107.8","","","","","","","fee schedule","107.8","797.51",""
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.61","","","","","","","fee schedule","107.8","797.51","APC"
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.32","","","","","","","fee schedule","107.8","797.51","APC"
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.72","","","","","","","fee schedule","107.8","797.51","APC"
"Targeted genomic seq analys","81450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797.51","","","","","","","fee schedule","107.8","797.51","APC"
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","759.53","","","","","","","fee schedule","759.53","911.44",""
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","759.53","","","","","","","fee schedule","759.53","911.44",""
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","759.53","","","","","","","fee schedule","759.53","911.44",""
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","911.44","","","","","","","fee schedule","759.53","911.44",""
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","911.44","","","","","","","fee schedule","759.53","911.44",""
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","795.61","","","","","","","fee schedule","759.53","911.44","APC"
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.32","","","","","","","fee schedule","759.53","911.44","APC"
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","774.72","","","","","","","fee schedule","759.53","911.44","APC"
"Tgsap hl neo 5-50 rna alys","81451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","797.51","","","","","","","fee schedule","759.53","911.44","APC"
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Targeted genomic seq analys","81455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2919.6","","","","","","","fee schedule","2919.6","3503.52",""
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3503.52","","","","","","","fee schedule","2919.6","3503.52",""
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3058.28","","","","","","","fee schedule","2919.6","3503.52","APC"
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3007.19","","","","","","","fee schedule","2919.6","3503.52","APC"
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2977.99","","","","","","","fee schedule","2919.6","3503.52","APC"
"Tgsap so/hl 51/< rna alys","81456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3065.58","","","","","","","fee schedule","2919.6","3503.52","APC"
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","896.87","","","","","","","fee schedule","896.87","941.71",""
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","896.87","","","","","","","fee schedule","896.87","941.71",""
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","896.87","","","","","","","fee schedule","896.87","941.71",""
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.47","","","","","","","fee schedule","896.87","941.71","APC"
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.78","","","","","","","fee schedule","896.87","941.71","APC"
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.81","","","","","","","fee schedule","896.87","941.71","APC"
"So neo gsap dna mcrstl ins","81457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.71","","","","","","","fee schedule","896.87","941.71","APC"
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1046.35","","","","","","","fee schedule","1046.35","1098.67",""
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1046.35","","","","","","","fee schedule","1046.35","1098.67",""
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1046.35","","","","","","","fee schedule","1046.35","1098.67",""
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1096.05","","","","","","","fee schedule","1046.35","1098.67","APC"
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1077.74","","","","","","","fee schedule","1046.35","1098.67","APC"
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1067.28","","","","","","","fee schedule","1046.35","1098.67","APC"
"So gsap dna cpy nmbr&mcrstl","81458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1098.67","","","","","","","fee schedule","1046.35","1098.67","APC"
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2989.55","","","","","","","fee schedule","2989.55","3139.03",""
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2989.55","","","","","","","fee schedule","2989.55","3139.03",""
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2989.55","","","","","","","fee schedule","2989.55","3139.03",""
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3131.55","","","","","","","fee schedule","2989.55","3139.03","APC"
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3079.24","","","","","","","fee schedule","2989.55","3139.03","APC"
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3049.34","","","","","","","fee schedule","2989.55","3139.03","APC"
"So neo gsap dna/dna&rna","81459","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3139.03","","","","","","","fee schedule","2989.55","3139.03","APC"
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1287","","","","","","","fee schedule","1287","1544.4",""
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1287","","","","","","","fee schedule","1287","1544.4",""
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1287","","","","","","","fee schedule","1287","1544.4",""
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1544.4","","","","","","","fee schedule","1287","1544.4",""
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1544.4","","","","","","","fee schedule","1287","1544.4",""
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1348.13","","","","","","","fee schedule","1287","1544.4","APC"
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1325.61","","","","","","","fee schedule","1287","1544.4","APC"
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1312.74","","","","","","","fee schedule","1287","1544.4","APC"
"Whole mitochondrial genome","81460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1351.35","","","","","","","fee schedule","1287","1544.4","APC"
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1195.83","","","","","","","fee schedule","1195.83","1255.62",""
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1195.83","","","","","","","fee schedule","1195.83","1255.62",""
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1195.83","","","","","","","fee schedule","1195.83","1255.62",""
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1252.63","","","","","","","fee schedule","1195.83","1255.62","APC"
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1231.7","","","","","","","fee schedule","1195.83","1255.62","APC"
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1219.75","","","","","","","fee schedule","1195.83","1255.62","APC"
"So gsap cll fr dna/dna&rna","81462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1255.62","","","","","","","fee schedule","1195.83","1255.62","APC"
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1345.31","","","","","","","fee schedule","1345.31","1412.58",""
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1345.31","","","","","","","fee schedule","1345.31","1412.58",""
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1345.31","","","","","","","fee schedule","1345.31","1412.58",""
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1409.21","","","","","","","fee schedule","1345.31","1412.58","APC"
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1385.67","","","","","","","fee schedule","1345.31","1412.58","APC"
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1372.22","","","","","","","fee schedule","1345.31","1412.58","APC"
"So gsap cl fr cpy nmbr&mcrst","81463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1412.58","","","","","","","fee schedule","1345.31","1412.58","APC"
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3288.51","","","","","","","fee schedule","3288.51","3452.94",""
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3288.51","","","","","","","fee schedule","3288.51","3452.94",""
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3288.51","","","","","","","fee schedule","3288.51","3452.94",""
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3444.71","","","","","","","fee schedule","3288.51","3452.94","APC"
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3387.17","","","","","","","fee schedule","3288.51","3452.94","APC"
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3354.28","","","","","","","fee schedule","3288.51","3452.94","APC"
"So gsap cll fr mcrstl ins","81464","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3452.94","","","","","","","fee schedule","3288.51","3452.94","APC"
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","936","","","","","","","fee schedule","936","1123.2",""
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","936","","","","","","","fee schedule","936","1123.2",""
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","936","","","","","","","fee schedule","936","1123.2",""
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1123.2","","","","","","","fee schedule","936","1123.2",""
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1123.2","","","","","","","fee schedule","936","1123.2",""
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","980.46","","","","","","","fee schedule","936","1123.2","APC"
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","964.08","","","","","","","fee schedule","936","1123.2","APC"
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","954.72","","","","","","","fee schedule","936","1123.2","APC"
"Whole mitochondrial genome","81465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","982.8","","","","","","","fee schedule","936","1123.2","APC"
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","914","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","914","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","914","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1096.8","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1096.8","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","957.42","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","941.42","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","932.28","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","959.7","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","914","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","914","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","914","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1096.8","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1096.8","","","","","","","fee schedule","914","1096.8",""
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","957.42","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","941.42","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","932.28","","","","","","","fee schedule","914","1096.8","APC"
"X-linked intellectual dblt","81471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","959.7","","","","","","","fee schedule","914","1096.8","APC"
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","840.65","","","","","","","fee schedule","708.73","882.68",""
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","840.65","","","","","","","fee schedule","708.73","882.68",""
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","840.65","","","","","","","fee schedule","708.73","882.68",""
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","708.73","","","","","","","fee schedule","708.73","882.68",""
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","708.73","","","","","","","fee schedule","708.73","882.68",""
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","880.58","","","","","","","fee schedule","708.73","882.68","APC"
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","865.87","","","","","","","fee schedule","708.73","882.68","APC"
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","857.46","","","","","","","fee schedule","708.73","882.68","APC"
"Autoimmune rheumatoid arthr","81490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","882.68","","","","","","","fee schedule","708.73","882.68","APC"
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1050","","","","","","","fee schedule","1050","1250.82",""
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1050","","","","","","","fee schedule","1050","1250.82",""
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1050","","","","","","","fee schedule","1050","1250.82",""
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1250.82","","","","","","","fee schedule","1050","1250.82",""
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1250.82","","","","","","","fee schedule","1050","1250.82",""
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1099.88","","","","","","","fee schedule","1050","1250.82","APC"
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1081.5","","","","","","","fee schedule","1050","1250.82","APC"
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1071","","","","","","","fee schedule","1050","1250.82","APC"
"Cor artery disease mrna","81493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1102.5","","","","","","","fee schedule","1050","1250.82","APC"
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","260.5","","","","","","","fee schedule","260.5","312.6",""
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","260.5","","","","","","","fee schedule","260.5","312.6",""
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.5","","","","","","","fee schedule","260.5","312.6",""
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","312.6","","","","","","","fee schedule","260.5","312.6",""
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","312.6","","","","","","","fee schedule","260.5","312.6",""
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.87","","","","","","","fee schedule","260.5","312.6","APC"
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.32","","","","","","","fee schedule","260.5","312.6","APC"
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.71","","","","","","","fee schedule","260.5","312.6","APC"
"Onco (ovar) two proteins","81500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.53","","","","","","","fee schedule","260.5","312.6","APC"
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","897","","","","","","","fee schedule","897","1076.4",""
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","897","","","","","","","fee schedule","897","1076.4",""
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","897","","","","","","","fee schedule","897","1076.4",""
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1076.4","","","","","","","fee schedule","897","1076.4",""
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","939.61","","","","","","","fee schedule","897","1076.4","APC"
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","923.91","","","","","","","fee schedule","897","1076.4","APC"
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","914.94","","","","","","","fee schedule","897","1076.4","APC"
"Onco (ovar) five proteins","81503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","941.85","","","","","","","fee schedule","897","1076.4","APC"
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","520","","","","","","","fee schedule","520","624",""
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","520","","","","","","","fee schedule","520","624",""
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","520","","","","","","","fee schedule","520","624",""
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","624","","","","","","","fee schedule","520","624",""
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","624","","","","","","","fee schedule","520","624",""
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","544.7","","","","","","","fee schedule","520","624","APC"
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","535.6","","","","","","","fee schedule","520","624","APC"
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","530.4","","","","","","","fee schedule","520","624","APC"
"Oncology tissue of origin","81504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","546","","","","","","","fee schedule","520","624","APC"
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68.92","","","","","","","fee schedule","68.92","97.24",""
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68.92","","","","","","","fee schedule","68.92","97.24",""
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","68.92","","","","","","","fee schedule","68.92","97.24",""
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","97.24","","","","","","","fee schedule","68.92","97.24",""
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","97.24","","","","","","","fee schedule","68.92","97.24",""
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","72.19","","","","","","","fee schedule","68.92","97.24","APC"
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","70.99","","","","","","","fee schedule","68.92","97.24","APC"
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","70.3","","","","","","","fee schedule","68.92","97.24","APC"
"Endo assay seven anal","81506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","72.37","","","","","","","fee schedule","68.92","97.24","APC"
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","795","","","","","","","fee schedule","795","954",""
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","795","","","","","","","fee schedule","795","954",""
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","795","","","","","","","fee schedule","795","954",""
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","954","","","","","","","fee schedule","795","954",""
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","954","","","","","","","fee schedule","795","954",""
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","832.76","","","","","","","fee schedule","795","954","APC"
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","818.85","","","","","","","fee schedule","795","954","APC"
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","810.9","","","","","","","fee schedule","795","954","APC"
"Fetal aneuploidy trisom risk","81507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","834.75","","","","","","","fee schedule","795","954","APC"
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54.3","","","","","","","fee schedule","54.3","65.16",""
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","54.3","","","","","","","fee schedule","54.3","65.16",""
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","54.3","","","","","","","fee schedule","54.3","65.16",""
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","65.16","","","","","","","fee schedule","54.3","65.16",""
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","65.16","","","","","","","fee schedule","54.3","65.16",""
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","56.88","","","","","","","fee schedule","54.3","65.16","APC"
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","55.93","","","","","","","fee schedule","54.3","65.16","APC"
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","55.39","","","","","","","fee schedule","54.3","65.16","APC"
"Ftl cgen abnor two proteins","81508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57.02","","","","","","","fee schedule","54.3","65.16","APC"
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1487.37","","","","","","","fee schedule","1487.37","1784.84",""
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1487.37","","","","","","","fee schedule","1487.37","1784.84",""
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1487.37","","","","","","","fee schedule","1487.37","1784.84",""
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","1784.84","","","","","","","fee schedule","1487.37","1784.84",""
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","1784.84","","","","","","","fee schedule","1487.37","1784.84",""
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1558.02","","","","","","","fee schedule","1487.37","1784.84","APC"
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1531.99","","","","","","","fee schedule","1487.37","1784.84","APC"
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1517.12","","","","","","","fee schedule","1487.37","1784.84","APC"
"Ftl cgen abnor 3 proteins","81509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1561.74","","","","","","","fee schedule","1487.37","1784.84","APC"
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.54","","","","","","","fee schedule","55.54","66.65",""
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","55.54","","","","","","","fee schedule","55.54","66.65",""
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","55.54","","","","","","","fee schedule","55.54","66.65",""
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","66.65","","","","","","","fee schedule","55.54","66.65",""
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","66.65","","","","","","","fee schedule","55.54","66.65",""
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.18","","","","","","","fee schedule","55.54","66.65","APC"
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.21","","","","","","","fee schedule","55.54","66.65","APC"
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.65","","","","","","","fee schedule","55.54","66.65","APC"
"Ftl cgen abnor three anal","81510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.32","","","","","","","fee schedule","55.54","66.65","APC"
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","153.5","","","","","","","fee schedule","153.5","184.2",""
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","153.5","","","","","","","fee schedule","153.5","184.2",""
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","153.5","","","","","","","fee schedule","153.5","184.2",""
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","184.2","","","","","","","fee schedule","153.5","184.2",""
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","184.2","","","","","","","fee schedule","153.5","184.2",""
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","160.79","","","","","","","fee schedule","153.5","184.2","APC"
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","158.11","","","","","","","fee schedule","153.5","184.2","APC"
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","156.57","","","","","","","fee schedule","153.5","184.2","APC"
"Ftl cgen abnor four anal","81511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","161.18","","","","","","","fee schedule","153.5","184.2","APC"
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","69.52","","","","","","","fee schedule","69.52","83.42",""
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","69.52","","","","","","","fee schedule","69.52","83.42",""
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","69.52","","","","","","","fee schedule","69.52","83.42",""
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","83.42","","","","","","","fee schedule","69.52","83.42",""
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","83.42","","","","","","","fee schedule","69.52","83.42",""
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","72.82","","","","","","","fee schedule","69.52","83.42","APC"
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","71.61","","","","","","","fee schedule","69.52","83.42","APC"
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","70.91","","","","","","","fee schedule","69.52","83.42","APC"
"Ftl cgen abnor five anal","81512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73","","","","","","","fee schedule","69.52","83.42","APC"
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.16",""
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.16",""
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.16","","","","","","","fee schedule","142.63","171.16",""
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.16","","","","","","","fee schedule","142.63","171.16",""
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct ds bv rna vag flu alg","81513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","171.16","APC"
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","262.99","","","","","","","fee schedule","262.99","315.59",""
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","262.99","","","","","","","fee schedule","262.99","315.59",""
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","262.99","","","","","","","fee schedule","262.99","315.59",""
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","315.59","","","","","","","fee schedule","262.99","315.59",""
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","315.59","","","","","","","fee schedule","262.99","315.59",""
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.48","","","","","","","fee schedule","262.99","315.59","APC"
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","270.88","","","","","","","fee schedule","262.99","315.59","APC"
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","268.25","","","","","","","fee schedule","262.99","315.59","APC"
"Nfct ds bv&vaginitis dna alg","81514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","276.14","","","","","","","fee schedule","262.99","315.59","APC"
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","262.99","","","","","","","fee schedule","262.99","276.14",""
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","262.99","","","","","","","fee schedule","262.99","276.14",""
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","262.99","","","","","","","fee schedule","262.99","276.14",""
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.48","","","","","","","fee schedule","262.99","276.14","APC"
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","270.88","","","","","","","fee schedule","262.99","276.14","APC"
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","268.25","","","","","","","fee schedule","262.99","276.14","APC"
"Nfct ds bv&vaginitis dna alg","81515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","276.14","","","","","","","fee schedule","262.99","276.14","APC"
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","176.19","","","","","","","fee schedule","176.19","211.43",""
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","176.19","","","","","","","fee schedule","176.19","211.43",""
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","176.19","","","","","","","fee schedule","176.19","211.43",""
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","211.43","","","","","","","fee schedule","176.19","211.43",""
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","211.43","","","","","","","fee schedule","176.19","211.43",""
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","184.56","","","","","","","fee schedule","176.19","211.43","APC"
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","181.48","","","","","","","fee schedule","176.19","211.43","APC"
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","179.71","","","","","","","fee schedule","176.19","211.43","APC"
"Liver ds alys 3 bmrk srm alg","81517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","185","","","","","","","fee schedule","176.19","211.43","APC"
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 11 genes","81518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4099.01",""
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4099.01",""
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4099.01",""
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4099.01","","","","","","","fee schedule","3873","4099.01",""
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4099.01","","","","","","","fee schedule","3873","4099.01",""
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4099.01","APC"
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4099.01","APC"
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4099.01","APC"
"Oncology breast mrna","81519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4099.01","APC"
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2510.21","","","","","","","fee schedule","2510.21","3718.82",""
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2510.21","","","","","","","fee schedule","2510.21","3718.82",""
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2510.21","","","","","","","fee schedule","2510.21","3718.82",""
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3718.82","","","","","","","fee schedule","2510.21","3718.82",""
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3718.82","","","","","","","fee schedule","2510.21","3718.82",""
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2629.44","","","","","","","fee schedule","2510.21","3718.82","APC"
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2585.52","","","","","","","fee schedule","2510.21","3718.82","APC"
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2560.41","","","","","","","fee schedule","2510.21","3718.82","APC"
"Onc breast mrna 58 genes","81520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2635.72","","","","","","","fee schedule","2510.21","3718.82","APC"
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 70 genes","81521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc breast mrna 12 genes","81522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc brst mrna 70 cnt 31 gene","81523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3116","","","","","","","fee schedule","3116","3750.88",""
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3116","","","","","","","fee schedule","3116","3750.88",""
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3116","","","","","","","fee schedule","3116","3750.88",""
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3750.88","","","","","","","fee schedule","3116","3750.88",""
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3750.88","","","","","","","fee schedule","3116","3750.88",""
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3264.01","","","","","","","fee schedule","3116","3750.88","APC"
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3209.48","","","","","","","fee schedule","3116","3750.88","APC"
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3178.32","","","","","","","fee schedule","3116","3750.88","APC"
"Oncology colon mrna","81525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3271.8","","","","","","","fee schedule","3116","3750.88","APC"
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","508.87","","","","","","","fee schedule","508.87","610.64",""
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","508.87","","","","","","","fee schedule","508.87","610.64",""
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","508.87","","","","","","","fee schedule","508.87","610.64",""
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","610.64","","","","","","","fee schedule","508.87","610.64",""
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","610.64","","","","","","","fee schedule","508.87","610.64",""
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","533.04","","","","","","","fee schedule","508.87","610.64","APC"
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","524.14","","","","","","","fee schedule","508.87","610.64","APC"
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","519.05","","","","","","","fee schedule","508.87","610.64","APC"
"Oncology colorectal scr","81528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","534.31","","","","","","","fee schedule","508.87","610.64","APC"
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7193","","","","","","","fee schedule","7193","8631.6",""
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7193","","","","","","","fee schedule","7193","8631.6",""
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7193","","","","","","","fee schedule","7193","8631.6",""
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8631.6","","","","","","","fee schedule","7193","8631.6",""
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8631.6","","","","","","","fee schedule","7193","8631.6",""
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7534.67","","","","","","","fee schedule","7193","8631.6","APC"
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7408.79","","","","","","","fee schedule","7193","8631.6","APC"
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7336.86","","","","","","","fee schedule","7193","8631.6","APC"
"Onc cutan mlnma mrna 31 gene","81529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7552.65","","","","","","","fee schedule","7193","8631.6","APC"
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","579.46","","","","","","","fee schedule","579.46","695.35",""
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","579.46","","","","","","","fee schedule","579.46","695.35",""
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","579.46","","","","","","","fee schedule","579.46","695.35",""
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","695.35","","","","","","","fee schedule","579.46","695.35",""
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","695.35","","","","","","","fee schedule","579.46","695.35",""
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","606.98","","","","","","","fee schedule","579.46","695.35","APC"
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","596.84","","","","","","","fee schedule","579.46","695.35","APC"
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","591.05","","","","","","","fee schedule","579.46","695.35","APC"
"Oncology gynecologic","81535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","608.43","","","","","","","fee schedule","579.46","695.35","APC"
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","177.56","","","","","","","fee schedule","177.56","213.07",""
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","177.56","","","","","","","fee schedule","177.56","213.07",""
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","177.56","","","","","","","fee schedule","177.56","213.07",""
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","213.07","","","","","","","fee schedule","177.56","213.07",""
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","213.07","","","","","","","fee schedule","177.56","213.07",""
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","185.99","","","","","","","fee schedule","177.56","213.07","APC"
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","182.89","","","","","","","fee schedule","177.56","213.07","APC"
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","181.11","","","","","","","fee schedule","177.56","213.07","APC"
"Oncology gynecologic","81536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","186.44","","","","","","","fee schedule","177.56","213.07","APC"
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2871","","","","","","","fee schedule","2552.14","3014.55",""
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2871","","","","","","","fee schedule","2552.14","3014.55",""
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2871","","","","","","","fee schedule","2552.14","3014.55",""
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2552.14","","","","","","","fee schedule","2552.14","3014.55",""
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2552.14","","","","","","","fee schedule","2552.14","3014.55",""
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3007.37","","","","","","","fee schedule","2552.14","3014.55","APC"
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2957.13","","","","","","","fee schedule","2552.14","3014.55","APC"
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2928.42","","","","","","","fee schedule","2552.14","3014.55","APC"
"Oncology lung","81538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3014.55","","","","","","","fee schedule","2552.14","3014.55","APC"
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","760","","","","","","","fee schedule","722.52","798",""
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","760","","","","","","","fee schedule","722.52","798",""
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","760","","","","","","","fee schedule","722.52","798",""
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","722.52","","","","","","","fee schedule","722.52","798",""
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","722.52","","","","","","","fee schedule","722.52","798",""
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","796.1","","","","","","","fee schedule","722.52","798","APC"
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","782.8","","","","","","","fee schedule","722.52","798","APC"
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","775.2","","","","","","","fee schedule","722.52","798","APC"
"Oncology prostate prob score","81539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","798","","","","","","","fee schedule","722.52","798","APC"
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3750","","","","","","","fee schedule","3504.36","3937.5",""
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3750","","","","","","","fee schedule","3504.36","3937.5",""
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3750","","","","","","","fee schedule","3504.36","3937.5",""
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3504.36","","","","","","","fee schedule","3504.36","3937.5",""
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3504.36","","","","","","","fee schedule","3504.36","3937.5",""
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3928.13","","","","","","","fee schedule","3504.36","3937.5","APC"
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3862.5","","","","","","","fee schedule","3504.36","3937.5","APC"
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3825","","","","","","","fee schedule","3504.36","3937.5","APC"
"Oncology tum unknown origin","81540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3937.5","","","","","","","fee schedule","3504.36","3937.5","APC"
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 46 genes","81541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3873","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4647.6","","","","","","","fee schedule","3873","4647.6",""
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4056.97","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3989.19","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3950.46","","","","","","","fee schedule","3873","4647.6","APC"
"Onc prostate mrna 22 cnt gen","81542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4066.65","","","","","","","fee schedule","3873","4647.6","APC"
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3600","","","","","","","fee schedule","3600","4320",""
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3600","","","","","","","fee schedule","3600","4320",""
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3600","","","","","","","fee schedule","3600","4320",""
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4320","","","","","","","fee schedule","3600","4320",""
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4320","","","","","","","fee schedule","3600","4320",""
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3771","","","","","","","fee schedule","3600","4320","APC"
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3708","","","","","","","fee schedule","3600","4320","APC"
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3672","","","","","","","fee schedule","3600","4320","APC"
"Onc thyr mrna 10,196 gen alg","81546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3780","","","","","","","fee schedule","3600","4320","APC"
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2030","","","","","","","fee schedule","2030","2436",""
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2030","","","","","","","fee schedule","2030","2436",""
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2030","","","","","","","fee schedule","2030","2436",""
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2436","","","","","","","fee schedule","2030","2436",""
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2436","","","","","","","fee schedule","2030","2436",""
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2126.43","","","","","","","fee schedule","2030","2436","APC"
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2090.9","","","","","","","fee schedule","2030","2436","APC"
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2070.6","","","","","","","fee schedule","2030","2436","APC"
"Onc prostate 3 genes","81551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2131.5","","","","","","","fee schedule","2030","2436","APC"
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7776","","","","","","","fee schedule","7776","9331.2",""
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7776","","","","","","","fee schedule","7776","9331.2",""
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7776","","","","","","","fee schedule","7776","9331.2",""
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9331.2","","","","","","","fee schedule","7776","9331.2",""
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9331.2","","","","","","","fee schedule","7776","9331.2",""
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8145.36","","","","","","","fee schedule","7776","9331.2","APC"
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8009.28","","","","","","","fee schedule","7776","9331.2","APC"
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7931.52","","","","","","","fee schedule","7776","9331.2","APC"
"Onc uveal mlnma mrna 15 gene","81552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8164.8","","","","","","","fee schedule","7776","9331.2","APC"
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5445","","","","","","","fee schedule","5445","6600",""
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5445","","","","","","","fee schedule","5445","6600",""
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5445","","","","","","","fee schedule","5445","6600",""
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6600","","","","","","","fee schedule","5445","6600",""
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6600","","","","","","","fee schedule","5445","6600",""
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5666.56","","","","","","","fee schedule","5445","6600","APC"
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5571.89","","","","","","","fee schedule","5445","6600","APC"
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5517.79","","","","","","","fee schedule","5445","6600","APC"
"Pulm ds ipf mrna 190 gen alg","81554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5680.08","","","","","","","fee schedule","5445","6600","APC"
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3240","","","","","","","fee schedule","3240","3402",""
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3240","","","","","","","fee schedule","3240","3402",""
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3240","","","","","","","fee schedule","3240","3402",""
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3393.9","","","","","","","fee schedule","3240","3402","APC"
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3337.2","","","","","","","fee schedule","3240","3402","APC"
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3304.8","","","","","","","fee schedule","3240","3402","APC"
"Trnspl rej kdn mrna qpcr 139","81558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3402","","","","","","","fee schedule","3240","3402","APC"
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","640.73","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","640.73","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","640.73","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","768.88","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","768.88","","","","","","","fee schedule","640.73","768.88",""
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","671.16","","","","","","","fee schedule","640.73","768.88","APC"
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","659.95","","","","","","","fee schedule","640.73","768.88","APC"
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","653.54","","","","","","","fee schedule","640.73","768.88","APC"
"Trnsplj pd lvr&bwl cd154+cll","81560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","672.77","","","","","","","fee schedule","640.73","768.88","APC"
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3240","","","","","","","fee schedule","3240","3408.9",""
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3240","","","","","","","fee schedule","3240","3408.9",""
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3240","","","","","","","fee schedule","3240","3408.9",""
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3408.9","","","","","","","fee schedule","3240","3408.9",""
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3408.9","","","","","","","fee schedule","3240","3408.9",""
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3393.9","","","","","","","fee schedule","3240","3408.9","APC"
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3337.2","","","","","","","fee schedule","3240","3408.9","APC"
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3304.8","","","","","","","fee schedule","3240","3408.9","APC"
"Cardiology hrt trnspl mrna","81595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3402","","","","","","","fee schedule","3240","3408.9","APC"
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","72.19","","","","","","","fee schedule","72.19","86.63",""
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","72.19","","","","","","","fee schedule","72.19","86.63",""
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","72.19","","","","","","","fee schedule","72.19","86.63",""
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","86.63","","","","","","","fee schedule","72.19","86.63",""
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","86.63","","","","","","","fee schedule","72.19","86.63",""
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","75.62","","","","","","","fee schedule","72.19","86.63","APC"
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","74.36","","","","","","","fee schedule","72.19","86.63","APC"
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","73.63","","","","","","","fee schedule","72.19","86.63","APC"
"Nfct ds chrnc hcv 6 assays","81596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","75.8","","","","","","","fee schedule","72.19","86.63","APC"
"Assay of blood acetaldehyde","82000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86","","","","","","","fee schedule","86","86",""
"Assay of acetaminophen","82003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","147.34","","","","","","","fee schedule","147.34","147.34",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.52","","","","","","","fee schedule","4.52","32.57",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.52","","","","","","","fee schedule","4.52","32.57",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.52","","","","","","","fee schedule","4.52","32.57",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.76","","","","","","","fee schedule","4.52","32.57",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.57","","","","","","","fee schedule","4.52","32.57",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.76","","","","","","","fee schedule","4.52","32.57",""
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.73","","","","","","","fee schedule","4.52","32.57","APC"
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.66","","","","","","","fee schedule","4.52","32.57","APC"
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.61","","","","","","","fee schedule","4.52","32.57","APC"
"Test for acetone/ketones","82009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.75","","","","","","","fee schedule","4.52","32.57","APC"
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.17","","","","","","","fee schedule","8.17","59.02",""
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.17","","","","","","","fee schedule","8.17","59.02",""
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.17","","","","","","","fee schedule","8.17","59.02",""
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.05","","","","","","","fee schedule","8.17","59.02",""
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.02","","","","","","","fee schedule","8.17","59.02",""
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.05","","","","","","","fee schedule","8.17","59.02",""
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.56","","","","","","","fee schedule","8.17","59.02","APC"
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.42","","","","","","","fee schedule","8.17","59.02","APC"
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.33","","","","","","","fee schedule","8.17","59.02","APC"
"Acetone assay","82010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.17","59.02","APC"
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.29","","","","","","","fee schedule","12.29","80.74",""
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.29","","","","","","","fee schedule","12.29","80.74",""
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.29","","","","","","","fee schedule","12.29","80.74",""
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.2","","","","","","","fee schedule","12.29","80.74",""
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","80.74","","","","","","","fee schedule","12.29","80.74",""
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.2","","","","","","","fee schedule","12.29","80.74",""
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.87","","","","","","","fee schedule","12.29","80.74","APC"
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.66","","","","","","","fee schedule","12.29","80.74","APC"
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.54","","","","","","","fee schedule","12.29","80.74","APC"
"Acetylcholinesterase assay","82013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.9","","","","","","","fee schedule","12.29","80.74","APC"
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.49","","","","","","","fee schedule","16.49","103.18",""
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.49","","","","","","","fee schedule","16.49","103.18",""
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.49","","","","","","","fee schedule","16.49","103.18",""
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.82","","","","","","","fee schedule","16.49","103.18",""
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","103.18","","","","","","","fee schedule","16.49","103.18",""
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.82","","","","","","","fee schedule","16.49","103.18",""
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.27","","","","","","","fee schedule","16.49","103.18","APC"
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.98","","","","","","","fee schedule","16.49","103.18","APC"
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.82","","","","","","","fee schedule","16.49","103.18","APC"
"Acylcarnitines qual","82016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.31","","","","","","","fee schedule","16.49","103.18","APC"
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.87","","","","","","","fee schedule","16.87","106.7",""
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","16.87","106.7",""
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.7","","","","","","","fee schedule","16.87","106.7",""
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","16.87","106.7",""
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.67","","","","","","","fee schedule","16.87","106.7","APC"
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.87","106.7","APC"
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.87","106.7","APC"
"Acylcarnitines quant","82017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.71","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.62","","","","","","","fee schedule","38.62","286.04",""
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.62","","","","","","","fee schedule","38.62","286.04",""
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.62","","","","","","","fee schedule","38.62","286.04",""
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","66.38","","","","","","","fee schedule","38.62","286.04",""
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","286.04","","","","","","","fee schedule","38.62","286.04",""
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","66.38","","","","","","","fee schedule","38.62","286.04",""
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.45","","","","","","","fee schedule","38.62","286.04","APC"
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.78","","","","","","","fee schedule","38.62","286.04","APC"
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.39","","","","","","","fee schedule","38.62","286.04","APC"
"Assay of acth","82024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.55","","","","","","","fee schedule","38.62","286.04","APC"
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.8","","","","","","","fee schedule","25.8","177.9",""
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.8","","","","","","","fee schedule","25.8","177.9",""
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.8","","","","","","","fee schedule","25.8","177.9",""
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","44.34","","","","","","","fee schedule","25.8","177.9",""
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","177.9","","","","","","","fee schedule","25.8","177.9",""
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","44.34","","","","","","","fee schedule","25.8","177.9",""
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.03","","","","","","","fee schedule","25.8","177.9","APC"
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.57","","","","","","","fee schedule","25.8","177.9","APC"
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.32","","","","","","","fee schedule","25.8","177.9","APC"
"Assay of adp & amp","82030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.09","","","","","","","fee schedule","25.8","177.9","APC"
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.95","","","","","","","fee schedule","4.95","35.67",""
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.95","","","","","","","fee schedule","4.95","35.67",""
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.95","","","","","","","fee schedule","4.95","35.67",""
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.51","","","","","","","fee schedule","4.95","35.67",""
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.67","","","","","","","fee schedule","4.95","35.67",""
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.51","","","","","","","fee schedule","4.95","35.67",""
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.19","","","","","","","fee schedule","4.95","35.67","APC"
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.1","","","","","","","fee schedule","4.95","35.67","APC"
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.95","35.67","APC"
"Assay of serum albumin","82040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.2","","","","","","","fee schedule","4.95","35.67","APC"
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.78","","","","","","","fee schedule","7.78","33.48",""
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.78","","","","","","","fee schedule","7.78","33.48",""
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.78","","","","","","","fee schedule","7.78","33.48",""
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","7.78","33.48",""
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.48","","","","","","","fee schedule","7.78","33.48",""
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","7.78","33.48",""
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.15","","","","","","","fee schedule","7.78","33.48","APC"
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.01","","","","","","","fee schedule","7.78","33.48","APC"
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.94","","","","","","","fee schedule","7.78","33.48","APC"
"Assay of urine albumin","82042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.17","","","","","","","fee schedule","7.78","33.48","APC"
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.78","","","","","","","fee schedule","5.78","41.52",""
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.78","","","","","","","fee schedule","5.78","41.52",""
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.78","","","","","","","fee schedule","5.78","41.52",""
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.95","","","","","","","fee schedule","5.78","41.52",""
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","41.52","","","","","","","fee schedule","5.78","41.52",""
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.95","","","","","","","fee schedule","5.78","41.52",""
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.05","","","","","","","fee schedule","5.78","41.52","APC"
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.95","","","","","","","fee schedule","5.78","41.52","APC"
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.9","","","","","","","fee schedule","5.78","41.52","APC"
"Microalbumin quantitative","82043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.07","","","","","","","fee schedule","5.78","41.52","APC"
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.23","","","","","","","fee schedule","6.23","29.62",""
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.23","","","","","","","fee schedule","6.23","29.62",""
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.23","","","","","","","fee schedule","6.23","29.62",""
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.87","","","","","","","fee schedule","6.23","29.62",""
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.62","","","","","","","fee schedule","6.23","29.62",""
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.87","","","","","","","fee schedule","6.23","29.62",""
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.53","","","","","","","fee schedule","6.23","29.62","APC"
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.42","","","","","","","fee schedule","6.23","29.62","APC"
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.35","","","","","","","fee schedule","6.23","29.62","APC"
"Microalbumin semiquant","82044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.54","","","","","","","fee schedule","6.23","29.62","APC"
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.94","","","","","","","fee schedule","33.94","251.71",""
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.94","","","","","","","fee schedule","33.94","251.71",""
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","33.94","","","","","","","fee schedule","33.94","251.71",""
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.34","","","","","","","fee schedule","33.94","251.71",""
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","251.71","","","","","","","fee schedule","33.94","251.71",""
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.34","","","","","","","fee schedule","33.94","251.71",""
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.55","","","","","","","fee schedule","33.94","251.71","APC"
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.96","","","","","","","fee schedule","33.94","251.71","APC"
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.62","","","","","","","fee schedule","33.94","251.71","APC"
"Albumin ischemia modified","82045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.64","","","","","","","fee schedule","33.94","251.71","APC"
"Assay of ethanol","82055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","80.12","","","","","","","fee schedule","80.12","80.12",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30","","","","","","","fee schedule","20.71","88.18",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30","","","","","","","fee schedule","20.71","88.18",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30","","","","","","","fee schedule","20.71","88.18",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.71","","","","","","","fee schedule","20.71","88.18",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.18","","","","","","","fee schedule","20.71","88.18",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.71","","","","","","","fee schedule","20.71","88.18",""
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.43","","","","","","","fee schedule","20.71","88.18","APC"
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.9","","","","","","","fee schedule","20.71","88.18","APC"
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.6","","","","","","","fee schedule","20.71","88.18","APC"
"Assay of breath ethanol","82075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.5","","","","","","","fee schedule","20.71","88.18","APC"
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","20.72",""
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.72","","","","","","","fee schedule","17.27","20.72",""
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.72","","","","","","","fee schedule","17.27","20.72",""
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","20.72","APC"
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","20.72","APC"
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","20.72","APC"
"Assay spec xcp ur&breath ia","82077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","20.72","APC"
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.71","","","","","","","fee schedule","9.71","72.87",""
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.71","","","","","","","fee schedule","9.71","72.87",""
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.71","","","","","","","fee schedule","9.71","72.87",""
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.68","","","","","","","fee schedule","9.71","72.87",""
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","72.87","","","","","","","fee schedule","9.71","72.87",""
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.68","","","","","","","fee schedule","9.71","72.87",""
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.17","","","","","","","fee schedule","9.71","72.87","APC"
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10","","","","","","","fee schedule","9.71","72.87","APC"
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.9","","","","","","","fee schedule","9.71","72.87","APC"
"Assay of aldolase","82085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.2","","","","","","","fee schedule","9.71","72.87","APC"
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40.75","","","","","","","fee schedule","40.75","302.89",""
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","40.75","","","","","","","fee schedule","40.75","302.89",""
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40.75","","","","","","","fee schedule","40.75","302.89",""
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","70.04","","","","","","","fee schedule","40.75","302.89",""
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","302.89","","","","","","","fee schedule","40.75","302.89",""
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","70.04","","","","","","","fee schedule","40.75","302.89",""
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.69","","","","","","","fee schedule","40.75","302.89","APC"
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.97","","","","","","","fee schedule","40.75","302.89","APC"
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.56","","","","","","","fee schedule","40.75","302.89","APC"
"Assay of aldosterone","82088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.79","","","","","","","fee schedule","40.75","302.89","APC"
"Assay of urine alkaloids","82101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","208.8","","","","","","","fee schedule","208.8","208.8",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.44","","","","","","","fee schedule","13.44","99.37",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.44","","","","","","","fee schedule","13.44","99.37",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.44","","","","","","","fee schedule","13.44","99.37",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.09","","","","","","","fee schedule","13.44","99.37",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.37","","","","","","","fee schedule","13.44","99.37",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.09","","","","","","","fee schedule","13.44","99.37",""
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.08","","","","","","","fee schedule","13.44","99.37","APC"
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.84","","","","","","","fee schedule","13.44","99.37","APC"
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.71","","","","","","","fee schedule","13.44","99.37","APC"
"Alpha-1-antitrypsin total","82103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.11","","","","","","","fee schedule","13.44","99.37","APC"
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.46","","","","","","","fee schedule","14.46","107.89",""
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.46","","","","","","","fee schedule","14.46","107.89",""
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.46","","","","","","","fee schedule","14.46","107.89",""
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.85","","","","","","","fee schedule","14.46","107.89",""
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.89","","","","","","","fee schedule","14.46","107.89",""
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.85","","","","","","","fee schedule","14.46","107.89",""
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.15","","","","","","","fee schedule","14.46","107.89","APC"
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.46","107.89","APC"
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.75","","","","","","","fee schedule","14.46","107.89","APC"
"Alpha-1-antitrypsin pheno","82104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.18","","","","","","","fee schedule","14.46","107.89","APC"
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.77","","","","","","","fee schedule","16.77","121.67",""
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.77","","","","","","","fee schedule","16.77","121.67",""
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.77","","","","","","","fee schedule","16.77","121.67",""
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.84","","","","","","","fee schedule","16.77","121.67",""
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","121.67","","","","","","","fee schedule","16.77","121.67",""
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.84","","","","","","","fee schedule","16.77","121.67",""
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.57","","","","","","","fee schedule","16.77","121.67","APC"
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.27","","","","","","","fee schedule","16.77","121.67","APC"
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.11","","","","","","","fee schedule","16.77","121.67","APC"
"Alpha-fetoprotein serum","82105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.61","","","","","","","fee schedule","16.77","121.67","APC"
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17","","","","","","","fee schedule","17","121.67",""
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17","","","","","","","fee schedule","17","121.67",""
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17","","","","","","","fee schedule","17","121.67",""
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.84","","","","","","","fee schedule","17","121.67",""
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","121.67","","","","","","","fee schedule","17","121.67",""
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.84","","","","","","","fee schedule","17","121.67",""
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.81","","","","","","","fee schedule","17","121.67","APC"
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.51","","","","","","","fee schedule","17","121.67","APC"
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.34","","","","","","","fee schedule","17","121.67","APC"
"Alpha-fetoprotein amniotic","82106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.85","","","","","","","fee schedule","17","121.67","APC"
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.41","","","","","","","fee schedule","64.41","467.63",""
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","110.71","","","","","","","fee schedule","64.41","467.63",""
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","467.63","","","","","","","fee schedule","64.41","467.63",""
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","110.71","","","","","","","fee schedule","64.41","467.63",""
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.47","","","","","","","fee schedule","64.41","467.63","APC"
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.34","","","","","","","fee schedule","64.41","467.63","APC"
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.7","","","","","","","fee schedule","64.41","467.63","APC"
"Alpha-Fetoprotein L3","82107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.63","","","","","","","fee schedule","64.41","467.63","APC"
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.48","","","","","","","fee schedule","25.48","176.53",""
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.48","","","","","","","fee schedule","25.48","176.53",""
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.48","","","","","","","fee schedule","25.48","176.53",""
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.79","","","","","","","fee schedule","25.48","176.53",""
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","176.53","","","","","","","fee schedule","25.48","176.53",""
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.79","","","","","","","fee schedule","25.48","176.53",""
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.69","","","","","","","fee schedule","25.48","176.53","APC"
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.24","","","","","","","fee schedule","25.48","176.53","APC"
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.99","","","","","","","fee schedule","25.48","176.53","APC"
"Assay of aluminum","82108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.75","","","","","","","fee schedule","25.48","176.53","APC"
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.99","","","","","","","fee schedule","5.99","26.07",""
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.99","","","","","","","fee schedule","5.99","26.07",""
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.99","","","","","","","fee schedule","5.99","26.07",""
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","5.99","26.07",""
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.07","","","","","","","fee schedule","5.99","26.07",""
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","5.99","26.07",""
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.27","","","","","","","fee schedule","5.99","26.07","APC"
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.17","","","","","","","fee schedule","5.99","26.07","APC"
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.11","","","","","","","fee schedule","5.99","26.07","APC"
"Amines vaginal fluid qual","82120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.29","","","","","","","fee schedule","5.99","26.07","APC"
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.18","","","","","","","fee schedule","14.18","103.18",""
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.18","","","","","","","fee schedule","14.18","103.18",""
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.18","","","","","","","fee schedule","14.18","103.18",""
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.82","","","","","","","fee schedule","14.18","103.18",""
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","103.18","","","","","","","fee schedule","14.18","103.18",""
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.82","","","","","","","fee schedule","14.18","103.18",""
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.85","","","","","","","fee schedule","14.18","103.18","APC"
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.61","","","","","","","fee schedule","14.18","103.18","APC"
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.46","","","","","","","fee schedule","14.18","103.18","APC"
"Amino acid single qual","82127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.18","103.18","APC"
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.87","","","","","","","fee schedule","13.87","103.18",""
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.87","","","","","","","fee schedule","13.87","103.18",""
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.87","","","","","","","fee schedule","13.87","103.18",""
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.82","","","","","","","fee schedule","13.87","103.18",""
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","103.18","","","","","","","fee schedule","13.87","103.18",""
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.82","","","","","","","fee schedule","13.87","103.18",""
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.53","","","","","","","fee schedule","13.87","103.18","APC"
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.29","","","","","","","fee schedule","13.87","103.18","APC"
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.15","","","","","","","fee schedule","13.87","103.18","APC"
"Amino acids mult qual","82128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.56","","","","","","","fee schedule","13.87","103.18","APC"
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.98","","","","","","","fee schedule","22.98","126.81",""
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.98","","","","","","","fee schedule","22.98","126.81",""
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.98","","","","","","","fee schedule","22.98","126.81",""
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","22.98","126.81",""
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.81","","","","","","","fee schedule","22.98","126.81",""
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","22.98","126.81",""
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.07","","","","","","","fee schedule","22.98","126.81","APC"
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.67","","","","","","","fee schedule","22.98","126.81","APC"
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.44","","","","","","","fee schedule","22.98","126.81","APC"
"Amino acids single quant","82131","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.13","","","","","","","fee schedule","22.98","126.81","APC"
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.45","","","","","","","fee schedule","16.45","122.18",""
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.45","","","","","","","fee schedule","16.45","122.18",""
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.45","","","","","","","fee schedule","16.45","122.18",""
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.3","","","","","","","fee schedule","16.45","122.18",""
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","122.18","","","","","","","fee schedule","16.45","122.18",""
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.3","","","","","","","fee schedule","16.45","122.18",""
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.23","","","","","","","fee schedule","16.45","122.18","APC"
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.94","","","","","","","fee schedule","16.45","122.18","APC"
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.78","","","","","","","fee schedule","16.45","122.18","APC"
"Assay aminolevulinic acid","82135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.27","","","","","","","fee schedule","16.45","122.18","APC"
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.61","","","","","","","fee schedule","19.61","109.57",""
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.61","","","","","","","fee schedule","19.61","109.57",""
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.61","","","","","","","fee schedule","19.61","109.57",""
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","19.61","109.57",""
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.57","","","","","","","fee schedule","19.61","109.57",""
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","19.61","109.57",""
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.54","","","","","","","fee schedule","19.61","109.57","APC"
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.2","","","","","","","fee schedule","19.61","109.57","APC"
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20","","","","","","","fee schedule","19.61","109.57","APC"
"Amino acids quant 2-5","82136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.59","","","","","","","fee schedule","19.61","109.57","APC"
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.87","","","","","","","fee schedule","16.87","109.57",""
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.87","","","","","","","fee schedule","16.87","109.57",""
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.87","","","","","","","fee schedule","16.87","109.57",""
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","16.87","109.57",""
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.57","","","","","","","fee schedule","16.87","109.57",""
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","16.87","109.57",""
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.67","","","","","","","fee schedule","16.87","109.57","APC"
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.87","109.57","APC"
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.87","109.57","APC"
"Amino acids quan 6 or more","82139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.71","","","","","","","fee schedule","16.87","109.57","APC"
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.57","","","","","","","fee schedule","14.57","106.39",""
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.57","","","","","","","fee schedule","14.57","106.39",""
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.57","","","","","","","fee schedule","14.57","106.39",""
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.04","","","","","","","fee schedule","14.57","106.39",""
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.39","","","","","","","fee schedule","14.57","106.39",""
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.04","","","","","","","fee schedule","14.57","106.39",""
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.26","","","","","","","fee schedule","14.57","106.39","APC"
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.01","","","","","","","fee schedule","14.57","106.39","APC"
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.86","","","","","","","fee schedule","14.57","106.39","APC"
"Assay of ammonia","82140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.3","","","","","","","fee schedule","14.57","106.39","APC"
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.35","","","","","","","fee schedule","9.35","50.75",""
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.35","","","","","","","fee schedule","9.35","50.75",""
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.35","","","","","","","fee schedule","9.35","50.75",""
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.81","","","","","","","fee schedule","9.35","50.75",""
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.75","","","","","","","fee schedule","9.35","50.75",""
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.81","","","","","","","fee schedule","9.35","50.75",""
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.79","","","","","","","fee schedule","9.35","50.75","APC"
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.63","","","","","","","fee schedule","9.35","50.75","APC"
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.54","","","","","","","fee schedule","9.35","50.75","APC"
"Amniotic fluid scan","82143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.82","","","","","","","fee schedule","9.35","50.75","APC"
"Assay of amphetamines","82145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.02","","","","","","","fee schedule","111.02","111.02",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.48","","","","","","","fee schedule","6.48","48.56",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.48","","","","","","","fee schedule","6.48","48.56",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.48","","","","","","","fee schedule","6.48","48.56",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.15","","","","","","","fee schedule","6.48","48.56",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.56","","","","","","","fee schedule","6.48","48.56",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.15","","","","","","","fee schedule","6.48","48.56",""
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.48","48.56","APC"
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.67","","","","","","","fee schedule","6.48","48.56","APC"
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.61","","","","","","","fee schedule","6.48","48.56","APC"
"Assay of amylase","82150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.8","","","","","","","fee schedule","6.48","48.56","APC"
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.83","","","","","","","fee schedule","28.83","211.67",""
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","28.83","","","","","","","fee schedule","28.83","211.67",""
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28.83","","","","","","","fee schedule","28.83","211.67",""
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","49.56","","","","","","","fee schedule","28.83","211.67",""
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","211.67","","","","","","","fee schedule","28.83","211.67",""
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","49.56","","","","","","","fee schedule","28.83","211.67",""
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.2","","","","","","","fee schedule","28.83","211.67","APC"
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.69","","","","","","","fee schedule","28.83","211.67","APC"
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.41","","","","","","","fee schedule","28.83","211.67","APC"
"Androstanediol glucuronide","82154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.27","","","","","","","fee schedule","28.83","211.67","APC"
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.28","","","","","","","fee schedule","29.28","218.11",""
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.28","","","","","","","fee schedule","29.28","218.11",""
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.28","","","","","","","fee schedule","29.28","218.11",""
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.32","","","","","","","fee schedule","29.28","218.11",""
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","218.11","","","","","","","fee schedule","29.28","218.11",""
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.32","","","","","","","fee schedule","29.28","218.11",""
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.67","","","","","","","fee schedule","29.28","218.11","APC"
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.16","","","","","","","fee schedule","29.28","218.11","APC"
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.87","","","","","","","fee schedule","29.28","218.11","APC"
"Assay of androstenedione","82157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.74","","","","","","","fee schedule","29.28","218.11","APC"
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.55","","","","","","","fee schedule","25.55","184.97",""
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.55","","","","","","","fee schedule","25.55","184.97",""
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.55","","","","","","","fee schedule","25.55","184.97",""
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","184.97","","","","","","","fee schedule","25.55","184.97",""
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.98","","","","","","","fee schedule","25.55","184.97",""
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.98","","","","","","","fee schedule","25.55","184.97",""
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.76","","","","","","","fee schedule","25.55","184.97","APC"
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.32","","","","","","","fee schedule","25.55","184.97","APC"
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.06","","","","","","","fee schedule","25.55","184.97","APC"
"Assay of androsterone","82160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.83","","","","","","","fee schedule","25.55","184.97","APC"
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.52","","","","","","","fee schedule","20.52","149.21",""
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.52","","","","","","","fee schedule","20.52","149.21",""
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.52","","","","","","","fee schedule","20.52","149.21",""
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","149.21","","","","","","","fee schedule","20.52","149.21",""
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.28","","","","","","","fee schedule","20.52","149.21",""
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.28","","","","","","","fee schedule","20.52","149.21",""
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.49","","","","","","","fee schedule","20.52","149.21","APC"
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.14","","","","","","","fee schedule","20.52","149.21","APC"
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.93","","","","","","","fee schedule","20.52","149.21","APC"
"Assay of angiotensin II","82163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.55","","","","","","","fee schedule","20.52","149.21","APC"
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.6","","","","","","","fee schedule","14.6","108.57",""
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.6","","","","","","","fee schedule","14.6","108.57",""
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.6","","","","","","","fee schedule","14.6","108.57",""
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","108.57","","","","","","","fee schedule","14.6","108.57",""
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.09","","","","","","","fee schedule","14.6","108.57",""
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.09","","","","","","","fee schedule","14.6","108.57",""
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.29","","","","","","","fee schedule","14.6","108.57","APC"
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.04","","","","","","","fee schedule","14.6","108.57","APC"
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.6","108.57","APC"
"Angiotensin I enzyme test","82164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.33","","","","","","","fee schedule","14.6","108.57","APC"
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.62","","","","","","","fee schedule","38.62","46.34",""
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.62","","","","","","","fee schedule","38.62","46.34",""
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.62","","","","","","","fee schedule","38.62","46.34",""
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.34","","","","","","","fee schedule","38.62","46.34",""
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.34","","","","","","","fee schedule","38.62","46.34",""
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.45","","","","","","","fee schedule","38.62","46.34","APC"
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.78","","","","","","","fee schedule","38.62","46.34","APC"
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.39","","","","","","","fee schedule","38.62","46.34","APC"
"Assay anti-mullerian horm","82166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.55","","","","","","","fee schedule","38.62","46.34","APC"
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.09","","","","","","","fee schedule","21.09","113.37",""
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.09","","","","","","","fee schedule","21.09","113.37",""
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.09","","","","","","","fee schedule","21.09","113.37",""
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","113.37","","","","","","","fee schedule","21.09","113.37",""
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.63","","","","","","","fee schedule","21.09","113.37",""
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.63","","","","","","","fee schedule","21.09","113.37",""
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.09","","","","","","","fee schedule","21.09","113.37","APC"
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.72","","","","","","","fee schedule","21.09","113.37","APC"
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.51","","","","","","","fee schedule","21.09","113.37","APC"
"Assay of apolipoprotein","82172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.14","","","","","","","fee schedule","21.09","113.37","APC"
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.97","","","","","","","fee schedule","18.97","137.17",""
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.97","","","","","","","fee schedule","18.97","137.17",""
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.97","","","","","","","fee schedule","18.97","137.17",""
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.17","","","","","","","fee schedule","18.97","137.17",""
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.6","","","","","","","fee schedule","18.97","137.17",""
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.6","","","","","","","fee schedule","18.97","137.17",""
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.87","","","","","","","fee schedule","18.97","137.17","APC"
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.54","","","","","","","fee schedule","18.97","137.17","APC"
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.35","","","","","","","fee schedule","18.97","137.17","APC"
"Assay of arsenic","82175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.92","","","","","","","fee schedule","18.97","137.17","APC"
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.89","","","","","","","fee schedule","9.89","69.44",""
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.89","","","","","","","fee schedule","9.89","69.44",""
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.89","","","","","","","fee schedule","9.89","69.44",""
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.44","","","","","","","fee schedule","9.89","69.44",""
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.99","","","","","","","fee schedule","9.89","69.44",""
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.99","","","","","","","fee schedule","9.89","69.44",""
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.36","","","","","","","fee schedule","9.89","69.44","APC"
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.19","","","","","","","fee schedule","9.89","69.44","APC"
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.09","","","","","","","fee schedule","9.89","69.44","APC"
"Assay of ascorbic acid","82180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.38","","","","","","","fee schedule","9.89","69.44","APC"
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.9","","","","","","","fee schedule","15.9","97.95",""
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.9","","","","","","","fee schedule","15.9","97.95",""
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.9","","","","","","","fee schedule","15.9","97.95",""
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.95","","","","","","","fee schedule","15.9","97.95",""
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.63","","","","","","","fee schedule","15.9","97.95",""
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.63","","","","","","","fee schedule","15.9","97.95",""
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.66","","","","","","","fee schedule","15.9","97.95","APC"
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.38","","","","","","","fee schedule","15.9","97.95","APC"
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.22","","","","","","","fee schedule","15.9","97.95","APC"
"Atomic absorption","82190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.7","","","","","","","fee schedule","15.9","97.95","APC"
"Assay of barbiturates","82205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85","","","","","","","fee schedule","85","85",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.18","","","","","","","fee schedule","16.18","119.82",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.18","","","","","","","fee schedule","16.18","119.82",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.18","","","","","","","fee schedule","16.18","119.82",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.82","","","","","","","fee schedule","16.18","119.82",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.8","","","","","","","fee schedule","16.18","119.82",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.8","","","","","","","fee schedule","16.18","119.82",""
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.95","","","","","","","fee schedule","16.18","119.82","APC"
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.67","","","","","","","fee schedule","16.18","119.82","APC"
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.5","","","","","","","fee schedule","16.18","119.82","APC"
"Assay of beta-2 protein","82232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.99","","","","","","","fee schedule","16.18","119.82","APC"
"Beta-amyloid 1-40 (abeta 40)","82233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.04","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-40 (abeta 40)","82233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.79","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-40 (abeta 40)","82233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.5","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-40 (abeta 40)","82233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.37","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-42 (abeta 42)","82234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.04","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-42 (abeta 42)","82234","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.79","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-42 (abeta 42)","82234","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.5","","","","","","","fee schedule","131.5","135.37","APC"
"Beta-amyloid 1-42 (abeta 42)","82234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.37","","","","","","","fee schedule","131.5","135.37","APC"
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.12","","","","","","","fee schedule","17.12","117.8",""
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.12","","","","","","","fee schedule","17.12","117.8",""
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.12","","","","","","","fee schedule","17.12","117.8",""
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","117.8","","","","","","","fee schedule","17.12","117.8",""
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.45","","","","","","","fee schedule","17.12","117.8",""
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.45","","","","","","","fee schedule","17.12","117.8",""
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.93","","","","","","","fee schedule","17.12","117.8","APC"
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.63","","","","","","","fee schedule","17.12","117.8","APC"
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.46","","","","","","","fee schedule","17.12","117.8","APC"
"Bile acids total","82239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.98","","","","","","","fee schedule","17.12","117.8","APC"
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.58","","","","","","","fee schedule","26.58","175.88",""
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.58","","","","","","","fee schedule","26.58","175.88",""
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.58","","","","","","","fee schedule","26.58","175.88",""
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","175.88","","","","","","","fee schedule","26.58","175.88",""
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45.68","","","","","","","fee schedule","26.58","175.88",""
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45.68","","","","","","","fee schedule","26.58","175.88",""
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.84","","","","","","","fee schedule","26.58","175.88","APC"
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.38","","","","","","","fee schedule","26.58","175.88","APC"
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.11","","","","","","","fee schedule","26.58","175.88","APC"
"Bile acids cholylglycine","82240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.91","","","","","","","fee schedule","26.58","175.88","APC"
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.18","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.63","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.63","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.26","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.17","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.12","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin total","82247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.27","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.18","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.63","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.63","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.26","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.17","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.12","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin direct","82248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.27","","","","","","","fee schedule","5.02","37.18","APC"
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.56","","","","","","","fee schedule","4.56","32.4",""
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.56","","","","","","","fee schedule","4.56","32.4",""
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.56","","","","","","","fee schedule","4.56","32.4",""
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.81","","","","","","","fee schedule","4.56","32.4",""
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.4","","","","","","","fee schedule","4.56","32.4",""
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.81","","","","","","","fee schedule","4.56","32.4",""
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.78","","","","","","","fee schedule","4.56","32.4","APC"
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.7","","","","","","","fee schedule","4.56","32.4","APC"
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.65","","","","","","","fee schedule","4.56","32.4","APC"
"Fecal bilirubin test","82252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.79","","","","","","","fee schedule","4.56","32.4","APC"
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","16.87","106.7",""
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.7","","","","","","","fee schedule","16.87","106.7",""
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","16.87","106.7",""
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.67","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of biotinidase","82261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.71","","","","","","","fee schedule","16.87","106.7","APC"
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.38","","","","","","","fee schedule","4.38","24.17",""
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.38","","","","","","","fee schedule","4.38","24.17",""
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.38","","","","","","","fee schedule","4.38","24.17",""
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.59","","","","","","","fee schedule","4.38","24.17",""
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","24.17","","","","","","","fee schedule","4.38","24.17",""
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.59","","","","","","","fee schedule","4.38","24.17",""
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.59","","","","","","","fee schedule","4.38","24.17","APC"
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.51","","","","","","","fee schedule","4.38","24.17","APC"
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.38","24.17","APC"
"Occult blood feces","82270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.6","","","","","","","fee schedule","4.38","24.17","APC"
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.32","","","","","","","fee schedule","5.32","24.17",""
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.32","","","","","","","fee schedule","5.32","24.17",""
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.32","","","","","","","fee schedule","5.32","24.17",""
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.59","","","","","","","fee schedule","5.32","24.17",""
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","24.17","","","","","","","fee schedule","5.32","24.17",""
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.59","","","","","","","fee schedule","5.32","24.17",""
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.57","","","","","","","fee schedule","5.32","24.17","APC"
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.48","","","","","","","fee schedule","5.32","24.17","APC"
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.32","24.17","APC"
"Occult blood other sources","82271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.59","","","","","","","fee schedule","5.32","24.17","APC"
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.23","","","","","","","fee schedule","4.23","24.17",""
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.23","","","","","","","fee schedule","4.23","24.17",""
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.23","","","","","","","fee schedule","4.23","24.17",""
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.59","","","","","","","fee schedule","4.23","24.17",""
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","24.17","","","","","","","fee schedule","4.23","24.17",""
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.59","","","","","","","fee schedule","4.23","24.17",""
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.43","","","","","","","fee schedule","4.23","24.17","APC"
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.23","24.17","APC"
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.31","","","","","","","fee schedule","4.23","24.17","APC"
"Occult bld feces 1-3 tests","82272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.23","24.17","APC"
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.92","","","","","","","fee schedule","15.92","115.13",""
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.92","","","","","","","fee schedule","15.92","115.13",""
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.92","","","","","","","fee schedule","15.92","115.13",""
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.34","","","","","","","fee schedule","15.92","115.13",""
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","115.13","","","","","","","fee schedule","15.92","115.13",""
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.34","","","","","","","fee schedule","15.92","115.13",""
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.68","","","","","","","fee schedule","15.92","115.13","APC"
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.4","","","","","","","fee schedule","15.92","115.13","APC"
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.24","","","","","","","fee schedule","15.92","115.13","APC"
"Assay test for blood fecal","82274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.72","","","","","","","fee schedule","15.92","115.13","APC"
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.16","","","","","","","fee schedule","5.16","51.66",""
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.16","","","","","","","fee schedule","5.16","51.66",""
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.16","","","","","","","fee schedule","5.16","51.66",""
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.83","","","","","","","fee schedule","5.16","51.66",""
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","51.66","","","","","","","fee schedule","5.16","51.66",""
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.83","","","","","","","fee schedule","5.16","51.66",""
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.41","","","","","","","fee schedule","5.16","51.66","APC"
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.31","","","","","","","fee schedule","5.16","51.66","APC"
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.26","","","","","","","fee schedule","5.16","51.66","APC"
"Assay of bradykinin","82286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.42","","","","","","","fee schedule","5.16","51.66","APC"
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.64","","","","","","","fee schedule","23.64","165.43",""
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.64","","","","","","","fee schedule","23.64","165.43",""
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.64","","","","","","","fee schedule","23.64","165.43",""
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.77","","","","","","","fee schedule","23.64","165.43",""
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","165.43","","","","","","","fee schedule","23.64","165.43",""
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.77","","","","","","","fee schedule","23.64","165.43",""
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.76","","","","","","","fee schedule","23.64","165.43","APC"
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.35","","","","","","","fee schedule","23.64","165.43","APC"
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.11","","","","","","","fee schedule","23.64","165.43","APC"
"Assay of cadmium","82300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.82","","","","","","","fee schedule","23.64","165.43","APC"
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.6","","","","","","","fee schedule","29.6","220.3",""
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.6","","","","","","","fee schedule","29.6","220.3",""
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.6","","","","","","","fee schedule","29.6","220.3",""
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.88","","","","","","","fee schedule","29.6","220.3",""
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","220.3","","","","","","","fee schedule","29.6","220.3",""
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.88","","","","","","","fee schedule","29.6","220.3",""
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.01","","","","","","","fee schedule","29.6","220.3","APC"
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.49","","","","","","","fee schedule","29.6","220.3","APC"
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.19","","","","","","","fee schedule","29.6","220.3","APC"
"Vitamin d 25 hydroxy","82306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.08","","","","","","","fee schedule","29.6","220.3","APC"
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.79","","","","","","","fee schedule","26.79","196.36",""
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.79","","","","","","","fee schedule","26.79","196.36",""
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.79","","","","","","","fee schedule","26.79","196.36",""
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.03","","","","","","","fee schedule","26.79","196.36",""
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","196.36","","","","","","","fee schedule","26.79","196.36",""
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.03","","","","","","","fee schedule","26.79","196.36",""
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.06","","","","","","","fee schedule","26.79","196.36","APC"
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.59","","","","","","","fee schedule","26.79","196.36","APC"
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.33","","","","","","","fee schedule","26.79","196.36","APC"
"Assay of calcitonin","82308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.13","","","","","","","fee schedule","26.79","196.36","APC"
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.16","","","","","","","fee schedule","5.16","38.54",""
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.16","","","","","","","fee schedule","5.16","38.54",""
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.16","","","","","","","fee schedule","5.16","38.54",""
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.87","","","","","","","fee schedule","5.16","38.54",""
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.54","","","","","","","fee schedule","5.16","38.54",""
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.87","","","","","","","fee schedule","5.16","38.54",""
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.41","","","","","","","fee schedule","5.16","38.54","APC"
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.31","","","","","","","fee schedule","5.16","38.54","APC"
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.26","","","","","","","fee schedule","5.16","38.54","APC"
"Assay of calcium","82310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.42","","","","","","","fee schedule","5.16","38.54","APC"
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.68","","","","","","","fee schedule","13.68","94.03",""
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.68","","","","","","","fee schedule","13.68","94.03",""
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.68","","","","","","","fee schedule","13.68","94.03",""
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.48","","","","","","","fee schedule","13.68","94.03",""
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","94.03","","","","","","","fee schedule","13.68","94.03",""
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.48","","","","","","","fee schedule","13.68","94.03",""
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.33","","","","","","","fee schedule","13.68","94.03","APC"
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.09","","","","","","","fee schedule","13.68","94.03","APC"
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.95","","","","","","","fee schedule","13.68","94.03","APC"
"Assay of calcium","82330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.36","","","","","","","fee schedule","13.68","94.03","APC"
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.34","","","","","","","fee schedule","8.89","38.88",""
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.34","","","","","","","fee schedule","8.89","38.88",""
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.34","","","","","","","fee schedule","8.89","38.88",""
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","8.89","38.88",""
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.88","","","","","","","fee schedule","8.89","38.88",""
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","8.89","38.88",""
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.97","","","","","","","fee schedule","8.89","38.88","APC"
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.74","","","","","","","fee schedule","8.89","38.88","APC"
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.61","","","","","","","fee schedule","8.89","38.88","APC"
"Calcium infusion test","82331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.01","","","","","","","fee schedule","8.89","38.88","APC"
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.03","","","","","","","fee schedule","6.03","44.19",""
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.03","","","","","","","fee schedule","6.03","44.19",""
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.03","","","","","","","fee schedule","6.03","44.19",""
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.37","","","","","","","fee schedule","6.03","44.19",""
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.19","","","","","","","fee schedule","6.03","44.19",""
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.37","","","","","","","fee schedule","6.03","44.19",""
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.32","","","","","","","fee schedule","6.03","44.19","APC"
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.21","","","","","","","fee schedule","6.03","44.19","APC"
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.15","","","","","","","fee schedule","6.03","44.19","APC"
"Assay of calcium in urine","82340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.33","","","","","","","fee schedule","6.03","44.19","APC"
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.58","","","","","","","fee schedule","11.58","84.83",""
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.58","","","","","","","fee schedule","11.58","84.83",""
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.58","","","","","","","fee schedule","11.58","84.83",""
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.9","","","","","","","fee schedule","11.58","84.83",""
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","84.83","","","","","","","fee schedule","11.58","84.83",""
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.9","","","","","","","fee schedule","11.58","84.83",""
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.13","","","","","","","fee schedule","11.58","84.83","APC"
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.93","","","","","","","fee schedule","11.58","84.83","APC"
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.81","","","","","","","fee schedule","11.58","84.83","APC"
"Calculus analysis qual","82355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.16","","","","","","","fee schedule","11.58","84.83","APC"
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.87","","","","","","","fee schedule","12.87","94.17",""
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.87","","","","","","","fee schedule","12.87","94.17",""
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.87","","","","","","","fee schedule","12.87","94.17",""
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.13","","","","","","","fee schedule","12.87","94.17",""
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","94.17","","","","","","","fee schedule","12.87","94.17",""
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.13","","","","","","","fee schedule","12.87","94.17",""
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.48","","","","","","","fee schedule","12.87","94.17","APC"
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.87","94.17","APC"
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.87","94.17","APC"
"Calculus assay quant","82360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.87","94.17","APC"
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.9","","","","","","","fee schedule","12.9","92.84",""
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.9","","","","","","","fee schedule","12.9","92.84",""
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.9","","","","","","","fee schedule","12.9","92.84",""
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.16","","","","","","","fee schedule","12.9","92.84",""
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.84","","","","","","","fee schedule","12.9","92.84",""
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.16","","","","","","","fee schedule","12.9","92.84",""
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.9","92.84","APC"
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.29","","","","","","","fee schedule","12.9","92.84","APC"
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.16","","","","","","","fee schedule","12.9","92.84","APC"
"Calculus spectroscopy","82365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.55","","","","","","","fee schedule","12.9","92.84","APC"
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.52","","","","","","","fee schedule","12.52","92.73",""
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.52","","","","","","","fee schedule","12.52","92.73",""
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.52","","","","","","","fee schedule","12.52","92.73",""
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.54","","","","","","","fee schedule","12.52","92.73",""
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.73","","","","","","","fee schedule","12.52","92.73",""
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.54","","","","","","","fee schedule","12.52","92.73",""
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.11","","","","","","","fee schedule","12.52","92.73","APC"
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.9","","","","","","","fee schedule","12.52","92.73","APC"
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.77","","","","","","","fee schedule","12.52","92.73","APC"
"X-ray assay calculus","82370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.15","","","","","","","fee schedule","12.52","92.73","APC"
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.06","","","","","","","fee schedule","18.06","128.57",""
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.06","","","","","","","fee schedule","18.06","128.57",""
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.06","","","","","","","fee schedule","18.06","128.57",""
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","18.06","128.57",""
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","18.06","128.57",""
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","18.06","128.57",""
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.92","","","","","","","fee schedule","18.06","128.57","APC"
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.6","","","","","","","fee schedule","18.06","128.57","APC"
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.42","","","","","","","fee schedule","18.06","128.57","APC"
"Assay c-d transfer measure","82373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.96","","","","","","","fee schedule","18.06","128.57","APC"
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.88","","","","","","","fee schedule","4.88","35.67",""
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.88","","","","","","","fee schedule","4.88","35.67",""
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.88","","","","","","","fee schedule","4.88","35.67",""
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.4","","","","","","","fee schedule","4.88","35.67",""
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.67","","","","","","","fee schedule","4.88","35.67",""
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.4","","","","","","","fee schedule","4.88","35.67",""
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.11","","","","","","","fee schedule","4.88","35.67","APC"
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.03","","","","","","","fee schedule","4.88","35.67","APC"
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.98","","","","","","","fee schedule","4.88","35.67","APC"
"Assay blood carbon dioxide","82374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.12","","","","","","","fee schedule","4.88","35.67","APC"
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.32","","","","","","","fee schedule","12.32","82.9",""
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.32","","","","","","","fee schedule","12.32","82.9",""
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.32","","","","","","","fee schedule","12.32","82.9",""
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.19","","","","","","","fee schedule","12.32","82.9",""
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.9","","","","","","","fee schedule","12.32","82.9",""
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.19","","","","","","","fee schedule","12.32","82.9",""
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.91","","","","","","","fee schedule","12.32","82.9","APC"
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.32","82.9","APC"
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.57","","","","","","","fee schedule","12.32","82.9","APC"
"Assay carboxyhb quant","82375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.94","","","","","","","fee schedule","12.32","82.9","APC"
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.07","","","","","","","fee schedule","10.3","43.25",""
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.07","","","","","","","fee schedule","10.3","43.25",""
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.07","","","","","","","fee schedule","10.3","43.25",""
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.3","","","","","","","fee schedule","10.3","43.25",""
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","43.25","","","","","","","fee schedule","10.3","43.25",""
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.3","","","","","","","fee schedule","10.3","43.25",""
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.74","","","","","","","fee schedule","10.3","43.25","APC"
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.49","","","","","","","fee schedule","10.3","43.25","APC"
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.35","","","","","","","fee schedule","10.3","43.25","APC"
"Assay carboxyhb qual","82376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.77","","","","","","","fee schedule","10.3","43.25","APC"
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.96","","","","","","","fee schedule","18.96","142.06",""
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.96","","","","","","","fee schedule","18.96","142.06",""
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.96","","","","","","","fee schedule","18.96","142.06",""
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.6","","","","","","","fee schedule","18.96","142.06",""
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.06","","","","","","","fee schedule","18.96","142.06",""
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.6","","","","","","","fee schedule","18.96","142.06",""
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.86","","","","","","","fee schedule","18.96","142.06","APC"
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.53","","","","","","","fee schedule","18.96","142.06","APC"
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.34","","","","","","","fee schedule","18.96","142.06","APC"
"Carcinoembryonic antigen","82378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.91","","","","","","","fee schedule","18.96","142.06","APC"
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","16.87","106.7",""
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.7","","","","","","","fee schedule","16.87","106.7",""
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","16.87","106.7",""
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.67","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of carnitine","82379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.71","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.22","","","","","","","fee schedule","9.22","69.15",""
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.22","","","","","","","fee schedule","9.22","69.15",""
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.22","","","","","","","fee schedule","9.22","69.15",""
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.85","","","","","","","fee schedule","9.22","69.15",""
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.15","","","","","","","fee schedule","9.22","69.15",""
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.85","","","","","","","fee schedule","9.22","69.15",""
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.66","","","","","","","fee schedule","9.22","69.15","APC"
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.5","","","","","","","fee schedule","9.22","69.15","APC"
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.4","","","","","","","fee schedule","9.22","69.15","APC"
"Assay of carotene","82380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.68","","","","","","","fee schedule","9.22","69.15","APC"
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.3","","","","","","","fee schedule","27.3","129.08",""
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.3","","","","","","","fee schedule","27.3","129.08",""
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.3","","","","","","","fee schedule","27.3","129.08",""
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.56","","","","","","","fee schedule","27.3","129.08",""
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","129.08","","","","","","","fee schedule","27.3","129.08",""
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.56","","","","","","","fee schedule","27.3","129.08",""
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.6","","","","","","","fee schedule","27.3","129.08","APC"
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.12","","","","","","","fee schedule","27.3","129.08","APC"
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.85","","","","","","","fee schedule","27.3","129.08","APC"
"Assay urine catecholamines","82382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.67","","","","","","","fee schedule","27.3","129.08","APC"
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.08","","","","","","","fee schedule","29.08","181.87",""
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.08","","","","","","","fee schedule","29.08","181.87",""
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.08","","","","","","","fee schedule","29.08","181.87",""
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.07","","","","","","","fee schedule","29.08","181.87",""
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","181.87","","","","","","","fee schedule","29.08","181.87",""
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.07","","","","","","","fee schedule","29.08","181.87",""
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.46","","","","","","","fee schedule","29.08","181.87","APC"
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.95","","","","","","","fee schedule","29.08","181.87","APC"
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.66","","","","","","","fee schedule","29.08","181.87","APC"
"Assay blood catecholamines","82383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.53","","","","","","","fee schedule","29.08","181.87","APC"
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.25","","","","","","","fee schedule","25.25","183.72",""
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.25","","","","","","","fee schedule","25.25","183.72",""
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.25","","","","","","","fee schedule","25.25","183.72",""
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","183.72","","","","","","","fee schedule","25.25","183.72",""
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.4","","","","","","","fee schedule","25.25","183.72",""
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.4","","","","","","","fee schedule","25.25","183.72",""
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.45","","","","","","","fee schedule","25.25","183.72","APC"
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.01","","","","","","","fee schedule","25.25","183.72","APC"
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.76","","","","","","","fee schedule","25.25","183.72","APC"
"Assay three catecholamines","82384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.51","","","","","","","fee schedule","25.25","183.72","APC"
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.06","","","","","","","fee schedule","18.06","137.94",""
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.06","","","","","","","fee schedule","18.06","137.94",""
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.06","","","","","","","fee schedule","18.06","137.94",""
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.94","","","","","","","fee schedule","18.06","137.94",""
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.76","","","","","","","fee schedule","18.06","137.94",""
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.76","","","","","","","fee schedule","18.06","137.94",""
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.92","","","","","","","fee schedule","18.06","137.94","APC"
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.6","","","","","","","fee schedule","18.06","137.94","APC"
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.42","","","","","","","fee schedule","18.06","137.94","APC"
"Assay of cathepsin-d","82387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.96","","","","","","","fee schedule","18.06","137.94","APC"
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.74","","","","","","","fee schedule","10.74","78.87",""
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.74","","","","","","","fee schedule","10.74","78.87",""
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.74","","","","","","","fee schedule","10.74","78.87",""
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","78.87","","","","","","","fee schedule","10.74","78.87",""
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.46","","","","","","","fee schedule","10.74","78.87",""
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.46","","","","","","","fee schedule","10.74","78.87",""
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.25","","","","","","","fee schedule","10.74","78.87","APC"
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.74","78.87","APC"
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.74","78.87","APC"
"Assay of ceruloplasmin","82390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.28","","","","","","","fee schedule","10.74","78.87","APC"
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.12","","","","","","","fee schedule","14.12","96.36",""
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.12","","","","","","","fee schedule","14.12","96.36",""
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.12","","","","","","","fee schedule","14.12","96.36",""
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.36","","","","","","","fee schedule","14.12","96.36",""
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.29","","","","","","","fee schedule","14.12","96.36",""
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.29","","","","","","","fee schedule","14.12","96.36",""
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.79","","","","","","","fee schedule","14.12","96.36","APC"
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.54","","","","","","","fee schedule","14.12","96.36","APC"
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.4","","","","","","","fee schedule","14.12","96.36","APC"
"Chemiluminescent assay","82397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.83","","","","","","","fee schedule","14.12","96.36","APC"
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.67","","","","","","","fee schedule","12.67","93.66",""
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.67","","","","","","","fee schedule","12.67","93.66",""
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.67","","","","","","","fee schedule","12.67","93.66",""
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.66","","","","","","","fee schedule","12.67","93.66",""
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.78","","","","","","","fee schedule","12.67","93.66",""
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.78","","","","","","","fee schedule","12.67","93.66",""
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.27","","","","","","","fee schedule","12.67","93.66","APC"
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.05","","","","","","","fee schedule","12.67","93.66","APC"
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.92","","","","","","","fee schedule","12.67","93.66","APC"
"Assay of chloramphenicol","82415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.3","","","","","","","fee schedule","12.67","93.66","APC"
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.6","","","","","","","fee schedule","4.6","33.68",""
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.6","","","","","","","fee schedule","4.6","33.68",""
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.6","","","","","","","fee schedule","4.6","33.68",""
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.68","","","","","","","fee schedule","4.6","33.68",""
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.9","","","","","","","fee schedule","4.6","33.68",""
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.9","","","","","","","fee schedule","4.6","33.68",""
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.82","","","","","","","fee schedule","4.6","33.68","APC"
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.74","","","","","","","fee schedule","4.6","33.68","APC"
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.69","","","","","","","fee schedule","4.6","33.68","APC"
"Assay of blood chloride","82435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.83","","","","","","","fee schedule","4.6","33.68","APC"
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.75","","","","","","","fee schedule","5.75","36.27",""
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.75","","","","","","","fee schedule","5.75","36.27",""
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.75","","","","","","","fee schedule","5.75","36.27",""
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","36.27","","","","","","","fee schedule","5.75","36.27",""
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.64","","","","","","","fee schedule","5.75","36.27",""
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.64","","","","","","","fee schedule","5.75","36.27",""
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.02","","","","","","","fee schedule","5.75","36.27","APC"
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.92","","","","","","","fee schedule","5.75","36.27","APC"
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.86","","","","","","","fee schedule","5.75","36.27","APC"
"Assay of urine chloride","82436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.04","","","","","","","fee schedule","5.75","36.27","APC"
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5","","","","","","","fee schedule","5","34.93",""
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5","","","","","","","fee schedule","5","34.93",""
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5","","","","","","","fee schedule","5","34.93",""
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","34.93","","","","","","","fee schedule","5","34.93",""
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.41","","","","","","","fee schedule","5","34.93",""
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.41","","","","","","","fee schedule","5","34.93",""
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.24","","","","","","","fee schedule","5","34.93","APC"
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.15","","","","","","","fee schedule","5","34.93","APC"
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.1","","","","","","","fee schedule","5","34.93","APC"
"Assay other fluid chlorides","82438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.25","","","","","","","fee schedule","5","34.93","APC"
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.01","","","","","","","fee schedule","6.01","44.76",""
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.01","","","","","","","fee schedule","6.01","44.76",""
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.01","","","","","","","fee schedule","6.01","44.76",""
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.76","","","","","","","fee schedule","6.01","44.76",""
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.32","","","","","","","fee schedule","6.01","44.76",""
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.32","","","","","","","fee schedule","6.01","44.76",""
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.3","","","","","","","fee schedule","6.01","44.76","APC"
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.19","","","","","","","fee schedule","6.01","44.76","APC"
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.13","","","","","","","fee schedule","6.01","44.76","APC"
"Test for chlorohydrocarbons","82441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.31","","","","","","","fee schedule","6.01","44.76","APC"
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.35","","","","","","","fee schedule","4.35","32.63",""
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.35","","","","","","","fee schedule","4.35","32.63",""
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.35","","","","","","","fee schedule","4.35","32.63",""
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.63","","","","","","","fee schedule","4.35","32.63",""
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.49","","","","","","","fee schedule","4.35","32.63",""
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.49","","","","","","","fee schedule","4.35","32.63",""
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.56","","","","","","","fee schedule","4.35","32.63","APC"
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.35","32.63","APC"
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.35","32.63","APC"
"Assay bld/serum cholesterol","82465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.57","","","","","","","fee schedule","4.35","32.63","APC"
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.87","","","","","","","fee schedule","7.87","57.57",""
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.87","","","","","","","fee schedule","7.87","57.57",""
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.87","","","","","","","fee schedule","7.87","57.57",""
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","57.57","","","","","","","fee schedule","7.87","57.57",""
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.55","","","","","","","fee schedule","7.87","57.57",""
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.55","","","","","","","fee schedule","7.87","57.57",""
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.24","","","","","","","fee schedule","7.87","57.57","APC"
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.11","","","","","","","fee schedule","7.87","57.57","APC"
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.03","","","","","","","fee schedule","7.87","57.57","APC"
"Assay serum cholinesterase","82480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.26","","","","","","","fee schedule","7.87","57.57","APC"
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.81","","","","","","","fee schedule","9.81","55.86",""
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.81","","","","","","","fee schedule","9.81","55.86",""
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.81","","","","","","","fee schedule","9.81","55.86",""
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","55.86","","","","","","","fee schedule","9.81","55.86",""
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.2","","","","","","","fee schedule","9.81","55.86",""
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.2","","","","","","","fee schedule","9.81","55.86",""
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.28","","","","","","","fee schedule","9.81","55.86","APC"
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.1","","","","","","","fee schedule","9.81","55.86","APC"
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.01","","","","","","","fee schedule","9.81","55.86","APC"
"Assay rbc cholinesterase","82482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.3","","","","","","","fee schedule","9.81","55.86","APC"
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.65","","","","","","","fee schedule","20.65","146.86",""
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.65","","","","","","","fee schedule","20.65","146.86",""
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.65","","","","","","","fee schedule","20.65","146.86",""
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.65","146.86",""
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.5","","","","","","","fee schedule","20.65","146.86",""
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.5","","","","","","","fee schedule","20.65","146.86",""
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.63","","","","","","","fee schedule","20.65","146.86","APC"
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.27","","","","","","","fee schedule","20.65","146.86","APC"
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.06","","","","","","","fee schedule","20.65","146.86","APC"
"Assay chondroitin sulfate","82485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.68","","","","","","","fee schedule","20.65","146.86","APC"
"Gas/liquid chromatography","82486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Paper chromatography","82487","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","112.09","","","","","","","fee schedule","112.09","112.09",""
"Paper chromatography","82488","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","149.78","","","","","","","fee schedule","149.78","149.78",""
"Thin layer chromatography","82489","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","131.26","","","","","","","fee schedule","131.26","131.26",""
"Chromotography, quant, sing","82491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Chromotography, quant, mult","82492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.28","","","","","","","fee schedule","20.28","135.1",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.28","","","","","","","fee schedule","20.28","135.1",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.28","","","","","","","fee schedule","20.28","135.1",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","135.1","","","","","","","fee schedule","20.28","135.1",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.86","","","","","","","fee schedule","20.28","135.1",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.86","","","","","","","fee schedule","20.28","135.1",""
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.24","","","","","","","fee schedule","20.28","135.1","APC"
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.89","","","","","","","fee schedule","20.28","135.1","APC"
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.69","","","","","","","fee schedule","20.28","135.1","APC"
"Assay of chromium","82495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.29","","","","","","","fee schedule","20.28","135.1","APC"
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.8","","","","","","","fee schedule","27.8","198.57",""
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.8","","","","","","","fee schedule","27.8","198.57",""
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.8","","","","","","","fee schedule","27.8","198.57",""
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","198.57","","","","","","","fee schedule","27.8","198.57",""
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","47.8","","","","","","","fee schedule","27.8","198.57",""
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","47.8","","","","","","","fee schedule","27.8","198.57",""
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.12","","","","","","","fee schedule","27.8","198.57","APC"
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.63","","","","","","","fee schedule","27.8","198.57","APC"
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.36","","","","","","","fee schedule","27.8","198.57","APC"
"Assay of citrate","82507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.19","","","","","","","fee schedule","27.8","198.57","APC"
"Assay of cocaine","82520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.89","","","","","","","fee schedule","107.89","107.89",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.68","","","","","","","fee schedule","18.68","126.21",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.68","","","","","","","fee schedule","18.68","126.21",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.68","","","","","","","fee schedule","18.68","126.21",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.21","","","","","","","fee schedule","18.68","126.21",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.12","","","","","","","fee schedule","18.68","126.21",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.12","","","","","","","fee schedule","18.68","126.21",""
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.57","","","","","","","fee schedule","18.68","126.21","APC"
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.24","","","","","","","fee schedule","18.68","126.21","APC"
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.05","","","","","","","fee schedule","18.68","126.21","APC"
"Collagen crosslinks","82523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.61","","","","","","","fee schedule","18.68","126.21","APC"
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.41","","","","","","","fee schedule","12.41","92.5",""
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.41","","","","","","","fee schedule","12.41","92.5",""
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.41","","","","","","","fee schedule","12.41","92.5",""
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.5","","","","","","","fee schedule","12.41","92.5",""
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.32","","","","","","","fee schedule","12.41","92.5",""
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.32","","","","","","","fee schedule","12.41","92.5",""
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13","","","","","","","fee schedule","12.41","92.5","APC"
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.78","","","","","","","fee schedule","12.41","92.5","APC"
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.66","","","","","","","fee schedule","12.41","92.5","APC"
"Assay of copper","82525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.03","","","","","","","fee schedule","12.41","92.5","APC"
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.52","","","","","","","fee schedule","22.52","164.1",""
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.52","","","","","","","fee schedule","22.52","164.1",""
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.52","","","","","","","fee schedule","22.52","164.1",""
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","164.1","","","","","","","fee schedule","22.52","164.1",""
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.69","","","","","","","fee schedule","22.52","164.1",""
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.69","","","","","","","fee schedule","22.52","164.1",""
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.59","","","","","","","fee schedule","22.52","164.1","APC"
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.2","","","","","","","fee schedule","22.52","164.1","APC"
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.97","","","","","","","fee schedule","22.52","164.1","APC"
"Assay of corticosterone","82528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.65","","","","","","","fee schedule","22.52","164.1","APC"
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.71","","","","","","","fee schedule","16.71","124.82",""
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.71","","","","","","","fee schedule","16.71","124.82",""
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.71","","","","","","","fee schedule","16.71","124.82",""
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.82","","","","","","","fee schedule","16.71","124.82",""
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.73","","","","","","","fee schedule","16.71","124.82",""
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.73","","","","","","","fee schedule","16.71","124.82",""
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.5","","","","","","","fee schedule","16.71","124.82","APC"
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.71","124.82","APC"
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.04","","","","","","","fee schedule","16.71","124.82","APC"
"Cortisol free","82530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.55","","","","","","","fee schedule","16.71","124.82","APC"
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.3","","","","","","","fee schedule","16.3","121.32",""
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.3","","","","","","","fee schedule","16.3","121.32",""
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.3","","","","","","","fee schedule","16.3","121.32",""
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","121.32","","","","","","","fee schedule","16.3","121.32",""
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.02","","","","","","","fee schedule","16.3","121.32",""
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.02","","","","","","","fee schedule","16.3","121.32",""
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.07","","","","","","","fee schedule","16.3","121.32","APC"
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.79","","","","","","","fee schedule","16.3","121.32","APC"
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.63","","","","","","","fee schedule","16.3","121.32","APC"
"Total cortisol","82533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.12","","","","","","","fee schedule","16.3","121.32","APC"
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.64","","","","","","","fee schedule","4.64","34.82",""
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.64","","","","","","","fee schedule","4.64","34.82",""
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.64","","","","","","","fee schedule","4.64","34.82",""
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","34.82","","","","","","","fee schedule","4.64","34.82",""
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.97","","","","","","","fee schedule","4.64","34.82",""
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.97","","","","","","","fee schedule","4.64","34.82",""
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.86","","","","","","","fee schedule","4.64","34.82","APC"
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.78","","","","","","","fee schedule","4.64","34.82","APC"
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.73","","","","","","","fee schedule","4.64","34.82","APC"
"Assay of creatine","82540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.87","","","","","","","fee schedule","4.64","34.82","APC"
"Column chromotography, qual","82541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.09","","","","","","","fee schedule","24.09","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.09","","","","","","","fee schedule","24.09","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.09","","","","","","","fee schedule","24.09","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","24.09","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","24.09","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","24.09","128.57",""
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.23","","","","","","","fee schedule","24.09","128.57","APC"
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.81","","","","","","","fee schedule","24.09","128.57","APC"
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.57","","","","","","","fee schedule","24.09","128.57","APC"
"Col chromotography qual/quan","82542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.29","","","","","","","fee schedule","24.09","128.57","APC"
"Column chromotograph/isotope","82543","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Column chromotograph/isotope","82544","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.51","","","","","","","fee schedule","6.51","48.9",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.51","","","","","","","fee schedule","6.51","48.9",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.51","","","","","","","fee schedule","6.51","48.9",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.9","","","","","","","fee schedule","6.51","48.9",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.2","","","","","","","fee schedule","6.51","48.9",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.2","","","","","","","fee schedule","6.51","48.9",""
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.82","","","","","","","fee schedule","6.51","48.9","APC"
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.71","","","","","","","fee schedule","6.51","48.9","APC"
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.64","","","","","","","fee schedule","6.51","48.9","APC"
"Assay of ck (cpk)","82550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.84","","","","","","","fee schedule","6.51","48.9","APC"
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.39","","","","","","","fee schedule","13.39","95.74",""
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.39","","","","","","","fee schedule","13.39","95.74",""
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.39","","","","","","","fee schedule","13.39","95.74",""
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.74","","","","","","","fee schedule","13.39","95.74",""
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.03","","","","","","","fee schedule","13.39","95.74",""
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.03","","","","","","","fee schedule","13.39","95.74",""
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.03","","","","","","","fee schedule","13.39","95.74","APC"
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.79","","","","","","","fee schedule","13.39","95.74","APC"
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.66","","","","","","","fee schedule","13.39","95.74","APC"
"Assay of cpk in blood","82552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.39","95.74","APC"
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.55","","","","","","","fee schedule","11.55","75.4",""
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.55","","","","","","","fee schedule","11.55","75.4",""
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.55","","","","","","","fee schedule","11.55","75.4",""
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.4","","","","","","","fee schedule","11.55","75.4",""
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.85","","","","","","","fee schedule","11.55","75.4",""
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.85","","","","","","","fee schedule","11.55","75.4",""
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.1","","","","","","","fee schedule","11.55","75.4","APC"
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.9","","","","","","","fee schedule","11.55","75.4","APC"
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.78","","","","","","","fee schedule","11.55","75.4","APC"
"Creatine mb fraction","82553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.13","","","","","","","fee schedule","11.55","75.4","APC"
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.87","","","","","","","fee schedule","11.87","81.54",""
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.87","","","","","","","fee schedule","11.87","81.54",""
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.87","","","","","","","fee schedule","11.87","81.54",""
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.54","","","","","","","fee schedule","11.87","81.54",""
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.4","","","","","","","fee schedule","11.87","81.54",""
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.4","","","","","","","fee schedule","11.87","81.54",""
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.43","","","","","","","fee schedule","11.87","81.54","APC"
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.23","","","","","","","fee schedule","11.87","81.54","APC"
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.87","81.54","APC"
"Creatine isoforms","82554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.46","","","","","","","fee schedule","11.87","81.54","APC"
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.12","","","","","","","fee schedule","5.12","38.37",""
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.12","","","","","","","fee schedule","5.12","38.37",""
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.12","","","","","","","fee schedule","5.12","38.37",""
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.37","","","","","","","fee schedule","5.12","38.37",""
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.81","","","","","","","fee schedule","5.12","38.37",""
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.81","","","","","","","fee schedule","5.12","38.37",""
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.36","","","","","","","fee schedule","5.12","38.37","APC"
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.27","","","","","","","fee schedule","5.12","38.37","APC"
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.22","","","","","","","fee schedule","5.12","38.37","APC"
"Assay of creatinine","82565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.38","","","","","","","fee schedule","5.12","38.37","APC"
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","38.37",""
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","38.37",""
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","38.37",""
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.37","","","","","","","fee schedule","5.18","38.37",""
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","38.37",""
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","38.37",""
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.18","38.37","APC"
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.18","38.37","APC"
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.18","38.37","APC"
"Assay of urine creatinine","82570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.18","38.37","APC"
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.46","","","","","","","fee schedule","9.46","70.29",""
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.46","","","","","","","fee schedule","9.46","70.29",""
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.46","","","","","","","fee schedule","9.46","70.29",""
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.29","","","","","","","fee schedule","9.46","70.29",""
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.24","","","","","","","fee schedule","9.46","70.29",""
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.24","","","","","","","fee schedule","9.46","70.29",""
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.46","70.29","APC"
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.74","","","","","","","fee schedule","9.46","70.29","APC"
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.65","","","","","","","fee schedule","9.46","70.29","APC"
"Creatinine clearance test","82575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.93","","","","","","","fee schedule","9.46","70.29","APC"
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.14","","","","","","","fee schedule","14.14","59.84",""
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.14","","","","","","","fee schedule","14.14","59.84",""
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.14","","","","","","","fee schedule","14.14","59.84",""
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.84","","","","","","","fee schedule","14.14","59.84",""
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.74","","","","","","","fee schedule","14.14","59.84",""
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.74","","","","","","","fee schedule","14.14","59.84",""
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.81","","","","","","","fee schedule","14.14","59.84","APC"
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.56","","","","","","","fee schedule","14.14","59.84","APC"
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.42","","","","","","","fee schedule","14.14","59.84","APC"
"Assay of cryofibrinogen","82585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.85","","","","","","","fee schedule","14.14","59.84","APC"
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","46.38",""
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","46.38",""
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","46.38",""
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","46.38","","","","","","","fee schedule","6.47","46.38",""
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","46.38",""
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","46.38",""
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","46.38","APC"
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","46.38","APC"
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","46.38","APC"
"Assay of cryoglobulin","82595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","46.38","APC"
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.4","","","","","","","fee schedule","19.4","143.39",""
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.4","","","","","","","fee schedule","19.4","143.39",""
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.4","","","","","","","fee schedule","19.4","143.39",""
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","143.39","","","","","","","fee schedule","19.4","143.39",""
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.35","","","","","","","fee schedule","19.4","143.39",""
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.35","","","","","","","fee schedule","19.4","143.39",""
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.32","","","","","","","fee schedule","19.4","143.39","APC"
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.98","","","","","","","fee schedule","19.4","143.39","APC"
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.79","","","","","","","fee schedule","19.4","143.39","APC"
"Assay of cyanide","82600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.37","","","","","","","fee schedule","19.4","143.39","APC"
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.08","","","","","","","fee schedule","15.08","111.73",""
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.08","","","","","","","fee schedule","15.08","111.73",""
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.08","","","","","","","fee schedule","15.08","111.73",""
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.73","","","","","","","fee schedule","15.08","111.73",""
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.91","","","","","","","fee schedule","15.08","111.73",""
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.91","","","","","","","fee schedule","15.08","111.73",""
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.08","111.73","APC"
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.53","","","","","","","fee schedule","15.08","111.73","APC"
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.38","","","","","","","fee schedule","15.08","111.73","APC"
"Vitamin B-12","82607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.83","","","","","","","fee schedule","15.08","111.73","APC"
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.32","","","","","","","fee schedule","14.32","106.53",""
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.32","","","","","","","fee schedule","14.32","106.53",""
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.32","","","","","","","fee schedule","14.32","106.53",""
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.53","","","","","","","fee schedule","14.32","106.53",""
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.61","","","","","","","fee schedule","14.32","106.53",""
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.61","","","","","","","fee schedule","14.32","106.53",""
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15","","","","","","","fee schedule","14.32","106.53","APC"
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.75","","","","","","","fee schedule","14.32","106.53","APC"
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.61","","","","","","","fee schedule","14.32","106.53","APC"
"B-12 binding capacity","82608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.04","","","","","","","fee schedule","14.32","106.53","APC"
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.52","","","","","","","fee schedule","18.52","93.18",""
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.52","","","","","","","fee schedule","18.52","93.18",""
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.52","","","","","","","fee schedule","18.52","93.18",""
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.18","","","","","","","fee schedule","18.52","93.18",""
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.36","","","","","","","fee schedule","18.52","93.18",""
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.36","","","","","","","fee schedule","18.52","93.18",""
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.4","","","","","","","fee schedule","18.52","93.18","APC"
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.08","","","","","","","fee schedule","18.52","93.18","APC"
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.89","","","","","","","fee schedule","18.52","93.18","APC"
"Cystatin c","82610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.45","","","","","","","fee schedule","18.52","93.18","APC"
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.55","","","","","","","fee schedule","9.55","60.26",""
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.55","","","","","","","fee schedule","9.55","60.26",""
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.55","","","","","","","fee schedule","9.55","60.26",""
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","60.26","","","","","","","fee schedule","9.55","60.26",""
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.03","","","","","","","fee schedule","9.55","60.26",""
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.03","","","","","","","fee schedule","9.55","60.26",""
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10","","","","","","","fee schedule","9.55","60.26","APC"
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.84","","","","","","","fee schedule","9.55","60.26","APC"
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.74","","","","","","","fee schedule","9.55","60.26","APC"
"Test for urine cystines","82615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.03","","","","","","","fee schedule","9.55","60.26","APC"
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.27","","","","","","","fee schedule","25.27","182.58",""
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.27","","","","","","","fee schedule","25.27","182.58",""
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.27","","","","","","","fee schedule","25.27","182.58",""
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","182.58","","","","","","","fee schedule","25.27","182.58",""
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.44","","","","","","","fee schedule","25.27","182.58",""
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.44","","","","","","","fee schedule","25.27","182.58",""
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.47","","","","","","","fee schedule","25.27","182.58","APC"
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.03","","","","","","","fee schedule","25.27","182.58","APC"
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.78","","","","","","","fee schedule","25.27","182.58","APC"
"Dehydroepiandrosterone","82626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.53","","","","","","","fee schedule","25.27","182.58","APC"
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.23","","","","","","","fee schedule","22.23","165.29",""
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.23","","","","","","","fee schedule","22.23","165.29",""
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.23","","","","","","","fee schedule","22.23","165.29",""
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","165.29","","","","","","","fee schedule","22.23","165.29",""
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.22","","","","","","","fee schedule","22.23","165.29",""
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.22","","","","","","","fee schedule","22.23","165.29",""
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.29","","","","","","","fee schedule","22.23","165.29","APC"
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.9","","","","","","","fee schedule","22.23","165.29","APC"
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.67","","","","","","","fee schedule","22.23","165.29","APC"
"Dehydroepiandrosterone","82627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.34","","","","","","","fee schedule","22.23","165.29","APC"
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.98","","","","","","","fee schedule","30.98","225.5",""
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.98","","","","","","","fee schedule","30.98","225.5",""
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.98","","","","","","","fee schedule","30.98","225.5",""
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","225.5","","","","","","","fee schedule","30.98","225.5",""
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","53.24","","","","","","","fee schedule","30.98","225.5",""
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","53.24","","","","","","","fee schedule","30.98","225.5",""
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.45","","","","","","","fee schedule","30.98","225.5","APC"
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.91","","","","","","","fee schedule","30.98","225.5","APC"
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.6","","","","","","","fee schedule","30.98","225.5","APC"
"Desoxycorticosterone","82633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.53","","","","","","","fee schedule","30.98","225.5","APC"
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.28","","","","","","","fee schedule","29.28","212.83",""
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.28","","","","","","","fee schedule","29.28","212.83",""
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.28","","","","","","","fee schedule","29.28","212.83",""
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","212.83","","","","","","","fee schedule","29.28","212.83",""
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.32","","","","","","","fee schedule","29.28","212.83",""
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.32","","","","","","","fee schedule","29.28","212.83",""
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.67","","","","","","","fee schedule","29.28","212.83","APC"
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.16","","","","","","","fee schedule","29.28","212.83","APC"
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.87","","","","","","","fee schedule","29.28","212.83","APC"
"Deoxycortisol","82634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.74","","","","","","","fee schedule","29.28","212.83","APC"
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.25","","","","","","","fee schedule","12.25","91.53",""
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.25","","","","","","","fee schedule","12.25","91.53",""
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.25","","","","","","","fee schedule","12.25","91.53",""
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.53","","","","","","","fee schedule","12.25","91.53",""
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.05","","","","","","","fee schedule","12.25","91.53",""
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.05","","","","","","","fee schedule","12.25","91.53",""
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.25","91.53","APC"
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.25","91.53","APC"
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.5","","","","","","","fee schedule","12.25","91.53","APC"
"Assay of dibucaine number","82638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.86","","","","","","","fee schedule","12.25","91.53","APC"
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.28","","","","","","","fee schedule","29.28","39.04",""
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.28","","","","","","","fee schedule","29.28","39.04",""
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.28","","","","","","","fee schedule","29.28","39.04",""
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.04","","","","","","","fee schedule","29.28","39.04",""
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.04","","","","","","","fee schedule","29.28","39.04",""
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.67","","","","","","","fee schedule","29.28","39.04","APC"
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.16","","","","","","","fee schedule","29.28","39.04","APC"
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.87","","","","","","","fee schedule","29.28","39.04","APC"
"Dihydrotestosterone","82642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.74","","","","","","","fee schedule","29.28","39.04","APC"
"Assay of dihydrocodeinone","82646","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.26","","","","","","","fee schedule","146.26","146.26",""
"Assay of dihydromorphinone","82649","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","186.82","","","","","","","fee schedule","186.82","186.82",""
"Assay of dihydrotestosterone","82651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","187.07","","","","","","","fee schedule","187.07","187.07",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.5","","","","","","","fee schedule","38.5","288.63",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.5","","","","","","","fee schedule","38.5","288.63",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.5","","","","","","","fee schedule","38.5","288.63",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","288.63","","","","","","","fee schedule","38.5","288.63",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","66.17","","","","","","","fee schedule","38.5","288.63",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","66.17","","","","","","","fee schedule","38.5","288.63",""
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.33","","","","","","","fee schedule","38.5","288.63","APC"
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.66","","","","","","","fee schedule","38.5","288.63","APC"
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.27","","","","","","","fee schedule","38.5","288.63","APC"
"Vit d 1 25-dihydroxy","82652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.43","","","","","","","fee schedule","38.5","288.63","APC"
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.97","","","","","","","fee schedule","22.97","27.56",""
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.97","","","","","","","fee schedule","22.97","27.56",""
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.97","","","","","","","fee schedule","22.97","27.56",""
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.56","","","","","","","fee schedule","22.97","27.56",""
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.56","","","","","","","fee schedule","22.97","27.56",""
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.06","","","","","","","fee schedule","22.97","27.56","APC"
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.66","","","","","","","fee schedule","22.97","27.56","APC"
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.43","","","","","","","fee schedule","22.97","27.56","APC"
"El-1 fecal quantitative","82653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.12","","","","","","","fee schedule","22.97","27.56","APC"
"Assay of dimethadione","82654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","104.03","","","","","","","fee schedule","104.03","104.03",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","84.49",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","84.49",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","84.49",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","84.49","","","","","","","fee schedule","11.53","84.49",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.82","","","","","","","fee schedule","11.53","84.49",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.82","","","","","","","fee schedule","11.53","84.49",""
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","84.49","APC"
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","84.49","APC"
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","84.49","APC"
"Pancreatic elastase fecal","82656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","84.49","APC"
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.17","","","","","","","fee schedule","22.17","128.57",""
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.17","","","","","","","fee schedule","22.17","128.57",""
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.17","","","","","","","fee schedule","22.17","128.57",""
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","22.17","128.57",""
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","22.17","128.57",""
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","22.17","128.57",""
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.22","","","","","","","fee schedule","22.17","128.57","APC"
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.84","","","","","","","fee schedule","22.17","128.57","APC"
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.61","","","","","","","fee schedule","22.17","128.57","APC"
"Enzyme cell activity","82657","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.28","","","","","","","fee schedule","22.17","128.57","APC"
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44.03","","","","","","","fee schedule","31.03","128.57",""
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.03","","","","","","","fee schedule","31.03","128.57",""
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44.03","","","","","","","fee schedule","31.03","128.57",""
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","31.03","128.57",""
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","31.03","128.57",""
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","31.03","128.57",""
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.12","","","","","","","fee schedule","31.03","128.57","APC"
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.35","","","","","","","fee schedule","31.03","128.57","APC"
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.91","","","","","","","fee schedule","31.03","128.57","APC"
"Enzyme cell activity ra","82658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.23","","","","","","","fee schedule","31.03","128.57","APC"
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","61.5","","","","","","","fee schedule","59.05","241.09",""
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.5","","","","","","","fee schedule","59.05","241.09",""
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.5","","","","","","","fee schedule","59.05","241.09",""
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","241.09","","","","","","","fee schedule","59.05","241.09",""
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.05","","","","","","","fee schedule","59.05","241.09",""
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.05","","","","","","","fee schedule","59.05","241.09",""
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.42","","","","","","","fee schedule","59.05","241.09","APC"
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.34","","","","","","","fee schedule","59.05","241.09","APC"
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.73","","","","","","","fee schedule","59.05","241.09","APC"
"Electrophoretic test","82664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.58","","","","","","","fee schedule","59.05","241.09","APC"
"Assay of epiandrosterone","82666","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","158.98","","","","","","","fee schedule","158.98","158.98",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.79","","","","","","","fee schedule","18.79","138.17",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.79","","","","","","","fee schedule","18.79","138.17",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.79","","","","","","","fee schedule","18.79","138.17",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","138.17","","","","","","","fee schedule","18.79","138.17",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.32","","","","","","","fee schedule","18.79","138.17",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.32","","","","","","","fee schedule","18.79","138.17",""
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.68","","","","","","","fee schedule","18.79","138.17","APC"
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.35","","","","","","","fee schedule","18.79","138.17","APC"
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.17","","","","","","","fee schedule","18.79","138.17","APC"
"Assay of erythropoietin","82668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.73","","","","","","","fee schedule","18.79","138.17","APC"
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.94","","","","","","","fee schedule","27.94","207.09",""
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.94","","","","","","","fee schedule","27.94","207.09",""
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.94","","","","","","","fee schedule","27.94","207.09",""
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","207.09","","","","","","","fee schedule","27.94","207.09",""
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","48.02","","","","","","","fee schedule","27.94","207.09",""
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","48.02","","","","","","","fee schedule","27.94","207.09",""
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.27","","","","","","","fee schedule","27.94","207.09","APC"
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","27.94","207.09","APC"
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.5","","","","","","","fee schedule","27.94","207.09","APC"
"Assay of estradiol","82670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.34","","","","","","","fee schedule","27.94","207.09","APC"
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.3","","","","","","","fee schedule","32.3","234.04",""
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","32.3","","","","","","","fee schedule","32.3","234.04",""
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.3","","","","","","","fee schedule","32.3","234.04",""
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","234.04","","","","","","","fee schedule","32.3","234.04",""
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","55.51","","","","","","","fee schedule","32.3","234.04",""
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55.51","","","","","","","fee schedule","32.3","234.04",""
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.83","","","","","","","fee schedule","32.3","234.04","APC"
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.27","","","","","","","fee schedule","32.3","234.04","APC"
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.95","","","","","","","fee schedule","32.3","234.04","APC"
"Assay of estrogens","82671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.92","","","","","","","fee schedule","32.3","234.04","APC"
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.7","","","","","","","fee schedule","21.7","157.36",""
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.7","","","","","","","fee schedule","21.7","157.36",""
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.7","","","","","","","fee schedule","21.7","157.36",""
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","157.36","","","","","","","fee schedule","21.7","157.36",""
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.28","","","","","","","fee schedule","21.7","157.36",""
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.28","","","","","","","fee schedule","21.7","157.36",""
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.73","","","","","","","fee schedule","21.7","157.36","APC"
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.35","","","","","","","fee schedule","21.7","157.36","APC"
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.13","","","","","","","fee schedule","21.7","157.36","APC"
"Assay of estrogen","82672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.78","","","","","","","fee schedule","21.7","157.36","APC"
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.18","","","","","","","fee schedule","24.18","176.99",""
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.18","","","","","","","fee schedule","24.18","176.99",""
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.18","","","","","","","fee schedule","24.18","176.99",""
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","176.99","","","","","","","fee schedule","24.18","176.99",""
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","41.57","","","","","","","fee schedule","24.18","176.99",""
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41.57","","","","","","","fee schedule","24.18","176.99",""
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.33","","","","","","","fee schedule","24.18","176.99","APC"
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.91","","","","","","","fee schedule","24.18","176.99","APC"
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.66","","","","","","","fee schedule","24.18","176.99","APC"
"Assay of estriol","82677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.39","","","","","","","fee schedule","24.18","176.99","APC"
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.95","","","","","","","fee schedule","24.95","180.94",""
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.95","","","","","","","fee schedule","24.95","180.94",""
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.95","","","","","","","fee schedule","24.95","180.94",""
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","180.94","","","","","","","fee schedule","24.95","180.94",""
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.9","","","","","","","fee schedule","24.95","180.94",""
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.9","","","","","","","fee schedule","24.95","180.94",""
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.14","","","","","","","fee schedule","24.95","180.94","APC"
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.7","","","","","","","fee schedule","24.95","180.94","APC"
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.45","","","","","","","fee schedule","24.95","180.94","APC"
"Assay of estrone","82679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.2","","","","","","","fee schedule","24.95","180.94","APC"
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.94","","","","","","","fee schedule","27.94","33.53",""
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.94","","","","","","","fee schedule","27.94","33.53",""
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.94","","","","","","","fee schedule","27.94","33.53",""
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.53","","","","","","","fee schedule","27.94","33.53",""
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.53","","","","","","","fee schedule","27.94","33.53",""
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.27","","","","","","","fee schedule","27.94","33.53","APC"
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","27.94","33.53","APC"
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.5","","","","","","","fee schedule","27.94","33.53","APC"
"Assay dir meas fr estradiol","82681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.34","","","","","","","fee schedule","27.94","33.53","APC"
"Assay of ethchlorvynol","82690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","129.02","","","","","","","fee schedule","129.02","129.02",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.9","","","","","","","fee schedule","14.9","106.3",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.9","","","","","","","fee schedule","14.9","106.3",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.9","","","","","","","fee schedule","14.9","106.3",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.3","","","","","","","fee schedule","14.9","106.3",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.6","","","","","","","fee schedule","14.9","106.3",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.6","","","","","","","fee schedule","14.9","106.3",""
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.61","","","","","","","fee schedule","14.9","106.3","APC"
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.35","","","","","","","fee schedule","14.9","106.3","APC"
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.2","","","","","","","fee schedule","14.9","106.3","APC"
"Assay of ethylene glycol","82693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.65","","","","","","","fee schedule","14.9","106.3","APC"
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.24","","","","","","","fee schedule","26.24","173.52",""
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.24","","","","","","","fee schedule","26.24","173.52",""
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.24","","","","","","","fee schedule","26.24","173.52",""
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","173.52","","","","","","","fee schedule","26.24","173.52",""
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","40.54","","","","","","","fee schedule","26.24","173.52",""
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","40.54","","","","","","","fee schedule","26.24","173.52",""
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.49","","","","","","","fee schedule","26.24","173.52","APC"
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.03","","","","","","","fee schedule","26.24","173.52","APC"
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.76","","","","","","","fee schedule","26.24","173.52","APC"
"Assay of etiocholanolone","82696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.55","","","","","","","fee schedule","26.24","173.52","APC"
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.1","","","","","","","fee schedule","5.1","33.91",""
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.1","","","","","","","fee schedule","5.1","33.91",""
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.1","","","","","","","fee schedule","5.1","33.91",""
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.91","","","","","","","fee schedule","5.1","33.91",""
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.75","","","","","","","fee schedule","5.1","33.91",""
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.75","","","","","","","fee schedule","5.1","33.91",""
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.1","33.91","APC"
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.25","","","","","","","fee schedule","5.1","33.91","APC"
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.2","","","","","","","fee schedule","5.1","33.91","APC"
"Fats/lipids feces qual","82705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.36","","","","","","","fee schedule","5.1","33.91","APC"
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.8","","","","","","","fee schedule","16.8","112.92",""
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.8","","","","","","","fee schedule","16.8","112.92",""
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.8","","","","","","","fee schedule","16.8","112.92",""
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","112.92","","","","","","","fee schedule","16.8","112.92",""
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.87","","","","","","","fee schedule","16.8","112.92",""
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.87","","","","","","","fee schedule","16.8","112.92",""
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.6","","","","","","","fee schedule","16.8","112.92","APC"
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.3","","","","","","","fee schedule","16.8","112.92","APC"
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.14","","","","","","","fee schedule","16.8","112.92","APC"
"Fats/lipids feces quant","82710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.64","","","","","","","fee schedule","16.8","112.92","APC"
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.97","","","","","","","fee schedule","22.97","112.27",""
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.97","","","","","","","fee schedule","22.97","112.27",""
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.97","","","","","","","fee schedule","22.97","112.27",""
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","112.27","","","","","","","fee schedule","22.97","112.27",""
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.58","","","","","","","fee schedule","22.97","112.27",""
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.58","","","","","","","fee schedule","22.97","112.27",""
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.06","","","","","","","fee schedule","22.97","112.27","APC"
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.66","","","","","","","fee schedule","22.97","112.27","APC"
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.43","","","","","","","fee schedule","22.97","112.27","APC"
"Assay of fecal fat","82715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.12","","","","","","","fee schedule","22.97","112.27","APC"
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.77","","","","","","","fee schedule","18.77","94.17",""
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.77","","","","","","","fee schedule","18.77","94.17",""
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.77","","","","","","","fee schedule","18.77","94.17",""
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","94.17","","","","","","","fee schedule","18.77","94.17",""
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.88","","","","","","","fee schedule","18.77","94.17",""
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.88","","","","","","","fee schedule","18.77","94.17",""
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.66","","","","","","","fee schedule","18.77","94.17","APC"
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.33","","","","","","","fee schedule","18.77","94.17","APC"
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.15","","","","","","","fee schedule","18.77","94.17","APC"
"Assay of blood fatty acids","82725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.71","","","","","","","fee schedule","18.77","94.17","APC"
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.75","","","","","","","fee schedule","19.75","128.57",""
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.75","","","","","","","fee schedule","19.75","128.57",""
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.75","","","","","","","fee schedule","19.75","128.57",""
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","19.75","128.57",""
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","19.75","128.57",""
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","19.75","128.57",""
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.69","","","","","","","fee schedule","19.75","128.57","APC"
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.34","","","","","","","fee schedule","19.75","128.57","APC"
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.14","","","","","","","fee schedule","19.75","128.57","APC"
"Long chain fatty acids","82726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.74","","","","","","","fee schedule","19.75","128.57","APC"
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.63","","","","","","","fee schedule","13.63","101.47",""
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.63","","","","","","","fee schedule","13.63","101.47",""
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.63","","","","","","","fee schedule","13.63","101.47",""
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.47","","","","","","","fee schedule","13.63","101.47",""
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.41","","","","","","","fee schedule","13.63","101.47",""
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.41","","","","","","","fee schedule","13.63","101.47",""
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.28","","","","","","","fee schedule","13.63","101.47","APC"
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.04","","","","","","","fee schedule","13.63","101.47","APC"
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.9","","","","","","","fee schedule","13.63","101.47","APC"
"Assay of ferritin","82728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.31","","","","","","","fee schedule","13.63","101.47","APC"
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.41","","","","","","","fee schedule","64.41","467.63",""
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","467.63","","","","","","","fee schedule","64.41","467.63",""
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","110.71","","","","","","","fee schedule","64.41","467.63",""
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","110.71","","","","","","","fee schedule","64.41","467.63",""
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.47","","","","","","","fee schedule","64.41","467.63","APC"
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.34","","","","","","","fee schedule","64.41","467.63","APC"
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.7","","","","","","","fee schedule","64.41","467.63","APC"
"Assay of fetal fibronectin","82731","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.63","","","","","","","fee schedule","64.41","467.63","APC"
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.54","","","","","","","fee schedule","18.54","136.6",""
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.54","","","","","","","fee schedule","18.54","136.6",""
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.54","","","","","","","fee schedule","18.54","136.6",""
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","136.6","","","","","","","fee schedule","18.54","136.6",""
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.87","","","","","","","fee schedule","18.54","136.6",""
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.87","","","","","","","fee schedule","18.54","136.6",""
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.54","136.6","APC"
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.54","136.6","APC"
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.54","136.6","APC"
"Assay of fluoride","82735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.54","136.6","APC"
"Assay of flurazepam","82742","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","143.22","","","","","","","fee schedule","143.22","143.22",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.7","","","","","","","fee schedule","14.7","108.72",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.7","","","","","","","fee schedule","14.7","108.72",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.7","","","","","","","fee schedule","14.7","108.72",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","108.72","","","","","","","fee schedule","14.7","108.72",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.27","","","","","","","fee schedule","14.7","108.72",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.27","","","","","","","fee schedule","14.7","108.72",""
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.4","","","","","","","fee schedule","14.7","108.72","APC"
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.14","","","","","","","fee schedule","14.7","108.72","APC"
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.99","","","","","","","fee schedule","14.7","108.72","APC"
"Assay of folic acid serum","82746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.44","","","","","","","fee schedule","14.7","108.72","APC"
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.65","","","","","","","fee schedule","17.65","123.2",""
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.65","","","","","","","fee schedule","17.65","123.2",""
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.65","","","","","","","fee schedule","17.65","123.2",""
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","123.2","","","","","","","fee schedule","17.65","123.2",""
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.76","","","","","","","fee schedule","17.65","123.2",""
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.76","","","","","","","fee schedule","17.65","123.2",""
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.49","","","","","","","fee schedule","17.65","123.2","APC"
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.18","","","","","","","fee schedule","17.65","123.2","APC"
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18","","","","","","","fee schedule","17.65","123.2","APC"
"Assay of folic acid rbc","82747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.53","","","","","","","fee schedule","17.65","123.2","APC"
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.34","","","","","","","fee schedule","17.34","117.46",""
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.34","","","","","","","fee schedule","17.34","117.46",""
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.34","","","","","","","fee schedule","17.34","117.46",""
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","117.46","","","","","","","fee schedule","17.34","117.46",""
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.81","","","","","","","fee schedule","17.34","117.46",""
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.81","","","","","","","fee schedule","17.34","117.46",""
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.16","","","","","","","fee schedule","17.34","117.46","APC"
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.86","","","","","","","fee schedule","17.34","117.46","APC"
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.69","","","","","","","fee schedule","17.34","117.46","APC"
"Assay of semen fructose","82757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.21","","","","","","","fee schedule","17.34","117.46","APC"
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.48","","","","","","","fee schedule","21.48","151.8",""
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.48","","","","","","","fee schedule","21.48","151.8",""
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.48","","","","","","","fee schedule","21.48","151.8",""
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","151.8","","","","","","","fee schedule","21.48","151.8",""
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.92","","","","","","","fee schedule","21.48","151.8",""
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.92","","","","","","","fee schedule","21.48","151.8",""
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.5","","","","","","","fee schedule","21.48","151.8","APC"
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.48","151.8","APC"
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.91","","","","","","","fee schedule","21.48","151.8","APC"
"Assay of rbc galactokinase","82759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.55","","","","","","","fee schedule","21.48","151.8","APC"
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.2","","","","","","","fee schedule","11.2","81.05",""
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.2","","","","","","","fee schedule","11.2","81.05",""
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.2","","","","","","","fee schedule","11.2","81.05",""
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.05","","","","","","","fee schedule","11.2","81.05",""
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.25","","","","","","","fee schedule","11.2","81.05",""
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.25","","","","","","","fee schedule","11.2","81.05",""
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.73","","","","","","","fee schedule","11.2","81.05","APC"
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.54","","","","","","","fee schedule","11.2","81.05","APC"
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.42","","","","","","","fee schedule","11.2","81.05","APC"
"Assay of galactose","82760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.2","81.05","APC"
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.07","","","","","","","fee schedule","21.07","153.5",""
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.07","","","","","","","fee schedule","21.07","153.5",""
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.07","","","","","","","fee schedule","21.07","153.5",""
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.2","","","","","","","fee schedule","21.07","153.5",""
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","153.5","","","","","","","fee schedule","21.07","153.5",""
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.2","","","","","","","fee schedule","21.07","153.5",""
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.07","153.5","APC"
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.07","153.5","APC"
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.07","153.5","APC"
"Assay galactose transferase","82775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.07","153.5","APC"
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.74","","","","","","","fee schedule","11.74","60.86",""
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.74","","","","","","","fee schedule","11.74","60.86",""
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.74","","","","","","","fee schedule","11.74","60.86",""
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.41","","","","","","","fee schedule","11.74","60.86",""
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","60.86","","","","","","","fee schedule","11.74","60.86",""
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.41","","","","","","","fee schedule","11.74","60.86",""
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.3","","","","","","","fee schedule","11.74","60.86","APC"
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.09","","","","","","","fee schedule","11.74","60.86","APC"
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.97","","","","","","","fee schedule","11.74","60.86","APC"
"Galactose transferase test","82776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.33","","","","","","","fee schedule","11.74","60.86","APC"
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44.25","","","","","","","fee schedule","21.36","97.38",""
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.25","","","","","","","fee schedule","21.36","97.38",""
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44.25","","","","","","","fee schedule","21.36","97.38",""
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.36","","","","","","","fee schedule","21.36","97.38",""
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.38","","","","","","","fee schedule","21.36","97.38",""
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.36","","","","","","","fee schedule","21.36","97.38",""
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.35","","","","","","","fee schedule","21.36","97.38","APC"
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.58","","","","","","","fee schedule","21.36","97.38","APC"
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45.14","","","","","","","fee schedule","21.36","97.38","APC"
"Galectin-3","82777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.46","","","","","","","fee schedule","21.36","97.38","APC"
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.3","","","","","","","fee schedule","9.3","64.24",""
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.3","","","","","","","fee schedule","9.3","64.24",""
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.3","","","","","","","fee schedule","9.3","64.24",""
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.98","","","","","","","fee schedule","9.3","64.24",""
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.24","","","","","","","fee schedule","9.3","64.24",""
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.98","","","","","","","fee schedule","9.3","64.24",""
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.74","","","","","","","fee schedule","9.3","64.24","APC"
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.58","","","","","","","fee schedule","9.3","64.24","APC"
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.49","","","","","","","fee schedule","9.3","64.24","APC"
"Assay iga/igd/igg/igm each","82784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.76","","","","","","","fee schedule","9.3","64.24","APC"
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.46","","","","","","","fee schedule","16.46","118.57",""
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.46","","","","","","","fee schedule","16.46","118.57",""
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.46","","","","","","","fee schedule","16.46","118.57",""
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.31","","","","","","","fee schedule","16.46","118.57",""
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","118.57","","","","","","","fee schedule","16.46","118.57",""
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.31","","","","","","","fee schedule","16.46","118.57",""
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.24","","","","","","","fee schedule","16.46","118.57","APC"
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.95","","","","","","","fee schedule","16.46","118.57","APC"
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.79","","","","","","","fee schedule","16.46","118.57","APC"
"Assay of ige","82785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.28","","","","","","","fee schedule","16.46","118.57","APC"
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.02","","","","","","","fee schedule","8.02","47.29",""
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.02","","","","","","","fee schedule","8.02","47.29",""
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.02","","","","","","","fee schedule","8.02","47.29",""
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.79","","","","","","","fee schedule","8.02","47.29",""
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.29","","","","","","","fee schedule","8.02","47.29",""
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.79","","","","","","","fee schedule","8.02","47.29",""
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.4","","","","","","","fee schedule","8.02","47.29","APC"
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.26","","","","","","","fee schedule","8.02","47.29","APC"
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.18","","","","","","","fee schedule","8.02","47.29","APC"
"Igg 1 2 3 or 4 each","82787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.42","","","","","","","fee schedule","8.02","47.29","APC"
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11","","","","","","","fee schedule","11","58.84",""
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11","","","","","","","fee schedule","11","58.84",""
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11","","","","","","","fee schedule","11","58.84",""
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.56","","","","","","","fee schedule","11","58.84",""
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.84","","","","","","","fee schedule","11","58.84",""
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.56","","","","","","","fee schedule","11","58.84",""
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.52","","","","","","","fee schedule","11","58.84","APC"
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.33","","","","","","","fee schedule","11","58.84","APC"
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.22","","","","","","","fee schedule","11","58.84","APC"
"Blood pH","82800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.55","","","","","","","fee schedule","11","58.84","APC"
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.07","","","","","","","fee schedule","26.07","134.96",""
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.07","","","","","","","fee schedule","26.07","134.96",""
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.07","","","","","","","fee schedule","26.07","134.96",""
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.25","","","","","","","fee schedule","26.07","134.96",""
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","134.96","","","","","","","fee schedule","26.07","134.96",""
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.25","","","","","","","fee schedule","26.07","134.96",""
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.31","","","","","","","fee schedule","26.07","134.96","APC"
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.85","","","","","","","fee schedule","26.07","134.96","APC"
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.59","","","","","","","fee schedule","26.07","134.96","APC"
"Blood gases any combination","82803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.37","","","","","","","fee schedule","26.07","134.96","APC"
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","78.77","","","","","","","fee schedule","48.78","202.46",""
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","78.77","","","","","","","fee schedule","48.78","202.46",""
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","78.77","","","","","","","fee schedule","48.78","202.46",""
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","202.46","","","","","","","fee schedule","48.78","202.46",""
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","48.78","","","","","","","fee schedule","48.78","202.46",""
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","48.78","","","","","","","fee schedule","48.78","202.46",""
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.51","","","","","","","fee schedule","48.78","202.46","APC"
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.13","","","","","","","fee schedule","48.78","202.46","APC"
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.35","","","","","","","fee schedule","48.78","202.46","APC"
"Blood gases w/o2 saturation","82805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.71","","","","","","","fee schedule","48.78","202.46","APC"
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.77","","","","","","","fee schedule","9.77","62.76",""
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.77","","","","","","","fee schedule","9.77","62.76",""
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.77","","","","","","","fee schedule","9.77","62.76",""
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","62.76","","","","","","","fee schedule","9.77","62.76",""
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15","","","","","","","fee schedule","9.77","62.76",""
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15","","","","","","","fee schedule","9.77","62.76",""
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.23","","","","","","","fee schedule","9.77","62.76","APC"
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.06","","","","","","","fee schedule","9.77","62.76","APC"
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.97","","","","","","","fee schedule","9.77","62.76","APC"
"Blood gases o2 sat only","82810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.26","","","","","","","fee schedule","9.77","62.76","APC"
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.34","","","","","","","fee schedule","13.34","71.8",""
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.34","","","","","","","fee schedule","13.34","71.8",""
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.34","","","","","","","fee schedule","13.34","71.8",""
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","71.8","","","","","","","fee schedule","13.34","71.8",""
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.18","","","","","","","fee schedule","13.34","71.8",""
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.18","","","","","","","fee schedule","13.34","71.8",""
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.97","","","","","","","fee schedule","13.34","71.8","APC"
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.74","","","","","","","fee schedule","13.34","71.8","APC"
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.61","","","","","","","fee schedule","13.34","71.8","APC"
"Hemoglobin-oxygen affinity","82820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.01","","","","","","","fee schedule","13.34","71.8","APC"
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.71","","","","","","","fee schedule","6.71","40.02",""
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.71","","","","","","","fee schedule","6.71","40.02",""
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.71","","","","","","","fee schedule","6.71","40.02",""
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.02","","","","","","","fee schedule","6.71","40.02",""
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.2","","","","","","","fee schedule","6.71","40.02",""
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.2","","","","","","","fee schedule","6.71","40.02",""
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.03","","","","","","","fee schedule","6.71","40.02","APC"
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.91","","","","","","","fee schedule","6.71","40.02","APC"
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.84","","","","","","","fee schedule","6.71","40.02","APC"
"Gastric analy w/ph ea spec","82930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.05","","","","","","","fee schedule","6.71","40.02","APC"
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.69","","","","","","","fee schedule","17.69","132.63",""
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.69","","","","","","","fee schedule","17.69","132.63",""
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.69","","","","","","","fee schedule","17.69","132.63",""
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.63","","","","","","","fee schedule","17.69","132.63",""
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.42","","","","","","","fee schedule","17.69","132.63",""
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.42","","","","","","","fee schedule","17.69","132.63",""
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.53","","","","","","","fee schedule","17.69","132.63","APC"
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.22","","","","","","","fee schedule","17.69","132.63","APC"
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.04","","","","","","","fee schedule","17.69","132.63","APC"
"Gastrin test","82938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.57","","","","","","","fee schedule","17.69","132.63","APC"
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.63","","","","","","","fee schedule","17.63","131.04",""
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.63","","","","","","","fee schedule","17.63","131.04",""
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.63","","","","","","","fee schedule","17.63","131.04",""
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","131.04","","","","","","","fee schedule","17.63","131.04",""
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.31","","","","","","","fee schedule","17.63","131.04",""
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.31","","","","","","","fee schedule","17.63","131.04",""
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.47","","","","","","","fee schedule","17.63","131.04","APC"
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.16","","","","","","","fee schedule","17.63","131.04","APC"
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.98","","","","","","","fee schedule","17.63","131.04","APC"
"Assay of gastrin","82941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.51","","","","","","","fee schedule","17.63","131.04","APC"
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.29","","","","","","","fee schedule","14.29","100.22",""
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.29","","","","","","","fee schedule","14.29","100.22",""
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.29","","","","","","","fee schedule","14.29","100.22",""
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","100.22","","","","","","","fee schedule","14.29","100.22",""
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.55","","","","","","","fee schedule","14.29","100.22",""
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.55","","","","","","","fee schedule","14.29","100.22",""
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.97","","","","","","","fee schedule","14.29","100.22","APC"
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.72","","","","","","","fee schedule","14.29","100.22","APC"
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.58","","","","","","","fee schedule","14.29","100.22","APC"
"Assay of glucagon","82943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15","","","","","","","fee schedule","14.29","100.22","APC"
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.93","","","","","","","fee schedule","3.93","29.45",""
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.93","","","","","","","fee schedule","3.93","29.45",""
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.93","","","","","","","fee schedule","3.93","29.45",""
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.45","","","","","","","fee schedule","3.93","29.45",""
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.74","","","","","","","fee schedule","3.93","29.45",""
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.74","","","","","","","fee schedule","3.93","29.45",""
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.12","","","","","","","fee schedule","3.93","29.45","APC"
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.05","","","","","","","fee schedule","3.93","29.45","APC"
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.01","","","","","","","fee schedule","3.93","29.45","APC"
"Glucose Other Fluid","82945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.13","","","","","","","fee schedule","3.93","29.45","APC"
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.77","","","","","","","fee schedule","17.77","101.64",""
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.77","","","","","","","fee schedule","17.77","101.64",""
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.77","","","","","","","fee schedule","17.77","101.64",""
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.64","","","","","","","fee schedule","17.77","101.64",""
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.91","","","","","","","fee schedule","17.77","101.64",""
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.91","","","","","","","fee schedule","17.77","101.64",""
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.61","","","","","","","fee schedule","17.77","101.64","APC"
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.3","","","","","","","fee schedule","17.77","101.64","APC"
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.77","101.64","APC"
"Glucagon tolerance test","82946","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.66","","","","","","","fee schedule","17.77","101.64","APC"
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.93","","","","","","","fee schedule","3.93","29.45",""
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.93","","","","","","","fee schedule","3.93","29.45",""
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.93","","","","","","","fee schedule","3.93","29.45",""
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.45","","","","","","","fee schedule","3.93","29.45",""
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.74","","","","","","","fee schedule","3.93","29.45",""
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.74","","","","","","","fee schedule","3.93","29.45",""
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.12","","","","","","","fee schedule","3.93","29.45","APC"
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.05","","","","","","","fee schedule","3.93","29.45","APC"
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.01","","","","","","","fee schedule","3.93","29.45","APC"
"Assay glucose blood quant","82947","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.13","","","","","","","fee schedule","3.93","29.45","APC"
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.04","","","","","","","fee schedule","5.04","23.03",""
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.04","","","","","","","fee schedule","5.04","23.03",""
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.04","","","","","","","fee schedule","5.04","23.03",""
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","23.03","","","","","","","fee schedule","5.04","23.03",""
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.45","","","","","","","fee schedule","5.04","23.03",""
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.45","","","","","","","fee schedule","5.04","23.03",""
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.04","23.03","APC"
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.19","","","","","","","fee schedule","5.04","23.03","APC"
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.14","","","","","","","fee schedule","5.04","23.03","APC"
"Reagent strip/blood glucose","82948","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.29","","","","","","","fee schedule","5.04","23.03","APC"
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.75","","","","","","","fee schedule","4.75","35.33",""
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.75","","","","","","","fee schedule","4.75","35.33",""
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.75","","","","","","","fee schedule","4.75","35.33",""
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.33","","","","","","","fee schedule","4.75","35.33",""
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","4.75","35.33",""
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","4.75","35.33",""
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.98","","","","","","","fee schedule","4.75","35.33","APC"
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.89","","","","","","","fee schedule","4.75","35.33","APC"
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.84","","","","","","","fee schedule","4.75","35.33","APC"
"Glucose test","82950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.99","","","","","","","fee schedule","4.75","35.33","APC"
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.87","","","","","","","fee schedule","12.87","91.05",""
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.87","","","","","","","fee schedule","12.87","91.05",""
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.87","","","","","","","fee schedule","12.87","91.05",""
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.05","","","","","","","fee schedule","12.87","91.05",""
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.13","","","","","","","fee schedule","12.87","91.05",""
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.13","","","","","","","fee schedule","12.87","91.05",""
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.48","","","","","","","fee schedule","12.87","91.05","APC"
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.87","91.05","APC"
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.87","91.05","APC"
"Glucose tolerance test (GTT)","82951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.87","91.05","APC"
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.92","","","","","","","fee schedule","3.92","26.92",""
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.92","","","","","","","fee schedule","3.92","26.92",""
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.92","","","","","","","fee schedule","3.92","26.92",""
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.92","","","","","","","fee schedule","3.92","26.92",""
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.73","","","","","","","fee schedule","3.92","26.92",""
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.73","","","","","","","fee schedule","3.92","26.92",""
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.11","","","","","","","fee schedule","3.92","26.92","APC"
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.04","","","","","","","fee schedule","3.92","26.92","APC"
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4","","","","","","","fee schedule","3.92","26.92","APC"
"GTT-added samples","82952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.12","","","","","","","fee schedule","3.92","26.92","APC"
"Glucose-tolbutamide test","82953","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.88","","","","","","","fee schedule","105.88","105.88",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.7","","","","","","","fee schedule","9.7","67.76",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.7","","","","","","","fee schedule","9.7","67.76",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.7","","","","","","","fee schedule","9.7","67.76",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","67.76","","","","","","","fee schedule","9.7","67.76",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.67","","","","","","","fee schedule","9.7","67.76",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.67","","","","","","","fee schedule","9.7","67.76",""
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.16","","","","","","","fee schedule","9.7","67.76","APC"
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.99","","","","","","","fee schedule","9.7","67.76","APC"
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.89","","","","","","","fee schedule","9.7","67.76","APC"
"Assay of g6pd enzyme","82955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.18","","","","","","","fee schedule","9.7","67.76","APC"
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.05","","","","","","","fee schedule","6.05","44.87",""
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.05","","","","","","","fee schedule","6.05","44.87",""
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.05","","","","","","","fee schedule","6.05","44.87",""
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.87","","","","","","","fee schedule","6.05","44.87",""
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.4","","","","","","","fee schedule","6.05","44.87",""
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.4","","","","","","","fee schedule","6.05","44.87",""
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.34","","","","","","","fee schedule","6.05","44.87","APC"
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.23","","","","","","","fee schedule","6.05","44.87","APC"
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.17","","","","","","","fee schedule","6.05","44.87","APC"
"Test for G6PD enzyme","82960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.35","","","","","","","fee schedule","6.05","44.87","APC"
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.28","","","","","","","fee schedule","3.28","16.84",""
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.28","","","","","","","fee schedule","3.28","16.84",""
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.28","","","","","","","fee schedule","3.28","16.84",""
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","16.84","","","","","","","fee schedule","3.28","16.84",""
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.02","","","","","","","fee schedule","3.28","16.84",""
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.02","","","","","","","fee schedule","3.28","16.84",""
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.44","","","","","","","fee schedule","3.28","16.84","APC"
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.38","","","","","","","fee schedule","3.28","16.84","APC"
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.35","","","","","","","fee schedule","3.28","16.84","APC"
"Glucose blood test","82962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.44","","","","","","","fee schedule","3.28","16.84","APC"
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.48","","","","","","","fee schedule","21.48","156.63",""
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.48","","","","","","","fee schedule","21.48","156.63",""
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.48","","","","","","","fee schedule","21.48","156.63",""
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","156.63","","","","","","","fee schedule","21.48","156.63",""
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.92","","","","","","","fee schedule","21.48","156.63",""
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.92","","","","","","","fee schedule","21.48","156.63",""
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.5","","","","","","","fee schedule","21.48","156.63","APC"
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.48","156.63","APC"
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.91","","","","","","","fee schedule","21.48","156.63","APC"
"Assay of glucosidase","82963","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.55","","","","","","","fee schedule","21.48","156.63","APC"
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.15","","","","","","","fee schedule","13.15","55.38",""
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.15","","","","","","","fee schedule","13.15","55.38",""
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.15","","","","","","","fee schedule","13.15","55.38",""
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","55.38","","","","","","","fee schedule","13.15","55.38",""
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.28","","","","","","","fee schedule","13.15","55.38",""
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.28","","","","","","","fee schedule","13.15","55.38",""
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.77","","","","","","","fee schedule","13.15","55.38","APC"
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.54","","","","","","","fee schedule","13.15","55.38","APC"
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.41","","","","","","","fee schedule","13.15","55.38","APC"
"Assay of gdh enzyme","82965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.81","","","","","","","fee schedule","13.15","55.38","APC"
"Assay of glutamine","82975","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","116.13","","","","","","","fee schedule","116.13","116.13",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.2","","","","","","","fee schedule","7.2","53.68",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.2","","","","","","","fee schedule","7.2","53.68",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.2","","","","","","","fee schedule","7.2","53.68",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","53.68","","","","","","","fee schedule","7.2","53.68",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.37","","","","","","","fee schedule","7.2","53.68",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.37","","","","","","","fee schedule","7.2","53.68",""
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.54","","","","","","","fee schedule","7.2","53.68","APC"
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.42","","","","","","","fee schedule","7.2","53.68","APC"
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.34","","","","","","","fee schedule","7.2","53.68","APC"
"Assay of GGT","82977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.56","","","","","","","fee schedule","7.2","53.68","APC"
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.45","","","","","","","fee schedule","15.45","99.97",""
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.45","","","","","","","fee schedule","15.45","99.97",""
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.45","","","","","","","fee schedule","15.45","99.97",""
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.97","","","","","","","fee schedule","15.45","99.97",""
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.5","","","","","","","fee schedule","15.45","99.97",""
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.5","","","","","","","fee schedule","15.45","99.97",""
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.18","","","","","","","fee schedule","15.45","99.97","APC"
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.91","","","","","","","fee schedule","15.45","99.97","APC"
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.45","99.97","APC"
"Assay of glutathione","82978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.22","","","","","","","fee schedule","15.45","99.97","APC"
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.44","","","","","","","fee schedule","9.44","51.18",""
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.44","","","","","","","fee schedule","9.44","51.18",""
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.44","","","","","","","fee schedule","9.44","51.18",""
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","51.18","","","","","","","fee schedule","9.44","51.18",""
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.83","","","","","","","fee schedule","9.44","51.18",""
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.83","","","","","","","fee schedule","9.44","51.18",""
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.89","","","","","","","fee schedule","9.44","51.18","APC"
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.72","","","","","","","fee schedule","9.44","51.18","APC"
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.63","","","","","","","fee schedule","9.44","51.18","APC"
"Assay rbc glutathione","82979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.44","51.18","APC"
"Assay of glutethimide","82980","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","134.13","","","","","","","fee schedule","134.13","134.13",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.76","","","","","","","fee schedule","16.76","109.17",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.76","","","","","","","fee schedule","16.76","109.17",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.76","","","","","","","fee schedule","16.76","109.17",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.17","","","","","","","fee schedule","16.76","109.17",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.91","","","","","","","fee schedule","16.76","109.17",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.91","","","","","","","fee schedule","16.76","109.17",""
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.56","","","","","","","fee schedule","16.76","109.17","APC"
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.26","","","","","","","fee schedule","16.76","109.17","APC"
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.1","","","","","","","fee schedule","16.76","109.17","APC"
"Assay of glycated protein","82985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.6","","","","","","","fee schedule","16.76","109.17","APC"
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.58","","","","","","","fee schedule","18.58","138.85",""
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.58","","","","","","","fee schedule","18.58","138.85",""
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.58","","","","","","","fee schedule","18.58","138.85",""
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","138.85","","","","","","","fee schedule","18.58","138.85",""
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.94","","","","","","","fee schedule","18.58","138.85",""
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.94","","","","","","","fee schedule","18.58","138.85",""
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.46","","","","","","","fee schedule","18.58","138.85","APC"
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.14","","","","","","","fee schedule","18.58","138.85","APC"
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.58","138.85","APC"
"Assay of gonadotropin (fsh)","83001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.51","","","","","","","fee schedule","18.58","138.85","APC"
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.52","","","","","","","fee schedule","18.52","138.25",""
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.52","","","","","","","fee schedule","18.52","138.25",""
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.52","","","","","","","fee schedule","18.52","138.25",""
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","138.25","","","","","","","fee schedule","18.52","138.25",""
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.84","","","","","","","fee schedule","18.52","138.25",""
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.84","","","","","","","fee schedule","18.52","138.25",""
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.4","","","","","","","fee schedule","18.52","138.25","APC"
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.08","","","","","","","fee schedule","18.52","138.25","APC"
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.89","","","","","","","fee schedule","18.52","138.25","APC"
"Assay of gonadotropin (lh)","83002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.45","","","","","","","fee schedule","18.52","138.25","APC"
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.67","","","","","","","fee schedule","16.67","124.53",""
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.67","","","","","","","fee schedule","16.67","124.53",""
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.67","","","","","","","fee schedule","16.67","124.53",""
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.53","","","","","","","fee schedule","16.67","124.53",""
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.66","","","","","","","fee schedule","16.67","124.53",""
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.66","","","","","","","fee schedule","16.67","124.53",""
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.46","","","","","","","fee schedule","16.67","124.53","APC"
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.17","","","","","","","fee schedule","16.67","124.53","APC"
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17","","","","","","","fee schedule","16.67","124.53","APC"
"Assay growth hormone (hgh)","83003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.5","","","","","","","fee schedule","16.67","124.53","APC"
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","75.6","","","","","","","fee schedule","35.92","79.38",""
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","75.6","","","","","","","fee schedule","35.92","79.38",""
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","75.6","","","","","","","fee schedule","35.92","79.38",""
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.92","","","","","","","fee schedule","35.92","79.38",""
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.92","","","","","","","fee schedule","35.92","79.38",""
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.19","","","","","","","fee schedule","35.92","79.38","APC"
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.87","","","","","","","fee schedule","35.92","79.38","APC"
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.11","","","","","","","fee schedule","35.92","79.38","APC"
"Growth stimulation gene 2","83006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.38","","","","","","","fee schedule","35.92","79.38","APC"
"Assay of guanosine","83008","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.82","","","","","","","fee schedule","124.82","124.82",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","67.36","","","","","","","fee schedule","67.36","474.19",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.36","","","","","","","fee schedule","67.36","474.19",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","67.36","","","","","","","fee schedule","67.36","474.19",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","474.19","","","","","","","fee schedule","67.36","474.19",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","115.76","","","","","","","fee schedule","67.36","474.19",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","115.76","","","","","","","fee schedule","67.36","474.19",""
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","70.56","","","","","","","fee schedule","67.36","474.19","APC"
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","69.38","","","","","","","fee schedule","67.36","474.19","APC"
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","68.71","","","","","","","fee schedule","67.36","474.19","APC"
"H pylori (c-13) blood","83009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70.73","","","","","","","fee schedule","67.36","474.19","APC"
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.58","","","","","","","fee schedule","12.58","92.24",""
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.58","","","","","","","fee schedule","12.58","92.24",""
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.58","","","","","","","fee schedule","12.58","92.24",""
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.24","","","","","","","fee schedule","12.58","92.24",""
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.62","","","","","","","fee schedule","12.58","92.24",""
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.62","","","","","","","fee schedule","12.58","92.24",""
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.18","","","","","","","fee schedule","12.58","92.24","APC"
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.96","","","","","","","fee schedule","12.58","92.24","APC"
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.58","92.24","APC"
"Assay of haptoglobin quant","83010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.21","","","","","","","fee schedule","12.58","92.24","APC"
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.89","","","","","","","fee schedule","26.89","126.07",""
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.89","","","","","","","fee schedule","26.89","126.07",""
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.89","","","","","","","fee schedule","26.89","126.07",""
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.07","","","","","","","fee schedule","26.89","126.07",""
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.56","","","","","","","fee schedule","26.89","126.07",""
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.56","","","","","","","fee schedule","26.89","126.07",""
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.17","","","","","","","fee schedule","26.89","126.07","APC"
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.7","","","","","","","fee schedule","26.89","126.07","APC"
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.43","","","","","","","fee schedule","26.89","126.07","APC"
"Assay of haptoglobins","83012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.23","","","","","","","fee schedule","26.89","126.07","APC"
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","67.36","","","","","","","fee schedule","67.36","481.27",""
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.36","","","","","","","fee schedule","67.36","481.27",""
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","67.36","","","","","","","fee schedule","67.36","481.27",""
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","481.27","","","","","","","fee schedule","67.36","481.27",""
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","115.76","","","","","","","fee schedule","67.36","481.27",""
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","115.76","","","","","","","fee schedule","67.36","481.27",""
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","70.56","","","","","","","fee schedule","67.36","481.27","APC"
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","69.38","","","","","","","fee schedule","67.36","481.27","APC"
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","68.71","","","","","","","fee schedule","67.36","481.27","APC"
"H pylori (c-13) breath","83013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70.73","","","","","","","fee schedule","67.36","481.27","APC"
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.86","","","","","","","fee schedule","7.86","59.16",""
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.86","","","","","","","fee schedule","7.86","59.16",""
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.86","","","","","","","fee schedule","7.86","59.16",""
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.16","","","","","","","fee schedule","7.86","59.16",""
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.51","","","","","","","fee schedule","7.86","59.16",""
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.51","","","","","","","fee schedule","7.86","59.16",""
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.23","","","","","","","fee schedule","7.86","59.16","APC"
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.1","","","","","","","fee schedule","7.86","59.16","APC"
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.02","","","","","","","fee schedule","7.86","59.16","APC"
"H pylori drug admin","83014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.25","","","","","","","fee schedule","7.86","59.16","APC"
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.94","","","","","","","fee schedule","20.94","132.4",""
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.94","","","","","","","fee schedule","20.94","132.4",""
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.94","","","","","","","fee schedule","20.94","132.4",""
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.4","","","","","","","fee schedule","20.94","132.4",""
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.36","","","","","","","fee schedule","20.94","132.4",""
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.36","","","","","","","fee schedule","20.94","132.4",""
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.93","","","","","","","fee schedule","20.94","132.4","APC"
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.57","","","","","","","fee schedule","20.94","132.4","APC"
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.36","","","","","","","fee schedule","20.94","132.4","APC"
"Heavy metal qual any anal","83015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.99","","","","","","","fee schedule","20.94","132.4","APC"
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.96","","","","","","","fee schedule","21.96","152.25",""
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.96","","","","","","","fee schedule","21.96","152.25",""
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.96","","","","","","","fee schedule","21.96","152.25",""
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","152.25","","","","","","","fee schedule","21.96","152.25",""
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.75","","","","","","","fee schedule","21.96","152.25",""
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.75","","","","","","","fee schedule","21.96","152.25",""
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23","","","","","","","fee schedule","21.96","152.25","APC"
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.62","","","","","","","fee schedule","21.96","152.25","APC"
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.4","","","","","","","fee schedule","21.96","152.25","APC"
"Heavy metal quant each nes","83018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.06","","","","","","","fee schedule","21.96","152.25","APC"
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.87","","","","","","","fee schedule","12.87","86.28",""
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.87","","","","","","","fee schedule","12.87","86.28",""
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.87","","","","","","","fee schedule","12.87","86.28",""
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.28","","","","","","","fee schedule","12.87","86.28",""
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.13","","","","","","","fee schedule","12.87","86.28",""
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.13","","","","","","","fee schedule","12.87","86.28",""
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.48","","","","","","","fee schedule","12.87","86.28","APC"
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.87","86.28","APC"
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.87","86.28","APC"
"Hemoglobin electrophoresis","83020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.87","86.28","APC"
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.06","","","","","","","fee schedule","18.06","128.57",""
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.06","","","","","","","fee schedule","18.06","128.57",""
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.06","","","","","","","fee schedule","18.06","128.57",""
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","18.06","128.57",""
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","18.06","128.57",""
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","18.06","128.57",""
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.92","","","","","","","fee schedule","18.06","128.57","APC"
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.6","","","","","","","fee schedule","18.06","128.57","APC"
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.42","","","","","","","fee schedule","18.06","128.57","APC"
"Hemoglobin chromotography","83021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.96","","","","","","","fee schedule","18.06","128.57","APC"
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.01","","","","","","","fee schedule","4.01","17.78",""
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.01","","","","","","","fee schedule","4.01","17.78",""
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.01","","","","","","","fee schedule","4.01","17.78",""
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","17.78","","","","","","","fee schedule","4.01","17.78",""
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.06","","","","","","","fee schedule","4.01","17.78",""
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.06","","","","","","","fee schedule","4.01","17.78",""
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.2","","","","","","","fee schedule","4.01","17.78","APC"
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.13","","","","","","","fee schedule","4.01","17.78","APC"
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.09","","","","","","","fee schedule","4.01","17.78","APC"
"Hemoglobin copper sulfate","83026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.21","","","","","","","fee schedule","4.01","17.78","APC"
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.74","","","","","","","fee schedule","10.74","58.56",""
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.74","","","","","","","fee schedule","10.74","58.56",""
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.74","","","","","","","fee schedule","10.74","58.56",""
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.56","","","","","","","fee schedule","10.74","58.56",""
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.22","","","","","","","fee schedule","10.74","58.56",""
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.22","","","","","","","fee schedule","10.74","58.56",""
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.25","","","","","","","fee schedule","10.74","58.56","APC"
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.74","58.56","APC"
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.74","58.56","APC"
"Fetal hemoglobin chemical","83030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.28","","","","","","","fee schedule","10.74","58.56","APC"
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8","","","","","","","fee schedule","8","43.57",""
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8","","","","","","","fee schedule","8","43.57",""
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8","","","","","","","fee schedule","8","43.57",""
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","43.57","","","","","","","fee schedule","8","43.57",""
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.25","","","","","","","fee schedule","8","43.57",""
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.25","","","","","","","fee schedule","8","43.57",""
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.38","","","","","","","fee schedule","8","43.57","APC"
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.24","","","","","","","fee schedule","8","43.57","APC"
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.16","","","","","","","fee schedule","8","43.57","APC"
"Fetal hemoglobin assay qual","83033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.4","","","","","","","fee schedule","8","43.57","APC"
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.71","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.71","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.71","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","71.97","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.68","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.68","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.17","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.9","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hemoglobin test","83036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.2","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.71","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.71","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.71","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","71.97","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.68","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.68","","","","","","","fee schedule","9.71","71.97",""
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.17","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.9","","","","","","","fee schedule","9.71","71.97","APC"
"Glycosylated hb home device","83037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.2","","","","","","","fee schedule","9.71","71.97","APC"
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.49","","","","","","","fee schedule","6.49","35.84",""
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.49","","","","","","","fee schedule","6.49","35.84",""
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.49","","","","","","","fee schedule","6.49","35.84",""
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.84","","","","","","","fee schedule","6.49","35.84",""
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.52","","","","","","","fee schedule","6.49","35.84",""
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.52","","","","","","","fee schedule","6.49","35.84",""
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.8","","","","","","","fee schedule","6.49","35.84","APC"
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.68","","","","","","","fee schedule","6.49","35.84","APC"
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.62","","","","","","","fee schedule","6.49","35.84","APC"
"Blood methemoglobin test","83045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.81","","","","","","","fee schedule","6.49","35.84","APC"
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.2","","","","","","","fee schedule","8.2","46.97",""
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.2","","","","","","","fee schedule","8.2","46.97",""
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.2","","","","","","","fee schedule","8.2","46.97",""
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","46.97","","","","","","","fee schedule","8.2","46.97",""
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.59","","","","","","","fee schedule","8.2","46.97",""
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.59","","","","","","","fee schedule","8.2","46.97",""
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.59","","","","","","","fee schedule","8.2","46.97","APC"
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.45","","","","","","","fee schedule","8.2","46.97","APC"
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.36","","","","","","","fee schedule","8.2","46.97","APC"
"Blood methemoglobin assay","83050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.61","","","","","","","fee schedule","8.2","46.97","APC"
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.31","","","","","","","fee schedule","7.31","48.05",""
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.31","","","","","","","fee schedule","7.31","48.05",""
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.31","","","","","","","fee schedule","7.31","48.05",""
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.05","","","","","","","fee schedule","7.31","48.05",""
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.56","","","","","","","fee schedule","7.31","48.05",""
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.56","","","","","","","fee schedule","7.31","48.05",""
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.66","","","","","","","fee schedule","7.31","48.05","APC"
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.53","","","","","","","fee schedule","7.31","48.05","APC"
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.46","","","","","","","fee schedule","7.31","48.05","APC"
"Assay of plasma hemoglobin","83051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.68","","","","","","","fee schedule","7.31","48.05","APC"
"Blood sulfhemoglobin test","83055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.61","","","","","","","fee schedule","35.61","35.61",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.8","","","","","","","fee schedule","8.8","55.29",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.8","","","","","","","fee schedule","8.8","55.29",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.8","","","","","","","fee schedule","8.8","55.29",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","55.29","","","","","","","fee schedule","8.8","55.29",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.22","","","","","","","fee schedule","8.8","55.29",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.22","","","","","","","fee schedule","8.8","55.29",""
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.22","","","","","","","fee schedule","8.8","55.29","APC"
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.06","","","","","","","fee schedule","8.8","55.29","APC"
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.98","","","","","","","fee schedule","8.8","55.29","APC"
"Blood sulfhemoglobin assay","83060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.24","","","","","","","fee schedule","8.8","55.29","APC"
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9","","","","","","","fee schedule","9","46.77",""
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9","","","","","","","fee schedule","9","46.77",""
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9","","","","","","","fee schedule","9","46.77",""
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","46.77","","","","","","","fee schedule","9","46.77",""
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.83","","","","","","","fee schedule","9","46.77",""
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.83","","","","","","","fee schedule","9","46.77",""
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.43","","","","","","","fee schedule","9","46.77","APC"
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.27","","","","","","","fee schedule","9","46.77","APC"
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.18","","","","","","","fee schedule","9","46.77","APC"
"Assay of hemoglobin heat","83065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.45","","","","","","","fee schedule","9","46.77","APC"
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.47","","","","","","","fee schedule","9.47","54.47",""
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.47","","","","","","","fee schedule","9.47","54.47",""
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.47","","","","","","","fee schedule","9.47","54.47",""
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","54.47","","","","","","","fee schedule","9.47","54.47",""
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.56","","","","","","","fee schedule","9.47","54.47",""
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.56","","","","","","","fee schedule","9.47","54.47",""
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.92","","","","","","","fee schedule","9.47","54.47","APC"
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.75","","","","","","","fee schedule","9.47","54.47","APC"
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.66","","","","","","","fee schedule","9.47","54.47","APC"
"Hemoglobin stability screen","83068","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.94","","","","","","","fee schedule","9.47","54.47","APC"
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.95","","","","","","","fee schedule","3.95","27.95",""
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.95","","","","","","","fee schedule","3.95","27.95",""
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.95","","","","","","","fee schedule","3.95","27.95",""
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.95","","","","","","","fee schedule","3.95","27.95",""
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.78","","","","","","","fee schedule","3.95","27.95",""
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.78","","","","","","","fee schedule","3.95","27.95",""
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.14","","","","","","","fee schedule","3.95","27.95","APC"
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.07","","","","","","","fee schedule","3.95","27.95","APC"
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.03","","","","","","","fee schedule","3.95","27.95","APC"
"Assay of urine hemoglobin","83069","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.15","","","","","","","fee schedule","3.95","27.95","APC"
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.75","","","","","","","fee schedule","4.75","32.26",""
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.75","","","","","","","fee schedule","4.75","32.26",""
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.75","","","","","","","fee schedule","4.75","32.26",""
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.26","","","","","","","fee schedule","4.75","32.26",""
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","4.75","32.26",""
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","4.75","32.26",""
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.98","","","","","","","fee schedule","4.75","32.26","APC"
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.89","","","","","","","fee schedule","4.75","32.26","APC"
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.84","","","","","","","fee schedule","4.75","32.26","APC"
"Assay of hemosiderin qual","83070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.99","","","","","","","fee schedule","4.75","32.26","APC"
"Assay of hemosiderin, quant","83071","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.76","","","","","","","fee schedule","48.76","48.76",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.87","","","","","","","fee schedule","16.87","106.7",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.7","","","","","","","fee schedule","16.87","106.7",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","16.87","106.7",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","16.87","106.7",""
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.67","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of b hexosaminidase","83080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.71","","","","","","","fee schedule","16.87","106.7","APC"
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.53","","","","","","","fee schedule","29.53","216.04",""
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.53","","","","","","","fee schedule","29.53","216.04",""
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.53","","","","","","","fee schedule","29.53","216.04",""
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","216.04","","","","","","","fee schedule","29.53","216.04",""
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.76","","","","","","","fee schedule","29.53","216.04",""
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.76","","","","","","","fee schedule","29.53","216.04",""
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.93","","","","","","","fee schedule","29.53","216.04","APC"
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.42","","","","","","","fee schedule","29.53","216.04","APC"
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.12","","","","","","","fee schedule","29.53","216.04","APC"
"Assay of histamine","83088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.01","","","","","","","fee schedule","29.53","216.04","APC"
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.92","","","","","","","fee schedule","17.92","126.81",""
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.92","","","","","","","fee schedule","17.92","126.81",""
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.92","","","","","","","fee schedule","17.92","126.81",""
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.81","","","","","","","fee schedule","17.92","126.81",""
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.99","","","","","","","fee schedule","17.92","126.81",""
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.99","","","","","","","fee schedule","17.92","126.81",""
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.77","","","","","","","fee schedule","17.92","126.81","APC"
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.46","","","","","","","fee schedule","17.92","126.81","APC"
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.28","","","","","","","fee schedule","17.92","126.81","APC"
"Assay Of Homocystine","83090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.82","","","","","","","fee schedule","17.92","126.81","APC"
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.41","","","","","","","fee schedule","22.41","130.1",""
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.41","","","","","","","fee schedule","22.41","130.1",""
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.41","","","","","","","fee schedule","22.41","130.1",""
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","130.1","","","","","","","fee schedule","22.41","130.1",""
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.25","","","","","","","fee schedule","22.41","130.1",""
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.25","","","","","","","fee schedule","22.41","130.1",""
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.47","","","","","","","fee schedule","22.41","130.1","APC"
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.08","","","","","","","fee schedule","22.41","130.1","APC"
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.86","","","","","","","fee schedule","22.41","130.1","APC"
"Assay of homovanillic acid","83150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.53","","","","","","","fee schedule","22.41","130.1","APC"
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.9","","","","","","","fee schedule","17.9","129.93",""
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.9","","","","","","","fee schedule","17.9","129.93",""
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.9","","","","","","","fee schedule","17.9","129.93",""
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","129.93","","","","","","","fee schedule","17.9","129.93",""
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.11","","","","","","","fee schedule","17.9","129.93",""
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.11","","","","","","","fee schedule","17.9","129.93",""
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.75","","","","","","","fee schedule","17.9","129.93","APC"
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.44","","","","","","","fee schedule","17.9","129.93","APC"
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.26","","","","","","","fee schedule","17.9","129.93","APC"
"Assay of corticosteroids 17","83491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.79","","","","","","","fee schedule","17.9","129.93","APC"
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.9","","","","","","","fee schedule","12.9","91.48",""
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.9","","","","","","","fee schedule","12.9","91.48",""
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.9","","","","","","","fee schedule","12.9","91.48",""
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.48","","","","","","","fee schedule","12.9","91.48",""
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.16","","","","","","","fee schedule","12.9","91.48",""
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.16","","","","","","","fee schedule","12.9","91.48",""
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.9","91.48","APC"
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.29","","","","","","","fee schedule","12.9","91.48","APC"
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.16","","","","","","","fee schedule","12.9","91.48","APC"
"Assay of 5-hiaa","83497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.55","","","","","","","fee schedule","12.9","91.48","APC"
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.17","","","","","","","fee schedule","27.17","199.85",""
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.17","","","","","","","fee schedule","27.17","199.85",""
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.17","","","","","","","fee schedule","27.17","199.85",""
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","199.85","","","","","","","fee schedule","27.17","199.85",""
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.69","","","","","","","fee schedule","27.17","199.85",""
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.69","","","","","","","fee schedule","27.17","199.85",""
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.46","","","","","","","fee schedule","27.17","199.85","APC"
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.99","","","","","","","fee schedule","27.17","199.85","APC"
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.71","","","","","","","fee schedule","27.17","199.85","APC"
"Assay of progesterone 17-d","83498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.53","","","","","","","fee schedule","27.17","199.85","APC"
"Assay of progesterone 20-","83499","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","183.86","","","","","","","fee schedule","183.86","183.86",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.65","","","","","","","fee schedule","22.65","166.62",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.65","","","","","","","fee schedule","22.65","166.62",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.65","","","","","","","fee schedule","22.65","166.62",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","166.62","","","","","","","fee schedule","22.65","166.62",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.93","","","","","","","fee schedule","22.65","166.62",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.93","","","","","","","fee schedule","22.65","166.62",""
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.73","","","","","","","fee schedule","22.65","166.62","APC"
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.33","","","","","","","fee schedule","22.65","166.62","APC"
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.1","","","","","","","fee schedule","22.65","166.62","APC"
"Assay free hydroxyproline","83500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.78","","","","","","","fee schedule","22.65","166.62","APC"
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.3","","","","","","","fee schedule","24.3","180.03",""
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.3","","","","","","","fee schedule","24.3","180.03",""
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.3","","","","","","","fee schedule","24.3","180.03",""
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","180.03","","","","","","","fee schedule","24.3","180.03",""
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","41.78","","","","","","","fee schedule","24.3","180.03",""
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41.78","","","","","","","fee schedule","24.3","180.03",""
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.45","","","","","","","fee schedule","24.3","180.03","APC"
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.03","","","","","","","fee schedule","24.3","180.03","APC"
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.79","","","","","","","fee schedule","24.3","180.03","APC"
"Assay total hydroxyproline","83505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.52","","","","","","","fee schedule","24.3","180.03","APC"
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","84.49",""
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","84.49",""
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","84.49",""
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","84.49","","","","","","","fee schedule","11.53","84.49",""
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.82","","","","","","","fee schedule","11.53","84.49",""
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.82","","","","","","","fee schedule","11.53","84.49",""
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","84.49","APC"
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","84.49","APC"
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","84.49","APC"
"Immunoassay nonantibody","83516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","84.49","APC"
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.64","","","","","","","fee schedule","9.64","59.02",""
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.64","","","","","","","fee schedule","9.64","59.02",""
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.64","","","","","","","fee schedule","9.64","59.02",""
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.02","","","","","","","fee schedule","9.64","59.02",""
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.57","","","","","","","fee schedule","9.64","59.02",""
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.57","","","","","","","fee schedule","9.64","59.02",""
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.1","","","","","","","fee schedule","9.64","59.02","APC"
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.93","","","","","","","fee schedule","9.64","59.02","APC"
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.83","","","","","","","fee schedule","9.64","59.02","APC"
"Immunoassay dipstick","83518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.12","","","","","","","fee schedule","9.64","59.02","APC"
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.4","","","","","","","fee schedule","18.4","98.78",""
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.4","","","","","","","fee schedule","18.4","98.78",""
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.4","","","","","","","fee schedule","18.4","98.78",""
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","98.78","","","","","","","fee schedule","18.4","98.78",""
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.22","","","","","","","fee schedule","18.4","98.78",""
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.22","","","","","","","fee schedule","18.4","98.78",""
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.27","","","","","","","fee schedule","18.4","98.78","APC"
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.4","98.78","APC"
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.77","","","","","","","fee schedule","18.4","98.78","APC"
"Ria nonantibody","83519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.32","","","","","","","fee schedule","18.4","98.78","APC"
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","97.38",""
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","97.38",""
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","97.38",""
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.38","","","","","","","fee schedule","17.27","97.38",""
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.25","","","","","","","fee schedule","17.27","97.38",""
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.25","","","","","","","fee schedule","17.27","97.38",""
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","97.38","APC"
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","97.38","APC"
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","97.38","APC"
"Immunoassay quant nos nonab","83520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","97.38","APC"
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","20.72",""
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.72","","","","","","","fee schedule","17.27","20.72",""
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.72","","","","","","","fee schedule","17.27","20.72",""
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","20.72","APC"
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","20.72","APC"
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","20.72","APC"
"Ig light chains free each","83521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","20.72","APC"
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.43","","","","","","","fee schedule","11.43","84.83",""
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.43","","","","","","","fee schedule","11.43","84.83",""
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.43","","","","","","","fee schedule","11.43","84.83",""
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","84.83","","","","","","","fee schedule","11.43","84.83",""
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.66","","","","","","","fee schedule","11.43","84.83",""
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.66","","","","","","","fee schedule","11.43","84.83",""
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.97","","","","","","","fee schedule","11.43","84.83","APC"
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.77","","","","","","","fee schedule","11.43","84.83","APC"
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.66","","","","","","","fee schedule","11.43","84.83","APC"
"Assay of insulin","83525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12","","","","","","","fee schedule","11.43","84.83","APC"
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.95","","","","","","","fee schedule","12.95","95.2",""
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.95","","","","","","","fee schedule","12.95","95.2",""
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.95","","","","","","","fee schedule","12.95","95.2",""
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.2","","","","","","","fee schedule","12.95","95.2",""
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.26","","","","","","","fee schedule","12.95","95.2",""
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.26","","","","","","","fee schedule","12.95","95.2",""
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.57","","","","","","","fee schedule","12.95","95.2","APC"
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.34","","","","","","","fee schedule","12.95","95.2","APC"
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.21","","","","","","","fee schedule","12.95","95.2","APC"
"Assay of insulin","83527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.6","","","","","","","fee schedule","12.95","95.2","APC"
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.82","","","","","","","fee schedule","19.82","118.91",""
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.82","","","","","","","fee schedule","19.82","118.91",""
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.82","","","","","","","fee schedule","19.82","118.91",""
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","118.91","","","","","","","fee schedule","19.82","118.91",""
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.34","","","","","","","fee schedule","19.82","118.91",""
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.34","","","","","","","fee schedule","19.82","118.91",""
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.76","","","","","","","fee schedule","19.82","118.91","APC"
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.41","","","","","","","fee schedule","19.82","118.91","APC"
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.22","","","","","","","fee schedule","19.82","118.91","APC"
"Assay of intrinsic factor","83528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.81","","","","","","","fee schedule","19.82","118.91","APC"
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","20.72",""
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","20.72",""
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.72","","","","","","","fee schedule","17.27","20.72",""
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.72","","","","","","","fee schedule","17.27","20.72",""
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","20.72","APC"
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","20.72","APC"
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","20.72","APC"
"Asay of interleukin-6 (il-6)","83529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","20.72","APC"
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","47.97",""
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","47.97",""
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","47.97",""
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.97","","","","","","","fee schedule","6.47","47.97",""
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.14","","","","","","","fee schedule","6.47","47.97",""
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.14","","","","","","","fee schedule","6.47","47.97",""
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","47.97","APC"
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","47.97","APC"
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","47.97","APC"
"Assay of iron","83540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","47.97","APC"
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.74","","","","","","","fee schedule","8.74","64.47",""
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.74","","","","","","","fee schedule","8.74","64.47",""
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.74","","","","","","","fee schedule","8.74","64.47",""
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.47","","","","","","","fee schedule","8.74","64.47",""
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.02","","","","","","","fee schedule","8.74","64.47",""
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.02","","","","","","","fee schedule","8.74","64.47",""
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.16","","","","","","","fee schedule","8.74","64.47","APC"
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9","","","","","","","fee schedule","8.74","64.47","APC"
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.91","","","","","","","fee schedule","8.74","64.47","APC"
"Iron binding test","83550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.18","","","","","","","fee schedule","8.74","64.47","APC"
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.85","","","","","","","fee schedule","8.85","65.41",""
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.85","","","","","","","fee schedule","8.85","65.41",""
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.85","","","","","","","fee schedule","8.85","65.41",""
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","65.41","","","","","","","fee schedule","8.85","65.41",""
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.2","","","","","","","fee schedule","8.85","65.41",""
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.2","","","","","","","fee schedule","8.85","65.41",""
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.27","","","","","","","fee schedule","8.85","65.41","APC"
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.12","","","","","","","fee schedule","8.85","65.41","APC"
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.03","","","","","","","fee schedule","8.85","65.41","APC"
"Assay of idh enzyme","83570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.29","","","","","","","fee schedule","8.85","65.41","APC"
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.47","","","","","","","fee schedule","15.47","106.19",""
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.47","","","","","","","fee schedule","15.47","106.19",""
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.47","","","","","","","fee schedule","15.47","106.19",""
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.19","","","","","","","fee schedule","15.47","106.19",""
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.36","","","","","","","fee schedule","15.47","106.19",""
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.36","","","","","","","fee schedule","15.47","106.19",""
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.2","","","","","","","fee schedule","15.47","106.19","APC"
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.93","","","","","","","fee schedule","15.47","106.19","APC"
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.78","","","","","","","fee schedule","15.47","106.19","APC"
"Assay of ketogenic steroids","83582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.24","","","","","","","fee schedule","15.47","106.19","APC"
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.8","","","","","","","fee schedule","12.8","95.2",""
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.8","","","","","","","fee schedule","12.8","95.2",""
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.8","","","","","","","fee schedule","12.8","95.2",""
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.2","","","","","","","fee schedule","12.8","95.2",""
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.01","","","","","","","fee schedule","12.8","95.2",""
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.01","","","","","","","fee schedule","12.8","95.2",""
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.41","","","","","","","fee schedule","12.8","95.2","APC"
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.18","","","","","","","fee schedule","12.8","95.2","APC"
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.06","","","","","","","fee schedule","12.8","95.2","APC"
"Assay 17- ketosteroids","83586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.44","","","","","","","fee schedule","12.8","95.2","APC"
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.5","","","","","","","fee schedule","28.5","183.27",""
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","28.5","","","","","","","fee schedule","28.5","183.27",""
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28.5","","","","","","","fee schedule","28.5","183.27",""
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","183.27","","","","","","","fee schedule","28.5","183.27",""
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45.2","","","","","","","fee schedule","28.5","183.27",""
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45.2","","","","","","","fee schedule","28.5","183.27",""
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.85","","","","","","","fee schedule","28.5","183.27","APC"
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.36","","","","","","","fee schedule","28.5","183.27","APC"
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.5","183.27","APC"
"Fractionation ketosteroids","83593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.92","","","","","","","fee schedule","28.5","183.27","APC"
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.57","","","","","","","fee schedule","11.57","76.68",""
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.57","","","","","","","fee schedule","11.57","76.68",""
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.57","","","","","","","fee schedule","11.57","76.68",""
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","76.68","","","","","","","fee schedule","11.57","76.68",""
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.36","","","","","","","fee schedule","11.57","76.68",""
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.36","","","","","","","fee schedule","11.57","76.68",""
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.12","","","","","","","fee schedule","11.57","76.68","APC"
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.92","","","","","","","fee schedule","11.57","76.68","APC"
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.8","","","","","","","fee schedule","11.57","76.68","APC"
"Assay of lactic acid","83605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.15","","","","","","","fee schedule","11.57","76.68","APC"
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.04","","","","","","","fee schedule","6.04","45.21",""
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.04","","","","","","","fee schedule","6.04","45.21",""
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.04","","","","","","","fee schedule","6.04","45.21",""
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","45.21","","","","","","","fee schedule","6.04","45.21",""
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.37","","","","","","","fee schedule","6.04","45.21",""
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.37","","","","","","","fee schedule","6.04","45.21",""
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.33","","","","","","","fee schedule","6.04","45.21","APC"
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.22","","","","","","","fee schedule","6.04","45.21","APC"
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.16","","","","","","","fee schedule","6.04","45.21","APC"
"Lactate (LD) (LDH) enzyme","83615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.34","","","","","","","fee schedule","6.04","45.21","APC"
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.79","","","","","","","fee schedule","12.79","90.14",""
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.79","","","","","","","fee schedule","12.79","90.14",""
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.79","","","","","","","fee schedule","12.79","90.14",""
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","90.14","","","","","","","fee schedule","12.79","90.14",""
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22","","","","","","","fee schedule","12.79","90.14",""
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22","","","","","","","fee schedule","12.79","90.14",""
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.4","","","","","","","fee schedule","12.79","90.14","APC"
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.17","","","","","","","fee schedule","12.79","90.14","APC"
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.05","","","","","","","fee schedule","12.79","90.14","APC"
"Assay of ldh enzymes","83625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.43","","","","","","","fee schedule","12.79","90.14","APC"
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.7","","","","","","","fee schedule","19.7","147.03",""
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.7","","","","","","","fee schedule","19.7","147.03",""
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.7","","","","","","","fee schedule","19.7","147.03",""
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","147.03","","","","","","","fee schedule","19.7","147.03",""
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.73","","","","","","","fee schedule","19.7","147.03",""
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.73","","","","","","","fee schedule","19.7","147.03",""
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.64","","","","","","","fee schedule","19.7","147.03","APC"
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.29","","","","","","","fee schedule","19.7","147.03","APC"
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.09","","","","","","","fee schedule","19.7","147.03","APC"
"Lactoferrin fecal (qual)","83630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.68","","","","","","","fee schedule","19.7","147.03","APC"
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.63","","","","","","","fee schedule","19.63","147.03",""
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.63","","","","","","","fee schedule","19.63","147.03",""
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.63","","","","","","","fee schedule","19.63","147.03",""
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","147.03","","","","","","","fee schedule","19.63","147.03",""
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.73","","","","","","","fee schedule","19.63","147.03",""
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.73","","","","","","","fee schedule","19.63","147.03",""
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.56","","","","","","","fee schedule","19.63","147.03","APC"
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.22","","","","","","","fee schedule","19.63","147.03","APC"
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.02","","","","","","","fee schedule","19.63","147.03","APC"
"Lactoferrin fecal (quant)","83631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.61","","","","","","","fee schedule","19.63","147.03","APC"
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.22","","","","","","","fee schedule","20.22","150.46",""
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.22","","","","","","","fee schedule","20.22","150.46",""
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.22","","","","","","","fee schedule","20.22","150.46",""
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.46","","","","","","","fee schedule","20.22","150.46",""
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.74","","","","","","","fee schedule","20.22","150.46",""
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.74","","","","","","","fee schedule","20.22","150.46",""
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.18","","","","","","","fee schedule","20.22","150.46","APC"
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.83","","","","","","","fee schedule","20.22","150.46","APC"
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.62","","","","","","","fee schedule","20.22","150.46","APC"
"Placental lactogen","83632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.22","150.46","APC"
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.25","","","","","","","fee schedule","9.46","40.21",""
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.25","","","","","","","fee schedule","9.46","40.21",""
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.25","","","","","","","fee schedule","9.46","40.21",""
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.21","","","","","","","fee schedule","9.46","40.21",""
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.46","","","","","","","fee schedule","9.46","40.21",""
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.46","","","","","","","fee schedule","9.46","40.21",""
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.78","","","","","","","fee schedule","9.46","40.21","APC"
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.59","","","","","","","fee schedule","9.46","40.21","APC"
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.48","","","","","","","fee schedule","9.46","40.21","APC"
"Test urine for lactose","83633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.81","","","","","","","fee schedule","9.46","40.21","APC"
"Assay of urine for lactose","83634","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.54","","","","","","","fee schedule","81.54","81.54",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.11","","","","","","","fee schedule","12.11","89.97",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.11","","","","","","","fee schedule","12.11","89.97",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.11","","","","","","","fee schedule","12.11","89.97",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.97","","","","","","","fee schedule","12.11","89.97",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.81","","","","","","","fee schedule","12.11","89.97",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.81","","","","","","","fee schedule","12.11","89.97",""
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.11","89.97","APC"
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.47","","","","","","","fee schedule","12.11","89.97","APC"
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.35","","","","","","","fee schedule","12.11","89.97","APC"
"Assay of lead","83655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.72","","","","","","","fee schedule","12.11","89.97","APC"
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.99","","","","","","","fee schedule","21.99","162.73",""
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.99","","","","","","","fee schedule","21.99","162.73",""
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.99","","","","","","","fee schedule","21.99","162.73",""
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","162.73","","","","","","","fee schedule","21.99","162.73",""
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.79","","","","","","","fee schedule","21.99","162.73",""
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.79","","","","","","","fee schedule","21.99","162.73",""
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.03","","","","","","","fee schedule","21.99","162.73","APC"
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.65","","","","","","","fee schedule","21.99","162.73","APC"
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.43","","","","","","","fee schedule","21.99","162.73","APC"
"L/s ratio fetal lung","83661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.09","","","","","","","fee schedule","21.99","162.73","APC"
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.91","","","","","","","fee schedule","18.91","126.07",""
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.91","","","","","","","fee schedule","18.91","126.07",""
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.91","","","","","","","fee schedule","18.91","126.07",""
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.07","","","","","","","fee schedule","18.91","126.07",""
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.52","","","","","","","fee schedule","18.91","126.07",""
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.52","","","","","","","fee schedule","18.91","126.07",""
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.81","","","","","","","fee schedule","18.91","126.07","APC"
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.48","","","","","","","fee schedule","18.91","126.07","APC"
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.29","","","","","","","fee schedule","18.91","126.07","APC"
"Foam stability fetal lung","83662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.86","","","","","","","fee schedule","18.91","126.07","APC"
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.91","","","","","","","fee schedule","18.91","126.07",""
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.91","","","","","","","fee schedule","18.91","126.07",""
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.91","","","","","","","fee schedule","18.91","126.07",""
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.07","","","","","","","fee schedule","18.91","126.07",""
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.52","","","","","","","fee schedule","18.91","126.07",""
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.52","","","","","","","fee schedule","18.91","126.07",""
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.81","","","","","","","fee schedule","18.91","126.07","APC"
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.48","","","","","","","fee schedule","18.91","126.07","APC"
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.29","","","","","","","fee schedule","18.91","126.07","APC"
"Fluoro polarize fetal lung","83663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.86","","","","","","","fee schedule","18.91","126.07","APC"
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.32","","","","","","","fee schedule","19.32","126.07",""
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.32","","","","","","","fee schedule","19.32","126.07",""
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.32","","","","","","","fee schedule","19.32","126.07",""
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.07","","","","","","","fee schedule","19.32","126.07",""
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.52","","","","","","","fee schedule","19.32","126.07",""
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.52","","","","","","","fee schedule","19.32","126.07",""
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.24","","","","","","","fee schedule","19.32","126.07","APC"
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.9","","","","","","","fee schedule","19.32","126.07","APC"
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.71","","","","","","","fee schedule","19.32","126.07","APC"
"Lamellar bdy fetal lung","83664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.29","","","","","","","fee schedule","19.32","126.07","APC"
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.81","","","","","","","fee schedule","9.81","66.6",""
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.81","","","","","","","fee schedule","9.81","66.6",""
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.81","","","","","","","fee schedule","9.81","66.6",""
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","66.6","","","","","","","fee schedule","9.81","66.6",""
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.76","","","","","","","fee schedule","9.81","66.6",""
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.76","","","","","","","fee schedule","9.81","66.6",""
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.28","","","","","","","fee schedule","9.81","66.6","APC"
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.1","","","","","","","fee schedule","9.81","66.6","APC"
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.01","","","","","","","fee schedule","9.81","66.6","APC"
"Assay of lap enzyme","83670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.3","","","","","","","fee schedule","9.81","66.6","APC"
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.89","","","","","","","fee schedule","6.89","50.1",""
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.89","","","","","","","fee schedule","6.89","50.1",""
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.89","","","","","","","fee schedule","6.89","50.1",""
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.1","","","","","","","fee schedule","6.89","50.1",""
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.83","","","","","","","fee schedule","6.89","50.1",""
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.83","","","","","","","fee schedule","6.89","50.1",""
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.22","","","","","","","fee schedule","6.89","50.1","APC"
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.1","","","","","","","fee schedule","6.89","50.1","APC"
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.03","","","","","","","fee schedule","6.89","50.1","APC"
"Assay of lipase","83690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.23","","","","","","","fee schedule","6.89","50.1","APC"
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.32","","","","","","","fee schedule","14.32","97.38",""
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.32","","","","","","","fee schedule","14.32","97.38",""
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.32","","","","","","","fee schedule","14.32","97.38",""
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.38","","","","","","","fee schedule","14.32","97.38",""
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.25","","","","","","","fee schedule","14.32","97.38",""
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.25","","","","","","","fee schedule","14.32","97.38",""
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15","","","","","","","fee schedule","14.32","97.38","APC"
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.75","","","","","","","fee schedule","14.32","97.38","APC"
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.61","","","","","","","fee schedule","14.32","97.38","APC"
"Assay of lipoprotein(a)","83695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.04","","","","","","","fee schedule","14.32","97.38","APC"
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.31","","","","","","","fee schedule","46.31","251.71",""
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46.31","","","","","","","fee schedule","46.31","251.71",""
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.31","","","","","","","fee schedule","46.31","251.71",""
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","251.71","","","","","","","fee schedule","46.31","251.71",""
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.34","","","","","","","fee schedule","46.31","251.71",""
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.34","","","","","","","fee schedule","46.31","251.71",""
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48.51","","","","","","","fee schedule","46.31","251.71","APC"
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.7","","","","","","","fee schedule","46.31","251.71","APC"
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.24","","","","","","","fee schedule","46.31","251.71","APC"
"Assay Lipoprotein Pla2","83698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.63","","","","","","","fee schedule","46.31","251.71","APC"
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.26","","","","","","","fee schedule","11.26","81.39",""
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.26","","","","","","","fee schedule","11.26","81.39",""
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.26","","","","","","","fee schedule","11.26","81.39",""
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.39","","","","","","","fee schedule","11.26","81.39",""
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.34","","","","","","","fee schedule","11.26","81.39",""
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.34","","","","","","","fee schedule","11.26","81.39",""
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.79","","","","","","","fee schedule","11.26","81.39","APC"
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.6","","","","","","","fee schedule","11.26","81.39","APC"
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.49","","","","","","","fee schedule","11.26","81.39","APC"
"Lipopro bld electrophoretic","83700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.82","","","","","","","fee schedule","11.26","81.39","APC"
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.86","","","","","","","fee schedule","33.86","165.77",""
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.86","","","","","","","fee schedule","33.86","165.77",""
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","33.86","","","","","","","fee schedule","33.86","165.77",""
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","165.77","","","","","","","fee schedule","33.86","165.77",""
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.66","","","","","","","fee schedule","33.86","165.77",""
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.66","","","","","","","fee schedule","33.86","165.77",""
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.47","","","","","","","fee schedule","33.86","165.77","APC"
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.88","","","","","","","fee schedule","33.86","165.77","APC"
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.54","","","","","","","fee schedule","33.86","165.77","APC"
"Lipoprotein bld hr fraction","83701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.55","","","","","","","fee schedule","33.86","165.77","APC"
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.19","","","","","","","fee schedule","34.19","219.82",""
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.19","","","","","","","fee schedule","34.19","219.82",""
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.19","","","","","","","fee schedule","34.19","219.82",""
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","219.82","","","","","","","fee schedule","34.19","219.82",""
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","54.23","","","","","","","fee schedule","34.19","219.82",""
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","54.23","","","","","","","fee schedule","34.19","219.82",""
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.81","","","","","","","fee schedule","34.19","219.82","APC"
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.22","","","","","","","fee schedule","34.19","219.82","APC"
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.87","","","","","","","fee schedule","34.19","219.82","APC"
"Lipoprotein bld quan part","83704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.9","","","","","","","fee schedule","34.19","219.82","APC"
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.19","","","","","","","fee schedule","8.19","60.52",""
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.19","","","","","","","fee schedule","8.19","60.52",""
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.19","","","","","","","fee schedule","8.19","60.52",""
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.08","","","","","","","fee schedule","8.19","60.52",""
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","60.52","","","","","","","fee schedule","8.19","60.52",""
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.08","","","","","","","fee schedule","8.19","60.52",""
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.19","60.52","APC"
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.44","","","","","","","fee schedule","8.19","60.52","APC"
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.35","","","","","","","fee schedule","8.19","60.52","APC"
"Assay of lipoprotein","83718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.6","","","","","","","fee schedule","8.19","60.52","APC"
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.75","","","","","","","fee schedule","12.75","83.58",""
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.75","","","","","","","fee schedule","12.75","83.58",""
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.75","","","","","","","fee schedule","12.75","83.58",""
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.99","","","","","","","fee schedule","12.75","83.58",""
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.58","","","","","","","fee schedule","12.75","83.58",""
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.99","","","","","","","fee schedule","12.75","83.58",""
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.36","","","","","","","fee schedule","12.75","83.58","APC"
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.75","83.58","APC"
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13","","","","","","","fee schedule","12.75","83.58","APC"
"Assay of blood lipoprotein","83719","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.39","","","","","","","fee schedule","12.75","83.58","APC"
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.5","","","","","","","fee schedule","10.5","70.46",""
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.5","","","","","","","fee schedule","10.5","70.46",""
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.5","","","","","","","fee schedule","10.5","70.46",""
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.39","","","","","","","fee schedule","10.5","70.46",""
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.46","","","","","","","fee schedule","10.5","70.46",""
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.39","","","","","","","fee schedule","10.5","70.46",""
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11","","","","","","","fee schedule","10.5","70.46","APC"
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.82","","","","","","","fee schedule","10.5","70.46","APC"
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.71","","","","","","","fee schedule","10.5","70.46","APC"
"Assay of blood lipoprotein","83721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.02","","","","","","","fee schedule","10.5","70.46","APC"
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.19","","","","","","","fee schedule","34.19","42.07",""
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.19","","","","","","","fee schedule","34.19","42.07",""
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.19","","","","","","","fee schedule","34.19","42.07",""
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.07","","","","","","","fee schedule","34.19","42.07",""
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.07","","","","","","","fee schedule","34.19","42.07",""
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.81","","","","","","","fee schedule","34.19","42.07","APC"
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.22","","","","","","","fee schedule","34.19","42.07","APC"
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.87","","","","","","","fee schedule","34.19","42.07","APC"
"Lipoprtn dir meas sd ldl chl","83722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.9","","","","","","","fee schedule","34.19","42.07","APC"
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.19","","","","","","","fee schedule","17.19","128.51",""
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.19","","","","","","","fee schedule","17.19","128.51",""
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.19","","","","","","","fee schedule","17.19","128.51",""
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.56","","","","","","","fee schedule","17.19","128.51",""
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.51","","","","","","","fee schedule","17.19","128.51",""
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.56","","","","","","","fee schedule","17.19","128.51",""
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.01","","","","","","","fee schedule","17.19","128.51","APC"
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.71","","","","","","","fee schedule","17.19","128.51","APC"
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.53","","","","","","","fee schedule","17.19","128.51","APC"
"Assay of lrh hormone","83727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.05","","","","","","","fee schedule","17.19","128.51","APC"
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.7","","","","","","","fee schedule","6.7","50.27",""
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.7","","","","","","","fee schedule","6.7","50.27",""
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.7","","","","","","","fee schedule","6.7","50.27",""
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.52","","","","","","","fee schedule","6.7","50.27",""
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.27","","","","","","","fee schedule","6.7","50.27",""
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.52","","","","","","","fee schedule","6.7","50.27",""
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.02","","","","","","","fee schedule","6.7","50.27","APC"
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.9","","","","","","","fee schedule","6.7","50.27","APC"
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.83","","","","","","","fee schedule","6.7","50.27","APC"
"Assay of magnesium","83735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.04","","","","","","","fee schedule","6.7","50.27","APC"
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.37","","","","","","","fee schedule","7.37","55.21",""
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.37","","","","","","","fee schedule","7.37","55.21",""
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.37","","","","","","","fee schedule","7.37","55.21",""
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.67","","","","","","","fee schedule","7.37","55.21",""
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","55.21","","","","","","","fee schedule","7.37","55.21",""
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.67","","","","","","","fee schedule","7.37","55.21",""
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.72","","","","","","","fee schedule","7.37","55.21","APC"
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.59","","","","","","","fee schedule","7.37","55.21","APC"
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.52","","","","","","","fee schedule","7.37","55.21","APC"
"Assay malate dehydrogenase","83775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.74","","","","","","","fee schedule","7.37","55.21","APC"
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.65","","","","","","","fee schedule","26.65","170.14",""
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.65","","","","","","","fee schedule","26.65","170.14",""
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.65","","","","","","","fee schedule","26.65","170.14",""
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.26","","","","","","","fee schedule","26.65","170.14",""
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","170.14","","","","","","","fee schedule","26.65","170.14",""
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.26","","","","","","","fee schedule","26.65","170.14",""
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.92","","","","","","","fee schedule","26.65","170.14","APC"
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.45","","","","","","","fee schedule","26.65","170.14","APC"
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.18","","","","","","","fee schedule","26.65","170.14","APC"
"Assay of manganese","83785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.98","","","","","","","fee schedule","26.65","170.14","APC"
"Mass spectrometry qual","83788","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","128.57","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.11","","","","","","","fee schedule","24.11","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.11","","","","","","","fee schedule","24.11","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.11","","","","","","","fee schedule","24.11","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.03","","","","","","","fee schedule","24.11","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.57","","","","","","","fee schedule","24.11","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.03","","","","","","","fee schedule","24.11","128.57",""
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.26","","","","","","","fee schedule","24.11","128.57","APC"
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.83","","","","","","","fee schedule","24.11","128.57","APC"
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.59","","","","","","","fee schedule","24.11","128.57","APC"
"Mass spectrometry qual/quan","83789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.32","","","","","","","fee schedule","24.11","128.57","APC"
"Assay of meprobamate","83805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","131.72","","","","","","","fee schedule","131.72","131.72",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.26","","","","","","","fee schedule","16.26","121.1",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.26","","","","","","","fee schedule","16.26","121.1",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.26","","","","","","","fee schedule","16.26","121.1",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.95","","","","","","","fee schedule","16.26","121.1",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","121.1","","","","","","","fee schedule","16.26","121.1",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.95","","","","","","","fee schedule","16.26","121.1",""
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.03","","","","","","","fee schedule","16.26","121.1","APC"
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.75","","","","","","","fee schedule","16.26","121.1","APC"
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.59","","","","","","","fee schedule","16.26","121.1","APC"
"Assay of mercury","83825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.07","","","","","","","fee schedule","16.26","121.1","APC"
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.94","","","","","","","fee schedule","16.94","125.16",""
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.94","","","","","","","fee schedule","16.94","125.16",""
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.94","","","","","","","fee schedule","16.94","125.16",""
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.11","","","","","","","fee schedule","16.94","125.16",""
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","125.16","","","","","","","fee schedule","16.94","125.16",""
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.11","","","","","","","fee schedule","16.94","125.16",""
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.74","","","","","","","fee schedule","16.94","125.16","APC"
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.45","","","","","","","fee schedule","16.94","125.16","APC"
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.28","","","","","","","fee schedule","16.94","125.16","APC"
"Assay of metanephrines","83835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.79","","","","","","","fee schedule","16.94","125.16","APC"
"Assay of methadone","83840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","117.75","","","","","","","fee schedule","117.75","117.75",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.74","","","","","","","fee schedule","10.74","78.24",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.74","","","","","","","fee schedule","10.74","78.24",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.74","","","","","","","fee schedule","10.74","78.24",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.46","","","","","","","fee schedule","10.74","78.24",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","78.24","","","","","","","fee schedule","10.74","78.24",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.46","","","","","","","fee schedule","10.74","78.24",""
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.25","","","","","","","fee schedule","10.74","78.24","APC"
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.74","78.24","APC"
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.74","78.24","APC"
"Assay of methemalbumin","83857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.28","","","","","","","fee schedule","10.74","78.24","APC"
"Assay of methsuximide","83858","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.31","","","","","","","fee schedule","109.31","109.31",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.48","","","","","","","fee schedule","22.48","124.22",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.48","","","","","","","fee schedule","22.48","124.22",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.48","","","","","","","fee schedule","22.48","124.22",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.22","","","","","","","fee schedule","22.48","124.22",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.3","","","","","","","fee schedule","22.48","124.22",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.3","","","","","","","fee schedule","22.48","124.22",""
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.55","","","","","","","fee schedule","22.48","124.22","APC"
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.15","","","","","","","fee schedule","22.48","124.22","APC"
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.93","","","","","","","fee schedule","22.48","124.22","APC"
"Microfluid analy tears","83861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.6","","","","","","","fee schedule","22.48","124.22","APC"
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.5","","","","","","","fee schedule","28.5","143.51",""
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","28.5","","","","","","","fee schedule","28.5","143.51",""
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28.5","","","","","","","fee schedule","28.5","143.51",""
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","143.51","","","","","","","fee schedule","28.5","143.51",""
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.21","","","","","","","fee schedule","28.5","143.51",""
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.21","","","","","","","fee schedule","28.5","143.51",""
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.85","","","","","","","fee schedule","28.5","143.51","APC"
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.36","","","","","","","fee schedule","28.5","143.51","APC"
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.5","143.51","APC"
"Mucopolysaccharides","83864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.92","","","","","","","fee schedule","28.5","143.51","APC"
"Mucopolysaccharides screen","83866","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","72.79","","","","","","","fee schedule","72.79","72.79",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.86","","","","","","","fee schedule","5.86","42.23",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.86","","","","","","","fee schedule","5.86","42.23",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.86","","","","","","","fee schedule","5.86","42.23",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","42.23","","","","","","","fee schedule","5.86","42.23",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.08","","","","","","","fee schedule","5.86","42.23",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.08","","","","","","","fee schedule","5.86","42.23",""
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.14","","","","","","","fee schedule","5.86","42.23","APC"
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.04","","","","","","","fee schedule","5.86","42.23","APC"
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.98","","","","","","","fee schedule","5.86","42.23","APC"
"Assay synovial fluid mucin","83872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.15","","","","","","","fee schedule","5.86","42.23","APC"
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.2","","","","","","","fee schedule","17.2","125.3",""
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.2","","","","","","","fee schedule","17.2","125.3",""
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.2","","","","","","","fee schedule","17.2","125.3",""
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","125.3","","","","","","","fee schedule","17.2","125.3",""
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.57","","","","","","","fee schedule","17.2","125.3",""
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.57","","","","","","","fee schedule","17.2","125.3",""
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.02","","","","","","","fee schedule","17.2","125.3","APC"
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.72","","","","","","","fee schedule","17.2","125.3","APC"
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.54","","","","","","","fee schedule","17.2","125.3","APC"
"Assay of csf protein","83873","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.06","","","","","","","fee schedule","17.2","125.3","APC"
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.92","","","","","","","fee schedule","12.92","96.36",""
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.92","","","","","","","fee schedule","12.92","96.36",""
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.92","","","","","","","fee schedule","12.92","96.36",""
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.36","","","","","","","fee schedule","12.92","96.36",""
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.2","","","","","","","fee schedule","12.92","96.36",""
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.2","","","","","","","fee schedule","12.92","96.36",""
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.53","","","","","","","fee schedule","12.92","96.36","APC"
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.31","","","","","","","fee schedule","12.92","96.36","APC"
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.18","","","","","","","fee schedule","12.92","96.36","APC"
"Assay of myoglobin","83874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.57","","","","","","","fee schedule","12.92","96.36","APC"
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","50.86","","","","","","","fee schedule","50.86","251.71",""
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.86","","","","","","","fee schedule","50.86","251.71",""
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","50.86","","","","","","","fee schedule","50.86","251.71",""
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","251.71","","","","","","","fee schedule","50.86","251.71",""
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.34","","","","","","","fee schedule","50.86","251.71",""
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.34","","","","","","","fee schedule","50.86","251.71",""
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.28","","","","","","","fee schedule","50.86","251.71","APC"
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.39","","","","","","","fee schedule","50.86","251.71","APC"
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.88","","","","","","","fee schedule","50.86","251.71","APC"
"Assay myeloperoxidase","83876","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.4","","","","","","","fee schedule","50.86","251.71","APC"
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.26","","","","","","","fee schedule","39.26","251.71",""
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.26","","","","","","","fee schedule","39.26","251.71",""
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.26","","","","","","","fee schedule","39.26","251.71",""
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","251.71","","","","","","","fee schedule","39.26","251.71",""
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.34","","","","","","","fee schedule","39.26","251.71",""
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.34","","","","","","","fee schedule","39.26","251.71",""
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.12","","","","","","","fee schedule","39.26","251.71","APC"
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.44","","","","","","","fee schedule","39.26","251.71","APC"
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.05","","","","","","","fee schedule","39.26","251.71","APC"
"Assay of natriuretic peptide","83880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.22","","","","","","","fee schedule","39.26","251.71","APC"
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.6","","","","","","","fee schedule","13.6","93.18",""
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.6","","","","","","","fee schedule","13.6","93.18",""
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.6","","","","","","","fee schedule","13.6","93.18",""
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.18","","","","","","","fee schedule","13.6","93.18",""
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.36","","","","","","","fee schedule","13.6","93.18",""
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.36","","","","","","","fee schedule","13.6","93.18",""
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.25","","","","","","","fee schedule","13.6","93.18","APC"
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.01","","","","","","","fee schedule","13.6","93.18","APC"
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.87","","","","","","","fee schedule","13.6","93.18","APC"
"Assay nephelometry not spec","83883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.28","","","","","","","fee schedule","13.6","93.18","APC"
"Assay neurflmnt light chain","83884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","121.75","","","","","","","fee schedule","118.55","122.04","APC"
"Assay neurflmnt light chain","83884","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","119.72","","","","","","","fee schedule","118.55","122.04","APC"
"Assay neurflmnt light chain","83884","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","118.55","","","","","","","fee schedule","118.55","122.04","APC"
"Assay neurflmnt light chain","83884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","122.04","","","","","","","fee schedule","118.55","122.04","APC"
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.51","","","","","","","fee schedule","24.51","171.42",""
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.51","","","","","","","fee schedule","24.51","171.42",""
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.51","","","","","","","fee schedule","24.51","171.42",""
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","171.42","","","","","","","fee schedule","24.51","171.42",""
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","24.51","171.42",""
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","24.51","171.42",""
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.67","","","","","","","fee schedule","24.51","171.42","APC"
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.25","","","","","","","fee schedule","24.51","171.42","APC"
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25","","","","","","","fee schedule","24.51","171.42","APC"
"Assay of nickel","83885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.74","","","","","","","fee schedule","24.51","171.42","APC"
"Assay of nicotine","83887","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","170.77","","","","","","","fee schedule","170.77","170.77",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.15","","","","","","","fee schedule","11.15","83.07",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.15","","","","","","","fee schedule","11.15","83.07",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.15","","","","","","","fee schedule","11.15","83.07",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.18","","","","","","","fee schedule","11.15","83.07",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.07","","","","","","","fee schedule","11.15","83.07",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.18","","","","","","","fee schedule","11.15","83.07",""
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.68","","","","","","","fee schedule","11.15","83.07","APC"
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.48","","","","","","","fee schedule","11.15","83.07","APC"
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.37","","","","","","","fee schedule","11.15","83.07","APC"
"Assay of nucleotidase","83915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.71","","","","","","","fee schedule","11.15","83.07","APC"
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.39","","","","","","","fee schedule","27.39","150.04",""
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.39","","","","","","","fee schedule","27.39","150.04",""
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.39","","","","","","","fee schedule","27.39","150.04",""
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.56","","","","","","","fee schedule","27.39","150.04",""
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.04","","","","","","","fee schedule","27.39","150.04",""
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.56","","","","","","","fee schedule","27.39","150.04",""
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.69","","","","","","","fee schedule","27.39","150.04","APC"
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.21","","","","","","","fee schedule","27.39","150.04","APC"
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.94","","","","","","","fee schedule","27.39","150.04","APC"
"Oligoclonal bands","83916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.76","","","","","","","fee schedule","27.39","150.04","APC"
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.6","","","","","","","fee schedule","23.6","122.52",""
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.6","","","","","","","fee schedule","23.6","122.52",""
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.6","","","","","","","fee schedule","23.6","122.52",""
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.3","","","","","","","fee schedule","23.6","122.52",""
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","122.52","","","","","","","fee schedule","23.6","122.52",""
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.3","","","","","","","fee schedule","23.6","122.52",""
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.72","","","","","","","fee schedule","23.6","122.52","APC"
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.31","","","","","","","fee schedule","23.6","122.52","APC"
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.07","","","","","","","fee schedule","23.6","122.52","APC"
"Organic acids total quant","83918","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.78","","","","","","","fee schedule","23.6","122.52","APC"
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.45","","","","","","","fee schedule","16.45","122.52",""
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.45","","","","","","","fee schedule","16.45","122.52",""
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.45","","","","","","","fee schedule","16.45","122.52",""
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.3","","","","","","","fee schedule","16.45","122.52",""
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","122.52","","","","","","","fee schedule","16.45","122.52",""
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.3","","","","","","","fee schedule","16.45","122.52",""
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.23","","","","","","","fee schedule","16.45","122.52","APC"
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.94","","","","","","","fee schedule","16.45","122.52","APC"
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.78","","","","","","","fee schedule","16.45","122.52","APC"
"Organic acids qual each","83919","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.27","","","","","","","fee schedule","16.45","122.52","APC"
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.21","","","","","","","fee schedule","21.21","122.52",""
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.21","","","","","","","fee schedule","21.21","122.52",""
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.21","","","","","","","fee schedule","21.21","122.52",""
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.3","","","","","","","fee schedule","21.21","122.52",""
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","122.52","","","","","","","fee schedule","21.21","122.52",""
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.3","","","","","","","fee schedule","21.21","122.52",""
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.22","","","","","","","fee schedule","21.21","122.52","APC"
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.85","","","","","","","fee schedule","21.21","122.52","APC"
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.63","","","","","","","fee schedule","21.21","122.52","APC"
"Organic acid single quant","83921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.27","","","","","","","fee schedule","21.21","122.52","APC"
"Assay of opiates","83925","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","143.56","","","","","","","fee schedule","143.56","143.56",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.61","","","","","","","fee schedule","6.61","48.76",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.61","","","","","","","fee schedule","6.61","48.76",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.61","","","","","","","fee schedule","6.61","48.76",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.35","","","","","","","fee schedule","6.61","48.76",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.76","","","","","","","fee schedule","6.61","48.76",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.35","","","","","","","fee schedule","6.61","48.76",""
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.92","","","","","","","fee schedule","6.61","48.76","APC"
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.81","","","","","","","fee schedule","6.61","48.76","APC"
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.74","","","","","","","fee schedule","6.61","48.76","APC"
"Assay of blood osmolality","83930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.94","","","","","","","fee schedule","6.61","48.76","APC"
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.82","","","","","","","fee schedule","6.82","50.41",""
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.82","","","","","","","fee schedule","6.82","50.41",""
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.82","","","","","","","fee schedule","6.82","50.41",""
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.71","","","","","","","fee schedule","6.82","50.41",""
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.41","","","","","","","fee schedule","6.82","50.41",""
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.71","","","","","","","fee schedule","6.82","50.41",""
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.14","","","","","","","fee schedule","6.82","50.41","APC"
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.02","","","","","","","fee schedule","6.82","50.41","APC"
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.96","","","","","","","fee schedule","6.82","50.41","APC"
"Assay of urine osmolality","83935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.16","","","","","","","fee schedule","6.82","50.41","APC"
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.85","","","","","","","fee schedule","29.85","212.91",""
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.85","","","","","","","fee schedule","29.85","212.91",""
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.85","","","","","","","fee schedule","29.85","212.91",""
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","51.31","","","","","","","fee schedule","29.85","212.91",""
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","212.91","","","","","","","fee schedule","29.85","212.91",""
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","51.31","","","","","","","fee schedule","29.85","212.91",""
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.27","","","","","","","fee schedule","29.85","212.91","APC"
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.75","","","","","","","fee schedule","29.85","212.91","APC"
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.45","","","","","","","fee schedule","29.85","212.91","APC"
"Assay of osteocalcin","83937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.34","","","","","","","fee schedule","29.85","212.91","APC"
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.45","","","","","","","fee schedule","14.45","95.74",""
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.45","","","","","","","fee schedule","14.45","95.74",""
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.45","","","","","","","fee schedule","14.45","95.74",""
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.13","","","","","","","fee schedule","14.45","95.74",""
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.74","","","","","","","fee schedule","14.45","95.74",""
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.13","","","","","","","fee schedule","14.45","95.74",""
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.14","","","","","","","fee schedule","14.45","95.74","APC"
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.88","","","","","","","fee schedule","14.45","95.74","APC"
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.74","","","","","","","fee schedule","14.45","95.74","APC"
"Assay of oxalate","83945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.17","","","","","","","fee schedule","14.45","95.74","APC"
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.41","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","110.71","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","467.63","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","110.71","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.47","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.34","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.7","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein her-2/neu","83950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.63","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.41","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.41","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","110.71","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","467.63","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","110.71","","","","","","","fee schedule","64.41","467.63",""
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.47","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.34","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.7","","","","","","","fee schedule","64.41","467.63","APC"
"Oncoprotein dcp","83951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.63","","","","","","","fee schedule","64.41","467.63","APC"
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.28","","","","","","","fee schedule","41.28","310.36",""
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.28","","","","","","","fee schedule","41.28","310.36",""
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.28","","","","","","","fee schedule","41.28","310.36",""
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","70.94","","","","","","","fee schedule","41.28","310.36",""
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.36","","","","","","","fee schedule","41.28","310.36",""
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","70.94","","","","","","","fee schedule","41.28","310.36",""
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.24","","","","","","","fee schedule","41.28","310.36","APC"
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.52","","","","","","","fee schedule","41.28","310.36","APC"
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.11","","","","","","","fee schedule","41.28","310.36","APC"
"Assay of parathormone","83970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.34","","","","","","","fee schedule","41.28","310.36","APC"
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.58","","","","","","","fee schedule","3.58","25.08",""
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.58","","","","","","","fee schedule","3.58","25.08",""
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.58","","","","","","","fee schedule","3.58","25.08",""
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.16","","","","","","","fee schedule","3.58","25.08",""
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","25.08","","","","","","","fee schedule","3.58","25.08",""
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.16","","","","","","","fee schedule","3.58","25.08",""
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.75","","","","","","","fee schedule","3.58","25.08","APC"
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.69","","","","","","","fee schedule","3.58","25.08","APC"
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.65","","","","","","","fee schedule","3.58","25.08","APC"
"Assay ph body fluid nos","83986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.76","","","","","","","fee schedule","3.58","25.08","APC"
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.58","","","","","","","fee schedule","3.58","115.47",""
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.58","","","","","","","fee schedule","3.58","115.47",""
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.58","","","","","","","fee schedule","3.58","115.47",""
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.29","","","","","","","fee schedule","3.58","115.47",""
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","115.47","","","","","","","fee schedule","3.58","115.47",""
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.29","","","","","","","fee schedule","3.58","115.47",""
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.75","","","","","","","fee schedule","3.58","115.47","APC"
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.69","","","","","","","fee schedule","3.58","115.47","APC"
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.65","","","","","","","fee schedule","3.58","115.47","APC"
"Exhaled breath condensate","83987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.76","","","","","","","fee schedule","3.58","115.47","APC"
"Assay for phencyclidine","83992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.26","","","","","","","fee schedule","25.26","108.03",""
"Assay for phencyclidine","83992","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","108.03","","","","","","","fee schedule","25.26","108.03",""
"Assay for phencyclidine","83992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.26","","","","","","","fee schedule","25.26","108.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.63","","","","","","","fee schedule","19.63","147.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.63","","","","","","","fee schedule","19.63","147.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.63","","","","","","","fee schedule","19.63","147.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.73","","","","","","","fee schedule","19.63","147.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","147.03","","","","","","","fee schedule","19.63","147.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.73","","","","","","","fee schedule","19.63","147.03",""
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.56","","","","","","","fee schedule","19.63","147.03","APC"
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.22","","","","","","","fee schedule","19.63","147.03","APC"
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.02","","","","","","","fee schedule","19.63","147.03","APC"
"Assay for calprotectin fecal","83993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.61","","","","","","","fee schedule","19.63","147.03","APC"
"Assay of phenothiazine","84022","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","114.03","","","","","","","fee schedule","114.03","114.03",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.5","","","","","","","fee schedule","5.5","40.21",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.5","","","","","","","fee schedule","5.5","40.21",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.5","","","","","","","fee schedule","5.5","40.21",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.46","","","","","","","fee schedule","5.5","40.21",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.21","","","","","","","fee schedule","5.5","40.21",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.46","","","","","","","fee schedule","5.5","40.21",""
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.76","","","","","","","fee schedule","5.5","40.21","APC"
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.66","","","","","","","fee schedule","5.5","40.21","APC"
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.61","","","","","","","fee schedule","5.5","40.21","APC"
"Assay of blood pku","84030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.78","","","","","","","fee schedule","5.5","40.21","APC"
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.98","","","","","","","fee schedule","3.98","26.18",""
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.98","","","","","","","fee schedule","3.98","26.18",""
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.98","","","","","","","fee schedule","3.98","26.18",""
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.29","","","","","","","fee schedule","3.98","26.18",""
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.18","","","","","","","fee schedule","3.98","26.18",""
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.29","","","","","","","fee schedule","3.98","26.18",""
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.17","","","","","","","fee schedule","3.98","26.18","APC"
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.1","","","","","","","fee schedule","3.98","26.18","APC"
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.06","","","","","","","fee schedule","3.98","26.18","APC"
"Assay of phenylketones","84035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.18","","","","","","","fee schedule","3.98","26.18","APC"
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.64","","","","","","","fee schedule","7.64","54.7",""
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.64","","","","","","","fee schedule","7.64","54.7",""
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.64","","","","","","","fee schedule","7.64","54.7",""
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.68","","","","","","","fee schedule","7.64","54.7",""
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","54.7","","","","","","","fee schedule","7.64","54.7",""
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.68","","","","","","","fee schedule","7.64","54.7",""
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8","","","","","","","fee schedule","7.64","54.7","APC"
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.87","","","","","","","fee schedule","7.64","54.7","APC"
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.79","","","","","","","fee schedule","7.64","54.7","APC"
"Assay acid phosphatase","84060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.02","","","","","","","fee schedule","7.64","54.7","APC"
"Phosphatase forensic exam","84061","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.56","","","","","","","fee schedule","58.56","58.56",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.66","","","","","","","fee schedule","9.66","72.36",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.66","","","","","","","fee schedule","9.66","72.36",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.66","","","","","","","fee schedule","9.66","72.36",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.61","","","","","","","fee schedule","9.66","72.36",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","72.36","","","","","","","fee schedule","9.66","72.36",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.61","","","","","","","fee schedule","9.66","72.36",""
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.12","","","","","","","fee schedule","9.66","72.36","APC"
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.95","","","","","","","fee schedule","9.66","72.36","APC"
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.85","","","","","","","fee schedule","9.66","72.36","APC"
"Assay prostate phosphatase","84066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.14","","","","","","","fee schedule","9.66","72.36","APC"
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","38.82",""
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","38.82",""
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","38.82",""
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","38.82",""
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.82","","","","","","","fee schedule","5.18","38.82",""
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","38.82",""
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.18","38.82","APC"
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.18","38.82","APC"
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.18","38.82","APC"
"Assay alkaline phosphatase","84075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.18","38.82","APC"
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.26","","","","","","","fee schedule","8.26","52.6",""
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.26","","","","","","","fee schedule","8.26","52.6",""
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.26","","","","","","","fee schedule","8.26","52.6",""
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.55","","","","","","","fee schedule","8.26","52.6",""
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.6","","","","","","","fee schedule","8.26","52.6",""
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.55","","","","","","","fee schedule","8.26","52.6",""
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.65","","","","","","","fee schedule","8.26","52.6","APC"
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.51","","","","","","","fee schedule","8.26","52.6","APC"
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.43","","","","","","","fee schedule","8.26","52.6","APC"
"Assay alkaline phosphatase","84078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.67","","","","","","","fee schedule","8.26","52.6","APC"
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.78","","","","","","","fee schedule","14.78","107.81",""
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.78","","","","","","","fee schedule","14.78","107.81",""
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.78","","","","","","","fee schedule","14.78","107.81",""
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.43","","","","","","","fee schedule","14.78","107.81",""
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.81","","","","","","","fee schedule","14.78","107.81",""
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.43","","","","","","","fee schedule","14.78","107.81",""
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.48","","","","","","","fee schedule","14.78","107.81","APC"
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.22","","","","","","","fee schedule","14.78","107.81","APC"
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.08","","","","","","","fee schedule","14.78","107.81","APC"
"Assay alkaline phosphatases","84080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.52","","","","","","","fee schedule","14.78","107.81","APC"
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.52","","","","","","","fee schedule","16.52","124.22",""
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.52","","","","","","","fee schedule","16.52","124.22",""
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.52","","","","","","","fee schedule","16.52","124.22",""
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.4","","","","","","","fee schedule","16.52","124.22",""
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.22","","","","","","","fee schedule","16.52","124.22",""
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.4","","","","","","","fee schedule","16.52","124.22",""
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.3","","","","","","","fee schedule","16.52","124.22","APC"
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.02","","","","","","","fee schedule","16.52","124.22","APC"
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.85","","","","","","","fee schedule","16.52","124.22","APC"
"Assay phosphatidylglycerol","84081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.35","","","","","","","fee schedule","16.52","124.22","APC"
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.44","","","","","","","fee schedule","9.44","50.47",""
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.44","","","","","","","fee schedule","9.44","50.47",""
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.44","","","","","","","fee schedule","9.44","50.47",""
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.59","","","","","","","fee schedule","9.44","50.47",""
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.47","","","","","","","fee schedule","9.44","50.47",""
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.59","","","","","","","fee schedule","9.44","50.47",""
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.89","","","","","","","fee schedule","9.44","50.47","APC"
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.72","","","","","","","fee schedule","9.44","50.47","APC"
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.63","","","","","","","fee schedule","9.44","50.47","APC"
"Assay of rbc pg6d enzyme","84085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.44","50.47","APC"
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.73","","","","","","","fee schedule","10.73","76.51",""
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.73","","","","","","","fee schedule","10.73","76.51",""
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.73","","","","","","","fee schedule","10.73","76.51",""
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.75","","","","","","","fee schedule","10.73","76.51",""
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","76.51","","","","","","","fee schedule","10.73","76.51",""
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.75","","","","","","","fee schedule","10.73","76.51",""
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.24","","","","","","","fee schedule","10.73","76.51","APC"
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.05","","","","","","","fee schedule","10.73","76.51","APC"
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.94","","","","","","","fee schedule","10.73","76.51","APC"
"Assay phosphohexose enzymes","84087","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.27","","","","","","","fee schedule","10.73","76.51","APC"
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.74","","","","","","","fee schedule","4.74","35.33",""
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.74","","","","","","","fee schedule","4.74","35.33",""
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.74","","","","","","","fee schedule","4.74","35.33",""
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.15","","","","","","","fee schedule","4.74","35.33",""
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.33","","","","","","","fee schedule","4.74","35.33",""
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.15","","","","","","","fee schedule","4.74","35.33",""
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.97","","","","","","","fee schedule","4.74","35.33","APC"
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.88","","","","","","","fee schedule","4.74","35.33","APC"
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.83","","","","","","","fee schedule","4.74","35.33","APC"
"Assay of phosphorus","84100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.98","","","","","","","fee schedule","4.74","35.33","APC"
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.78","","","","","","","fee schedule","5.78","38.37",""
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.78","","","","","","","fee schedule","5.78","38.37",""
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.78","","","","","","","fee schedule","5.78","38.37",""
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.78","38.37",""
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.37","","","","","","","fee schedule","5.78","38.37",""
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.78","38.37",""
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.05","","","","","","","fee schedule","5.78","38.37","APC"
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.95","","","","","","","fee schedule","5.78","38.37","APC"
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.9","","","","","","","fee schedule","5.78","38.37","APC"
"Assay of urine phosphorus","84105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.07","","","","","","","fee schedule","5.78","38.37","APC"
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.82","","","","","","","fee schedule","5.82","31.81",""
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.82","","","","","","","fee schedule","5.82","31.81",""
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.82","","","","","","","fee schedule","5.82","31.81",""
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.36","","","","","","","fee schedule","5.82","31.81",""
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.81","","","","","","","fee schedule","5.82","31.81",""
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.36","","","","","","","fee schedule","5.82","31.81",""
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.1","","","","","","","fee schedule","5.82","31.81","APC"
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.99","","","","","","","fee schedule","5.82","31.81","APC"
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.94","","","","","","","fee schedule","5.82","31.81","APC"
"Test for porphobilinogen","84106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.11","","","","","","","fee schedule","5.82","31.81","APC"
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.44","","","","","","","fee schedule","8.44","59.16",""
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.44","","","","","","","fee schedule","8.44","59.16",""
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.44","","","","","","","fee schedule","8.44","59.16",""
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.52","","","","","","","fee schedule","8.44","59.16",""
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.16","","","","","","","fee schedule","8.44","59.16",""
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.52","","","","","","","fee schedule","8.44","59.16",""
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.84","","","","","","","fee schedule","8.44","59.16","APC"
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.69","","","","","","","fee schedule","8.44","59.16","APC"
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.61","","","","","","","fee schedule","8.44","59.16","APC"
"Assay of porphobilinogen","84110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.86","","","","","","","fee schedule","8.44","59.16","APC"
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","98.11","","","","","","","fee schedule","98.11","467.63",""
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","98.11","","","","","","","fee schedule","98.11","467.63",""
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","98.11","","","","","","","fee schedule","98.11","467.63",""
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","108.77","","","","","","","fee schedule","98.11","467.63",""
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","467.63","","","","","","","fee schedule","98.11","467.63",""
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","108.77","","","","","","","fee schedule","98.11","467.63",""
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","102.77","","","","","","","fee schedule","98.11","467.63","APC"
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","101.05","","","","","","","fee schedule","98.11","467.63","APC"
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","100.07","","","","","","","fee schedule","98.11","467.63","APC"
"Eval amniotic fluid protein","84112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","103.02","","","","","","","fee schedule","98.11","467.63","APC"
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.36","","","","","","","fee schedule","13.36","61.68",""
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.36","","","","","","","fee schedule","13.36","61.68",""
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.36","","","","","","","fee schedule","13.36","61.68",""
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.81","","","","","","","fee schedule","13.36","61.68",""
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","61.68","","","","","","","fee schedule","13.36","61.68",""
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.81","","","","","","","fee schedule","13.36","61.68",""
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.99","","","","","","","fee schedule","13.36","61.68","APC"
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.76","","","","","","","fee schedule","13.36","61.68","APC"
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.63","","","","","","","fee schedule","13.36","61.68","APC"
"Test urine for porphyrins","84119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.03","","","","","","","fee schedule","13.36","61.68","APC"
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.71","","","","","","","fee schedule","14.71","108.23",""
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.71","","","","","","","fee schedule","14.71","108.23",""
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.71","","","","","","","fee schedule","14.71","108.23",""
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.28","","","","","","","fee schedule","14.71","108.23",""
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","108.23","","","","","","","fee schedule","14.71","108.23",""
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.28","","","","","","","fee schedule","14.71","108.23",""
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.41","","","","","","","fee schedule","14.71","108.23","APC"
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.15","","","","","","","fee schedule","14.71","108.23","APC"
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15","","","","","","","fee schedule","14.71","108.23","APC"
"Assay of urine porphyrins","84120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.45","","","","","","","fee schedule","14.71","108.23","APC"
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.11","","","","","","","fee schedule","39.11","182.1",""
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.11","","","","","","","fee schedule","39.11","182.1",""
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.11","","","","","","","fee schedule","39.11","182.1",""
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.78","","","","","","","fee schedule","39.11","182.1",""
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","182.1","","","","","","","fee schedule","39.11","182.1",""
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.78","","","","","","","fee schedule","39.11","182.1",""
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.97","","","","","","","fee schedule","39.11","182.1","APC"
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.28","","","","","","","fee schedule","39.11","182.1","APC"
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.89","","","","","","","fee schedule","39.11","182.1","APC"
"Assay of feces porphyrins","84126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.07","","","","","","","fee schedule","39.11","182.1","APC"
"Assay of feces porphyrins","84127","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.95","","","","","","","fee schedule","79.95","79.95",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.76","","","","","","","fee schedule","4.76","34.62",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.76","","","","","","","fee schedule","4.76","34.62",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.76","","","","","","","fee schedule","4.76","34.62",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","34.62","","","","","","","fee schedule","4.76","34.62",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.9","","","","","","","fee schedule","4.76","34.62",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.9","","","","","","","fee schedule","4.76","34.62",""
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.99","","","","","","","fee schedule","4.76","34.62","APC"
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.9","","","","","","","fee schedule","4.76","34.62","APC"
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.86","","","","","","","fee schedule","4.76","34.62","APC"
"Assay of serum potassium","84132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5","","","","","","","fee schedule","4.76","34.62","APC"
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.73","","","","","","","fee schedule","4.73","32.15",""
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.73","","","","","","","fee schedule","4.73","32.15",""
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.73","","","","","","","fee schedule","4.73","32.15",""
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.15","","","","","","","fee schedule","4.73","32.15",""
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.39","","","","","","","fee schedule","4.73","32.15",""
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.39","","","","","","","fee schedule","4.73","32.15",""
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.95","","","","","","","fee schedule","4.73","32.15","APC"
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.87","","","","","","","fee schedule","4.73","32.15","APC"
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.82","","","","","","","fee schedule","4.73","32.15","APC"
"Assay of urine potassium","84133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.97","","","","","","","fee schedule","4.73","32.15","APC"
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.59","","","","","","","fee schedule","14.59","93.66",""
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.59","","","","","","","fee schedule","14.59","93.66",""
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.59","","","","","","","fee schedule","14.59","93.66",""
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.66","","","","","","","fee schedule","14.59","93.66",""
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.07","","","","","","","fee schedule","14.59","93.66",""
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.07","","","","","","","fee schedule","14.59","93.66",""
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.28","","","","","","","fee schedule","14.59","93.66","APC"
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.03","","","","","","","fee schedule","14.59","93.66","APC"
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.88","","","","","","","fee schedule","14.59","93.66","APC"
"Assay of prealbumin","84134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.32","","","","","","","fee schedule","14.59","93.66","APC"
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.27","","","","","","","fee schedule","21.27","137.65",""
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.27","","","","","","","fee schedule","21.27","137.65",""
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.27","","","","","","","fee schedule","21.27","137.65",""
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.65","","","","","","","fee schedule","21.27","137.65",""
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.88","","","","","","","fee schedule","21.27","137.65",""
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.88","","","","","","","fee schedule","21.27","137.65",""
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.28","","","","","","","fee schedule","21.27","137.65","APC"
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.91","","","","","","","fee schedule","21.27","137.65","APC"
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.27","137.65","APC"
"Assay of pregnanediol","84135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.33","","","","","","","fee schedule","21.27","137.65","APC"
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.05","","","","","","","fee schedule","21.05","140.64",""
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.05","","","","","","","fee schedule","21.05","140.64",""
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.05","","","","","","","fee schedule","21.05","140.64",""
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","140.64","","","","","","","fee schedule","21.05","140.64",""
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.54","","","","","","","fee schedule","21.05","140.64",""
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.54","","","","","","","fee schedule","21.05","140.64",""
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.05","","","","","","","fee schedule","21.05","140.64","APC"
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.68","","","","","","","fee schedule","21.05","140.64","APC"
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.47","","","","","","","fee schedule","21.05","140.64","APC"
"Assay of pregnanetriol","84138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.1","","","","","","","fee schedule","21.05","140.64","APC"
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.67","","","","","","","fee schedule","20.67","145.24",""
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.67","","","","","","","fee schedule","20.67","145.24",""
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.67","","","","","","","fee schedule","20.67","145.24",""
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","145.24","","","","","","","fee schedule","20.67","145.24",""
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.53","","","","","","","fee schedule","20.67","145.24",""
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.53","","","","","","","fee schedule","20.67","145.24",""
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.65","","","","","","","fee schedule","20.67","145.24","APC"
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.29","","","","","","","fee schedule","20.67","145.24","APC"
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.08","","","","","","","fee schedule","20.67","145.24","APC"
"Assay of pregnenolone","84140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.7","","","","","","","fee schedule","20.67","145.24","APC"
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.81","","","","","","","fee schedule","22.81","158.36",""
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.81","","","","","","","fee schedule","22.81","158.36",""
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.81","","","","","","","fee schedule","22.81","158.36",""
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","158.36","","","","","","","fee schedule","22.81","158.36",""
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.23","","","","","","","fee schedule","22.81","158.36",""
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.23","","","","","","","fee schedule","22.81","158.36",""
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.89","","","","","","","fee schedule","22.81","158.36","APC"
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.49","","","","","","","fee schedule","22.81","158.36","APC"
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.27","","","","","","","fee schedule","22.81","158.36","APC"
"Assay of 17-hydroxypregneno","84143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.95","","","","","","","fee schedule","22.81","158.36","APC"
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.86","","","","","","","fee schedule","20.86","155.09",""
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.86","","","","","","","fee schedule","20.86","155.09",""
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.86","","","","","","","fee schedule","20.86","155.09",""
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","155.09","","","","","","","fee schedule","20.86","155.09",""
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.86","","","","","","","fee schedule","20.86","155.09",""
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.86","","","","","","","fee schedule","20.86","155.09",""
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.86","155.09","APC"
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","20.86","155.09","APC"
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.28","","","","","","","fee schedule","20.86","155.09","APC"
"Assay of progesterone","84144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.9","","","","","","","fee schedule","20.86","155.09","APC"
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.22","","","","","","","fee schedule","27.22","196.36",""
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.22","","","","","","","fee schedule","27.22","196.36",""
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.22","","","","","","","fee schedule","27.22","196.36",""
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","196.36","","","","","","","fee schedule","27.22","196.36",""
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.31","","","","","","","fee schedule","27.22","196.36",""
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.31","","","","","","","fee schedule","27.22","196.36",""
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.51","","","","","","","fee schedule","27.22","196.36","APC"
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.04","","","","","","","fee schedule","27.22","196.36","APC"
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.76","","","","","","","fee schedule","27.22","196.36","APC"
"Procalcitonin (PCT)","84145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.58","","","","","","","fee schedule","27.22","196.36","APC"
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.38","","","","","","","fee schedule","19.38","145.75",""
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.38","","","","","","","fee schedule","19.38","145.75",""
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.38","","","","","","","fee schedule","19.38","145.75",""
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","145.75","","","","","","","fee schedule","19.38","145.75",""
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.31","","","","","","","fee schedule","19.38","145.75",""
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.31","","","","","","","fee schedule","19.38","145.75",""
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.3","","","","","","","fee schedule","19.38","145.75","APC"
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.96","","","","","","","fee schedule","19.38","145.75","APC"
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.77","","","","","","","fee schedule","19.38","145.75","APC"
"Assay of prolactin","84146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.35","","","","","","","fee schedule","19.38","145.75","APC"
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.77","","","","","","","fee schedule","41.77","175.2",""
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.77","","","","","","","fee schedule","41.77","175.2",""
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.77","","","","","","","fee schedule","41.77","175.2",""
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","175.2","","","","","","","fee schedule","41.77","175.2",""
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.9","","","","","","","fee schedule","41.77","175.2",""
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.9","","","","","","","fee schedule","41.77","175.2",""
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.75","","","","","","","fee schedule","41.77","175.2","APC"
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.02","","","","","","","fee schedule","41.77","175.2","APC"
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.61","","","","","","","fee schedule","41.77","175.2","APC"
"Assay of prostaglandin","84150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.86","","","","","","","fee schedule","41.77","175.2","APC"
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.46","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.61","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.61","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.26","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.94","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.76","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa complexed","84152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.31","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.46","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.61","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.61","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.26","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.94","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.76","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa total","84153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.31","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.39","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.46","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.61","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.61","","","","","","","fee schedule","18.39","137.46",""
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.26","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.94","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.76","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of psa free","84154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.31","","","","","","","fee schedule","18.39","137.46","APC"
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.67","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.67","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.67","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.38","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.3","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.3","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.84","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.78","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.74","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein serum","84155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.85","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.67","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.67","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.67","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.38","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.3","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.3","","","","","","","fee schedule","3.67","27.38",""
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.84","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.78","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.74","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein urine","84156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.85","","","","","","","fee schedule","3.67","27.38","APC"
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4","","","","","","","fee schedule","4","27.38",""
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4","","","","","","","fee schedule","4","27.38",""
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4","","","","","","","fee schedule","4","27.38",""
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.38","","","","","","","fee schedule","4","27.38",""
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.3","","","","","","","fee schedule","4","27.38",""
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.3","","","","","","","fee schedule","4","27.38",""
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.19","","","","","","","fee schedule","4","27.38","APC"
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.12","","","","","","","fee schedule","4","27.38","APC"
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.08","","","","","","","fee schedule","4","27.38","APC"
"Assay of protein other","84157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.2","","","","","","","fee schedule","4","27.38","APC"
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.61","","","","","","","fee schedule","5.61","36.78",""
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.61","","","","","","","fee schedule","5.61","36.78",""
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.61","","","","","","","fee schedule","5.61","36.78",""
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","36.78","","","","","","","fee schedule","5.61","36.78",""
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.61","36.78",""
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.61","36.78",""
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.88","","","","","","","fee schedule","5.61","36.78","APC"
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.78","","","","","","","fee schedule","5.61","36.78","APC"
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.72","","","","","","","fee schedule","5.61","36.78","APC"
"Assay of protein any source","84160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.89","","","","","","","fee schedule","5.61","36.78","APC"
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.05","","","","","","","fee schedule","15.05","101.27",""
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.05","","","","","","","fee schedule","15.05","101.27",""
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.05","","","","","","","fee schedule","15.05","101.27",""
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.27","","","","","","","fee schedule","15.05","101.27",""
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","15.05","101.27",""
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","15.05","101.27",""
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.05","101.27","APC"
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.5","","","","","","","fee schedule","15.05","101.27","APC"
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.35","","","","","","","fee schedule","15.05","101.27","APC"
"Pappa serum","84163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.05","101.27","APC"
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.74","","","","","","","fee schedule","10.74","80.74",""
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.74","","","","","","","fee schedule","10.74","80.74",""
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.74","","","","","","","fee schedule","10.74","80.74",""
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","80.74","","","","","","","fee schedule","10.74","80.74",""
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.46","","","","","","","fee schedule","10.74","80.74",""
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.46","","","","","","","fee schedule","10.74","80.74",""
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.25","","","","","","","fee schedule","10.74","80.74","APC"
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.74","80.74","APC"
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.74","80.74","APC"
"Protein e-phoresis serum","84165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.28","","","","","","","fee schedule","10.74","80.74","APC"
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.83","","","","","","","fee schedule","17.83","132.8",""
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.83","","","","","","","fee schedule","17.83","132.8",""
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.83","","","","","","","fee schedule","17.83","132.8",""
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.8","","","","","","","fee schedule","17.83","132.8",""
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.65","","","","","","","fee schedule","17.83","132.8",""
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.65","","","","","","","fee schedule","17.83","132.8",""
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.68","","","","","","","fee schedule","17.83","132.8","APC"
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.36","","","","","","","fee schedule","17.83","132.8","APC"
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.19","","","","","","","fee schedule","17.83","132.8","APC"
"Protein e-phoresis/urine/csf","84166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.72","","","","","","","fee schedule","17.83","132.8","APC"
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.03","","","","","","","fee schedule","17.03","124.22",""
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.03","","","","","","","fee schedule","17.03","124.22",""
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.03","","","","","","","fee schedule","17.03","124.22",""
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.22","","","","","","","fee schedule","17.03","124.22",""
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.28","","","","","","","fee schedule","17.03","124.22",""
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.28","","","","","","","fee schedule","17.03","124.22",""
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.84","","","","","","","fee schedule","17.03","124.22","APC"
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.54","","","","","","","fee schedule","17.03","124.22","APC"
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.37","","","","","","","fee schedule","17.03","124.22","APC"
"Western blot test","84181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.88","","","","","","","fee schedule","17.03","124.22","APC"
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.21","","","","","","","fee schedule","29.21","129.62",""
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.21","","","","","","","fee schedule","29.21","129.62",""
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.21","","","","","","","fee schedule","29.21","129.62",""
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","129.62","","","","","","","fee schedule","29.21","129.62",""
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.94","","","","","","","fee schedule","29.21","129.62",""
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.94","","","","","","","fee schedule","29.21","129.62",""
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.6","","","","","","","fee schedule","29.21","129.62","APC"
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.09","","","","","","","fee schedule","29.21","129.62","APC"
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.79","","","","","","","fee schedule","29.21","129.62","APC"
"Protein western blot test","84182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.67","","","","","","","fee schedule","29.21","129.62","APC"
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.35","","","","","","","fee schedule","14.35","103.35",""
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.35","","","","","","","fee schedule","14.35","103.35",""
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.35","","","","","","","fee schedule","14.35","103.35",""
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","103.35","","","","","","","fee schedule","14.35","103.35",""
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.66","","","","","","","fee schedule","14.35","103.35",""
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.66","","","","","","","fee schedule","14.35","103.35",""
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.03","","","","","","","fee schedule","14.35","103.35","APC"
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.78","","","","","","","fee schedule","14.35","103.35","APC"
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.64","","","","","","","fee schedule","14.35","103.35","APC"
"Assay RBC protoporphyrin","84202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.07","","","","","","","fee schedule","14.35","103.35","APC"
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.74","","","","","","","fee schedule","9.74","63.1",""
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.74","","","","","","","fee schedule","9.74","63.1",""
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.74","","","","","","","fee schedule","9.74","63.1",""
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.1","","","","","","","fee schedule","9.74","63.1",""
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.8","","","","","","","fee schedule","9.74","63.1",""
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.8","","","","","","","fee schedule","9.74","63.1",""
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.2","","","","","","","fee schedule","9.74","63.1","APC"
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.03","","","","","","","fee schedule","9.74","63.1","APC"
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.93","","","","","","","fee schedule","9.74","63.1","APC"
"Test RBC protoporphyrin","84203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.23","","","","","","","fee schedule","9.74","63.1","APC"
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.69","","","","","","","fee schedule","26.69","130.41",""
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.69","","","","","","","fee schedule","26.69","130.41",""
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.69","","","","","","","fee schedule","26.69","130.41",""
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","130.41","","","","","","","fee schedule","26.69","130.41",""
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.62","","","","","","","fee schedule","26.69","130.41",""
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.62","","","","","","","fee schedule","26.69","130.41",""
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.96","","","","","","","fee schedule","26.69","130.41","APC"
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.49","","","","","","","fee schedule","26.69","130.41","APC"
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.22","","","","","","","fee schedule","26.69","130.41","APC"
"Assay of proinsulin","84206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.02","","","","","","","fee schedule","26.69","130.41","APC"
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.1","","","","","","","fee schedule","28.1","197.92",""
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","28.1","","","","","","","fee schedule","28.1","197.92",""
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28.1","","","","","","","fee schedule","28.1","197.92",""
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","197.92","","","","","","","fee schedule","28.1","197.92",""
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","48.29","","","","","","","fee schedule","28.1","197.92",""
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","48.29","","","","","","","fee schedule","28.1","197.92",""
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.43","","","","","","","fee schedule","28.1","197.92","APC"
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.94","","","","","","","fee schedule","28.1","197.92","APC"
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.66","","","","","","","fee schedule","28.1","197.92","APC"
"Assay of vitamin b-6","84207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.51","","","","","","","fee schedule","28.1","197.92","APC"
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.48","","","","","","","fee schedule","14.48","79.61",""
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.48","","","","","","","fee schedule","14.48","79.61",""
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.48","","","","","","","fee schedule","14.48","79.61",""
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.61","","","","","","","fee schedule","14.48","79.61",""
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.66","","","","","","","fee schedule","14.48","79.61",""
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.66","","","","","","","fee schedule","14.48","79.61",""
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.17","","","","","","","fee schedule","14.48","79.61","APC"
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.91","","","","","","","fee schedule","14.48","79.61","APC"
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.77","","","","","","","fee schedule","14.48","79.61","APC"
"Assay of pyruvate","84210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.2","","","","","","","fee schedule","14.48","79.61","APC"
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.44","","","","","","","fee schedule","9.44","68.76",""
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.44","","","","","","","fee schedule","9.44","68.76",""
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.44","","","","","","","fee schedule","9.44","68.76",""
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","68.76","","","","","","","fee schedule","9.44","68.76",""
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.21","","","","","","","fee schedule","9.44","68.76",""
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.21","","","","","","","fee schedule","9.44","68.76",""
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.89","","","","","","","fee schedule","9.44","68.76","APC"
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.72","","","","","","","fee schedule","9.44","68.76","APC"
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.63","","","","","","","fee schedule","9.44","68.76","APC"
"Assay of pyruvate kinase","84220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.44","68.76","APC"
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.63","","","","","","","fee schedule","11.63","83.81",""
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.63","","","","","","","fee schedule","11.63","83.81",""
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.63","","","","","","","fee schedule","11.63","83.81",""
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.81","","","","","","","fee schedule","11.63","83.81",""
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.99","","","","","","","fee schedule","11.63","83.81",""
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.99","","","","","","","fee schedule","11.63","83.81",""
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.18","","","","","","","fee schedule","11.63","83.81","APC"
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.98","","","","","","","fee schedule","11.63","83.81","APC"
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.86","","","","","","","fee schedule","11.63","83.81","APC"
"Assay of quinine","84228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.21","","","","","","","fee schedule","11.63","83.81","APC"
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","87.88","","","","","","","fee schedule","87.88","467.63",""
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","87.88","","","","","","","fee schedule","87.88","467.63",""
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","87.88","","","","","","","fee schedule","87.88","467.63",""
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","467.63","","","","","","","fee schedule","87.88","467.63",""
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","110.71","","","","","","","fee schedule","87.88","467.63",""
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","110.71","","","","","","","fee schedule","87.88","467.63",""
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","92.05","","","","","","","fee schedule","87.88","467.63","APC"
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","90.52","","","","","","","fee schedule","87.88","467.63","APC"
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","89.64","","","","","","","fee schedule","87.88","467.63","APC"
"Assay of estrogen","84233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.27","","","","","","","fee schedule","87.88","467.63","APC"
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.88","","","","","","","fee schedule","64.88","468.54",""
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.88","","","","","","","fee schedule","64.88","468.54",""
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.88","","","","","","","fee schedule","64.88","468.54",""
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","468.54","","","","","","","fee schedule","64.88","468.54",""
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","111.5","","","","","","","fee schedule","64.88","468.54",""
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","111.5","","","","","","","fee schedule","64.88","468.54",""
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.96","","","","","","","fee schedule","64.88","468.54","APC"
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.83","","","","","","","fee schedule","64.88","468.54","APC"
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.18","","","","","","","fee schedule","64.88","468.54","APC"
"Assay of progesterone","84234","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.12","","","","","","","fee schedule","64.88","468.54","APC"
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","71.23","","","","","","","fee schedule","71.23","371.1",""
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.23","","","","","","","fee schedule","71.23","371.1",""
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","71.23","","","","","","","fee schedule","71.23","371.1",""
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","371.1","","","","","","","fee schedule","71.23","371.1",""
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","89.95","","","","","","","fee schedule","71.23","371.1",""
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","89.95","","","","","","","fee schedule","71.23","371.1",""
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","74.61","","","","","","","fee schedule","71.23","371.1","APC"
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","73.37","","","","","","","fee schedule","71.23","371.1","APC"
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","72.65","","","","","","","fee schedule","71.23","371.1","APC"
"Assay of endocrine hormone","84235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","74.79","","","","","","","fee schedule","71.23","371.1","APC"
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.57","","","","","","","fee schedule","36.57","275",""
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.57","","","","","","","fee schedule","36.57","275",""
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.57","","","","","","","fee schedule","36.57","275",""
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","275","","","","","","","fee schedule","36.57","275",""
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","62.86","","","","","","","fee schedule","36.57","275",""
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","62.86","","","","","","","fee schedule","36.57","275",""
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.31","","","","","","","fee schedule","36.57","275","APC"
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.67","","","","","","","fee schedule","36.57","275","APC"
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.3","","","","","","","fee schedule","36.57","275","APC"
"Assay nonendocrine receptor","84238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.4","","","","","","","fee schedule","36.57","275","APC"
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.99","","","","","","","fee schedule","21.99","164.52",""
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.99","","","","","","","fee schedule","21.99","164.52",""
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.99","","","","","","","fee schedule","21.99","164.52",""
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","164.52","","","","","","","fee schedule","21.99","164.52",""
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.81","","","","","","","fee schedule","21.99","164.52",""
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.81","","","","","","","fee schedule","21.99","164.52",""
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.03","","","","","","","fee schedule","21.99","164.52","APC"
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.65","","","","","","","fee schedule","21.99","164.52","APC"
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.43","","","","","","","fee schedule","21.99","164.52","APC"
"Assay of renin","84244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.09","","","","","","","fee schedule","21.99","164.52","APC"
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.24","","","","","","","fee schedule","20.24","141.72",""
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.24","","","","","","","fee schedule","20.24","141.72",""
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.24","","","","","","","fee schedule","20.24","141.72",""
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","141.72","","","","","","","fee schedule","20.24","141.72",""
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.79","","","","","","","fee schedule","20.24","141.72",""
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.79","","","","","","","fee schedule","20.24","141.72",""
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.2","","","","","","","fee schedule","20.24","141.72","APC"
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.85","","","","","","","fee schedule","20.24","141.72","APC"
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.64","","","","","","","fee schedule","20.24","141.72","APC"
"Assay of vitamin b-2","84252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.25","","","","","","","fee schedule","20.24","141.72","APC"
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.53","","","","","","","fee schedule","25.53","181.87",""
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.53","","","","","","","fee schedule","25.53","181.87",""
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.53","","","","","","","fee schedule","25.53","181.87",""
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","181.87","","","","","","","fee schedule","25.53","181.87",""
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.87","","","","","","","fee schedule","25.53","181.87",""
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.87","","","","","","","fee schedule","25.53","181.87",""
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.74","","","","","","","fee schedule","25.53","181.87","APC"
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.3","","","","","","","fee schedule","25.53","181.87","APC"
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.04","","","","","","","fee schedule","25.53","181.87","APC"
"Assay of selenium","84255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.81","","","","","","","fee schedule","25.53","181.87","APC"
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.98","","","","","","","fee schedule","30.98","197.58",""
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.98","","","","","","","fee schedule","30.98","197.58",""
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.98","","","","","","","fee schedule","30.98","197.58",""
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","197.58","","","","","","","fee schedule","30.98","197.58",""
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","53.24","","","","","","","fee schedule","30.98","197.58",""
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","53.24","","","","","","","fee schedule","30.98","197.58",""
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.45","","","","","","","fee schedule","30.98","197.58","APC"
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.91","","","","","","","fee schedule","30.98","197.58","APC"
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.6","","","","","","","fee schedule","30.98","197.58","APC"
"Assay of serotonin","84260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.53","","","","","","","fee schedule","30.98","197.58","APC"
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.73","","","","","","","fee schedule","21.73","155.35",""
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.73","","","","","","","fee schedule","21.73","155.35",""
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.73","","","","","","","fee schedule","21.73","155.35",""
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","155.35","","","","","","","fee schedule","21.73","155.35",""
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","37.36","","","","","","","fee schedule","21.73","155.35",""
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","37.36","","","","","","","fee schedule","21.73","155.35",""
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.76","","","","","","","fee schedule","21.73","155.35","APC"
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.38","","","","","","","fee schedule","21.73","155.35","APC"
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.16","","","","","","","fee schedule","21.73","155.35","APC"
"Assay of sex hormone globul","84270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.82","","","","","","","fee schedule","21.73","155.35","APC"
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.44","","","","","","","fee schedule","13.44","98.24",""
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.44","","","","","","","fee schedule","13.44","98.24",""
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.44","","","","","","","fee schedule","13.44","98.24",""
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","98.24","","","","","","","fee schedule","13.44","98.24",""
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.09","","","","","","","fee schedule","13.44","98.24",""
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.09","","","","","","","fee schedule","13.44","98.24",""
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.08","","","","","","","fee schedule","13.44","98.24","APC"
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.84","","","","","","","fee schedule","13.44","98.24","APC"
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.71","","","","","","","fee schedule","13.44","98.24","APC"
"Assay of sialic acid","84275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.11","","","","","","","fee schedule","13.44","98.24","APC"
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.21","","","","","","","fee schedule","25.21","168.64",""
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.21","","","","","","","fee schedule","25.21","168.64",""
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.21","","","","","","","fee schedule","25.21","168.64",""
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","168.64","","","","","","","fee schedule","25.21","168.64",""
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","40.48","","","","","","","fee schedule","25.21","168.64",""
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","40.48","","","","","","","fee schedule","25.21","168.64",""
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.41","","","","","","","fee schedule","25.21","168.64","APC"
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.97","","","","","","","fee schedule","25.21","168.64","APC"
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.71","","","","","","","fee schedule","25.21","168.64","APC"
"Assay of silica","84285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.47","","","","","","","fee schedule","25.21","168.64","APC"
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.81","","","","","","","fee schedule","4.81","35.84",""
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.81","","","","","","","fee schedule","4.81","35.84",""
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.81","","","","","","","fee schedule","4.81","35.84",""
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.84","","","","","","","fee schedule","4.81","35.84",""
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.27","","","","","","","fee schedule","4.81","35.84",""
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.27","","","","","","","fee schedule","4.81","35.84",""
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.04","","","","","","","fee schedule","4.81","35.84","APC"
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.95","","","","","","","fee schedule","4.81","35.84","APC"
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.91","","","","","","","fee schedule","4.81","35.84","APC"
"Assay of serum sodium","84295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.81","35.84","APC"
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.06","","","","","","","fee schedule","5.06","35.44",""
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.06","","","","","","","fee schedule","5.06","35.44",""
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.06","","","","","","","fee schedule","5.06","35.44",""
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.44","","","","","","","fee schedule","5.06","35.44",""
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.35","","","","","","","fee schedule","5.06","35.44",""
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.35","","","","","","","fee schedule","5.06","35.44",""
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.3","","","","","","","fee schedule","5.06","35.44","APC"
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.21","","","","","","","fee schedule","5.06","35.44","APC"
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.16","","","","","","","fee schedule","5.06","35.44","APC"
"Assay of urine sodium","84300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.31","","","","","","","fee schedule","5.06","35.44","APC"
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.86","","","","","","","fee schedule","4.86","35.44",""
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.86","","","","","","","fee schedule","4.86","35.44",""
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.86","","","","","","","fee schedule","4.86","35.44",""
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.44","","","","","","","fee schedule","4.86","35.44",""
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.35","","","","","","","fee schedule","4.86","35.44",""
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.35","","","","","","","fee schedule","4.86","35.44",""
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.09","","","","","","","fee schedule","4.86","35.44","APC"
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.01","","","","","","","fee schedule","4.86","35.44","APC"
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.96","","","","","","","fee schedule","4.86","35.44","APC"
"Assay of sweat sodium","84302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.1","","","","","","","fee schedule","4.86","35.44","APC"
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.26","","","","","","","fee schedule","21.26","150.12",""
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.26","","","","","","","fee schedule","21.26","150.12",""
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.26","","","","","","","fee schedule","21.26","150.12",""
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.12","","","","","","","fee schedule","21.26","150.12",""
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.54","","","","","","","fee schedule","21.26","150.12",""
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.54","","","","","","","fee schedule","21.26","150.12",""
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.27","","","","","","","fee schedule","21.26","150.12","APC"
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.9","","","","","","","fee schedule","21.26","150.12","APC"
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.69","","","","","","","fee schedule","21.26","150.12","APC"
"Assay of somatomedin","84305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.32","","","","","","","fee schedule","21.26","150.12","APC"
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.28","","","","","","","fee schedule","18.28","133.39",""
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.28","","","","","","","fee schedule","18.28","133.39",""
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.28","","","","","","","fee schedule","18.28","133.39",""
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","133.39","","","","","","","fee schedule","18.28","133.39",""
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.43","","","","","","","fee schedule","18.28","133.39",""
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.43","","","","","","","fee schedule","18.28","133.39",""
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.15","","","","","","","fee schedule","18.28","133.39","APC"
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.83","","","","","","","fee schedule","18.28","133.39","APC"
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.65","","","","","","","fee schedule","18.28","133.39","APC"
"Assay of somatostatin","84307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.19","","","","","","","fee schedule","18.28","133.39","APC"
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.1","","","","","","","fee schedule","8.1","52.31",""
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.1","","","","","","","fee schedule","8.1","52.31",""
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.1","","","","","","","fee schedule","8.1","52.31",""
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.31","","","","","","","fee schedule","8.1","52.31",""
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.01","","","","","","","fee schedule","8.1","52.31",""
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.01","","","","","","","fee schedule","8.1","52.31",""
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.48","","","","","","","fee schedule","8.1","52.31","APC"
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.34","","","","","","","fee schedule","8.1","52.31","APC"
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.26","","","","","","","fee schedule","8.1","52.31","APC"
"Spectrophotometry","84311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.51","","","","","","","fee schedule","8.1","52.31","APC"
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.28","","","","","","","fee schedule","3.28","18.18",""
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.28","","","","","","","fee schedule","3.28","18.18",""
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.28","","","","","","","fee schedule","3.28","18.18",""
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","18.18","","","","","","","fee schedule","3.28","18.18",""
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.31","","","","","","","fee schedule","3.28","18.18",""
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.31","","","","","","","fee schedule","3.28","18.18",""
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.44","","","","","","","fee schedule","3.28","18.18","APC"
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.38","","","","","","","fee schedule","3.28","18.18","APC"
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.35","","","","","","","fee schedule","3.28","18.18","APC"
"Body fluid specific gravity","84315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.44","","","","","","","fee schedule","3.28","18.18","APC"
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39","","","","","","","fee schedule","33.7","121.18",""
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39","","","","","","","fee schedule","33.7","121.18",""
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39","","","","","","","fee schedule","33.7","121.18",""
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","121.18","","","","","","","fee schedule","33.7","121.18",""
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.7","","","","","","","fee schedule","33.7","121.18",""
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.7","","","","","","","fee schedule","33.7","121.18",""
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.85","","","","","","","fee schedule","33.7","121.18","APC"
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.17","","","","","","","fee schedule","33.7","121.18","APC"
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.78","","","","","","","fee schedule","33.7","121.18","APC"
"Chromatogram assay sugars","84375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.95","","","","","","","fee schedule","33.7","121.18","APC"
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.5","","","","","","","fee schedule","5.5","40.21",""
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.5","","","","","","","fee schedule","5.5","40.21",""
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.5","","","","","","","fee schedule","5.5","40.21",""
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.21","","","","","","","fee schedule","5.5","40.21",""
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.46","","","","","","","fee schedule","5.5","40.21",""
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.46","","","","","","","fee schedule","5.5","40.21",""
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.76","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.66","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.61","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars single qual","84376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.78","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.5","","","","","","","fee schedule","5.5","40.21",""
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.5","","","","","","","fee schedule","5.5","40.21",""
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.5","","","","","","","fee schedule","5.5","40.21",""
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.21","","","","","","","fee schedule","5.5","40.21",""
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.46","","","","","","","fee schedule","5.5","40.21",""
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.46","","","","","","","fee schedule","5.5","40.21",""
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.76","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.66","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.61","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars multiple qual","84377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.78","","","","","","","fee schedule","5.5","40.21","APC"
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","81.54",""
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","81.54",""
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","81.54",""
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.54","","","","","","","fee schedule","11.53","81.54",""
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.81","","","","","","","fee schedule","11.53","81.54",""
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.81","","","","","","","fee schedule","11.53","81.54",""
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars single quant","84378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","81.54",""
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","81.54",""
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","81.54",""
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.54","","","","","","","fee schedule","11.53","81.54",""
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.81","","","","","","","fee schedule","11.53","81.54",""
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.81","","","","","","","fee schedule","11.53","81.54",""
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","81.54","APC"
"Sugars multiple quant","84379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","81.54","APC"
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.49","","","","","","","fee schedule","5.49","35.44",""
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.49","","","","","","","fee schedule","5.49","35.44",""
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.49","","","","","","","fee schedule","5.49","35.44",""
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.44","","","","","","","fee schedule","5.49","35.44",""
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","5.49","35.44",""
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","5.49","35.44",""
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.75","","","","","","","fee schedule","5.49","35.44","APC"
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.65","","","","","","","fee schedule","5.49","35.44","APC"
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.6","","","","","","","fee schedule","5.49","35.44","APC"
"Assay of urine sulfate","84392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.76","","","","","","","fee schedule","5.49","35.44","APC"
"Tau phosphorylated ea","84393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.04","","","","","","","fee schedule","131.5","135.37","APC"
"Tau phosphorylated ea","84393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.79","","","","","","","fee schedule","131.5","135.37","APC"
"Tau phosphorylated ea","84393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.5","","","","","","","fee schedule","131.5","135.37","APC"
"Tau phosphorylated ea","84393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.37","","","","","","","fee schedule","131.5","135.37","APC"
"Total tau","84394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.04","","","","","","","fee schedule","131.5","135.37","APC"
"Total tau","84394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.79","","","","","","","fee schedule","131.5","135.37","APC"
"Total tau","84394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.5","","","","","","","fee schedule","131.5","135.37","APC"
"Total tau","84394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.37","","","","","","","fee schedule","131.5","135.37","APC"
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.47","","","","","","","fee schedule","25.47","190.45",""
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.47","","","","","","","fee schedule","25.47","190.45",""
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.47","","","","","","","fee schedule","25.47","190.45",""
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","190.45","","","","","","","fee schedule","25.47","190.45",""
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.76","","","","","","","fee schedule","25.47","190.45",""
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.76","","","","","","","fee schedule","25.47","190.45",""
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.68","","","","","","","fee schedule","25.47","190.45","APC"
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.23","","","","","","","fee schedule","25.47","190.45","APC"
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.98","","","","","","","fee schedule","25.47","190.45","APC"
"Assay of free testosterone","84402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.74","","","","","","","fee schedule","25.47","190.45","APC"
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.81","","","","","","","fee schedule","25.81","192.13",""
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.81","","","","","","","fee schedule","25.81","192.13",""
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.81","","","","","","","fee schedule","25.81","192.13",""
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","192.13","","","","","","","fee schedule","25.81","192.13",""
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","44.38","","","","","","","fee schedule","25.81","192.13",""
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","44.38","","","","","","","fee schedule","25.81","192.13",""
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.04","","","","","","","fee schedule","25.81","192.13","APC"
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.58","","","","","","","fee schedule","25.81","192.13","APC"
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.33","","","","","","","fee schedule","25.81","192.13","APC"
"Assay of total testosterone","84403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.1","","","","","","","fee schedule","25.81","192.13","APC"
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.28","","","","","","","fee schedule","51.28","87.06",""
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.28","","","","","","","fee schedule","51.28","87.06",""
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.28","","","","","","","fee schedule","51.28","87.06",""
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","87.06","","","","","","","fee schedule","51.28","87.06",""
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","87.06","","","","","","","fee schedule","51.28","87.06",""
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.72","","","","","","","fee schedule","51.28","87.06","APC"
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.82","","","","","","","fee schedule","51.28","87.06","APC"
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.31","","","","","","","fee schedule","51.28","87.06","APC"
"Testosterone bioavailable","84410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.84","","","","","","","fee schedule","51.28","87.06","APC"
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.23","","","","","","","fee schedule","21.23","150.24",""
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.23","","","","","","","fee schedule","21.23","150.24",""
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.23","","","","","","","fee schedule","21.23","150.24",""
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.24","","","","","","","fee schedule","21.23","150.24",""
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.49","","","","","","","fee schedule","21.23","150.24",""
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.49","","","","","","","fee schedule","21.23","150.24",""
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.24","","","","","","","fee schedule","21.23","150.24","APC"
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.87","","","","","","","fee schedule","21.23","150.24","APC"
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.65","","","","","","","fee schedule","21.23","150.24","APC"
"Assay of vitamin b-1","84425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.29","","","","","","","fee schedule","21.23","150.24","APC"
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.63","","","","","","","fee schedule","11.63","75.54",""
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.63","","","","","","","fee schedule","11.63","75.54",""
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.63","","","","","","","fee schedule","11.63","75.54",""
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.54","","","","","","","fee schedule","11.63","75.54",""
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.99","","","","","","","fee schedule","11.63","75.54",""
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.99","","","","","","","fee schedule","11.63","75.54",""
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.18","","","","","","","fee schedule","11.63","75.54","APC"
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.98","","","","","","","fee schedule","11.63","75.54","APC"
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.86","","","","","","","fee schedule","11.63","75.54","APC"
"Assay of thiocyanate","84430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.21","","","","","","","fee schedule","11.63","75.54","APC"
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.11","","","","","","","fee schedule","22.25","126.07",""
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.11","","","","","","","fee schedule","22.25","126.07",""
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.11","","","","","","","fee schedule","22.25","126.07",""
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.07","","","","","","","fee schedule","22.25","126.07",""
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.25","","","","","","","fee schedule","22.25","126.07",""
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.25","","","","","","","fee schedule","22.25","126.07",""
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.78","","","","","","","fee schedule","22.25","126.07","APC"
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.16","","","","","","","fee schedule","22.25","126.07","APC"
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.81","","","","","","","fee schedule","22.25","126.07","APC"
"Thromboxane urine","84431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.87","","","","","","","fee schedule","22.25","126.07","APC"
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.06","","","","","","","fee schedule","16.06","115.73",""
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.06","","","","","","","fee schedule","16.06","115.73",""
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.06","","","","","","","fee schedule","16.06","115.73",""
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","115.73","","","","","","","fee schedule","16.06","115.73",""
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.61","","","","","","","fee schedule","16.06","115.73",""
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.61","","","","","","","fee schedule","16.06","115.73",""
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.82","","","","","","","fee schedule","16.06","115.73","APC"
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.54","","","","","","","fee schedule","16.06","115.73","APC"
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.38","","","","","","","fee schedule","16.06","115.73","APC"
"Assay of thyroglobulin","84432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.86","","","","","","","fee schedule","16.06","115.73","APC"
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.17","","","","","","","fee schedule","22.17","26.6",""
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.17","","","","","","","fee schedule","22.17","26.6",""
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.17","","","","","","","fee schedule","22.17","26.6",""
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.6","","","","","","","fee schedule","22.17","26.6",""
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.6","","","","","","","fee schedule","22.17","26.6",""
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.22","","","","","","","fee schedule","22.17","26.6","APC"
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.84","","","","","","","fee schedule","22.17","26.6","APC"
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.61","","","","","","","fee schedule","22.17","26.6","APC"
"Asy thiopurin s-mthyltrnsfrs","84433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.28","","","","","","","fee schedule","22.17","26.6","APC"
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.87","","","","","","","fee schedule","6.87","50.47",""
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.87","","","","","","","fee schedule","6.87","50.47",""
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.87","","","","","","","fee schedule","6.87","50.47",""
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.47","","","","","","","fee schedule","6.87","50.47",""
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.81","","","","","","","fee schedule","6.87","50.47",""
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.81","","","","","","","fee schedule","6.87","50.47",""
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.2","","","","","","","fee schedule","6.87","50.47","APC"
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.08","","","","","","","fee schedule","6.87","50.47","APC"
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.01","","","","","","","fee schedule","6.87","50.47","APC"
"Assay of total thyroxine","84436","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.21","","","","","","","fee schedule","6.87","50.47","APC"
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","45.87",""
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","45.87",""
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","45.87",""
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","45.87","","","","","","","fee schedule","6.47","45.87",""
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","45.87",""
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","45.87",""
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","45.87","APC"
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","45.87","APC"
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","45.87","APC"
"Assay of neonatal thyroxine","84437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","45.87","APC"
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.02","","","","","","","fee schedule","9.02","66.65",""
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.02","","","","","","","fee schedule","9.02","66.65",""
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.02","","","","","","","fee schedule","9.02","66.65",""
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","66.65","","","","","","","fee schedule","9.02","66.65",""
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.5","","","","","","","fee schedule","9.02","66.65",""
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.5","","","","","","","fee schedule","9.02","66.65",""
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.45","","","","","","","fee schedule","9.02","66.65","APC"
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.29","","","","","","","fee schedule","9.02","66.65","APC"
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.2","","","","","","","fee schedule","9.02","66.65","APC"
"Assay of free thyroxine","84439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.47","","","","","","","fee schedule","9.02","66.65","APC"
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.78","","","","","","","fee schedule","14.78","107.66",""
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.78","","","","","","","fee schedule","14.78","107.66",""
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.78","","","","","","","fee schedule","14.78","107.66",""
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.66","","","","","","","fee schedule","14.78","107.66",""
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.43","","","","","","","fee schedule","14.78","107.66",""
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.43","","","","","","","fee schedule","14.78","107.66",""
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.48","","","","","","","fee schedule","14.78","107.66","APC"
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.22","","","","","","","fee schedule","14.78","107.66","APC"
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.08","","","","","","","fee schedule","14.78","107.66","APC"
"Assay of thyroid activity","84442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.52","","","","","","","fee schedule","14.78","107.66","APC"
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.8","","","","","","","fee schedule","16.8","126.07",""
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.8","","","","","","","fee schedule","16.8","126.07",""
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.8","","","","","","","fee schedule","16.8","126.07",""
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.07","","","","","","","fee schedule","16.8","126.07",""
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.87","","","","","","","fee schedule","16.8","126.07",""
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.87","","","","","","","fee schedule","16.8","126.07",""
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.6","","","","","","","fee schedule","16.8","126.07","APC"
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.3","","","","","","","fee schedule","16.8","126.07","APC"
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.14","","","","","","","fee schedule","16.8","126.07","APC"
"Assay thyroid stim hormone","84443","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.64","","","","","","","fee schedule","16.8","126.07","APC"
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","50.86","","","","","","","fee schedule","50.86","340.57",""
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.86","","","","","","","fee schedule","50.86","340.57",""
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","50.86","","","","","","","fee schedule","50.86","340.57",""
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","340.57","","","","","","","fee schedule","50.86","340.57",""
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","87.4","","","","","","","fee schedule","50.86","340.57",""
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","87.4","","","","","","","fee schedule","50.86","340.57",""
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.28","","","","","","","fee schedule","50.86","340.57","APC"
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.39","","","","","","","fee schedule","50.86","340.57","APC"
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.88","","","","","","","fee schedule","50.86","340.57","APC"
"Assay of tsi globulin","84445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.4","","","","","","","fee schedule","50.86","340.57","APC"
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.18","","","","","","","fee schedule","14.18","103.83",""
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.18","","","","","","","fee schedule","14.18","103.83",""
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.18","","","","","","","fee schedule","14.18","103.83",""
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","103.83","","","","","","","fee schedule","14.18","103.83",""
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.37","","","","","","","fee schedule","14.18","103.83",""
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.37","","","","","","","fee schedule","14.18","103.83",""
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.85","","","","","","","fee schedule","14.18","103.83","APC"
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.61","","","","","","","fee schedule","14.18","103.83","APC"
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.46","","","","","","","fee schedule","14.18","103.83","APC"
"Assay of vitamin e","84446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.18","103.83","APC"
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18","","","","","","","fee schedule","18","129.08",""
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18","","","","","","","fee schedule","18","129.08",""
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18","","","","","","","fee schedule","18","129.08",""
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","129.08","","","","","","","fee schedule","18","129.08",""
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.94","","","","","","","fee schedule","18","129.08",""
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.94","","","","","","","fee schedule","18","129.08",""
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.86","","","","","","","fee schedule","18","129.08","APC"
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.54","","","","","","","fee schedule","18","129.08","APC"
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.36","","","","","","","fee schedule","18","129.08","APC"
"Assay of transcortin","84449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.9","","","","","","","fee schedule","18","129.08","APC"
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","38.88",""
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","38.88",""
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","38.88",""
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.88","","","","","","","fee schedule","5.18","38.88",""
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","38.88",""
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","38.88",""
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.18","38.88","APC"
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.18","38.88","APC"
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.18","38.88","APC"
"Transferase (AST) (SGOT)","84450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.18","38.88","APC"
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.3","","","","","","","fee schedule","5.3","39.56",""
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.3","","","","","","","fee schedule","5.3","39.56",""
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.3","","","","","","","fee schedule","5.3","39.56",""
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","39.56","","","","","","","fee schedule","5.3","39.56",""
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.1","","","","","","","fee schedule","5.3","39.56",""
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.1","","","","","","","fee schedule","5.3","39.56",""
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.55","","","","","","","fee schedule","5.3","39.56","APC"
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.46","","","","","","","fee schedule","5.3","39.56","APC"
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.41","","","","","","","fee schedule","5.3","39.56","APC"
"Alanine amino (ALT) (SGPT)","84460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.56","","","","","","","fee schedule","5.3","39.56","APC"
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.76","","","","","","","fee schedule","12.76","93.18",""
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.76","","","","","","","fee schedule","12.76","93.18",""
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.76","","","","","","","fee schedule","12.76","93.18",""
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.18","","","","","","","fee schedule","12.76","93.18",""
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.95","","","","","","","fee schedule","12.76","93.18",""
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.95","","","","","","","fee schedule","12.76","93.18",""
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.37","","","","","","","fee schedule","12.76","93.18","APC"
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.14","","","","","","","fee schedule","12.76","93.18","APC"
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.02","","","","","","","fee schedule","12.76","93.18","APC"
"Assay of transferrin","84466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.4","","","","","","","fee schedule","12.76","93.18","APC"
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.74","","","","","","","fee schedule","5.74","43.08",""
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.74","","","","","","","fee schedule","5.74","43.08",""
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.74","","","","","","","fee schedule","5.74","43.08",""
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","43.08","","","","","","","fee schedule","5.74","43.08",""
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.89","","","","","","","fee schedule","5.74","43.08",""
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.89","","","","","","","fee schedule","5.74","43.08",""
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.01","","","","","","","fee schedule","5.74","43.08","APC"
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.91","","","","","","","fee schedule","5.74","43.08","APC"
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.85","","","","","","","fee schedule","5.74","43.08","APC"
"Assay of triglycerides","84478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.03","","","","","","","fee schedule","5.74","43.08","APC"
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","47.63",""
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","47.63",""
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","47.63",""
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.63","","","","","","","fee schedule","6.47","47.63",""
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","47.63",""
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","47.63",""
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","47.63","APC"
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","47.63","APC"
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","47.63","APC"
"Assay of thyroid (t3 or t4)","84479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","47.63","APC"
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.18","","","","","","","fee schedule","14.18","101.81",""
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.18","","","","","","","fee schedule","14.18","101.81",""
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.18","","","","","","","fee schedule","14.18","101.81",""
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.37","","","","","","","fee schedule","14.18","101.81",""
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.81","","","","","","","fee schedule","14.18","101.81",""
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.37","","","","","","","fee schedule","14.18","101.81",""
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.85","","","","","","","fee schedule","14.18","101.81","APC"
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.61","","","","","","","fee schedule","14.18","101.81","APC"
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.46","","","","","","","fee schedule","14.18","101.81","APC"
"Assay triiodothyronine (t3)","84480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.18","101.81","APC"
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.94","","","","","","","fee schedule","16.94","119.93",""
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.94","","","","","","","fee schedule","16.94","119.93",""
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.94","","","","","","","fee schedule","16.94","119.93",""
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.11","","","","","","","fee schedule","16.94","119.93",""
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.93","","","","","","","fee schedule","16.94","119.93",""
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.11","","","","","","","fee schedule","16.94","119.93",""
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.74","","","","","","","fee schedule","16.94","119.93","APC"
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.45","","","","","","","fee schedule","16.94","119.93","APC"
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.28","","","","","","","fee schedule","16.94","119.93","APC"
"Free assay (FT-3)","84481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.79","","","","","","","fee schedule","16.94","119.93","APC"
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.76","","","","","","","fee schedule","15.76","110.08",""
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.76","","","","","","","fee schedule","15.76","110.08",""
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.76","","","","","","","fee schedule","15.76","110.08",""
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.1","","","","","","","fee schedule","15.76","110.08",""
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","110.08","","","","","","","fee schedule","15.76","110.08",""
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.1","","","","","","","fee schedule","15.76","110.08",""
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.51","","","","","","","fee schedule","15.76","110.08","APC"
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.23","","","","","","","fee schedule","15.76","110.08","APC"
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.08","","","","","","","fee schedule","15.76","110.08","APC"
"T3 reverse","84482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.55","","","","","","","fee schedule","15.76","110.08","APC"
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.47","","","","","","","fee schedule","12.47","70.01",""
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.47","","","","","","","fee schedule","12.47","70.01",""
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.47","","","","","","","fee schedule","12.47","70.01",""
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.92","","","","","","","fee schedule","12.47","70.01",""
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.01","","","","","","","fee schedule","12.47","70.01",""
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.92","","","","","","","fee schedule","12.47","70.01",""
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.06","","","","","","","fee schedule","12.47","70.01","APC"
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.84","","","","","","","fee schedule","12.47","70.01","APC"
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.72","","","","","","","fee schedule","12.47","70.01","APC"
"Assay of troponin quant","84484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.09","","","","","","","fee schedule","12.47","70.01","APC"
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.2","","","","","","","fee schedule","7.2","53.96",""
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.2","","","","","","","fee schedule","7.2","53.96",""
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.2","","","","","","","fee schedule","7.2","53.96",""
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.9","","","","","","","fee schedule","7.2","53.96",""
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","53.96","","","","","","","fee schedule","7.2","53.96",""
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.9","","","","","","","fee schedule","7.2","53.96",""
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.54","","","","","","","fee schedule","7.2","53.96","APC"
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.42","","","","","","","fee schedule","7.2","53.96","APC"
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.34","","","","","","","fee schedule","7.2","53.96","APC"
"Assay duodenal fluid trypsin","84485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.56","","","","","","","fee schedule","7.2","53.96","APC"
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.3","","","","","","","fee schedule","7.3","51.18",""
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.3","","","","","","","fee schedule","7.3","51.18",""
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.3","","","","","","","fee schedule","7.3","51.18",""
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.55","","","","","","","fee schedule","7.3","51.18",""
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","51.18","","","","","","","fee schedule","7.3","51.18",""
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.55","","","","","","","fee schedule","7.3","51.18",""
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.65","","","","","","","fee schedule","7.3","51.18","APC"
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.52","","","","","","","fee schedule","7.3","51.18","APC"
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.45","","","","","","","fee schedule","7.3","51.18","APC"
"Test feces for trypsin","84488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.66","","","","","","","fee schedule","7.3","51.18","APC"
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.93","","","","","","","fee schedule","9.93","54.95",""
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.93","","","","","","","fee schedule","9.93","54.95",""
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.93","","","","","","","fee schedule","9.93","54.95",""
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.08","","","","","","","fee schedule","9.93","54.95",""
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","54.95","","","","","","","fee schedule","9.93","54.95",""
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.08","","","","","","","fee schedule","9.93","54.95",""
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.4","","","","","","","fee schedule","9.93","54.95","APC"
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.23","","","","","","","fee schedule","9.93","54.95","APC"
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.13","","","","","","","fee schedule","9.93","54.95","APC"
"Assay of feces for trypsin","84490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.43","","","","","","","fee schedule","9.93","54.95","APC"
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.63","","","","","","","fee schedule","10.63","74.15",""
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.63","","","","","","","fee schedule","10.63","74.15",""
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.63","","","","","","","fee schedule","10.63","74.15",""
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.88","","","","","","","fee schedule","10.63","74.15",""
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","74.15","","","","","","","fee schedule","10.63","74.15",""
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.88","","","","","","","fee schedule","10.63","74.15",""
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.13","","","","","","","fee schedule","10.63","74.15","APC"
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.63","74.15","APC"
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.84","","","","","","","fee schedule","10.63","74.15","APC"
"Assay of tyrosine","84510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.16","","","","","","","fee schedule","10.63","74.15","APC"
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.09","","","","","","","fee schedule","10.09","54.81",""
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.09","","","","","","","fee schedule","10.09","54.81",""
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.09","","","","","","","fee schedule","10.09","54.81",""
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.24","","","","","","","fee schedule","10.09","54.81",""
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","54.81","","","","","","","fee schedule","10.09","54.81",""
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.24","","","","","","","fee schedule","10.09","54.81",""
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.57","","","","","","","fee schedule","10.09","54.81","APC"
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.39","","","","","","","fee schedule","10.09","54.81","APC"
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.29","","","","","","","fee schedule","10.09","54.81","APC"
"Assay of troponin qual","84512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.59","","","","","","","fee schedule","10.09","54.81","APC"
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.95","","","","","","","fee schedule","3.95","29.62",""
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.95","","","","","","","fee schedule","3.95","29.62",""
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.95","","","","","","","fee schedule","3.95","29.62",""
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.78","","","","","","","fee schedule","3.95","29.62",""
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.62","","","","","","","fee schedule","3.95","29.62",""
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.78","","","","","","","fee schedule","3.95","29.62",""
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.14","","","","","","","fee schedule","3.95","29.62","APC"
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.07","","","","","","","fee schedule","3.95","29.62","APC"
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.03","","","","","","","fee schedule","3.95","29.62","APC"
"Assay of urea nitrogen","84520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.15","","","","","","","fee schedule","3.95","29.62","APC"
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.13","","","","","","","fee schedule","5.13","26.07",""
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.13","","","","","","","fee schedule","5.13","26.07",""
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.13","","","","","","","fee schedule","5.13","26.07",""
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","5.13","26.07",""
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.07","","","","","","","fee schedule","5.13","26.07",""
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","5.13","26.07",""
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.37","","","","","","","fee schedule","5.13","26.07","APC"
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.13","26.07","APC"
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.23","","","","","","","fee schedule","5.13","26.07","APC"
"Urea nitrogen semi-quant","84525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.39","","","","","","","fee schedule","5.13","26.07","APC"
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.56","","","","","","","fee schedule","5.56","35.02",""
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.56","","","","","","","fee schedule","5.56","35.02",""
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.56","","","","","","","fee schedule","5.56","35.02",""
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","5.56","35.02",""
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.02","","","","","","","fee schedule","5.56","35.02",""
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","5.56","35.02",""
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.82","","","","","","","fee schedule","5.56","35.02","APC"
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.73","","","","","","","fee schedule","5.56","35.02","APC"
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.67","","","","","","","fee schedule","5.56","35.02","APC"
"Assay of urine/urea-n","84540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.84","","","","","","","fee schedule","5.56","35.02","APC"
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.2","","","","","","","fee schedule","7.2","46.89",""
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.2","","","","","","","fee schedule","7.2","46.89",""
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.2","","","","","","","fee schedule","7.2","46.89",""
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.35","","","","","","","fee schedule","7.2","46.89",""
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","46.89","","","","","","","fee schedule","7.2","46.89",""
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.35","","","","","","","fee schedule","7.2","46.89",""
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.54","","","","","","","fee schedule","7.2","46.89","APC"
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.42","","","","","","","fee schedule","7.2","46.89","APC"
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.34","","","","","","","fee schedule","7.2","46.89","APC"
"Urea-N clearance test","84545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.56","","","","","","","fee schedule","7.2","46.89","APC"
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.52","","","","","","","fee schedule","4.52","33.99",""
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.52","","","","","","","fee schedule","4.52","33.99",""
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.52","","","","","","","fee schedule","4.52","33.99",""
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.76","","","","","","","fee schedule","4.52","33.99",""
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.99","","","","","","","fee schedule","4.52","33.99",""
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.76","","","","","","","fee schedule","4.52","33.99",""
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.73","","","","","","","fee schedule","4.52","33.99","APC"
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.66","","","","","","","fee schedule","4.52","33.99","APC"
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.61","","","","","","","fee schedule","4.52","33.99","APC"
"Assay of blood/uric acid","84550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.75","","","","","","","fee schedule","4.52","33.99","APC"
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.08","","","","","","","fee schedule","5.08","34.82",""
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.08","","","","","","","fee schedule","5.08","34.82",""
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.08","","","","","","","fee schedule","5.08","34.82",""
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","5.08","34.82",""
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","34.82","","","","","","","fee schedule","5.08","34.82",""
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","5.08","34.82",""
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.32","","","","","","","fee schedule","5.08","34.82","APC"
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.23","","","","","","","fee schedule","5.08","34.82","APC"
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.18","","","","","","","fee schedule","5.08","34.82","APC"
"Assay of urine/uric acid","84560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.33","","","","","","","fee schedule","5.08","34.82","APC"
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.8","","","","","","","fee schedule","16.8","85",""
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.8","","","","","","","fee schedule","16.8","85",""
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.8","","","","","","","fee schedule","16.8","85",""
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.44","","","","","","","fee schedule","16.8","85",""
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85","","","","","","","fee schedule","16.8","85",""
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.44","","","","","","","fee schedule","16.8","85",""
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.6","","","","","","","fee schedule","16.8","85","APC"
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.3","","","","","","","fee schedule","16.8","85","APC"
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.14","","","","","","","fee schedule","16.8","85","APC"
"Assay of feces/urobilinogen","84577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.64","","","","","","","fee schedule","16.8","85","APC"
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.47","","","","","","","fee schedule","4.47","23.74",""
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.47","","","","","","","fee schedule","4.47","23.74",""
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.47","","","","","","","fee schedule","4.47","23.74",""
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.58","","","","","","","fee schedule","4.47","23.74",""
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","23.74","","","","","","","fee schedule","4.47","23.74",""
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.58","","","","","","","fee schedule","4.47","23.74",""
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.68","","","","","","","fee schedule","4.47","23.74","APC"
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.6","","","","","","","fee schedule","4.47","23.74","APC"
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.56","","","","","","","fee schedule","4.47","23.74","APC"
"Test urine urobilinogen","84578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.69","","","","","","","fee schedule","4.47","23.74","APC"
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.55","","","","","","","fee schedule","9.55","49.9",""
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.55","","","","","","","fee schedule","9.55","49.9",""
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.55","","","","","","","fee schedule","9.55","49.9",""
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.19","","","","","","","fee schedule","9.55","49.9",""
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","49.9","","","","","","","fee schedule","9.55","49.9",""
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.19","","","","","","","fee schedule","9.55","49.9",""
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10","","","","","","","fee schedule","9.55","49.9","APC"
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.84","","","","","","","fee schedule","9.55","49.9","APC"
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.74","","","","","","","fee schedule","9.55","49.9","APC"
"Assay of urine urobilinogen","84580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.03","","","","","","","fee schedule","9.55","49.9","APC"
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.05","","","","","","","fee schedule","6.05","37.03",""
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.05","","","","","","","fee schedule","6.05","37.03",""
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.05","","","","","","","fee schedule","6.05","37.03",""
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.64","","","","","","","fee schedule","6.05","37.03",""
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.03","","","","","","","fee schedule","6.05","37.03",""
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.64","","","","","","","fee schedule","6.05","37.03",""
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.34","","","","","","","fee schedule","6.05","37.03","APC"
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.23","","","","","","","fee schedule","6.05","37.03","APC"
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.17","","","","","","","fee schedule","6.05","37.03","APC"
"Assay of urine urobilinogen","84583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.35","","","","","","","fee schedule","6.05","37.03","APC"
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.5","","","","","","","fee schedule","15.5","114.11",""
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.5","","","","","","","fee schedule","15.5","114.11",""
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.5","","","","","","","fee schedule","15.5","114.11",""
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.65","","","","","","","fee schedule","15.5","114.11",""
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","114.11","","","","","","","fee schedule","15.5","114.11",""
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.65","","","","","","","fee schedule","15.5","114.11",""
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.24","","","","","","","fee schedule","15.5","114.11","APC"
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.96","","","","","","","fee schedule","15.5","114.11","APC"
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.81","","","","","","","fee schedule","15.5","114.11","APC"
"Assay of urine vma","84585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.28","","","","","","","fee schedule","15.5","114.11","APC"
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.33","","","","","","","fee schedule","35.33","207.52",""
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.33","","","","","","","fee schedule","35.33","207.52",""
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.33","","","","","","","fee schedule","35.33","207.52",""
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.73","","","","","","","fee schedule","35.33","207.52",""
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","207.52","","","","","","","fee schedule","35.33","207.52",""
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.73","","","","","","","fee schedule","35.33","207.52",""
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37.01","","","","","","","fee schedule","35.33","207.52","APC"
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.39","","","","","","","fee schedule","35.33","207.52","APC"
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36.04","","","","","","","fee schedule","35.33","207.52","APC"
"Assay of vip","84586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.1","","","","","","","fee schedule","35.33","207.52","APC"
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.94","","","","","","","fee schedule","33.94","251.71",""
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.94","","","","","","","fee schedule","33.94","251.71",""
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","33.94","","","","","","","fee schedule","33.94","251.71",""
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.34","","","","","","","fee schedule","33.94","251.71",""
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","251.71","","","","","","","fee schedule","33.94","251.71",""
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.34","","","","","","","fee schedule","33.94","251.71",""
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.55","","","","","","","fee schedule","33.94","251.71","APC"
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.96","","","","","","","fee schedule","33.94","251.71","APC"
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.62","","","","","","","fee schedule","33.94","251.71","APC"
"Assay of vasopressin","84588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.64","","","","","","","fee schedule","33.94","251.71","APC"
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.61","","","","","","","fee schedule","11.61","85.77",""
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.61","","","","","","","fee schedule","11.61","85.77",""
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.61","","","","","","","fee schedule","11.61","85.77",""
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.93","","","","","","","fee schedule","11.61","85.77",""
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85.77","","","","","","","fee schedule","11.61","85.77",""
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.93","","","","","","","fee schedule","11.61","85.77",""
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.16","","","","","","","fee schedule","11.61","85.77","APC"
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.96","","","","","","","fee schedule","11.61","85.77","APC"
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.84","","","","","","","fee schedule","11.61","85.77","APC"
"Assay of vitamin a","84590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.19","","","","","","","fee schedule","11.61","85.77","APC"
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.06","","","","","","","fee schedule","17.06","85.77",""
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.06","","","","","","","fee schedule","17.06","85.77",""
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.06","","","","","","","fee schedule","17.06","85.77",""
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.93","","","","","","","fee schedule","17.06","85.77",""
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85.77","","","","","","","fee schedule","17.06","85.77",""
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.93","","","","","","","fee schedule","17.06","85.77",""
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.87","","","","","","","fee schedule","17.06","85.77","APC"
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.57","","","","","","","fee schedule","17.06","85.77","APC"
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.4","","","","","","","fee schedule","17.06","85.77","APC"
"Assay Of Nos Vitamin","84591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.91","","","","","","","fee schedule","17.06","85.77","APC"
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.72","","","","","","","fee schedule","13.72","99.97",""
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.72","","","","","","","fee schedule","13.72","99.97",""
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.72","","","","","","","fee schedule","13.72","99.97",""
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.56","","","","","","","fee schedule","13.72","99.97",""
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","99.97","","","","","","","fee schedule","13.72","99.97",""
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.56","","","","","","","fee schedule","13.72","99.97",""
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.37","","","","","","","fee schedule","13.72","99.97","APC"
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.13","","","","","","","fee schedule","13.72","99.97","APC"
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.99","","","","","","","fee schedule","13.72","99.97","APC"
"Assay of vitamin k","84597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.41","","","","","","","fee schedule","13.72","99.97","APC"
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.11","","","","","","","fee schedule","17.11","118.4",""
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.11","","","","","","","fee schedule","17.11","118.4",""
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.11","","","","","","","fee schedule","17.11","118.4",""
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.62","","","","","","","fee schedule","17.11","118.4",""
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","118.4","","","","","","","fee schedule","17.11","118.4",""
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.62","","","","","","","fee schedule","17.11","118.4",""
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.92","","","","","","","fee schedule","17.11","118.4","APC"
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.11","118.4","APC"
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.45","","","","","","","fee schedule","17.11","118.4","APC"
"Assay of volatiles","84600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.97","","","","","","","fee schedule","17.11","118.4","APC"
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.91","","","","","","","fee schedule","12.91","85.65",""
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.91","","","","","","","fee schedule","12.91","85.65",""
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.91","","","","","","","fee schedule","12.91","85.65",""
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.36","","","","","","","fee schedule","12.91","85.65",""
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85.65","","","","","","","fee schedule","12.91","85.65",""
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.36","","","","","","","fee schedule","12.91","85.65",""
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.52","","","","","","","fee schedule","12.91","85.65","APC"
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.3","","","","","","","fee schedule","12.91","85.65","APC"
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.17","","","","","","","fee schedule","12.91","85.65","APC"
"Xylose tolerance test","84620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.56","","","","","","","fee schedule","12.91","85.65","APC"
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.39","","","","","","","fee schedule","11.39","81.28",""
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.39","","","","","","","fee schedule","11.39","81.28",""
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.39","","","","","","","fee schedule","11.39","81.28",""
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.57","","","","","","","fee schedule","11.39","81.28",""
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.28","","","","","","","fee schedule","11.39","81.28",""
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.57","","","","","","","fee schedule","11.39","81.28",""
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.93","","","","","","","fee schedule","11.39","81.28","APC"
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.73","","","","","","","fee schedule","11.39","81.28","APC"
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.62","","","","","","","fee schedule","11.39","81.28","APC"
"Assay of zinc","84630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.96","","","","","","","fee schedule","11.39","81.28","APC"
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.81","","","","","","","fee schedule","20.81","147.94",""
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.81","","","","","","","fee schedule","20.81","147.94",""
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.81","","","","","","","fee schedule","20.81","147.94",""
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.76","","","","","","","fee schedule","20.81","147.94",""
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","147.94","","","","","","","fee schedule","20.81","147.94",""
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.76","","","","","","","fee schedule","20.81","147.94",""
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","20.81","147.94","APC"
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","147.94","APC"
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.81","147.94","APC"
"Assay of c-peptide","84681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.81","147.94","APC"
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.05","","","","","","","fee schedule","15.05","101.27",""
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.05","","","","","","","fee schedule","15.05","101.27",""
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.05","","","","","","","fee schedule","15.05","101.27",""
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","15.05","101.27",""
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.27","","","","","","","fee schedule","15.05","101.27",""
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","15.05","101.27",""
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.05","101.27","APC"
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.5","","","","","","","fee schedule","15.05","101.27","APC"
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.35","","","","","","","fee schedule","15.05","101.27","APC"
"Chorionic gonadotropin test","84702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.05","101.27","APC"
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.52","","","","","","","fee schedule","7.52","56.06",""
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.52","","","","","","","fee schedule","7.52","56.06",""
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.52","","","","","","","fee schedule","7.52","56.06",""
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.91","","","","","","","fee schedule","7.52","56.06",""
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","56.06","","","","","","","fee schedule","7.52","56.06",""
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.91","","","","","","","fee schedule","7.52","56.06",""
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.88","","","","","","","fee schedule","7.52","56.06","APC"
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.75","","","","","","","fee schedule","7.52","56.06","APC"
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.67","","","","","","","fee schedule","7.52","56.06","APC"
"Chorionic gonadotropin assay","84703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.9","","","","","","","fee schedule","7.52","56.06","APC"
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.29","","","","","","","fee schedule","15.29","101.27",""
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.29","","","","","","","fee schedule","15.29","101.27",""
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.29","","","","","","","fee schedule","15.29","101.27",""
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","15.29","101.27",""
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.27","","","","","","","fee schedule","15.29","101.27",""
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","15.29","101.27",""
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.02","","","","","","","fee schedule","15.29","101.27","APC"
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.75","","","","","","","fee schedule","15.29","101.27","APC"
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.6","","","","","","","fee schedule","15.29","101.27","APC"
"Hcg free betachain test","84704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.05","","","","","","","fee schedule","15.29","101.27","APC"
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.7","","","","","","","fee schedule","12.7","71.71",""
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.7","","","","","","","fee schedule","12.7","71.71",""
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.7","","","","","","","fee schedule","12.7","71.71",""
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.24","","","","","","","fee schedule","12.7","71.71",""
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","71.71","","","","","","","fee schedule","12.7","71.71",""
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.24","","","","","","","fee schedule","12.7","71.71",""
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.3","","","","","","","fee schedule","12.7","71.71","APC"
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.08","","","","","","","fee schedule","12.7","71.71","APC"
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.95","","","","","","","fee schedule","12.7","71.71","APC"
"Ovulation tests","84830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.34","","","","","","","fee schedule","12.7","71.71","APC"
"Clinical chemistry test","84999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.82","","","","","","","fee schedule","4.82","33.43",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.82","","","","","","","fee schedule","4.82","33.43",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.82","","","","","","","fee schedule","4.82","33.43",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.74","","","","","","","fee schedule","4.82","33.43",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.43","","","","","","","fee schedule","4.82","33.43",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.74","","","","","","","fee schedule","4.82","33.43",""
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.82","33.43","APC"
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.96","","","","","","","fee schedule","4.82","33.43","APC"
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.92","","","","","","","fee schedule","4.82","33.43","APC"
"Bleeding time test","85002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.06","","","","","","","fee schedule","4.82","33.43","APC"
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","47.57",""
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","47.57",""
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","47.57",""
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","47.57",""
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.57","","","","","","","fee schedule","6.47","47.57",""
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","47.57",""
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","47.57","APC"
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","47.57","APC"
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","47.57","APC"
"Automated diff wbc count","85004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","47.57","APC"
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.8","","","","","","","fee schedule","3.8","24.94",""
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.8","","","","","","","fee schedule","3.8","24.94",""
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.8","","","","","","","fee schedule","3.8","24.94",""
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.92","","","","","","","fee schedule","3.8","24.94",""
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","24.94","","","","","","","fee schedule","3.8","24.94",""
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.92","","","","","","","fee schedule","3.8","24.94",""
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.98","","","","","","","fee schedule","3.8","24.94","APC"
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.91","","","","","","","fee schedule","3.8","24.94","APC"
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.88","","","","","","","fee schedule","3.8","24.94","APC"
"Bl smear w/diff wbc count","85007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.99","","","","","","","fee schedule","3.8","24.94","APC"
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.43","","","","","","","fee schedule","3.43","24.94",""
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.43","","","","","","","fee schedule","3.43","24.94",""
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.43","","","","","","","fee schedule","3.43","24.94",""
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.92","","","","","","","fee schedule","3.43","24.94",""
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","24.94","","","","","","","fee schedule","3.43","24.94",""
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.92","","","","","","","fee schedule","3.43","24.94",""
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.59","","","","","","","fee schedule","3.43","24.94","APC"
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.53","","","","","","","fee schedule","3.43","24.94","APC"
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.5","","","","","","","fee schedule","3.43","24.94","APC"
"Bl smear w/o diff wbc count","85008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.6","","","","","","","fee schedule","3.43","24.94","APC"
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.07","","","","","","","fee schedule","5.07","27.04",""
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.07","","","","","","","fee schedule","5.07","27.04",""
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.07","","","","","","","fee schedule","5.07","27.04",""
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.4","","","","","","","fee schedule","5.07","27.04",""
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.04","","","","","","","fee schedule","5.07","27.04",""
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.4","","","","","","","fee schedule","5.07","27.04",""
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.31","","","","","","","fee schedule","5.07","27.04","APC"
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.22","","","","","","","fee schedule","5.07","27.04","APC"
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.17","","","","","","","fee schedule","5.07","27.04","APC"
"Manual diff wbc count b-coat","85009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.32","","","","","","","fee schedule","5.07","27.04","APC"
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7","","","","","","","fee schedule","4.07","17.78",""
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7","","","","","","","fee schedule","4.07","17.78",""
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7","","","","","","","fee schedule","4.07","17.78",""
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.07","","","","","","","fee schedule","4.07","17.78",""
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","17.78","","","","","","","fee schedule","4.07","17.78",""
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.07","","","","","","","fee schedule","4.07","17.78",""
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.33","","","","","","","fee schedule","4.07","17.78","APC"
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.21","","","","","","","fee schedule","4.07","17.78","APC"
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.14","","","","","","","fee schedule","4.07","17.78","APC"
"Spun microhematocrit","85013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.35","","","","","","","fee schedule","4.07","17.78","APC"
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.37","","","","","","","fee schedule","2.37","17.78",""
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.37","","","","","","","fee schedule","2.37","17.78",""
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.37","","","","","","","fee schedule","2.37","17.78",""
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.07","","","","","","","fee schedule","2.37","17.78",""
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","17.78","","","","","","","fee schedule","2.37","17.78",""
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.07","","","","","","","fee schedule","2.37","17.78",""
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.48","","","","","","","fee schedule","2.37","17.78","APC"
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.44","","","","","","","fee schedule","2.37","17.78","APC"
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.42","","","","","","","fee schedule","2.37","17.78","APC"
"Hematocrit","85014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.49","","","","","","","fee schedule","2.37","17.78","APC"
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.37","","","","","","","fee schedule","2.37","17.58",""
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.37","","","","","","","fee schedule","2.37","17.58",""
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.37","","","","","","","fee schedule","2.37","17.58",""
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.07","","","","","","","fee schedule","2.37","17.58",""
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","17.58","","","","","","","fee schedule","2.37","17.58",""
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.07","","","","","","","fee schedule","2.37","17.58",""
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.48","","","","","","","fee schedule","2.37","17.58","APC"
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.44","","","","","","","fee schedule","2.37","17.58","APC"
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.42","","","","","","","fee schedule","2.37","17.58","APC"
"Hemoglobin","85018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.49","","","","","","","fee schedule","2.37","17.58","APC"
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.77","","","","","","","fee schedule","7.77","57",""
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.77","","","","","","","fee schedule","7.77","57",""
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.77","","","","","","","fee schedule","7.77","57",""
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.37","","","","","","","fee schedule","7.77","57",""
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","57","","","","","","","fee schedule","7.77","57",""
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.37","","","","","","","fee schedule","7.77","57",""
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.14","","","","","","","fee schedule","7.77","57","APC"
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8","","","","","","","fee schedule","7.77","57","APC"
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.93","","","","","","","fee schedule","7.77","57","APC"
"Complete cbc w/auto diff wbc","85025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.16","","","","","","","fee schedule","7.77","57","APC"
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","47.57",""
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","47.57",""
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","47.57",""
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","47.57",""
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.57","","","","","","","fee schedule","6.47","47.57",""
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","47.57",""
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","47.57","APC"
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","47.57","APC"
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","47.57","APC"
"Complete cbc automated","85027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","47.57","APC"
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.31","","","","","","","fee schedule","4.31","32.26",""
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.31","","","","","","","fee schedule","4.31","32.26",""
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.31","","","","","","","fee schedule","4.31","32.26",""
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.39","","","","","","","fee schedule","4.31","32.26",""
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.26","","","","","","","fee schedule","4.31","32.26",""
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.39","","","","","","","fee schedule","4.31","32.26",""
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.51","","","","","","","fee schedule","4.31","32.26","APC"
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.31","32.26","APC"
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.31","32.26","APC"
"Manual cell count each","85032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.53","","","","","","","fee schedule","4.31","32.26","APC"
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.02","","","","","","","fee schedule","3.02","22.12",""
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.02","","","","","","","fee schedule","3.02","22.12",""
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.02","","","","","","","fee schedule","3.02","22.12",""
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.17","","","","","","","fee schedule","3.02","22.12",""
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","22.12","","","","","","","fee schedule","3.02","22.12",""
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.17","","","","","","","fee schedule","3.02","22.12",""
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.16","","","","","","","fee schedule","3.02","22.12","APC"
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.11","","","","","","","fee schedule","3.02","22.12","APC"
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.08","","","","","","","fee schedule","3.02","22.12","APC"
"Automated rbc count","85041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.17","","","","","","","fee schedule","3.02","22.12","APC"
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.31","","","","","","","fee schedule","4.31","32.15",""
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.31","","","","","","","fee schedule","4.31","32.15",""
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.31","","","","","","","fee schedule","4.31","32.15",""
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.39","","","","","","","fee schedule","4.31","32.15",""
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","32.15","","","","","","","fee schedule","4.31","32.15",""
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.39","","","","","","","fee schedule","4.31","32.15",""
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.51","","","","","","","fee schedule","4.31","32.15","APC"
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.31","32.15","APC"
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.31","32.15","APC"
"Manual reticulocyte count","85044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.53","","","","","","","fee schedule","4.31","32.15","APC"
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.99","","","","","","","fee schedule","3.99","29.96",""
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.99","","","","","","","fee schedule","3.99","29.96",""
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.99","","","","","","","fee schedule","3.99","29.96",""
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.89","","","","","","","fee schedule","3.99","29.96",""
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.96","","","","","","","fee schedule","3.99","29.96",""
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.89","","","","","","","fee schedule","3.99","29.96",""
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.18","","","","","","","fee schedule","3.99","29.96","APC"
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.11","","","","","","","fee schedule","3.99","29.96","APC"
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.07","","","","","","","fee schedule","3.99","29.96","APC"
"Automated reticulocyte count","85045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.19","","","","","","","fee schedule","3.99","29.96","APC"
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.57","","","","","","","fee schedule","5.57","41.32",""
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.57","","","","","","","fee schedule","5.57","41.32",""
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.57","","","","","","","fee schedule","5.57","41.32",""
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.59","","","","","","","fee schedule","5.57","41.32",""
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","41.32","","","","","","","fee schedule","5.57","41.32",""
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.59","","","","","","","fee schedule","5.57","41.32",""
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.83","","","","","","","fee schedule","5.57","41.32","APC"
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.74","","","","","","","fee schedule","5.57","41.32","APC"
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.68","","","","","","","fee schedule","5.57","41.32","APC"
"Reticyte/hgb concentrate","85046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.85","","","","","","","fee schedule","5.57","41.32","APC"
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.54","","","","","","","fee schedule","2.54","18.83",""
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.54","","","","","","","fee schedule","2.54","18.83",""
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.54","","","","","","","fee schedule","2.54","18.83",""
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.37","","","","","","","fee schedule","2.54","18.83",""
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","18.83","","","","","","","fee schedule","2.54","18.83",""
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.37","","","","","","","fee schedule","2.54","18.83",""
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.66","","","","","","","fee schedule","2.54","18.83","APC"
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.62","","","","","","","fee schedule","2.54","18.83","APC"
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.59","","","","","","","fee schedule","2.54","18.83","APC"
"Automated leukocyte count","85048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.67","","","","","","","fee schedule","2.54","18.83","APC"
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.48","","","","","","","fee schedule","4.48","33.43",""
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.48","","","","","","","fee schedule","4.48","33.43",""
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.48","","","","","","","fee schedule","4.48","33.43",""
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.68","","","","","","","fee schedule","4.48","33.43",""
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.43","","","","","","","fee schedule","4.48","33.43",""
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.68","","","","","","","fee schedule","4.48","33.43",""
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.69","","","","","","","fee schedule","4.48","33.43","APC"
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.61","","","","","","","fee schedule","4.48","33.43","APC"
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.57","","","","","","","fee schedule","4.48","33.43","APC"
"Automated platelet count","85049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.7","","","","","","","fee schedule","4.48","33.43","APC"
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.74","","","","","","","fee schedule","35.74","162.53",""
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.74","","","","","","","fee schedule","35.74","162.53",""
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.74","","","","","","","fee schedule","35.74","162.53",""
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.02","","","","","","","fee schedule","35.74","162.53",""
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","162.53","","","","","","","fee schedule","35.74","162.53",""
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.02","","","","","","","fee schedule","35.74","162.53",""
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37.44","","","","","","","fee schedule","35.74","162.53","APC"
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.81","","","","","","","fee schedule","35.74","162.53","APC"
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36.45","","","","","","","fee schedule","35.74","162.53","APC"
"Reticulated platelet assay","85055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.53","","","","","","","fee schedule","35.74","162.53","APC"
"Blood smear interpretation","85060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.71","","","","","","","fee schedule","27.71","132.12",""
"Blood smear interpretation","85060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.12","","","","","","","fee schedule","27.71","132.12",""
"Blood smear interpretation","85060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.71","","","","","","","fee schedule","27.71","132.12",""
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","2781.52",""
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","260.54","","","","","","","fee schedule","42.88","2781.52",""
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","2781.52",""
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","42.88","2781.52","APC 277.30"
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","42.88","2781.52","APC 296.56"
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","42.88","2781.52","APC 308.91"
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","42.88","2781.52","APC"
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","42.88","2781.52","APC"
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","42.88","2781.52","APC"
"Bone marrow interpretation","85097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","42.88","2781.52","APC"
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.89","","","","","","","fee schedule","11.89","75.74",""
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.89","","","","","","","fee schedule","11.89","75.74",""
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.89","","","","","","","fee schedule","11.89","75.74",""
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.44","","","","","","","fee schedule","11.89","75.74",""
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.74","","","","","","","fee schedule","11.89","75.74",""
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.44","","","","","","","fee schedule","11.89","75.74",""
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.45","","","","","","","fee schedule","11.89","75.74","APC"
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.25","","","","","","","fee schedule","11.89","75.74","APC"
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.13","","","","","","","fee schedule","11.89","75.74","APC"
"Chromogenic substrate assay","85130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.48","","","","","","","fee schedule","11.89","75.74","APC"
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.3","","","","","","","fee schedule","6.22","25.08",""
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.3","","","","","","","fee schedule","6.22","25.08",""
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.3","","","","","","","fee schedule","6.22","25.08",""
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.22","","","","","","","fee schedule","6.22","25.08",""
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","25.08","","","","","","","fee schedule","6.22","25.08",""
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.22","","","","","","","fee schedule","6.22","25.08",""
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.07","","","","","","","fee schedule","6.22","25.08","APC"
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.79","","","","","","","fee schedule","6.22","25.08","APC"
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.63","","","","","","","fee schedule","6.22","25.08","APC"
"Blood clot retraction","85170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.12","","","","","","","fee schedule","6.22","25.08","APC"
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.37","","","","","","","fee schedule","7.81","33.31",""
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.37","","","","","","","fee schedule","7.81","33.31",""
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.37","","","","","","","fee schedule","7.81","33.31",""
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.81","","","","","","","fee schedule","7.81","33.31",""
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.31","","","","","","","fee schedule","7.81","33.31",""
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.81","","","","","","","fee schedule","7.81","33.31",""
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.34","","","","","","","fee schedule","7.81","33.31","APC"
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.98","","","","","","","fee schedule","7.81","33.31","APC"
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.78","","","","","","","fee schedule","7.81","33.31","APC"
"Blood clot lysis time","85175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.39","","","","","","","fee schedule","7.81","33.31","APC"
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.98","","","","","","","fee schedule","12.98","79.38",""
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.98","","","","","","","fee schedule","12.98","79.38",""
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.98","","","","","","","fee schedule","12.98","79.38",""
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.32","","","","","","","fee schedule","12.98","79.38",""
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.38","","","","","","","fee schedule","12.98","79.38",""
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.32","","","","","","","fee schedule","12.98","79.38",""
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.6","","","","","","","fee schedule","12.98","79.38","APC"
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.37","","","","","","","fee schedule","12.98","79.38","APC"
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.24","","","","","","","fee schedule","12.98","79.38","APC"
"Clot factor ii prothrom spec","85210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.63","","","","","","","fee schedule","12.98","79.38","APC"
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.65","","","","","","","fee schedule","17.65","122.6",""
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.65","","","","","","","fee schedule","17.65","122.6",""
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.65","","","","","","","fee schedule","17.65","122.6",""
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.34","","","","","","","fee schedule","17.65","122.6",""
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","122.6","","","","","","","fee schedule","17.65","122.6",""
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.34","","","","","","","fee schedule","17.65","122.6",""
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.49","","","","","","","fee schedule","17.65","122.6","APC"
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.18","","","","","","","fee schedule","17.65","122.6","APC"
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18","","","","","","","fee schedule","17.65","122.6","APC"
"Blooc clot factor v test","85220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.53","","","","","","","fee schedule","17.65","122.6","APC"
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.9","","","","","","","fee schedule","17.9","124.22",""
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.9","","","","","","","fee schedule","17.9","124.22",""
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.9","","","","","","","fee schedule","17.9","124.22",""
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.78","","","","","","","fee schedule","17.9","124.22",""
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.22","","","","","","","fee schedule","17.9","124.22",""
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.78","","","","","","","fee schedule","17.9","124.22",""
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.75","","","","","","","fee schedule","17.9","124.22","APC"
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.44","","","","","","","fee schedule","17.9","124.22","APC"
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.26","","","","","","","fee schedule","17.9","124.22","APC"
"Clot factor vii proconvertin","85230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.79","","","","","","","fee schedule","17.9","124.22","APC"
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.9","","","","","","","fee schedule","17.9","118.57",""
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.9","","","","","","","fee schedule","17.9","118.57",""
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.9","","","","","","","fee schedule","17.9","118.57",""
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.78","","","","","","","fee schedule","17.9","118.57",""
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","118.57","","","","","","","fee schedule","17.9","118.57",""
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.78","","","","","","","fee schedule","17.9","118.57",""
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.75","","","","","","","fee schedule","17.9","118.57","APC"
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.44","","","","","","","fee schedule","17.9","118.57","APC"
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.26","","","","","","","fee schedule","17.9","118.57","APC"
"Clot factor viii ahg 1 stage","85240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.79","","","","","","","fee schedule","17.9","118.57","APC"
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.42","","","","","","","fee schedule","20.42","143.22",""
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.42","","","","","","","fee schedule","20.42","143.22",""
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.42","","","","","","","fee schedule","20.42","143.22",""
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.09","","","","","","","fee schedule","20.42","143.22",""
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","143.22","","","","","","","fee schedule","20.42","143.22",""
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.09","","","","","","","fee schedule","20.42","143.22",""
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.39","","","","","","","fee schedule","20.42","143.22","APC"
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.03","","","","","","","fee schedule","20.42","143.22","APC"
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.83","","","","","","","fee schedule","20.42","143.22","APC"
"Clot factor viii reltd antgn","85244","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.44","","","","","","","fee schedule","20.42","143.22","APC"
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.44","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","159.32","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.44","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.03","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.63","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.4","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw ristoctn","85245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.09","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.44","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","159.32","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.44","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.03","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.63","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.4","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii vw antigen","85246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.09","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.94","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.44","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","159.32","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.44","","","","","","","fee schedule","22.94","159.32",""
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.03","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.63","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.4","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor viii multimetric","85247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.09","","","","","","","fee schedule","22.94","159.32","APC"
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.04","","","","","","","fee schedule","19.04","132.26",""
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.04","","","","","","","fee schedule","19.04","132.26",""
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.04","","","","","","","fee schedule","19.04","132.26",""
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.72","","","","","","","fee schedule","19.04","132.26",""
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.26","","","","","","","fee schedule","19.04","132.26",""
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.72","","","","","","","fee schedule","19.04","132.26",""
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.94","","","","","","","fee schedule","19.04","132.26","APC"
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.61","","","","","","","fee schedule","19.04","132.26","APC"
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.42","","","","","","","fee schedule","19.04","132.26","APC"
"Clot factor ix ptc/chrstmas","85250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.99","","","","","","","fee schedule","19.04","132.26","APC"
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.9","","","","","","","fee schedule","17.9","125.22",""
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.9","","","","","","","fee schedule","17.9","125.22",""
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.9","","","","","","","fee schedule","17.9","125.22",""
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.78","","","","","","","fee schedule","17.9","125.22",""
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","125.22","","","","","","","fee schedule","17.9","125.22",""
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.78","","","","","","","fee schedule","17.9","125.22",""
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.75","","","","","","","fee schedule","17.9","125.22","APC"
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.44","","","","","","","fee schedule","17.9","125.22","APC"
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.26","","","","","","","fee schedule","17.9","125.22","APC"
"Clot factor x stuart-power","85260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.79","","","","","","","fee schedule","17.9","125.22","APC"
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.9","","","","","","","fee schedule","17.9","125.81",""
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.9","","","","","","","fee schedule","17.9","125.81",""
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.9","","","","","","","fee schedule","17.9","125.81",""
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.78","","","","","","","fee schedule","17.9","125.81",""
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","125.81","","","","","","","fee schedule","17.9","125.81",""
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.78","","","","","","","fee schedule","17.9","125.81",""
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.75","","","","","","","fee schedule","17.9","125.81","APC"
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.44","","","","","","","fee schedule","17.9","125.81","APC"
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.26","","","","","","","fee schedule","17.9","125.81","APC"
"Clot factor xi pta","85270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.79","","","","","","","fee schedule","17.9","125.81","APC"
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.35","","","","","","","fee schedule","19.35","134.96",""
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.35","","","","","","","fee schedule","19.35","134.96",""
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.35","","","","","","","fee schedule","19.35","134.96",""
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.25","","","","","","","fee schedule","19.35","134.96",""
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","134.96","","","","","","","fee schedule","19.35","134.96",""
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.25","","","","","","","fee schedule","19.35","134.96",""
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.27","","","","","","","fee schedule","19.35","134.96","APC"
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.93","","","","","","","fee schedule","19.35","134.96","APC"
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.74","","","","","","","fee schedule","19.35","134.96","APC"
"Clot factor xii hageman","85280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.32","","","","","","","fee schedule","19.35","134.96","APC"
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.34","","","","","","","fee schedule","16.34","111.67",""
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.34","","","","","","","fee schedule","16.34","111.67",""
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.34","","","","","","","fee schedule","16.34","111.67",""
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.09","","","","","","","fee schedule","16.34","111.67",""
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.67","","","","","","","fee schedule","16.34","111.67",""
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.09","","","","","","","fee schedule","16.34","111.67",""
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.12","","","","","","","fee schedule","16.34","111.67","APC"
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.83","","","","","","","fee schedule","16.34","111.67","APC"
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.67","","","","","","","fee schedule","16.34","111.67","APC"
"Clot factor xiii fibrin stab","85290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.16","","","","","","","fee schedule","16.34","111.67","APC"
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.11","","","","","","","fee schedule","9.11","65.29",""
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.11","","","","","","","fee schedule","9.11","65.29",""
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.11","","","","","","","fee schedule","9.11","65.29",""
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.29","","","","","","","fee schedule","9.11","65.29",""
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","65.29","","","","","","","fee schedule","9.11","65.29",""
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.29","","","","","","","fee schedule","9.11","65.29",""
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.54","","","","","","","fee schedule","9.11","65.29","APC"
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.38","","","","","","","fee schedule","9.11","65.29","APC"
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.29","","","","","","","fee schedule","9.11","65.29","APC"
"Clot factor xiii fibrin scrn","85291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.57","","","","","","","fee schedule","9.11","65.29","APC"
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.93","","","","","","","fee schedule","18.93","139.36",""
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.93","","","","","","","fee schedule","18.93","139.36",""
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.93","","","","","","","fee schedule","18.93","139.36",""
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.56","","","","","","","fee schedule","18.93","139.36",""
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","139.36","","","","","","","fee schedule","18.93","139.36",""
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.56","","","","","","","fee schedule","18.93","139.36",""
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.83","","","","","","","fee schedule","18.93","139.36","APC"
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.5","","","","","","","fee schedule","18.93","139.36","APC"
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.31","","","","","","","fee schedule","18.93","139.36","APC"
"Clot factor fletcher fact","85292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.88","","","","","","","fee schedule","18.93","139.36","APC"
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.93","","","","","","","fee schedule","18.93","139.16",""
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.93","","","","","","","fee schedule","18.93","139.16",""
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.93","","","","","","","fee schedule","18.93","139.16",""
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.56","","","","","","","fee schedule","18.93","139.16",""
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","139.16","","","","","","","fee schedule","18.93","139.16",""
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.56","","","","","","","fee schedule","18.93","139.16",""
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.83","","","","","","","fee schedule","18.93","139.16","APC"
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.5","","","","","","","fee schedule","18.93","139.16","APC"
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.31","","","","","","","fee schedule","18.93","139.16","APC"
"Clot factor wght kininogen","85293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.88","","","","","","","fee schedule","18.93","139.16","APC"
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.85","","","","","","","fee schedule","11.85","82.25",""
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.85","","","","","","","fee schedule","11.85","82.25",""
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.85","","","","","","","fee schedule","11.85","82.25",""
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.38","","","","","","","fee schedule","11.85","82.25",""
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.25","","","","","","","fee schedule","11.85","82.25",""
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.38","","","","","","","fee schedule","11.85","82.25",""
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.41","","","","","","","fee schedule","11.85","82.25","APC"
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.21","","","","","","","fee schedule","11.85","82.25","APC"
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.09","","","","","","","fee schedule","11.85","82.25","APC"
"Antithrombin iii activity","85300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.44","","","","","","","fee schedule","11.85","82.25","APC"
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.81","","","","","","","fee schedule","10.81","81.28",""
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.81","","","","","","","fee schedule","10.81","81.28",""
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.81","","","","","","","fee schedule","10.81","81.28",""
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.59","","","","","","","fee schedule","10.81","81.28",""
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.28","","","","","","","fee schedule","10.81","81.28",""
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.59","","","","","","","fee schedule","10.81","81.28",""
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.32","","","","","","","fee schedule","10.81","81.28","APC"
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.13","","","","","","","fee schedule","10.81","81.28","APC"
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.03","","","","","","","fee schedule","10.81","81.28","APC"
"Antithrombin iii antigen","85301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.35","","","","","","","fee schedule","10.81","81.28","APC"
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.01","","","","","","","fee schedule","12.01","90.4",""
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.01","","","","","","","fee schedule","12.01","90.4",""
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.01","","","","","","","fee schedule","12.01","90.4",""
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.66","","","","","","","fee schedule","12.01","90.4",""
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","90.4","","","","","","","fee schedule","12.01","90.4",""
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.66","","","","","","","fee schedule","12.01","90.4",""
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.58","","","","","","","fee schedule","12.01","90.4","APC"
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.37","","","","","","","fee schedule","12.01","90.4","APC"
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.25","","","","","","","fee schedule","12.01","90.4","APC"
"Clot inhibit prot c antigen","85302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.61","","","","","","","fee schedule","12.01","90.4","APC"
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.84","","","","","","","fee schedule","13.84","102.58",""
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.84","","","","","","","fee schedule","13.84","102.58",""
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.84","","","","","","","fee schedule","13.84","102.58",""
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.77","","","","","","","fee schedule","13.84","102.58",""
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.58","","","","","","","fee schedule","13.84","102.58",""
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.77","","","","","","","fee schedule","13.84","102.58",""
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.5","","","","","","","fee schedule","13.84","102.58","APC"
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.26","","","","","","","fee schedule","13.84","102.58","APC"
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.12","","","","","","","fee schedule","13.84","102.58","APC"
"Clot inhibit prot c activity","85303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.53","","","","","","","fee schedule","13.84","102.58","APC"
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.61","","","","","","","fee schedule","11.61","87.27",""
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.61","","","","","","","fee schedule","11.61","87.27",""
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.61","","","","","","","fee schedule","11.61","87.27",""
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.93","","","","","","","fee schedule","11.61","87.27",""
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","87.27","","","","","","","fee schedule","11.61","87.27",""
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.93","","","","","","","fee schedule","11.61","87.27",""
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.16","","","","","","","fee schedule","11.61","87.27","APC"
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.96","","","","","","","fee schedule","11.61","87.27","APC"
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.84","","","","","","","fee schedule","11.61","87.27","APC"
"Clot inhibit prot s total","85305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.19","","","","","","","fee schedule","11.61","87.27","APC"
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.32","","","","","","","fee schedule","15.32","111.07",""
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.32","","","","","","","fee schedule","15.32","111.07",""
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.32","","","","","","","fee schedule","15.32","111.07",""
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.34","","","","","","","fee schedule","15.32","111.07",""
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.07","","","","","","","fee schedule","15.32","111.07",""
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.34","","","","","","","fee schedule","15.32","111.07",""
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.05","","","","","","","fee schedule","15.32","111.07","APC"
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.78","","","","","","","fee schedule","15.32","111.07","APC"
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.63","","","","","","","fee schedule","15.32","111.07","APC"
"Clot inhibit prot s free","85306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.09","","","","","","","fee schedule","15.32","111.07","APC"
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.32","","","","","","","fee schedule","15.32","111.07",""
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.32","","","","","","","fee schedule","15.32","111.07",""
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.32","","","","","","","fee schedule","15.32","111.07",""
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.34","","","","","","","fee schedule","15.32","111.07",""
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.07","","","","","","","fee schedule","15.32","111.07",""
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.34","","","","","","","fee schedule","15.32","111.07",""
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.05","","","","","","","fee schedule","15.32","111.07","APC"
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.78","","","","","","","fee schedule","15.32","111.07","APC"
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.63","","","","","","","fee schedule","15.32","111.07","APC"
"Assay Activated Protein C","85307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.09","","","","","","","fee schedule","15.32","111.07","APC"
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.87","","","","","","","fee schedule","12.87","90.88",""
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.87","","","","","","","fee schedule","12.87","90.88",""
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.87","","","","","","","fee schedule","12.87","90.88",""
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.13","","","","","","","fee schedule","12.87","90.88",""
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","90.88","","","","","","","fee schedule","12.87","90.88",""
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.13","","","","","","","fee schedule","12.87","90.88",""
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.48","","","","","","","fee schedule","12.87","90.88","APC"
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.87","90.88","APC"
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.87","90.88","APC"
"Factor inhibitor test","85335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.87","90.88","APC"
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.27","","","","","","","fee schedule","17.27","76.51",""
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.27","","","","","","","fee schedule","17.27","76.51",""
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.27","","","","","","","fee schedule","17.27","76.51",""
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.92","","","","","","","fee schedule","17.27","76.51",""
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","76.51","","","","","","","fee schedule","17.27","76.51",""
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.92","","","","","","","fee schedule","17.27","76.51",""
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.09","","","","","","","fee schedule","17.27","76.51","APC"
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.79","","","","","","","fee schedule","17.27","76.51","APC"
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.62","","","","","","","fee schedule","17.27","76.51","APC"
"Thrombomodulin","85337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.13","","","","","","","fee schedule","17.27","76.51","APC"
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.69","","","","","","","fee schedule","4.69","31.07",""
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.69","","","","","","","fee schedule","4.69","31.07",""
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.69","","","","","","","fee schedule","4.69","31.07",""
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.39","","","","","","","fee schedule","4.69","31.07",""
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.07","","","","","","","fee schedule","4.69","31.07",""
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.39","","","","","","","fee schedule","4.69","31.07",""
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.91","","","","","","","fee schedule","4.69","31.07","APC"
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.83","","","","","","","fee schedule","4.69","31.07","APC"
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.78","","","","","","","fee schedule","4.69","31.07","APC"
"Coagulation time lee & white","85345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.92","","","","","","","fee schedule","4.69","31.07","APC"
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.28","","","","","","","fee schedule","4.28","30.56",""
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.28","","","","","","","fee schedule","4.28","30.56",""
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.28","","","","","","","fee schedule","4.28","30.56",""
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.32","","","","","","","fee schedule","4.28","30.56",""
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","30.56","","","","","","","fee schedule","4.28","30.56",""
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.32","","","","","","","fee schedule","4.28","30.56",""
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.28","30.56","APC"
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.41","","","","","","","fee schedule","4.28","30.56","APC"
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.37","","","","","","","fee schedule","4.28","30.56","APC"
"Coagulation time activated","85347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.49","","","","","","","fee schedule","4.28","30.56","APC"
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.49","","","","","","","fee schedule","4.49","26.92",""
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.49","","","","","","","fee schedule","4.49","26.92",""
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.49","","","","","","","fee schedule","4.49","26.92",""
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.41","","","","","","","fee schedule","4.49","26.92",""
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.92","","","","","","","fee schedule","4.49","26.92",""
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.41","","","","","","","fee schedule","4.49","26.92",""
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.7","","","","","","","fee schedule","4.49","26.92","APC"
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.62","","","","","","","fee schedule","4.49","26.92","APC"
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.58","","","","","","","fee schedule","4.49","26.92","APC"
"Coagulation time otr method","85348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.71","","","","","","","fee schedule","4.49","26.92","APC"
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.41","","","","","","","fee schedule","8.41","60.69",""
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.41","","","","","","","fee schedule","8.41","60.69",""
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.41","","","","","","","fee schedule","8.41","60.69",""
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.44","","","","","","","fee schedule","8.41","60.69",""
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","60.69","","","","","","","fee schedule","8.41","60.69",""
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.44","","","","","","","fee schedule","8.41","60.69",""
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.81","","","","","","","fee schedule","8.41","60.69","APC"
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.66","","","","","","","fee schedule","8.41","60.69","APC"
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.41","60.69","APC"
"Euglobulin lysis","85360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.83","","","","","","","fee schedule","8.41","60.69","APC"
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.89","","","","","","","fee schedule","6.89","49.9",""
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.89","","","","","","","fee schedule","6.89","49.9",""
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.89","","","","","","","fee schedule","6.89","49.9",""
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.83","","","","","","","fee schedule","6.89","49.9",""
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","49.9","","","","","","","fee schedule","6.89","49.9",""
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.83","","","","","","","fee schedule","6.89","49.9",""
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.22","","","","","","","fee schedule","6.89","49.9","APC"
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.1","","","","","","","fee schedule","6.89","49.9","APC"
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.03","","","","","","","fee schedule","6.89","49.9","APC"
"Fibrin degradation products","85362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.23","","","","","","","fee schedule","6.89","49.9","APC"
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","80.46","","","","","","","fee schedule","14.81","84.48",""
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","80.46","","","","","","","fee schedule","14.81","84.48",""
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","80.46","","","","","","","fee schedule","14.81","84.48",""
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.81","","","","","","","fee schedule","14.81","84.48",""
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","61.91","","","","","","","fee schedule","14.81","84.48",""
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.81","","","","","","","fee schedule","14.81","84.48",""
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","84.28","","","","","","","fee schedule","14.81","84.48","APC"
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","82.87","","","","","","","fee schedule","14.81","84.48","APC"
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","82.07","","","","","","","fee schedule","14.81","84.48","APC"
"Fibrinogen test","85366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","84.48","","","","","","","fee schedule","14.81","84.48","APC"
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.43","","","","","","","fee schedule","12.43","76.25",""
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.43","","","","","","","fee schedule","12.43","76.25",""
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.43","","","","","","","fee schedule","12.43","76.25",""
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.51","","","","","","","fee schedule","12.43","76.25",""
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","76.25","","","","","","","fee schedule","12.43","76.25",""
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.51","","","","","","","fee schedule","12.43","76.25",""
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.02","","","","","","","fee schedule","12.43","76.25","APC"
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.8","","","","","","","fee schedule","12.43","76.25","APC"
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.68","","","","","","","fee schedule","12.43","76.25","APC"
"Fibrinogen test","85370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.05","","","","","","","fee schedule","12.43","76.25","APC"
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.72","","","","","","","fee schedule","9.72","52.85",""
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.72","","","","","","","fee schedule","9.72","52.85",""
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.72","","","","","","","fee schedule","9.72","52.85",""
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.25","","","","","","","fee schedule","9.72","52.85",""
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.85","","","","","","","fee schedule","9.72","52.85",""
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.25","","","","","","","fee schedule","9.72","52.85",""
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.18","","","","","","","fee schedule","9.72","52.85","APC"
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.01","","","","","","","fee schedule","9.72","52.85","APC"
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.72","52.85","APC"
"Fibrin degrade semiquant","85378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.21","","","","","","","fee schedule","9.72","52.85","APC"
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.18","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.18","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.18","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.48","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","71.28","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.48","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.38","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradation quant","85379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.18","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.18","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.18","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","71.28","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.48","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.48","","","","","","","fee schedule","10.18","71.28",""
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.38","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrin degradj d-dimer","85380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.18","71.28","APC"
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.72","","","","","","","fee schedule","9.72","63.7",""
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.72","","","","","","","fee schedule","9.72","63.7",""
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.72","","","","","","","fee schedule","9.72","63.7",""
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.7","","","","","","","fee schedule","9.72","63.7",""
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.6","","","","","","","fee schedule","9.72","63.7",""
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.6","","","","","","","fee schedule","9.72","63.7",""
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.18","","","","","","","fee schedule","9.72","63.7","APC"
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.01","","","","","","","fee schedule","9.72","63.7","APC"
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.72","63.7","APC"
"Fibrinogen activity","85384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.21","","","","","","","fee schedule","9.72","63.7","APC"
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.46","","","","","","","fee schedule","14.46","63.7",""
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.46","","","","","","","fee schedule","14.46","63.7",""
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.46","","","","","","","fee schedule","14.46","63.7",""
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.7","","","","","","","fee schedule","14.46","63.7",""
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.6","","","","","","","fee schedule","14.46","63.7",""
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.6","","","","","","","fee schedule","14.46","63.7",""
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.15","","","","","","","fee schedule","14.46","63.7","APC"
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.89","","","","","","","fee schedule","14.46","63.7","APC"
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.75","","","","","","","fee schedule","14.46","63.7","APC"
"Fibrinogen antigen","85385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.18","","","","","","","fee schedule","14.46","63.7","APC"
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.48","","","","","","","fee schedule","8.88","36.86",""
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.48","","","","","","","fee schedule","8.88","36.86",""
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.48","","","","","","","fee schedule","8.88","36.86",""
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","36.86","","","","","","","fee schedule","8.88","36.86",""
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.88","","","","","","","fee schedule","8.88","36.86",""
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.88","","","","","","","fee schedule","8.88","36.86",""
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.22","","","","","","","fee schedule","8.88","36.86","APC"
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.94","","","","","","","fee schedule","8.88","36.86","APC"
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.79","","","","","","","fee schedule","8.88","36.86","APC"
"Fibrinolysins screen i&r","85390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.25","","","","","","","fee schedule","8.88","36.86","APC"
"Clotting assay whole blood","85396","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.82","","","","","","","fee schedule","24.5","109.82",""
"Clotting assay whole blood","85396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.5","","","","","","","fee schedule","24.5","109.82",""
"Clotting assay whole blood","85396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.5","","","","","","","fee schedule","24.5","109.82",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.86","","","","","","","fee schedule","30.86","159.32",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.86","","","","","","","fee schedule","30.86","159.32",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.86","","","","","","","fee schedule","30.86","159.32",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","159.32","","","","","","","fee schedule","30.86","159.32",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.44","","","","","","","fee schedule","30.86","159.32",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.44","","","","","","","fee schedule","30.86","159.32",""
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.33","","","","","","","fee schedule","30.86","159.32","APC"
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.79","","","","","","","fee schedule","30.86","159.32","APC"
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.48","","","","","","","fee schedule","30.86","159.32","APC"
"Clotting funct activity","85397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.4","","","","","","","fee schedule","30.86","159.32","APC"
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.71","","","","","","","fee schedule","7.71","64.47",""
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.71","","","","","","","fee schedule","7.71","64.47",""
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.71","","","","","","","fee schedule","7.71","64.47",""
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.47","","","","","","","fee schedule","7.71","64.47",""
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.2","","","","","","","fee schedule","7.71","64.47",""
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.2","","","","","","","fee schedule","7.71","64.47",""
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.08","","","","","","","fee schedule","7.71","64.47","APC"
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.94","","","","","","","fee schedule","7.71","64.47","APC"
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.86","","","","","","","fee schedule","7.71","64.47","APC"
"Fibrinolytic plasmin","85400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.1","","","","","","","fee schedule","7.71","64.47","APC"
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.71","","","","","","","fee schedule","7.71","54.95",""
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.71","","","","","","","fee schedule","7.71","54.95",""
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.71","","","","","","","fee schedule","7.71","54.95",""
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","54.95","","","","","","","fee schedule","7.71","54.95",""
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.26","","","","","","","fee schedule","7.71","54.95",""
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.26","","","","","","","fee schedule","7.71","54.95",""
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.08","","","","","","","fee schedule","7.71","54.95","APC"
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.94","","","","","","","fee schedule","7.71","54.95","APC"
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.86","","","","","","","fee schedule","7.71","54.95","APC"
"Fibrinolytic antiplasmin","85410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.1","","","","","","","fee schedule","7.71","54.95","APC"
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.19","","","","","","","fee schedule","17.19","116.41",""
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.19","","","","","","","fee schedule","17.19","116.41",""
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.19","","","","","","","fee schedule","17.19","116.41",""
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","116.41","","","","","","","fee schedule","17.19","116.41",""
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.56","","","","","","","fee schedule","17.19","116.41",""
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.56","","","","","","","fee schedule","17.19","116.41",""
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.01","","","","","","","fee schedule","17.19","116.41","APC"
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.71","","","","","","","fee schedule","17.19","116.41","APC"
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.53","","","","","","","fee schedule","17.19","116.41","APC"
"Fibrinolytic plasminogen","85415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.05","","","","","","","fee schedule","17.19","116.41","APC"
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.53","","","","","","","fee schedule","6.53","48.25",""
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.53","","","","","","","fee schedule","6.53","48.25",""
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.53","","","","","","","fee schedule","6.53","48.25",""
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.25","","","","","","","fee schedule","6.53","48.25",""
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.23","","","","","","","fee schedule","6.53","48.25",""
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.23","","","","","","","fee schedule","6.53","48.25",""
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.84","","","","","","","fee schedule","6.53","48.25","APC"
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.73","","","","","","","fee schedule","6.53","48.25","APC"
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.53","48.25","APC"
"Fibrinolytic plasminogen","85420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.86","","","","","","","fee schedule","6.53","48.25","APC"
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.18","","","","","","","fee schedule","10.18","74.83",""
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.18","","","","","","","fee schedule","10.18","74.83",""
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.18","","","","","","","fee schedule","10.18","74.83",""
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","74.83","","","","","","","fee schedule","10.18","74.83",""
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.51","","","","","","","fee schedule","10.18","74.83",""
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.51","","","","","","","fee schedule","10.18","74.83",""
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.18","74.83","APC"
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.18","74.83","APC"
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.38","","","","","","","fee schedule","10.18","74.83","APC"
"Fibrinolytic plasminogen","85421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.18","74.83","APC"
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.2","","","","","","","fee schedule","4.2","31.07",""
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.2","","","","","","","fee schedule","4.2","31.07",""
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.2","","","","","","","fee schedule","4.2","31.07",""
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.07","","","","","","","fee schedule","4.2","31.07",""
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.22","","","","","","","fee schedule","4.2","31.07",""
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.22","","","","","","","fee schedule","4.2","31.07",""
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.2","31.07","APC"
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.33","","","","","","","fee schedule","4.2","31.07","APC"
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.28","","","","","","","fee schedule","4.2","31.07","APC"
"Heinz bodies direct","85441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.41","","","","","","","fee schedule","4.2","31.07","APC"
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.82","","","","","","","fee schedule","6.82","50.61",""
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.82","","","","","","","fee schedule","6.82","50.61",""
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.82","","","","","","","fee schedule","6.82","50.61",""
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.61","","","","","","","fee schedule","6.82","50.61",""
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.71","","","","","","","fee schedule","6.82","50.61",""
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.71","","","","","","","fee schedule","6.82","50.61",""
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.14","","","","","","","fee schedule","6.82","50.61","APC"
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.02","","","","","","","fee schedule","6.82","50.61","APC"
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.96","","","","","","","fee schedule","6.82","50.61","APC"
"Heinz bodies induced","85445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.16","","","","","","","fee schedule","6.82","50.61","APC"
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.73","","","","","","","fee schedule","7.73","52.45",""
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.73","","","","","","","fee schedule","7.73","52.45",""
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.73","","","","","","","fee schedule","7.73","52.45",""
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.45","","","","","","","fee schedule","7.73","52.45",""
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.31","","","","","","","fee schedule","7.73","52.45",""
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.31","","","","","","","fee schedule","7.73","52.45",""
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.1","","","","","","","fee schedule","7.73","52.45","APC"
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.96","","","","","","","fee schedule","7.73","52.45","APC"
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.88","","","","","","","fee schedule","7.73","52.45","APC"
"Hemoglobin fetal","85460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.12","","","","","","","fee schedule","7.73","52.45","APC"
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.36","","","","","","","fee schedule","9.36","48.39",""
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.36","","","","","","","fee schedule","9.36","48.39",""
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.36","","","","","","","fee schedule","9.36","48.39",""
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.39","","","","","","","fee schedule","9.36","48.39",""
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.4","","","","","","","fee schedule","9.36","48.39",""
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.4","","","","","","","fee schedule","9.36","48.39",""
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.8","","","","","","","fee schedule","9.36","48.39","APC"
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.64","","","","","","","fee schedule","9.36","48.39","APC"
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.55","","","","","","","fee schedule","9.36","48.39","APC"
"Hemoglobin fetal","85461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.83","","","","","","","fee schedule","9.36","48.39","APC"
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.87","","","","","","","fee schedule","8.87","62.76",""
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.87","","","","","","","fee schedule","8.87","62.76",""
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.87","","","","","","","fee schedule","8.87","62.76",""
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","62.76","","","","","","","fee schedule","8.87","62.76",""
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.25","","","","","","","fee schedule","8.87","62.76",""
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.25","","","","","","","fee schedule","8.87","62.76",""
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.29","","","","","","","fee schedule","8.87","62.76","APC"
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.14","","","","","","","fee schedule","8.87","62.76","APC"
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.05","","","","","","","fee schedule","8.87","62.76","APC"
"Hemolysin acid","85475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.31","","","","","","","fee schedule","8.87","62.76","APC"
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.09","","","","","","","fee schedule","13.09","91.39",""
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.09","","","","","","","fee schedule","13.09","91.39",""
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.09","","","","","","","fee schedule","13.09","91.39",""
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.39","","","","","","","fee schedule","13.09","91.39",""
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.5","","","","","","","fee schedule","13.09","91.39",""
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.5","","","","","","","fee schedule","13.09","91.39",""
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.71","","","","","","","fee schedule","13.09","91.39","APC"
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.48","","","","","","","fee schedule","13.09","91.39","APC"
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.35","","","","","","","fee schedule","13.09","91.39","APC"
"Heparin assay","85520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.74","","","","","","","fee schedule","13.09","91.39","APC"
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.84","","","","","","","fee schedule","11.84","82.3",""
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.84","","","","","","","fee schedule","11.84","82.3",""
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.84","","","","","","","fee schedule","11.84","82.3",""
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.3","","","","","","","fee schedule","11.84","82.3",""
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.36","","","","","","","fee schedule","11.84","82.3",""
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.36","","","","","","","fee schedule","11.84","82.3",""
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.4","","","","","","","fee schedule","11.84","82.3","APC"
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.2","","","","","","","fee schedule","11.84","82.3","APC"
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.84","82.3","APC"
"Heparin neutralization","85525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.43","","","","","","","fee schedule","11.84","82.3","APC"
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.09","","","","","","","fee schedule","13.09","101.81",""
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.09","","","","","","","fee schedule","13.09","101.81",""
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.09","","","","","","","fee schedule","13.09","101.81",""
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","101.81","","","","","","","fee schedule","13.09","101.81",""
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.37","","","","","","","fee schedule","13.09","101.81",""
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.37","","","","","","","fee schedule","13.09","101.81",""
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.71","","","","","","","fee schedule","13.09","101.81","APC"
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.48","","","","","","","fee schedule","13.09","101.81","APC"
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.35","","","","","","","fee schedule","13.09","101.81","APC"
"Heparin-protamine tolerance","85530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.74","","","","","","","fee schedule","13.09","101.81","APC"
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.88","","","","","","","fee schedule","6.88","47.57",""
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.88","","","","","","","fee schedule","6.88","47.57",""
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.88","","","","","","","fee schedule","6.88","47.57",""
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.57","","","","","","","fee schedule","6.88","47.57",""
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.88","47.57",""
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.88","47.57",""
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.21","","","","","","","fee schedule","6.88","47.57","APC"
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.09","","","","","","","fee schedule","6.88","47.57","APC"
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.02","","","","","","","fee schedule","6.88","47.57","APC"
"Iron Stain Peripheral Blood","85536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.22","","","","","","","fee schedule","6.88","47.57","APC"
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.6","","","","","","","fee schedule","8.6","63.1",""
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.6","","","","","","","fee schedule","8.6","63.1",""
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.6","","","","","","","fee schedule","8.6","63.1",""
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.1","","","","","","","fee schedule","8.6","63.1",""
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.78","","","","","","","fee schedule","8.6","63.1",""
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.78","","","","","","","fee schedule","8.6","63.1",""
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.01","","","","","","","fee schedule","8.6","63.1","APC"
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.86","","","","","","","fee schedule","8.6","63.1","APC"
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.77","","","","","","","fee schedule","8.6","63.1","APC"
"Wbc alkaline phosphatase","85540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.03","","","","","","","fee schedule","8.6","63.1","APC"
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.6","","","","","","","fee schedule","8.6","58.16",""
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.6","","","","","","","fee schedule","8.6","58.16",""
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.6","","","","","","","fee schedule","8.6","58.16",""
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.16","","","","","","","fee schedule","8.6","58.16",""
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.78","","","","","","","fee schedule","8.6","58.16",""
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.78","","","","","","","fee schedule","8.6","58.16",""
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.01","","","","","","","fee schedule","8.6","58.16","APC"
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.86","","","","","","","fee schedule","8.6","58.16","APC"
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.77","","","","","","","fee schedule","8.6","58.16","APC"
"RBC mechanical fragility","85547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.03","","","","","","","fee schedule","8.6","58.16","APC"
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.75","","","","","","","fee schedule","18.75","137",""
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.75","","","","","","","fee schedule","18.75","137",""
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.75","","","","","","","fee schedule","18.75","137",""
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137","","","","","","","fee schedule","18.75","137",""
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.24","","","","","","","fee schedule","18.75","137",""
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.24","","","","","","","fee schedule","18.75","137",""
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.64","","","","","","","fee schedule","18.75","137","APC"
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.31","","","","","","","fee schedule","18.75","137","APC"
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.12","","","","","","","fee schedule","18.75","137","APC"
"Muramidase","85549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.69","","","","","","","fee schedule","18.75","137","APC"
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.47","","","","","","","fee schedule","7.47","49.25",""
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.47","","","","","","","fee schedule","7.47","49.25",""
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.47","","","","","","","fee schedule","7.47","49.25",""
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","49.25","","","","","","","fee schedule","7.47","49.25",""
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.5","","","","","","","fee schedule","7.47","49.25",""
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.5","","","","","","","fee schedule","7.47","49.25",""
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.82","","","","","","","fee schedule","7.47","49.25","APC"
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.69","","","","","","","fee schedule","7.47","49.25","APC"
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.62","","","","","","","fee schedule","7.47","49.25","APC"
"RBC osmotic fragility","85555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.84","","","","","","","fee schedule","7.47","49.25","APC"
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.36","","","","","","","fee schedule","13.36","92.9",""
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.36","","","","","","","fee schedule","13.36","92.9",""
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.36","","","","","","","fee schedule","13.36","92.9",""
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.9","","","","","","","fee schedule","13.36","92.9",""
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.96","","","","","","","fee schedule","13.36","92.9",""
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.96","","","","","","","fee schedule","13.36","92.9",""
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.99","","","","","","","fee schedule","13.36","92.9","APC"
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.76","","","","","","","fee schedule","13.36","92.9","APC"
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.63","","","","","","","fee schedule","13.36","92.9","APC"
"RBC osmotic fragility","85557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.03","","","","","","","fee schedule","13.36","92.9","APC"
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.91","","","","","","","fee schedule","24.91","156.68",""
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.91","","","","","","","fee schedule","24.91","156.68",""
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.91","","","","","","","fee schedule","24.91","156.68",""
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","156.68","","","","","","","fee schedule","24.91","156.68",""
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.92","","","","","","","fee schedule","24.91","156.68",""
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.92","","","","","","","fee schedule","24.91","156.68",""
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.09","","","","","","","fee schedule","24.91","156.68","APC"
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.66","","","","","","","fee schedule","24.91","156.68","APC"
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.41","","","","","","","fee schedule","24.91","156.68","APC"
"Blood platelet aggregation","85576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.16","","","","","","","fee schedule","24.91","156.68","APC"
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.98","","","","","","","fee schedule","17.98","111.73",""
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.98","","","","","","","fee schedule","17.98","111.73",""
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.98","","","","","","","fee schedule","17.98","111.73",""
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.73","","","","","","","fee schedule","17.98","111.73",""
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.9","","","","","","","fee schedule","17.98","111.73",""
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.9","","","","","","","fee schedule","17.98","111.73",""
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.83","","","","","","","fee schedule","17.98","111.73","APC"
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.52","","","","","","","fee schedule","17.98","111.73","APC"
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.34","","","","","","","fee schedule","17.98","111.73","APC"
"Phospholipid pltlt neutraliz","85597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.88","","","","","","","fee schedule","17.98","111.73","APC"
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.98","","","","","","","fee schedule","17.98","111.73",""
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.98","","","","","","","fee schedule","17.98","111.73",""
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.98","","","","","","","fee schedule","17.98","111.73",""
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.73","","","","","","","fee schedule","17.98","111.73",""
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.36","","","","","","","fee schedule","17.98","111.73",""
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.36","","","","","","","fee schedule","17.98","111.73",""
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.83","","","","","","","fee schedule","17.98","111.73","APC"
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.52","","","","","","","fee schedule","17.98","111.73","APC"
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.34","","","","","","","fee schedule","17.98","111.73","APC"
"Hexagnal phosph pltlt neutrl","85598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.88","","","","","","","fee schedule","17.98","111.73","APC"
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.29","","","","","","","fee schedule","4.29","29.37",""
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.29","","","","","","","fee schedule","4.29","29.37",""
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.29","","","","","","","fee schedule","4.29","29.37",""
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.37","","","","","","","fee schedule","4.29","29.37",""
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.74","","","","","","","fee schedule","4.29","29.37",""
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.74","","","","","","","fee schedule","4.29","29.37",""
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.49","","","","","","","fee schedule","4.29","29.37","APC"
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.42","","","","","","","fee schedule","4.29","29.37","APC"
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.38","","","","","","","fee schedule","4.29","29.37","APC"
"Prothrombin time","85610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.5","","","","","","","fee schedule","4.29","29.37","APC"
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.94","","","","","","","fee schedule","3.94","29.56",""
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.94","","","","","","","fee schedule","3.94","29.56",""
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.94","","","","","","","fee schedule","3.94","29.56",""
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","29.56","","","","","","","fee schedule","3.94","29.56",""
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.77","","","","","","","fee schedule","3.94","29.56",""
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.77","","","","","","","fee schedule","3.94","29.56",""
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.13","","","","","","","fee schedule","3.94","29.56","APC"
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.06","","","","","","","fee schedule","3.94","29.56","APC"
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.02","","","","","","","fee schedule","3.94","29.56","APC"
"Prothrombin test","85611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.14","","","","","","","fee schedule","3.94","29.56","APC"
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.49","","","","","","","fee schedule","16.44","64.61",""
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.49","","","","","","","fee schedule","16.44","64.61",""
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.49","","","","","","","fee schedule","16.44","64.61",""
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.61","","","","","","","fee schedule","16.44","64.61",""
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.44","","","","","","","fee schedule","16.44","64.61",""
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.44","","","","","","","fee schedule","16.44","64.61",""
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.32","","","","","","","fee schedule","16.44","64.61","APC"
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.01","","","","","","","fee schedule","16.44","64.61","APC"
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.84","","","","","","","fee schedule","16.44","64.61","APC"
"Viper venom prothrombin time","85612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.36","","","","","","","fee schedule","16.44","64.61","APC"
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.58","","","","","","","fee schedule","9.58","64.61",""
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.58","","","","","","","fee schedule","9.58","64.61",""
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.58","","","","","","","fee schedule","9.58","64.61",""
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.61","","","","","","","fee schedule","9.58","64.61",""
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.44","","","","","","","fee schedule","9.58","64.61",""
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.44","","","","","","","fee schedule","9.58","64.61",""
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.04","","","","","","","fee schedule","9.58","64.61","APC"
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.87","","","","","","","fee schedule","9.58","64.61","APC"
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.77","","","","","","","fee schedule","9.58","64.61","APC"
"Russell viper venom diluted","85613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.06","","","","","","","fee schedule","9.58","64.61","APC"
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.85","","","","","","","fee schedule","9.85","69.15",""
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.85","","","","","","","fee schedule","9.85","69.15",""
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.85","","","","","","","fee schedule","9.85","69.15",""
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.15","","","","","","","fee schedule","9.85","69.15",""
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.92","","","","","","","fee schedule","9.85","69.15",""
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.92","","","","","","","fee schedule","9.85","69.15",""
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.32","","","","","","","fee schedule","9.85","69.15","APC"
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.15","","","","","","","fee schedule","9.85","69.15","APC"
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.05","","","","","","","fee schedule","9.85","69.15","APC"
"Reptilase test","85635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.34","","","","","","","fee schedule","9.85","69.15","APC"
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","26.67",""
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","26.67",""
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","26.67",""
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.67","","","","","","","fee schedule","4.27","26.67",""
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.1","","","","","","","fee schedule","4.27","26.67",""
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.1","","","","","","","fee schedule","4.27","26.67",""
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","26.67","APC"
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","26.67","APC"
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","26.67","APC"
"Rbc sed rate nonautomated","85651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","26.67","APC"
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.7","","","","","","","fee schedule","2.7","20.19",""
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.7","","","","","","","fee schedule","2.7","20.19",""
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.7","","","","","","","fee schedule","2.7","20.19",""
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","20.19","","","","","","","fee schedule","2.7","20.19",""
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","4.64","","","","","","","fee schedule","2.7","20.19",""
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","4.64","","","","","","","fee schedule","2.7","20.19",""
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.83","","","","","","","fee schedule","2.7","20.19","APC"
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.78","","","","","","","fee schedule","2.7","20.19","APC"
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.75","","","","","","","fee schedule","2.7","20.19","APC"
"Rbc sed rate automated","85652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.84","","","","","","","fee schedule","2.7","20.19","APC"
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.51","","","","","","","fee schedule","5.51","40.73",""
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.51","","","","","","","fee schedule","5.51","40.73",""
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.51","","","","","","","fee schedule","5.51","40.73",""
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.73","","","","","","","fee schedule","5.51","40.73",""
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.48","","","","","","","fee schedule","5.51","40.73",""
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.48","","","","","","","fee schedule","5.51","40.73",""
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.77","","","","","","","fee schedule","5.51","40.73","APC"
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.68","","","","","","","fee schedule","5.51","40.73","APC"
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.62","","","","","","","fee schedule","5.51","40.73","APC"
"RBC sickle cell test","85660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.79","","","","","","","fee schedule","5.51","40.73","APC"
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.77","","","","","","","fee schedule","5.77","41.66",""
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.77","","","","","","","fee schedule","5.77","41.66",""
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.77","","","","","","","fee schedule","5.77","41.66",""
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","41.66","","","","","","","fee schedule","5.77","41.66",""
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.92","","","","","","","fee schedule","5.77","41.66",""
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.92","","","","","","","fee schedule","5.77","41.66",""
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.04","","","","","","","fee schedule","5.77","41.66","APC"
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.94","","","","","","","fee schedule","5.77","41.66","APC"
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.89","","","","","","","fee schedule","5.77","41.66","APC"
"Thrombin time plasma","85670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.06","","","","","","","fee schedule","5.77","41.66","APC"
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.85","","","","","","","fee schedule","6.85","50.32",""
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.85","","","","","","","fee schedule","6.85","50.32",""
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.85","","","","","","","fee schedule","6.85","50.32",""
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","50.32","","","","","","","fee schedule","6.85","50.32",""
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.77","","","","","","","fee schedule","6.85","50.32",""
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.77","","","","","","","fee schedule","6.85","50.32",""
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.18","","","","","","","fee schedule","6.85","50.32","APC"
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.06","","","","","","","fee schedule","6.85","50.32","APC"
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.99","","","","","","","fee schedule","6.85","50.32","APC"
"Thrombin time titer","85675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.19","","","","","","","fee schedule","6.85","50.32","APC"
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.63","","","","","","","fee schedule","9.63","64.3",""
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.63","","","","","","","fee schedule","9.63","64.3",""
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.63","","","","","","","fee schedule","9.63","64.3",""
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.3","","","","","","","fee schedule","9.63","64.3",""
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.55","","","","","","","fee schedule","9.63","64.3",""
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.55","","","","","","","fee schedule","9.63","64.3",""
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.09","","","","","","","fee schedule","9.63","64.3","APC"
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.92","","","","","","","fee schedule","9.63","64.3","APC"
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.82","","","","","","","fee schedule","9.63","64.3","APC"
"Thromboplastin inhibition","85705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.11","","","","","","","fee schedule","9.63","64.3","APC"
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.01","","","","","","","fee schedule","6.01","44.76",""
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.01","","","","","","","fee schedule","6.01","44.76",""
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.01","","","","","","","fee schedule","6.01","44.76",""
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.76","","","","","","","fee schedule","6.01","44.76",""
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.32","","","","","","","fee schedule","6.01","44.76",""
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.32","","","","","","","fee schedule","6.01","44.76",""
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.3","","","","","","","fee schedule","6.01","44.76","APC"
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.19","","","","","","","fee schedule","6.01","44.76","APC"
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.13","","","","","","","fee schedule","6.01","44.76","APC"
"Thromboplastin time partial","85730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.31","","","","","","","fee schedule","6.01","44.76","APC"
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","47.91",""
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","47.91",""
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","47.91",""
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.91","","","","","","","fee schedule","6.47","47.91",""
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","47.91",""
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","47.91",""
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","47.91","APC"
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","47.91","APC"
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","47.91","APC"
"Thromboplastin time partial","85732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","47.91","APC"
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.67","","","","","","","fee schedule","11.67","86.28",""
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.67","","","","","","","fee schedule","11.67","86.28",""
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.67","","","","","","","fee schedule","11.67","86.28",""
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.28","","","","","","","fee schedule","11.67","86.28",""
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.06","","","","","","","fee schedule","11.67","86.28",""
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.06","","","","","","","fee schedule","11.67","86.28",""
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.67","86.28","APC"
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.02","","","","","","","fee schedule","11.67","86.28","APC"
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.9","","","","","","","fee schedule","11.67","86.28","APC"
"Blood viscosity examination","85810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.25","","","","","","","fee schedule","11.67","86.28","APC"
"Hematology procedure","85999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.98","","","","","","","fee schedule","6.98","48.76",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.98","","","","","","","fee schedule","6.98","48.76",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.98","","","","","","","fee schedule","6.98","48.76",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.76","","","","","","","fee schedule","6.98","48.76",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12","","","","","","","fee schedule","6.98","48.76",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12","","","","","","","fee schedule","6.98","48.76",""
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.31","","","","","","","fee schedule","6.98","48.76","APC"
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.19","","","","","","","fee schedule","6.98","48.76","APC"
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.12","","","","","","","fee schedule","6.98","48.76","APC"
"Agglutinins febrile antigen","86000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.33","","","","","","","fee schedule","6.98","48.76","APC"
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.82","","","","","","","fee schedule","7.82","37.89",""
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.82","","","","","","","fee schedule","7.82","37.89",""
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.82","","","","","","","fee schedule","7.82","37.89",""
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.89","","","","","","","fee schedule","7.82","37.89",""
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.96","","","","","","","fee schedule","7.82","37.89",""
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.96","","","","","","","fee schedule","7.82","37.89",""
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.19","","","","","","","fee schedule","7.82","37.89","APC"
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.05","","","","","","","fee schedule","7.82","37.89","APC"
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.98","","","","","","","fee schedule","7.82","37.89","APC"
"Allergen Specific Igg","86001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.21","","","","","","","fee schedule","7.82","37.89","APC"
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.22","","","","","","","fee schedule","5.22","37.89",""
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.22","","","","","","","fee schedule","5.22","37.89",""
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.22","","","","","","","fee schedule","5.22","37.89",""
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.89","","","","","","","fee schedule","5.22","37.89",""
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.96","","","","","","","fee schedule","5.22","37.89",""
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.96","","","","","","","fee schedule","5.22","37.89",""
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.47","","","","","","","fee schedule","5.22","37.89","APC"
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.38","","","","","","","fee schedule","5.22","37.89","APC"
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.32","","","","","","","fee schedule","5.22","37.89","APC"
"Allergen specific IgE","86003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.48","","","","","","","fee schedule","5.22","37.89","APC"
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.97","","","","","","","fee schedule","7.97","51.4",""
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.97","","","","","","","fee schedule","7.97","51.4",""
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.97","","","","","","","fee schedule","7.97","51.4",""
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","51.4","","","","","","","fee schedule","7.97","51.4",""
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.7","","","","","","","fee schedule","7.97","51.4",""
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.7","","","","","","","fee schedule","7.97","51.4",""
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.35","","","","","","","fee schedule","7.97","51.4","APC"
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.21","","","","","","","fee schedule","7.97","51.4","APC"
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.13","","","","","","","fee schedule","7.97","51.4","APC"
"Allergen specific IgE","86005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.37","","","","","","","fee schedule","7.97","51.4","APC"
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.93","","","","","","","fee schedule","17.93","26.57",""
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.93","","","","","","","fee schedule","17.93","26.57",""
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.93","","","","","","","fee schedule","17.93","26.57",""
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.57","","","","","","","fee schedule","17.93","26.57",""
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.57","","","","","","","fee schedule","17.93","26.57",""
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.78","","","","","","","fee schedule","17.93","26.57","APC"
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.47","","","","","","","fee schedule","17.93","26.57","APC"
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.29","","","","","","","fee schedule","17.93","26.57","APC"
"Allg spec ige recomb ea","86008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.83","","","","","","","fee schedule","17.93","26.57","APC"
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","13.84",""
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","13.84",""
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","13.84",""
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.84","","","","","","","fee schedule","12.05","13.84",""
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.84","","","","","","","fee schedule","12.05","13.84",""
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","13.84","APC"
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","13.84","APC"
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","13.84","APC"
"Actin antibody each","86015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","13.84","APC"
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.05","","","","","","","fee schedule","15.05","102.27",""
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.05","","","","","","","fee schedule","15.05","102.27",""
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.05","","","","","","","fee schedule","15.05","102.27",""
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.27","","","","","","","fee schedule","15.05","102.27",""
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","15.05","102.27",""
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","15.05","102.27",""
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.05","102.27","APC"
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.5","","","","","","","fee schedule","15.05","102.27","APC"
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.35","","","","","","","fee schedule","15.05","102.27","APC"
"WBC antibody identification","86021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.05","102.27","APC"
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.37","","","","","","","fee schedule","18.37","123.51",""
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.37","","","","","","","fee schedule","18.37","123.51",""
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.37","","","","","","","fee schedule","18.37","123.51",""
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","123.51","","","","","","","fee schedule","18.37","123.51",""
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.57","","","","","","","fee schedule","18.37","123.51",""
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.57","","","","","","","fee schedule","18.37","123.51",""
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.24","","","","","","","fee schedule","18.37","123.51","APC"
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.92","","","","","","","fee schedule","18.37","123.51","APC"
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.74","","","","","","","fee schedule","18.37","123.51","APC"
"Platelet antibodies","86022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.29","","","","","","","fee schedule","18.37","123.51","APC"
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.46","","","","","","","fee schedule","12.46","89.12",""
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.46","","","","","","","fee schedule","12.46","89.12",""
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.46","","","","","","","fee schedule","12.46","89.12",""
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.12","","","","","","","fee schedule","12.46","89.12",""
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.41","","","","","","","fee schedule","12.46","89.12",""
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.41","","","","","","","fee schedule","12.46","89.12",""
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.05","","","","","","","fee schedule","12.46","89.12","APC"
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.46","89.12","APC"
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.71","","","","","","","fee schedule","12.46","89.12","APC"
"Immunoglobulin assay","86023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.08","","","","","","","fee schedule","12.46","89.12","APC"
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","14.46",""
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","12.05","14.46",""
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","12.05","14.46",""
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","14.46","APC"
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","14.46","APC"
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","14.46","APC"
"Anca screen each antibody","86036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","14.46","APC"
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","14.46",""
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","12.05","14.46",""
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","12.05","14.46",""
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","14.46","APC"
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","14.46","APC"
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","14.46","APC"
"Anca titer each antibody","86037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","14.46","APC"
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.09","","","","","","","fee schedule","12.09","89.55",""
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.09","","","","","","","fee schedule","12.09","89.55",""
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.09","","","","","","","fee schedule","12.09","89.55",""
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.55","","","","","","","fee schedule","12.09","89.55",""
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.78","","","","","","","fee schedule","12.09","89.55",""
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.78","","","","","","","fee schedule","12.09","89.55",""
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.66","","","","","","","fee schedule","12.09","89.55","APC"
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.45","","","","","","","fee schedule","12.09","89.55","APC"
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.33","","","","","","","fee schedule","12.09","89.55","APC"
"Antinuclear antibodies","86038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.09","89.55","APC"
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.16","","","","","","","fee schedule","11.16","83.64",""
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.16","","","","","","","fee schedule","11.16","83.64",""
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.16","","","","","","","fee schedule","11.16","83.64",""
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.64","","","","","","","fee schedule","11.16","83.64",""
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.19","","","","","","","fee schedule","11.16","83.64",""
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.19","","","","","","","fee schedule","11.16","83.64",""
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.69","","","","","","","fee schedule","11.16","83.64","APC"
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.49","","","","","","","fee schedule","11.16","83.64","APC"
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.38","","","","","","","fee schedule","11.16","83.64","APC"
"Antinuclear antibodies (ANA)","86039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.72","","","","","","","fee schedule","11.16","83.64","APC"
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.4","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.4","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.4","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.08","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.08","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.27","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.77","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr bndng antb","86041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.32","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.4","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.4","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.4","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.08","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.08","","","","","","","fee schedule","18.4","22.08",""
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.27","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.77","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr blckg antb","86042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.32","","","","","","","fee schedule","18.4","22.08","APC"
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","14.46",""
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","12.05","14.46",""
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","12.05","14.46",""
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","14.46","APC"
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","14.46","APC"
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","14.46","APC"
"Acetylcholn rcptr modlg antb","86043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","14.46","APC"
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","13.84",""
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","13.84",""
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","13.84",""
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.84","","","","","","","fee schedule","11.53","13.84",""
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.84","","","","","","","fee schedule","11.53","13.84",""
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","13.84","APC"
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","13.84","APC"
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","13.84","APC"
"Aquaporin-4 antb elisa","86051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","13.84","APC"
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","14.46",""
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","12.05","14.46",""
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","12.05","14.46",""
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","14.46","APC"
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","14.46","APC"
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","14.46","APC"
"Aquaporin-4 antb cba each","86052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","14.46","APC"
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","37.73","","","","","","","fee schedule","14.46","39.62",""
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.73","","","","","","","fee schedule","14.46","39.62",""
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.73","","","","","","","fee schedule","14.46","39.62",""
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","14.46","39.62",""
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","14.46","39.62",""
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","14.46","39.62","APC"
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","14.46","39.62","APC"
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","14.46","39.62","APC"
"Aqaprn-4 antb flo cytmtry ea","86053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","14.46","39.62","APC"
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.3","","","","","","","fee schedule","7.3","53.16",""
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.3","","","","","","","fee schedule","7.3","53.16",""
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.3","","","","","","","fee schedule","7.3","53.16",""
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","53.16","","","","","","","fee schedule","7.3","53.16",""
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.55","","","","","","","fee schedule","7.3","53.16",""
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.55","","","","","","","fee schedule","7.3","53.16",""
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.65","","","","","","","fee schedule","7.3","53.16","APC"
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.52","","","","","","","fee schedule","7.3","53.16","APC"
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.45","","","","","","","fee schedule","7.3","53.16","APC"
"Antistreptolysin o titer","86060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.66","","","","","","","fee schedule","7.3","53.16","APC"
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.77","","","","","","","fee schedule","5.77","41.52",""
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.77","","","","","","","fee schedule","5.77","41.52",""
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.77","","","","","","","fee schedule","5.77","41.52",""
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","41.52","","","","","","","fee schedule","5.77","41.52",""
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.92","","","","","","","fee schedule","5.77","41.52",""
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.92","","","","","","","fee schedule","5.77","41.52",""
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.04","","","","","","","fee schedule","5.77","41.52","APC"
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.94","","","","","","","fee schedule","5.77","41.52","APC"
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.89","","","","","","","fee schedule","5.77","41.52","APC"
"Antistreptolysin o screen","86063","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.06","","","","","","","fee schedule","5.77","41.52","APC"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","271.76","","","","","","","fee schedule","20.08","271.76",""
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","271.76",""
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","271.76",""
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","20.08","271.76","APC 277.30"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","20.08","271.76","APC 296.56"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","20.08","271.76","APC 308.91"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv xmatch","86077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","271.76","","","","","","","fee schedule","42.88","588.18",""
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Phys blood bank serv reactj","86078","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","271.76","","","","","","","fee schedule","20.08","271.76",""
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","271.76",""
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","271.76",""
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","20.08","271.76","APC 277.30"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","20.08","271.76","APC 296.56"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","20.08","271.76","APC 308.91"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","20.08","271.76","APC"
"Phys blood bank serv authrj","86079","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","20.08","271.76","APC"
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","37.37",""
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","37.37",""
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","37.37",""
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.37","","","","","","","fee schedule","5.18","37.37",""
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","37.37",""
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","37.37",""
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.18","37.37","APC"
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.18","37.37","APC"
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.18","37.37","APC"
"C-reactive protein","86140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.18","37.37","APC"
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.95","","","","","","","fee schedule","12.95","97.38",""
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.95","","","","","","","fee schedule","12.95","97.38",""
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.95","","","","","","","fee schedule","12.95","97.38",""
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.38","","","","","","","fee schedule","12.95","97.38",""
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.25","","","","","","","fee schedule","12.95","97.38",""
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.25","","","","","","","fee schedule","12.95","97.38",""
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.57","","","","","","","fee schedule","12.95","97.38","APC"
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.34","","","","","","","fee schedule","12.95","97.38","APC"
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.21","","","","","","","fee schedule","12.95","97.38","APC"
"C-reactive protein hs","86141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.6","","","","","","","fee schedule","12.95","97.38","APC"
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.45","","","","","","","fee schedule","25.45","153.08",""
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.45","","","","","","","fee schedule","25.45","153.08",""
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.45","","","","","","","fee schedule","25.45","153.08",""
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","153.08","","","","","","","fee schedule","25.45","153.08",""
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.73","","","","","","","fee schedule","25.45","153.08",""
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.73","","","","","","","fee schedule","25.45","153.08",""
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.66","","","","","","","fee schedule","25.45","153.08","APC"
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.21","","","","","","","fee schedule","25.45","153.08","APC"
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.96","","","","","","","fee schedule","25.45","153.08","APC"
"Beta-2 glycoprotein antibody","86146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.72","","","","","","","fee schedule","25.45","153.08","APC"
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.45","","","","","","","fee schedule","25.45","153.08",""
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.45","","","","","","","fee schedule","25.45","153.08",""
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.45","","","","","","","fee schedule","25.45","153.08",""
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","153.08","","","","","","","fee schedule","25.45","153.08",""
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.73","","","","","","","fee schedule","25.45","153.08",""
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.73","","","","","","","fee schedule","25.45","153.08",""
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.66","","","","","","","fee schedule","25.45","153.08","APC"
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.21","","","","","","","fee schedule","25.45","153.08","APC"
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.96","","","","","","","fee schedule","25.45","153.08","APC"
"Cardiolipin antibody ea ig","86147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.72","","","","","","","fee schedule","25.45","153.08","APC"
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.07","","","","","","","fee schedule","16.07","111.73",""
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.07","","","","","","","fee schedule","16.07","111.73",""
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.07","","","","","","","fee schedule","16.07","111.73",""
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.73","","","","","","","fee schedule","16.07","111.73",""
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.61","","","","","","","fee schedule","16.07","111.73",""
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.61","","","","","","","fee schedule","16.07","111.73",""
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.83","","","","","","","fee schedule","16.07","111.73","APC"
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.55","","","","","","","fee schedule","16.07","111.73","APC"
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.39","","","","","","","fee schedule","16.07","111.73","APC"
"Anti-phospholipid antibody","86148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.87","","","","","","","fee schedule","16.07","111.73","APC"
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","250.78","","","","","","","fee schedule","15.25","263.32",""
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","250.78","","","","","","","fee schedule","15.25","263.32",""
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","250.78","","","","","","","fee schedule","15.25","263.32",""
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","15.25","263.32",""
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.25","","","","","","","fee schedule","15.25","263.32",""
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.25","","","","","","","fee schedule","15.25","263.32",""
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","262.69","","","","","","","fee schedule","15.25","263.32","APC"
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","258.3","","","","","","","fee schedule","15.25","263.32","APC"
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","255.8","","","","","","","fee schedule","15.25","263.32","APC"
"Cell enumeration & id","86152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","263.32","","","","","","","fee schedule","15.25","263.32","APC"
"Cell enumeration phys interp","86153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","15.25","69.49",""
"Cell enumeration phys interp","86153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.25","","","","","","","fee schedule","15.25","69.49",""
"Cell enumeration phys interp","86153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.25","","","","","","","fee schedule","15.25","69.49",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.99","","","","","","","fee schedule","15.99","116.07",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.99","","","","","","","fee schedule","15.99","116.07",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.99","","","","","","","fee schedule","15.99","116.07",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","116.07","","","","","","","fee schedule","15.99","116.07",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.47","","","","","","","fee schedule","15.99","116.07",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.47","","","","","","","fee schedule","15.99","116.07",""
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.75","","","","","","","fee schedule","15.99","116.07","APC"
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.47","","","","","","","fee schedule","15.99","116.07","APC"
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.31","","","","","","","fee schedule","15.99","116.07","APC"
"Chemotaxis assay","86155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.79","","","","","","","fee schedule","15.99","116.07","APC"
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.07","","","","","","","fee schedule","8.07","47.71",""
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.07","","","","","","","fee schedule","8.07","47.71",""
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.07","","","","","","","fee schedule","8.07","47.71",""
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.71","","","","","","","fee schedule","8.07","47.71",""
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.52","","","","","","","fee schedule","8.07","47.71",""
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.52","","","","","","","fee schedule","8.07","47.71",""
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.45","","","","","","","fee schedule","8.07","47.71","APC"
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.31","","","","","","","fee schedule","8.07","47.71","APC"
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.23","","","","","","","fee schedule","8.07","47.71","APC"
"Cold agglutinin screen","86156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.47","","","","","","","fee schedule","8.07","47.71","APC"
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.06","","","","","","","fee schedule","8.06","58.5",""
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.06","","","","","","","fee schedule","8.06","58.5",""
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.06","","","","","","","fee schedule","8.06","58.5",""
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.5","","","","","","","fee schedule","8.06","58.5",""
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.86","","","","","","","fee schedule","8.06","58.5",""
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.86","","","","","","","fee schedule","8.06","58.5",""
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.44","","","","","","","fee schedule","8.06","58.5","APC"
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.3","","","","","","","fee schedule","8.06","58.5","APC"
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.22","","","","","","","fee schedule","8.06","58.5","APC"
"Cold agglutinin titer","86157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.46","","","","","","","fee schedule","8.06","58.5","APC"
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12","","","","","","","fee schedule","12","89.63",""
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12","","","","","","","fee schedule","12","89.63",""
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12","","","","","","","fee schedule","12","89.63",""
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.63","","","","","","","fee schedule","12","89.63",""
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.64","","","","","","","fee schedule","12","89.63",""
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.64","","","","","","","fee schedule","12","89.63",""
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.57","","","","","","","fee schedule","12","89.63","APC"
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.36","","","","","","","fee schedule","12","89.63","APC"
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.24","","","","","","","fee schedule","12","89.63","APC"
"Complement antigen","86160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.6","","","","","","","fee schedule","12","89.63","APC"
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12","","","","","","","fee schedule","12","89.63",""
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12","","","","","","","fee schedule","12","89.63",""
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12","","","","","","","fee schedule","12","89.63",""
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.63","","","","","","","fee schedule","12","89.63",""
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.64","","","","","","","fee schedule","12","89.63",""
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.64","","","","","","","fee schedule","12","89.63",""
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.57","","","","","","","fee schedule","12","89.63","APC"
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.36","","","","","","","fee schedule","12","89.63","APC"
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.24","","","","","","","fee schedule","12","89.63","APC"
"Complement/function activity","86161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.6","","","","","","","fee schedule","12","89.63","APC"
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.32","","","","","","","fee schedule","20.32","150.29",""
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.32","","","","","","","fee schedule","20.32","150.29",""
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.32","","","","","","","fee schedule","20.32","150.29",""
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.29","","","","","","","fee schedule","20.32","150.29",""
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.92","","","","","","","fee schedule","20.32","150.29",""
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.92","","","","","","","fee schedule","20.32","150.29",""
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.29","","","","","","","fee schedule","20.32","150.29","APC"
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.93","","","","","","","fee schedule","20.32","150.29","APC"
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.73","","","","","","","fee schedule","20.32","150.29","APC"
"Complement total (ch50)","86162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.34","","","","","","","fee schedule","20.32","150.29","APC"
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.01","","","","","","","fee schedule","10.01","67",""
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.01","","","","","","","fee schedule","10.01","67",""
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.01","","","","","","","fee schedule","10.01","67",""
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","67","","","","","","","fee schedule","10.01","67",""
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.22","","","","","","","fee schedule","10.01","67",""
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.22","","","","","","","fee schedule","10.01","67",""
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.01","67","APC"
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.31","","","","","","","fee schedule","10.01","67","APC"
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.21","","","","","","","fee schedule","10.01","67","APC"
"Complement fixation each","86171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.51","","","","","","","fee schedule","10.01","67","APC"
"Counterimmunoelectrophoresis","86185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","67.17","","","","","","","fee schedule","67.17","67.17",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.95","","","","","","","fee schedule","12.95","97.38",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.95","","","","","","","fee schedule","12.95","97.38",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.95","","","","","","","fee schedule","12.95","97.38",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.38","","","","","","","fee schedule","12.95","97.38",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.25","","","","","","","fee schedule","12.95","97.38",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.25","","","","","","","fee schedule","12.95","97.38",""
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.57","","","","","","","fee schedule","12.95","97.38","APC"
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.34","","","","","","","fee schedule","12.95","97.38","APC"
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.21","","","","","","","fee schedule","12.95","97.38","APC"
"Ccp antibody","86200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.6","","","","","","","fee schedule","12.95","97.38","APC"
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","98.72",""
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","98.72",""
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","98.72",""
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","98.72","","","","","","","fee schedule","13.25","98.72",""
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.78","","","","","","","fee schedule","13.25","98.72",""
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.78","","","","","","","fee schedule","13.25","98.72",""
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","98.72","APC"
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","98.72","APC"
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","98.72","APC"
"Deoxyribonuclease antibody","86215","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","98.72","APC"
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.74","","","","","","","fee schedule","13.74","102.78",""
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.74","","","","","","","fee schedule","13.74","102.78",""
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.74","","","","","","","fee schedule","13.74","102.78",""
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.78","","","","","","","fee schedule","13.74","102.78",""
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.62","","","","","","","fee schedule","13.74","102.78",""
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.62","","","","","","","fee schedule","13.74","102.78",""
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.39","","","","","","","fee schedule","13.74","102.78","APC"
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.15","","","","","","","fee schedule","13.74","102.78","APC"
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.01","","","","","","","fee schedule","13.74","102.78","APC"
"Dna antibody native","86225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.43","","","","","","","fee schedule","13.74","102.78","APC"
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.11","","","","","","","fee schedule","12.11","88.86",""
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.11","","","","","","","fee schedule","12.11","88.86",""
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.11","","","","","","","fee schedule","12.11","88.86",""
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.86","","","","","","","fee schedule","12.11","88.86",""
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.82","","","","","","","fee schedule","12.11","88.86",""
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.82","","","","","","","fee schedule","12.11","88.86",""
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.11","88.86","APC"
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.47","","","","","","","fee schedule","12.11","88.86","APC"
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.35","","","","","","","fee schedule","12.11","88.86","APC"
"Dna antibody single strand","86226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.72","","","","","","","fee schedule","12.11","88.86","APC"
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.09","","","","","","","fee schedule","12.09","14.51",""
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.09","","","","","","","fee schedule","12.09","14.51",""
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.09","","","","","","","fee schedule","12.09","14.51",""
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.51","","","","","","","fee schedule","12.09","14.51",""
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.51","","","","","","","fee schedule","12.09","14.51",""
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.66","","","","","","","fee schedule","12.09","14.51","APC"
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.45","","","","","","","fee schedule","12.09","14.51","APC"
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.33","","","","","","","fee schedule","12.09","14.51","APC"
"Ema each ig class","86231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.09","14.51","APC"
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.93","","","","","","","fee schedule","17.93","126.66",""
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.93","","","","","","","fee schedule","17.93","126.66",""
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.93","","","","","","","fee schedule","17.93","126.66",""
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","126.66","","","","","","","fee schedule","17.93","126.66",""
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.83","","","","","","","fee schedule","17.93","126.66",""
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.83","","","","","","","fee schedule","17.93","126.66",""
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.78","","","","","","","fee schedule","17.93","126.66","APC"
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.47","","","","","","","fee schedule","17.93","126.66","APC"
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.29","","","","","","","fee schedule","17.93","126.66","APC"
"Nuclear antigen antibody","86235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.83","","","","","","","fee schedule","17.93","126.66","APC"
"Fc receptor","86243","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","149.21","","","","","","","fee schedule","149.21","149.21",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","88.86",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","88.86",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","88.86",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.86","","","","","","","fee schedule","12.05","88.86",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.71","","","","","","","fee schedule","12.05","88.86",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.71","","","","","","","fee schedule","12.05","88.86",""
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","88.86","APC"
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","88.86","APC"
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","88.86","APC"
"Fluorescent antibody screen","86255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","88.86","APC"
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","88.13",""
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","88.13",""
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","88.13",""
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.13","","","","","","","fee schedule","12.05","88.13",""
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.71","","","","","","","fee schedule","12.05","88.13",""
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.71","","","","","","","fee schedule","12.05","88.13",""
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","88.13","APC"
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","88.13","APC"
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","88.13","APC"
"Fluorescent antibody titer","86256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","88.13","APC"
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","13.84",""
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","13.84",""
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","13.84",""
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.84","","","","","","","fee schedule","12.05","13.84",""
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.84","","","","","","","fee schedule","12.05","13.84",""
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","13.84","APC"
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","13.84","APC"
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","13.84","APC"
"Dgp antibody each ig class","86258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","13.84","APC"
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.74","","","","","","","fee schedule","15.74","117.32",""
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.74","","","","","","","fee schedule","15.74","117.32",""
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.74","","","","","","","fee schedule","15.74","117.32",""
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","117.32","","","","","","","fee schedule","15.74","117.32",""
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.05","","","","","","","fee schedule","15.74","117.32",""
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.05","","","","","","","fee schedule","15.74","117.32",""
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.49","","","","","","","fee schedule","15.74","117.32","APC"
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.21","","","","","","","fee schedule","15.74","117.32","APC"
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.05","","","","","","","fee schedule","15.74","117.32","APC"
"Growth hormone antibody","86277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.53","","","","","","","fee schedule","15.74","117.32","APC"
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.19","","","","","","","fee schedule","8.19","59.36",""
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.19","","","","","","","fee schedule","8.19","59.36",""
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.19","","","","","","","fee schedule","8.19","59.36",""
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.36","","","","","","","fee schedule","8.19","59.36",""
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.08","","","","","","","fee schedule","8.19","59.36",""
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.08","","","","","","","fee schedule","8.19","59.36",""
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.19","59.36","APC"
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.44","","","","","","","fee schedule","8.19","59.36","APC"
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.35","","","","","","","fee schedule","8.19","59.36","APC"
"Hemagglutination inhibition","86280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.6","","","","","","","fee schedule","8.19","59.36","APC"
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.57","","","","","","","fee schedule","25.57","130.55",""
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.57","","","","","","","fee schedule","25.57","130.55",""
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.57","","","","","","","fee schedule","25.57","130.55",""
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","130.55","","","","","","","fee schedule","25.57","130.55",""
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.72","","","","","","","fee schedule","25.57","130.55",""
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.72","","","","","","","fee schedule","25.57","130.55",""
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.78","","","","","","","fee schedule","25.57","130.55","APC"
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.34","","","","","","","fee schedule","25.57","130.55","APC"
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.08","","","","","","","fee schedule","25.57","130.55","APC"
"Immunoassay tumor qual","86294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.85","","","","","","","fee schedule","25.57","130.55","APC"
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.63","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 15-3","86300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.63","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 19-9","86301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.63","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor ca 125","86304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.81","150.63","APC"
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.81","","","","","","","fee schedule","20.81","150.63",""
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.63","","","","","","","fee schedule","20.81","150.63",""
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.77","","","","","","","fee schedule","20.81","150.63",""
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.77","","","","","","","fee schedule","20.81","150.63",""
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","20.81","150.63","APC"
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","150.63","APC"
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.81","150.63","APC"
"Human epididymis protein 4","86305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.81","150.63","APC"
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","38.54",""
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","38.54",""
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","38.54",""
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.54","","","","","","","fee schedule","5.18","38.54",""
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","38.54",""
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","38.54",""
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.18","38.54","APC"
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.18","38.54","APC"
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.18","38.54","APC"
"Heterophile antibody screen","86308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.18","38.54","APC"
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","48.14",""
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","48.14",""
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","48.14",""
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","48.14","","","","","","","fee schedule","6.47","48.14",""
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","48.14",""
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","48.14",""
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","48.14","APC"
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","48.14","APC"
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","48.14","APC"
"Heterophile antibody titer","86309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","48.14","APC"
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.37","","","","","","","fee schedule","7.37","54.87",""
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.37","","","","","","","fee schedule","7.37","54.87",""
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.37","","","","","","","fee schedule","7.37","54.87",""
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","54.87","","","","","","","fee schedule","7.37","54.87",""
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.67","","","","","","","fee schedule","7.37","54.87",""
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.67","","","","","","","fee schedule","7.37","54.87",""
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.72","","","","","","","fee schedule","7.37","54.87","APC"
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.59","","","","","","","fee schedule","7.37","54.87","APC"
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.52","","","","","","","fee schedule","7.37","54.87","APC"
"Heterophile antibody absrbj","86310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.74","","","","","","","fee schedule","7.37","54.87","APC"
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.81","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","150.63","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.77","","","","","","","fee schedule","20.81","150.63",""
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.8","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.23","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay tumor other","86316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.85","","","","","","","fee schedule","20.81","150.63","APC"
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.99","","","","","","","fee schedule","14.99","109.82",""
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.99","","","","","","","fee schedule","14.99","109.82",""
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.99","","","","","","","fee schedule","14.99","109.82",""
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.82","","","","","","","fee schedule","14.99","109.82",""
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.76","","","","","","","fee schedule","14.99","109.82",""
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.76","","","","","","","fee schedule","14.99","109.82",""
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.7","","","","","","","fee schedule","14.99","109.82","APC"
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.44","","","","","","","fee schedule","14.99","109.82","APC"
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.29","","","","","","","fee schedule","14.99","109.82","APC"
"Immunoassay infectious agent","86317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.74","","","","","","","fee schedule","14.99","109.82","APC"
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.09","","","","","","","fee schedule","18.09","97.38",""
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.09","","","","","","","fee schedule","18.09","97.38",""
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.09","","","","","","","fee schedule","18.09","97.38",""
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.38","","","","","","","fee schedule","18.09","97.38",""
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.25","","","","","","","fee schedule","18.09","97.38",""
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.25","","","","","","","fee schedule","18.09","97.38",""
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.09","97.38","APC"
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.63","","","","","","","fee schedule","18.09","97.38","APC"
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.45","","","","","","","fee schedule","18.09","97.38","APC"
"Immunoassay infectious agent","86318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.99","","","","","","","fee schedule","18.09","97.38","APC"
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.92","","","","","","","fee schedule","29.92","165.77",""
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.92","","","","","","","fee schedule","29.92","165.77",""
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.92","","","","","","","fee schedule","29.92","165.77",""
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","165.77","","","","","","","fee schedule","29.92","165.77",""
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.52","","","","","","","fee schedule","29.92","165.77",""
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.52","","","","","","","fee schedule","29.92","165.77",""
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.34","","","","","","","fee schedule","29.92","165.77","APC"
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.82","","","","","","","fee schedule","29.92","165.77","APC"
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.52","","","","","","","fee schedule","29.92","165.77","APC"
"Serum immunoelectrophoresis","86320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.42","","","","","","","fee schedule","29.92","165.77","APC"
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.13","","","","","","","fee schedule","23.13","167.56",""
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.13","","","","","","","fee schedule","23.13","167.56",""
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.13","","","","","","","fee schedule","23.13","167.56",""
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","167.56","","","","","","","fee schedule","23.13","167.56",""
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.44","","","","","","","fee schedule","23.13","167.56",""
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.44","","","","","","","fee schedule","23.13","167.56",""
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.23","","","","","","","fee schedule","23.13","167.56","APC"
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.82","","","","","","","fee schedule","23.13","167.56","APC"
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.59","","","","","","","fee schedule","23.13","167.56","APC"
"Other immunoelectrophoresis","86325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.29","","","","","","","fee schedule","23.13","167.56","APC"
"Immunoelectrophoresis assay","86327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.92","","","","","","","fee schedule","29.92","169.49",""
"Immunoelectrophoresis assay","86327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.92","","","","","","","fee schedule","29.92","169.49",""
"Immunoelectrophoresis assay","86327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.92","","","","","","","fee schedule","29.92","169.49",""
"Immunoelectrophoresis assay","86327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","169.49","","","","","","","fee schedule","29.92","169.49",""
"Immunoelectrophoresis assay","86327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39","","","","","","","fee schedule","29.92","169.49",""
"Immunoelectrophoresis assay","86327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39","","","","","","","fee schedule","29.92","169.49",""
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","45.28","","","","","","","fee schedule","45.28","54.34",""
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","45.28","","","","","","","fee schedule","45.28","54.34",""
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45.28","","","","","","","fee schedule","45.28","54.34",""
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","54.34","","","","","","","fee schedule","45.28","54.34",""
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","54.34","","","","","","","fee schedule","45.28","54.34",""
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.43","","","","","","","fee schedule","45.28","54.34","APC"
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46.64","","","","","","","fee schedule","45.28","54.34","APC"
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.19","","","","","","","fee schedule","45.28","54.34","APC"
"Ia nfct ab sarscov2 covid19","86328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.54","","","","","","","fee schedule","45.28","54.34","APC"
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.05","","","","","","","fee schedule","14.05","100.65",""
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.05","","","","","","","fee schedule","14.05","100.65",""
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.05","","","","","","","fee schedule","14.05","100.65",""
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","100.65","","","","","","","fee schedule","14.05","100.65",""
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.13","","","","","","","fee schedule","14.05","100.65",""
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.13","","","","","","","fee schedule","14.05","100.65",""
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.72","","","","","","","fee schedule","14.05","100.65","APC"
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.47","","","","","","","fee schedule","14.05","100.65","APC"
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.33","","","","","","","fee schedule","14.05","100.65","APC"
"Immunodiffusion nes","86329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.75","","","","","","","fee schedule","14.05","100.65","APC"
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","87.95",""
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","87.95",""
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","87.95",""
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","87.95","","","","","","","fee schedule","11.98","87.95",""
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.6","","","","","","","fee schedule","11.98","87.95",""
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.6","","","","","","","fee schedule","11.98","87.95",""
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","87.95","APC"
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","87.95","APC"
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","87.95","APC"
"Immunodiffusion ouchterlony","86331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","87.95","APC"
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.37","","","","","","","fee schedule","24.37","178.89",""
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.37","","","","","","","fee schedule","24.37","178.89",""
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.37","","","","","","","fee schedule","24.37","178.89",""
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","178.89","","","","","","","fee schedule","24.37","178.89",""
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","41.89","","","","","","","fee schedule","24.37","178.89",""
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41.89","","","","","","","fee schedule","24.37","178.89",""
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.53","","","","","","","fee schedule","24.37","178.89","APC"
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.1","","","","","","","fee schedule","24.37","178.89","APC"
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.86","","","","","","","fee schedule","24.37","178.89","APC"
"Immune complex assay","86332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.59","","","","","","","fee schedule","24.37","178.89","APC"
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.34","","","","","","","fee schedule","22.34","167.39",""
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.34","","","","","","","fee schedule","22.34","167.39",""
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.34","","","","","","","fee schedule","22.34","167.39",""
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","167.39","","","","","","","fee schedule","22.34","167.39",""
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.4","","","","","","","fee schedule","22.34","167.39",""
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.4","","","","","","","fee schedule","22.34","167.39",""
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.4","","","","","","","fee schedule","22.34","167.39","APC"
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.01","","","","","","","fee schedule","22.34","167.39","APC"
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.79","","","","","","","fee schedule","22.34","167.39","APC"
"Immunofix e-phoresis serum","86334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.46","","","","","","","fee schedule","22.34","167.39","APC"
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.35","","","","","","","fee schedule","29.35","219.82",""
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.35","","","","","","","fee schedule","29.35","219.82",""
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.35","","","","","","","fee schedule","29.35","219.82",""
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","219.82","","","","","","","fee schedule","29.35","219.82",""
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.45","","","","","","","fee schedule","29.35","219.82",""
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.45","","","","","","","fee schedule","29.35","219.82",""
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.74","","","","","","","fee schedule","29.35","219.82","APC"
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.23","","","","","","","fee schedule","29.35","219.82","APC"
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.94","","","","","","","fee schedule","29.35","219.82","APC"
"Immunfix e-phorsis/urine/csf","86335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.82","","","","","","","fee schedule","29.35","219.82","APC"
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.59","","","","","","","fee schedule","15.59","110.42",""
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.59","","","","","","","fee schedule","15.59","110.42",""
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.59","","","","","","","fee schedule","15.59","110.42",""
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","110.42","","","","","","","fee schedule","15.59","110.42",""
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.78","","","","","","","fee schedule","15.59","110.42",""
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.78","","","","","","","fee schedule","15.59","110.42",""
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.33","","","","","","","fee schedule","15.59","110.42","APC"
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.06","","","","","","","fee schedule","15.59","110.42","APC"
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.9","","","","","","","fee schedule","15.59","110.42","APC"
"Inhibin A","86336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.37","","","","","","","fee schedule","15.59","110.42","APC"
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.41","","","","","","","fee schedule","21.41","155.94",""
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.41","","","","","","","fee schedule","21.41","155.94",""
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.41","","","","","","","fee schedule","21.41","155.94",""
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","155.94","","","","","","","fee schedule","21.41","155.94",""
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.8","","","","","","","fee schedule","21.41","155.94",""
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.8","","","","","","","fee schedule","21.41","155.94",""
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.43","","","","","","","fee schedule","21.41","155.94","APC"
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.05","","","","","","","fee schedule","21.41","155.94","APC"
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.84","","","","","","","fee schedule","21.41","155.94","APC"
"Insulin antibodies","86337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.48","","","","","","","fee schedule","21.41","155.94","APC"
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.08","","","","","","","fee schedule","15.08","112.18",""
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.08","","","","","","","fee schedule","15.08","112.18",""
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.08","","","","","","","fee schedule","15.08","112.18",""
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","112.18","","","","","","","fee schedule","15.08","112.18",""
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.91","","","","","","","fee schedule","15.08","112.18",""
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.91","","","","","","","fee schedule","15.08","112.18",""
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.08","112.18","APC"
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.53","","","","","","","fee schedule","15.08","112.18","APC"
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.38","","","","","","","fee schedule","15.08","112.18","APC"
"Intrinsic factor antibody","86340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.83","","","","","","","fee schedule","15.08","112.18","APC"
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.57","","","","","","","fee schedule","23.57","139.1",""
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.57","","","","","","","fee schedule","23.57","139.1",""
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.57","","","","","","","fee schedule","23.57","139.1",""
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","139.1","","","","","","","fee schedule","23.57","139.1",""
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.01","","","","","","","fee schedule","23.57","139.1",""
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.01","","","","","","","fee schedule","23.57","139.1",""
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.69","","","","","","","fee schedule","23.57","139.1","APC"
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.28","","","","","","","fee schedule","23.57","139.1","APC"
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.04","","","","","","","fee schedule","23.57","139.1","APC"
"Islet cell antibody","86341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.75","","","","","","","fee schedule","23.57","139.1","APC"
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.46","","","","","","","fee schedule","12.46","89.49",""
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.46","","","","","","","fee schedule","12.46","89.49",""
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.46","","","","","","","fee schedule","12.46","89.49",""
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.49","","","","","","","fee schedule","12.46","89.49",""
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.42","","","","","","","fee schedule","12.46","89.49",""
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.42","","","","","","","fee schedule","12.46","89.49",""
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.05","","","","","","","fee schedule","12.46","89.49","APC"
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.46","89.49","APC"
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.71","","","","","","","fee schedule","12.46","89.49","APC"
"Leukocyte histamine release","86343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.08","","","","","","","fee schedule","12.46","89.49","APC"
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.39","","","","","","","fee schedule","10.39","59.16",""
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.39","","","","","","","fee schedule","10.39","59.16",""
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.39","","","","","","","fee schedule","10.39","59.16",""
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.16","","","","","","","fee schedule","10.39","59.16",""
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.73","","","","","","","fee schedule","10.39","59.16",""
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.73","","","","","","","fee schedule","10.39","59.16",""
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.88","","","","","","","fee schedule","10.39","59.16","APC"
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.7","","","","","","","fee schedule","10.39","59.16","APC"
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.6","","","","","","","fee schedule","10.39","59.16","APC"
"Leukocyte phagocytosis","86344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.91","","","","","","","fee schedule","10.39","59.16","APC"
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","135.86","","","","","","","fee schedule","116.76","981.96",""
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","135.86","","","","","","","fee schedule","116.76","981.96",""
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","135.86","","","","","","","fee schedule","116.76","981.96",""
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","981.96","","","","","","","fee schedule","116.76","981.96",""
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","116.76","","","","","","","fee schedule","116.76","981.96",""
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","116.76","","","","","","","fee schedule","116.76","981.96",""
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","142.31","","","","","","","fee schedule","116.76","981.96","APC"
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","139.94","","","","","","","fee schedule","116.76","981.96","APC"
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","138.58","","","","","","","fee schedule","116.76","981.96","APC"
"Cell function assay w/stim","86352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","142.65","","","","","","","fee schedule","116.76","981.96","APC"
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","49.03","","","","","","","fee schedule","49.03","358.61",""
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","49.03","","","","","","","fee schedule","49.03","358.61",""
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","49.03","","","","","","","fee schedule","49.03","358.61",""
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","358.61","","","","","","","fee schedule","49.03","358.61",""
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","84.26","","","","","","","fee schedule","49.03","358.61",""
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","84.26","","","","","","","fee schedule","49.03","358.61",""
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.36","","","","","","","fee schedule","49.03","358.61","APC"
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.5","","","","","","","fee schedule","49.03","358.61","APC"
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.01","","","","","","","fee schedule","49.03","358.61","APC"
"Lymphocyte transformation","86353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.48","","","","","","","fee schedule","49.03","358.61","APC"
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","37.73","","","","","","","fee schedule","37.73","247.08",""
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.73","","","","","","","fee schedule","37.73","247.08",""
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.73","","","","","","","fee schedule","37.73","247.08",""
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","247.08","","","","","","","fee schedule","37.73","247.08",""
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.84","","","","","","","fee schedule","37.73","247.08",""
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.84","","","","","","","fee schedule","37.73","247.08",""
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","37.73","247.08","APC"
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","37.73","247.08","APC"
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","37.73","247.08","APC"
"B cells total count","86355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","37.73","247.08","APC"
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.78","","","","","","","fee schedule","26.78","162.53",""
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.78","","","","","","","fee schedule","26.78","162.53",""
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.78","","","","","","","fee schedule","26.78","162.53",""
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","162.53","","","","","","","fee schedule","26.78","162.53",""
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.02","","","","","","","fee schedule","26.78","162.53",""
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.02","","","","","","","fee schedule","26.78","162.53",""
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.05","","","","","","","fee schedule","26.78","162.53","APC"
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.58","","","","","","","fee schedule","26.78","162.53","APC"
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.32","","","","","","","fee schedule","26.78","162.53","APC"
"Mononuclear cell antigen","86356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.12","","","","","","","fee schedule","26.78","162.53","APC"
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","37.73","","","","","","","fee schedule","37.73","247.08",""
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.73","","","","","","","fee schedule","37.73","247.08",""
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.73","","","","","","","fee schedule","37.73","247.08",""
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","247.08","","","","","","","fee schedule","37.73","247.08",""
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.84","","","","","","","fee schedule","37.73","247.08",""
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.84","","","","","","","fee schedule","37.73","247.08",""
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","37.73","247.08","APC"
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","37.73","247.08","APC"
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","37.73","247.08","APC"
"Nk cells total count","86357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","37.73","247.08","APC"
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","37.73","","","","","","","fee schedule","37.73","247.08",""
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.73","","","","","","","fee schedule","37.73","247.08",""
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.73","","","","","","","fee schedule","37.73","247.08",""
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","247.08","","","","","","","fee schedule","37.73","247.08",""
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.84","","","","","","","fee schedule","37.73","247.08",""
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.84","","","","","","","fee schedule","37.73","247.08",""
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","37.73","247.08","APC"
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","37.73","247.08","APC"
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","37.73","247.08","APC"
"T cells total count","86359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","37.73","247.08","APC"
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.98","","","","","","","fee schedule","46.98","310.18",""
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46.98","","","","","","","fee schedule","46.98","310.18",""
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.98","","","","","","","fee schedule","46.98","310.18",""
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.18","","","","","","","fee schedule","46.98","310.18",""
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","80.76","","","","","","","fee schedule","46.98","310.18",""
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","80.76","","","","","","","fee schedule","46.98","310.18",""
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.21","","","","","","","fee schedule","46.98","310.18","APC"
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.39","","","","","","","fee schedule","46.98","310.18","APC"
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.92","","","","","","","fee schedule","46.98","310.18","APC"
"T cell absolute count/ratio","86360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.33","","","","","","","fee schedule","46.98","310.18","APC"
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.78","","","","","","","fee schedule","26.78","162.53",""
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.78","","","","","","","fee schedule","26.78","162.53",""
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.78","","","","","","","fee schedule","26.78","162.53",""
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","162.53","","","","","","","fee schedule","26.78","162.53",""
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.02","","","","","","","fee schedule","26.78","162.53",""
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.02","","","","","","","fee schedule","26.78","162.53",""
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.05","","","","","","","fee schedule","26.78","162.53","APC"
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.58","","","","","","","fee schedule","26.78","162.53","APC"
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.32","","","","","","","fee schedule","26.78","162.53","APC"
"T cell absolute count","86361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.12","","","","","","","fee schedule","26.78","162.53","APC"
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","14.46",""
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","14.46",""
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","12.05","14.46",""
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","12.05","14.46",""
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","14.46","APC"
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","14.46","APC"
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","14.46","APC"
"Mog-igg1 antb cba each","86362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","14.46","APC"
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","37.73","","","","","","","fee schedule","14.46","39.62",""
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.73","","","","","","","fee schedule","14.46","39.62",""
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.73","","","","","","","fee schedule","14.46","39.62",""
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.46","","","","","","","fee schedule","14.46","39.62",""
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.46","","","","","","","fee schedule","14.46","39.62",""
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.52","","","","","","","fee schedule","14.46","39.62","APC"
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.86","","","","","","","fee schedule","14.46","39.62","APC"
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","14.46","39.62","APC"
"Mog-igg1 antb flo cytmtry ea","86363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.62","","","","","","","fee schedule","14.46","39.62","APC"
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","13.84",""
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","13.84",""
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","13.84",""
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.84","","","","","","","fee schedule","11.53","13.84",""
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.84","","","","","","","fee schedule","11.53","13.84",""
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","13.84","APC"
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","13.84","APC"
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","13.84","APC"
"Tiss trnsgltmnase ea ig clas","86364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","13.84","APC"
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.4","","","","","","","fee schedule","18.4","22.08",""
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.4","","","","","","","fee schedule","18.4","22.08",""
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.4","","","","","","","fee schedule","18.4","22.08",""
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.08","","","","","","","fee schedule","18.4","22.08",""
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.08","","","","","","","fee schedule","18.4","22.08",""
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.27","","","","","","","fee schedule","18.4","22.08","APC"
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.4","22.08","APC"
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.77","","","","","","","fee schedule","18.4","22.08","APC"
"Muscle-specific kinase antb","86366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.32","","","","","","","fee schedule","18.4","22.08","APC"
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","77.78","","","","","","","fee schedule","64.84","247.08",""
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","77.78","","","","","","","fee schedule","64.84","247.08",""
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","77.78","","","","","","","fee schedule","64.84","247.08",""
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","247.08","","","","","","","fee schedule","64.84","247.08",""
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.84","","","","","","","fee schedule","64.84","247.08",""
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.84","","","","","","","fee schedule","64.84","247.08",""
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","81.47","","","","","","","fee schedule","64.84","247.08","APC"
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.11","","","","","","","fee schedule","64.84","247.08","APC"
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.34","","","","","","","fee schedule","64.84","247.08","APC"
"Stem cells total count","86367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81.67","","","","","","","fee schedule","64.84","247.08","APC"
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.55","","","","","","","fee schedule","14.55","107.72",""
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.55","","","","","","","fee schedule","14.55","107.72",""
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.55","","","","","","","fee schedule","14.55","107.72",""
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.72","","","","","","","fee schedule","14.55","107.72",""
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.01","","","","","","","fee schedule","14.55","107.72",""
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.01","","","","","","","fee schedule","14.55","107.72",""
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.24","","","","","","","fee schedule","14.55","107.72","APC"
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.99","","","","","","","fee schedule","14.55","107.72","APC"
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.84","","","","","","","fee schedule","14.55","107.72","APC"
"Microsomal antibody each","86376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.28","","","","","","","fee schedule","14.55","107.72","APC"
"Migration inhibitory factor","86378","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.46","","","","","","","fee schedule","137.46","137.46",""
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.45","","","","","","","fee schedule","25.45","30.54",""
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.45","","","","","","","fee schedule","25.45","30.54",""
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.45","","","","","","","fee schedule","25.45","30.54",""
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.54","","","","","","","fee schedule","25.45","30.54",""
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.54","","","","","","","fee schedule","25.45","30.54",""
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.66","","","","","","","fee schedule","25.45","30.54","APC"
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.21","","","","","","","fee schedule","25.45","30.54","APC"
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.96","","","","","","","fee schedule","25.45","30.54","APC"
"Mitochondrial antibody each","86381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.72","","","","","","","fee schedule","25.45","30.54","APC"
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.91","","","","","","","fee schedule","16.91","121.18",""
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.91","","","","","","","fee schedule","16.91","121.18",""
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.91","","","","","","","fee schedule","16.91","121.18",""
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","121.18","","","","","","","fee schedule","16.91","121.18",""
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.06","","","","","","","fee schedule","16.91","121.18",""
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.06","","","","","","","fee schedule","16.91","121.18",""
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.71","","","","","","","fee schedule","16.91","121.18","APC"
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.42","","","","","","","fee schedule","16.91","121.18","APC"
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.25","","","","","","","fee schedule","16.91","121.18","APC"
"Neutralization test viral","86382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.76","","","","","","","fee schedule","16.91","121.18","APC"
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.61","","","","","","","fee schedule","13.61","83.64",""
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.61","","","","","","","fee schedule","13.61","83.64",""
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.61","","","","","","","fee schedule","13.61","83.64",""
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.64","","","","","","","fee schedule","13.61","83.64",""
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.57","","","","","","","fee schedule","13.61","83.64",""
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.57","","","","","","","fee schedule","13.61","83.64",""
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.26","","","","","","","fee schedule","13.61","83.64","APC"
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.02","","","","","","","fee schedule","13.61","83.64","APC"
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.61","83.64","APC"
"Nitroblue tetrazolium dye","86384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.29","","","","","","","fee schedule","13.61","83.64","APC"
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.78","","","","","","","fee schedule","21.78","112.09",""
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.78","","","","","","","fee schedule","21.78","112.09",""
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.78","","","","","","","fee schedule","21.78","112.09",""
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","112.09","","","","","","","fee schedule","21.78","112.09",""
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.13","","","","","","","fee schedule","21.78","112.09",""
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.13","","","","","","","fee schedule","21.78","112.09",""
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.81","","","","","","","fee schedule","21.78","112.09","APC"
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.43","","","","","","","fee schedule","21.78","112.09","APC"
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.22","","","","","","","fee schedule","21.78","112.09","APC"
"Nuclear matrix protein 22","86386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.87","","","","","","","fee schedule","21.78","112.09","APC"
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.54","","","","","","","fee schedule","11.54","74.83",""
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.54","","","","","","","fee schedule","11.54","74.83",""
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.54","","","","","","","fee schedule","11.54","74.83",""
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","74.83","","","","","","","fee schedule","11.54","74.83",""
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.52","","","","","","","fee schedule","11.54","74.83",""
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.52","","","","","","","fee schedule","11.54","74.83",""
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.09","","","","","","","fee schedule","11.54","74.83","APC"
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.89","","","","","","","fee schedule","11.54","74.83","APC"
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.77","","","","","","","fee schedule","11.54","74.83","APC"
"Particle agglut antbdy scrn","86403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.12","","","","","","","fee schedule","11.54","74.83","APC"
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.64","","","","","","","fee schedule","10.64","76.68",""
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.64","","","","","","","fee schedule","10.64","76.68",""
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.64","","","","","","","fee schedule","10.64","76.68",""
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","76.68","","","","","","","fee schedule","10.64","76.68",""
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.29","","","","","","","fee schedule","10.64","76.68",""
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.29","","","","","","","fee schedule","10.64","76.68",""
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.15","","","","","","","fee schedule","10.64","76.68","APC"
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.96","","","","","","","fee schedule","10.64","76.68","APC"
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.85","","","","","","","fee schedule","10.64","76.68","APC"
"Particle agglut antbdy titr","86406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.17","","","","","","","fee schedule","10.64","76.68","APC"
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.13","","","","","","","fee schedule","42.13","50.56",""
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.13","","","","","","","fee schedule","42.13","50.56",""
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.13","","","","","","","fee schedule","42.13","50.56",""
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.56","","","","","","","fee schedule","42.13","50.56",""
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.56","","","","","","","fee schedule","42.13","50.56",""
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.13","50.56","APC"
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.39","","","","","","","fee schedule","42.13","50.56","APC"
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.97","","","","","","","fee schedule","42.13","50.56","APC"
"Neutrlzg antb sarscov2 scr","86408","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.24","","","","","","","fee schedule","42.13","50.56","APC"
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79.61","","","","","","","fee schedule","79.61","126.4",""
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","79.61","","","","","","","fee schedule","79.61","126.4",""
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","79.61","","","","","","","fee schedule","79.61","126.4",""
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","126.4","","","","","","","fee schedule","79.61","126.4",""
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","126.4","","","","","","","fee schedule","79.61","126.4",""
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","83.39","","","","","","","fee schedule","79.61","126.4","APC"
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","82","","","","","","","fee schedule","79.61","126.4","APC"
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","81.2","","","","","","","fee schedule","79.61","126.4","APC"
"Neutrlzg antb sarscov2 titer","86409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.59","","","","","","","fee schedule","79.61","126.4","APC"
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.43","","","","","","","fee schedule","50.56","54",""
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.43","","","","","","","fee schedule","50.56","54",""
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.43","","","","","","","fee schedule","50.56","54",""
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.56","","","","","","","fee schedule","50.56","54",""
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.56","","","","","","","fee schedule","50.56","54",""
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.87","","","","","","","fee schedule","50.56","54","APC"
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.97","","","","","","","fee schedule","50.56","54","APC"
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.46","","","","","","","fee schedule","50.56","54","APC"
"Sars-cov-2 antb quantitative","86413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54","","","","","","","fee schedule","50.56","54","APC"
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.14","","","","","","","fee schedule","6.14","42.43",""
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.14","","","","","","","fee schedule","6.14","42.43",""
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.14","","","","","","","fee schedule","6.14","42.43",""
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","42.43","","","","","","","fee schedule","6.14","42.43",""
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.76","","","","","","","fee schedule","6.14","42.43",""
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.76","","","","","","","fee schedule","6.14","42.43",""
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.43","","","","","","","fee schedule","6.14","42.43","APC"
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.32","","","","","","","fee schedule","6.14","42.43","APC"
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.26","","","","","","","fee schedule","6.14","42.43","APC"
"Rheumatoid factor test qual","86430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.45","","","","","","","fee schedule","6.14","42.43","APC"
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.67","","","","","","","fee schedule","5.67","42.43",""
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.67","","","","","","","fee schedule","5.67","42.43",""
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.67","","","","","","","fee schedule","5.67","42.43",""
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","42.43","","","","","","","fee schedule","5.67","42.43",""
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.76","","","","","","","fee schedule","5.67","42.43",""
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.76","","","","","","","fee schedule","5.67","42.43",""
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.94","","","","","","","fee schedule","5.67","42.43","APC"
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.84","","","","","","","fee schedule","5.67","42.43","APC"
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.78","","","","","","","fee schedule","5.67","42.43","APC"
"Rheumatoid factor quant","86431","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.95","","","","","","","fee schedule","5.67","42.43","APC"
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","61.98","","","","","","","fee schedule","61.98","459.74",""
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.98","","","","","","","fee schedule","61.98","459.74",""
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.98","","","","","","","fee schedule","61.98","459.74",""
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","459.74","","","","","","","fee schedule","61.98","459.74",""
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","106.52","","","","","","","fee schedule","61.98","459.74",""
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","106.52","","","","","","","fee schedule","61.98","459.74",""
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.92","","","","","","","fee schedule","61.98","459.74","APC"
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.84","","","","","","","fee schedule","61.98","459.74","APC"
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.22","","","","","","","fee schedule","61.98","459.74","APC"
"Tb test cell immun measure","86480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.08","","","","","","","fee schedule","61.98","459.74","APC"
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","100","","","","","","","fee schedule","100","558.43",""
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","100","","","","","","","fee schedule","100","558.43",""
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","100","","","","","","","fee schedule","100","558.43",""
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","558.43","","","","","","","fee schedule","100","558.43",""
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","104.66","","","","","","","fee schedule","100","558.43",""
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","104.66","","","","","","","fee schedule","100","558.43",""
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.75","","","","","","","fee schedule","100","558.43","APC"
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","103","","","","","","","fee schedule","100","558.43","APC"
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","102","","","","","","","fee schedule","100","558.43","APC"
"Tb ag response t-cell susp","86481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","105","","","","","","","fee schedule","100","558.43","APC"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","74.49","","","","","","","fee schedule","6.47","99.86",""
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","6.47","99.86",""
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","6.47","99.86",""
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","6.47","99.86","APC 277.30"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","6.47","99.86","APC 296.56"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","6.47","99.86","APC 308.91"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test candida","86485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.64","","","","","","","fee schedule","6.47","99.86",""
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","6.47","99.86",""
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","6.47","99.86",""
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","6.47","99.86","APC 277.30"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","6.47","99.86","APC 296.56"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","6.47","99.86","APC 308.91"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","6.47","99.86","APC"
"Skin test nos antigen","86486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","6.47","99.86","APC"
"Coccidioidomycosis skin test","86490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.95","","","","","","","fee schedule","6.47","27.95",""
"Coccidioidomycosis skin test","86490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","6.47","27.95",""
"Coccidioidomycosis skin test","86490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","6.47","27.95",""
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","35.33","","","","","","","fee schedule","6.47","128.95",""
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","6.47","128.95",""
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","6.47","128.95",""
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","6.47","128.95","APC 277.30"
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","6.47","128.95","APC 296.56"
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","6.47","128.95","APC 308.91"
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","6.47","128.95","APC"
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","6.47","128.95","APC"
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","6.47","128.95","APC"
"Histoplasmosis skin test","86510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","6.47","128.95","APC"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.7","","","","","","","fee schedule","6.47","99.86",""
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.47","","","","","","","fee schedule","6.47","99.86",""
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.47","","","","","","","fee schedule","6.47","99.86",""
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","6.47","99.86","APC 277.30"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","6.47","99.86","APC 296.56"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","6.47","99.86","APC 308.91"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","6.47","99.86","APC"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","6.47","99.86","APC"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","6.47","99.86","APC"
"TB intradermal test","86580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","6.47","99.86","APC"
"Strptcs pneum antb serot ia","86581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","96.4","","","","","","","fee schedule","93.87","96.63","APC"
"Strptcs pneum antb serot ia","86581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.79","","","","","","","fee schedule","93.87","96.63","APC"
"Strptcs pneum antb serot ia","86581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.87","","","","","","","fee schedule","93.87","96.63","APC"
"Strptcs pneum antb serot ia","86581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.63","","","","","","","fee schedule","93.87","96.63","APC"
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.66","","","","","","","fee schedule","12.66","78.24",""
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.66","","","","","","","fee schedule","12.66","78.24",""
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.66","","","","","","","fee schedule","12.66","78.24",""
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","78.24","","","","","","","fee schedule","12.66","78.24",""
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.97","","","","","","","fee schedule","12.66","78.24",""
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.97","","","","","","","fee schedule","12.66","78.24",""
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.66","78.24","APC"
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.04","","","","","","","fee schedule","12.66","78.24","APC"
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.91","","","","","","","fee schedule","12.66","78.24","APC"
"Streptokinase antibody","86590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.29","","","","","","","fee schedule","12.66","78.24","APC"
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","31.47",""
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","31.47",""
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","31.47",""
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.47","","","","","","","fee schedule","4.27","31.47",""
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.27","31.47",""
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.27","31.47",""
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","31.47","APC"
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","31.47","APC"
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","31.47","APC"
"Syphilis test non-trep qual","86592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","31.47","APC"
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.4","","","","","","","fee schedule","4.4","33.09",""
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.4","","","","","","","fee schedule","4.4","33.09",""
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.4","","","","","","","fee schedule","4.4","33.09",""
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.09","","","","","","","fee schedule","4.4","33.09",""
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.56","","","","","","","fee schedule","4.4","33.09",""
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.56","","","","","","","fee schedule","4.4","33.09",""
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.61","","","","","","","fee schedule","4.4","33.09","APC"
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.53","","","","","","","fee schedule","4.4","33.09","APC"
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.49","","","","","","","fee schedule","4.4","33.09","APC"
"Syphilis test non-trep quant","86593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.62","","","","","","","fee schedule","4.4","33.09","APC"
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","22.08",""
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","22.08",""
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","22.08",""
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.08","","","","","","","fee schedule","12.05","22.08",""
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.08","","","","","","","fee schedule","12.05","22.08",""
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","22.08","APC"
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","22.08","APC"
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","22.08","APC"
"Voltage-gtd ca chnl antb ea","86596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","22.08","APC"
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.18","","","","","","","fee schedule","10.18","70.09",""
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.18","","","","","","","fee schedule","10.18","70.09",""
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.18","","","","","","","fee schedule","10.18","70.09",""
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.09","","","","","","","fee schedule","10.18","70.09",""
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.48","","","","","","","fee schedule","10.18","70.09",""
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.48","","","","","","","fee schedule","10.18","70.09",""
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.18","70.09","APC"
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.18","70.09","APC"
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.38","","","","","","","fee schedule","10.18","70.09","APC"
"Antinomyces antibody","86602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.18","70.09","APC"
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.87","","","","","","","fee schedule","12.87","84.92",""
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.87","","","","","","","fee schedule","12.87","84.92",""
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.87","","","","","","","fee schedule","12.87","84.92",""
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","84.92","","","","","","","fee schedule","12.87","84.92",""
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.12","","","","","","","fee schedule","12.87","84.92",""
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.12","","","","","","","fee schedule","12.87","84.92",""
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.48","","","","","","","fee schedule","12.87","84.92","APC"
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.87","84.92","APC"
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.87","84.92","APC"
"Adenovirus antibody","86603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.87","84.92","APC"
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.05","","","","","","","fee schedule","15.05","100.42",""
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.05","","","","","","","fee schedule","15.05","100.42",""
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.05","","","","","","","fee schedule","15.05","100.42",""
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","100.42","","","","","","","fee schedule","15.05","100.42",""
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","15.05","100.42",""
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","15.05","100.42",""
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.05","100.42","APC"
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.5","","","","","","","fee schedule","15.05","100.42","APC"
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.35","","","","","","","fee schedule","15.05","100.42","APC"
"Aspergillus antibody","86606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.05","100.42","APC"
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.88","","","","","","","fee schedule","12.88","89.55",""
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.88","","","","","","","fee schedule","12.88","89.55",""
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.88","","","","","","","fee schedule","12.88","89.55",""
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.55","","","","","","","fee schedule","12.88","89.55",""
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.15","","","","","","","fee schedule","12.88","89.55",""
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.15","","","","","","","fee schedule","12.88","89.55",""
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.49","","","","","","","fee schedule","12.88","89.55","APC"
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.27","","","","","","","fee schedule","12.88","89.55","APC"
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.14","","","","","","","fee schedule","12.88","89.55","APC"
"Bacterium antibody","86609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.52","","","","","","","fee schedule","12.88","89.55","APC"
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.18","","","","","","","fee schedule","10.18","70.09",""
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.18","","","","","","","fee schedule","10.18","70.09",""
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.18","","","","","","","fee schedule","10.18","70.09",""
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.09","","","","","","","fee schedule","10.18","70.09",""
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.48","","","","","","","fee schedule","10.18","70.09",""
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.48","","","","","","","fee schedule","10.18","70.09",""
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.18","70.09","APC"
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.18","70.09","APC"
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.38","","","","","","","fee schedule","10.18","70.09","APC"
"Bartonella Antibody","86611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.18","70.09","APC"
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.9","","","","","","","fee schedule","12.9","86.34",""
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.9","","","","","","","fee schedule","12.9","86.34",""
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.9","","","","","","","fee schedule","12.9","86.34",""
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.34","","","","","","","fee schedule","12.9","86.34",""
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.19","","","","","","","fee schedule","12.9","86.34",""
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.19","","","","","","","fee schedule","12.9","86.34",""
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.9","86.34","APC"
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.29","","","","","","","fee schedule","12.9","86.34","APC"
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.16","","","","","","","fee schedule","12.9","86.34","APC"
"Blastomyces antibody","86612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.55","","","","","","","fee schedule","12.9","86.34","APC"
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","93.75",""
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","93.75",""
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","93.75",""
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.75","","","","","","","fee schedule","13.19","93.75",""
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","93.75",""
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","93.75",""
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","93.75","APC"
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","93.75","APC"
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","93.75","APC"
"Bordetella antibody","86615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","93.75","APC"
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.49","","","","","","","fee schedule","15.49","113.71",""
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.49","","","","","","","fee schedule","15.49","113.71",""
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.49","","","","","","","fee schedule","15.49","113.71",""
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","113.71","","","","","","","fee schedule","15.49","113.71",""
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.63","","","","","","","fee schedule","15.49","113.71",""
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.63","","","","","","","fee schedule","15.49","113.71",""
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.23","","","","","","","fee schedule","15.49","113.71","APC"
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.95","","","","","","","fee schedule","15.49","113.71","APC"
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.49","113.71","APC"
"Lyme disease antibody","86617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.26","","","","","","","fee schedule","15.49","113.71","APC"
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.03","","","","","","","fee schedule","17.03","122.01",""
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.03","","","","","","","fee schedule","17.03","122.01",""
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.03","","","","","","","fee schedule","17.03","122.01",""
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","122.01","","","","","","","fee schedule","17.03","122.01",""
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.28","","","","","","","fee schedule","17.03","122.01",""
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.28","","","","","","","fee schedule","17.03","122.01",""
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.84","","","","","","","fee schedule","17.03","122.01","APC"
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.54","","","","","","","fee schedule","17.03","122.01","APC"
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.37","","","","","","","fee schedule","17.03","122.01","APC"
"Lyme disease antibody","86618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.88","","","","","","","fee schedule","17.03","122.01","APC"
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.38","","","","","","","fee schedule","13.38","96.93",""
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.38","","","","","","","fee schedule","13.38","96.93",""
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.38","","","","","","","fee schedule","13.38","96.93",""
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.93","","","","","","","fee schedule","13.38","96.93",""
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23","","","","","","","fee schedule","13.38","96.93",""
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23","","","","","","","fee schedule","13.38","96.93",""
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.02","","","","","","","fee schedule","13.38","96.93","APC"
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.78","","","","","","","fee schedule","13.38","96.93","APC"
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.38","96.93","APC"
"Borrelia antibody","86619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.05","","","","","","","fee schedule","13.38","96.93","APC"
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.93","","","","","","","fee schedule","8.93","63.39",""
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.93","","","","","","","fee schedule","8.93","63.39",""
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.93","","","","","","","fee schedule","8.93","63.39",""
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.39","","","","","","","fee schedule","8.93","63.39",""
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.35","","","","","","","fee schedule","8.93","63.39",""
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.35","","","","","","","fee schedule","8.93","63.39",""
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.35","","","","","","","fee schedule","8.93","63.39","APC"
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.2","","","","","","","fee schedule","8.93","63.39","APC"
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.11","","","","","","","fee schedule","8.93","63.39","APC"
"Brucella antibody","86622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.38","","","","","","","fee schedule","8.93","63.39","APC"
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.12","","","","","","","fee schedule","13.12","88.52",""
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.12","","","","","","","fee schedule","13.12","88.52",""
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.12","","","","","","","fee schedule","13.12","88.52",""
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.52","","","","","","","fee schedule","13.12","88.52",""
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.56","","","","","","","fee schedule","13.12","88.52",""
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.56","","","","","","","fee schedule","13.12","88.52",""
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.74","","","","","","","fee schedule","13.12","88.52","APC"
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.51","","","","","","","fee schedule","13.12","88.52","APC"
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.38","","","","","","","fee schedule","13.12","88.52","APC"
"Campylobacter antibody","86625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.78","","","","","","","fee schedule","13.12","88.52","APC"
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.01","","","","","","","fee schedule","12.01","82.3",""
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.01","","","","","","","fee schedule","12.01","82.3",""
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.01","","","","","","","fee schedule","12.01","82.3",""
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.3","","","","","","","fee schedule","12.01","82.3",""
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.64","","","","","","","fee schedule","12.01","82.3",""
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.64","","","","","","","fee schedule","12.01","82.3",""
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.58","","","","","","","fee schedule","12.01","82.3","APC"
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.37","","","","","","","fee schedule","12.01","82.3","APC"
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.25","","","","","","","fee schedule","12.01","82.3","APC"
"Candida antibody","86628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.61","","","","","","","fee schedule","12.01","82.3","APC"
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.82","","","","","","","fee schedule","11.82","82.73",""
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.82","","","","","","","fee schedule","11.82","82.73",""
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.82","","","","","","","fee schedule","11.82","82.73",""
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.73","","","","","","","fee schedule","11.82","82.73",""
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.33","","","","","","","fee schedule","11.82","82.73",""
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.33","","","","","","","fee schedule","11.82","82.73",""
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.38","","","","","","","fee schedule","11.82","82.73","APC"
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.17","","","","","","","fee schedule","11.82","82.73","APC"
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.06","","","","","","","fee schedule","11.82","82.73","APC"
"Chlamydia antibody","86631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.41","","","","","","","fee schedule","11.82","82.73","APC"
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.68","","","","","","","fee schedule","12.68","89.97",""
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.68","","","","","","","fee schedule","12.68","89.97",""
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.68","","","","","","","fee schedule","12.68","89.97",""
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.97","","","","","","","fee schedule","12.68","89.97",""
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.82","","","","","","","fee schedule","12.68","89.97",""
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.82","","","","","","","fee schedule","12.68","89.97",""
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.28","","","","","","","fee schedule","12.68","89.97","APC"
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.06","","","","","","","fee schedule","12.68","89.97","APC"
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.93","","","","","","","fee schedule","12.68","89.97","APC"
"Chlamydia igm antibody","86632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.31","","","","","","","fee schedule","12.68","89.97","APC"
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.47","","","","","","","fee schedule","11.47","78.24",""
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.47","","","","","","","fee schedule","11.47","78.24",""
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.47","","","","","","","fee schedule","11.47","78.24",""
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","78.24","","","","","","","fee schedule","11.47","78.24",""
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.72","","","","","","","fee schedule","11.47","78.24",""
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.72","","","","","","","fee schedule","11.47","78.24",""
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.01","","","","","","","fee schedule","11.47","78.24","APC"
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.81","","","","","","","fee schedule","11.47","78.24","APC"
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.7","","","","","","","fee schedule","11.47","78.24","APC"
"Coccidioides antibody","86635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.04","","","","","","","fee schedule","11.47","78.24","APC"
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.12","","","","","","","fee schedule","12.12","79.78",""
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.12","","","","","","","fee schedule","12.12","79.78",""
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.12","","","","","","","fee schedule","12.12","79.78",""
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.78","","","","","","","fee schedule","12.12","79.78",""
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.84","","","","","","","fee schedule","12.12","79.78",""
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.84","","","","","","","fee schedule","12.12","79.78",""
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.7","","","","","","","fee schedule","12.12","79.78","APC"
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.48","","","","","","","fee schedule","12.12","79.78","APC"
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.36","","","","","","","fee schedule","12.12","79.78","APC"
"Q fever antibody","86638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.73","","","","","","","fee schedule","12.12","79.78","APC"
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.41","","","","","","","fee schedule","14.41","97.04",""
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.41","","","","","","","fee schedule","14.41","97.04",""
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.41","","","","","","","fee schedule","14.41","97.04",""
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","97.04","","","","","","","fee schedule","14.41","97.04",""
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.78","","","","","","","fee schedule","14.41","97.04",""
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.78","","","","","","","fee schedule","14.41","97.04",""
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.09","","","","","","","fee schedule","14.41","97.04","APC"
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.84","","","","","","","fee schedule","14.41","97.04","APC"
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.7","","","","","","","fee schedule","14.41","97.04","APC"
"Cryptococcus antibody","86641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.13","","","","","","","fee schedule","14.41","97.04","APC"
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.39","","","","","","","fee schedule","14.39","105.96",""
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.39","","","","","","","fee schedule","14.39","105.96",""
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.39","","","","","","","fee schedule","14.39","105.96",""
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.96","","","","","","","fee schedule","14.39","105.96",""
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.74","","","","","","","fee schedule","14.39","105.96",""
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.74","","","","","","","fee schedule","14.39","105.96",""
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.07","","","","","","","fee schedule","14.39","105.96","APC"
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.82","","","","","","","fee schedule","14.39","105.96","APC"
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.68","","","","","","","fee schedule","14.39","105.96","APC"
"CMV antibody","86644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.11","","","","","","","fee schedule","14.39","105.96","APC"
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.85","","","","","","","fee schedule","16.85","113.09",""
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.85","","","","","","","fee schedule","16.85","113.09",""
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.85","","","","","","","fee schedule","16.85","113.09",""
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","113.09","","","","","","","fee schedule","16.85","113.09",""
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.94","","","","","","","fee schedule","16.85","113.09",""
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.94","","","","","","","fee schedule","16.85","113.09",""
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.65","","","","","","","fee schedule","16.85","113.09","APC"
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.36","","","","","","","fee schedule","16.85","113.09","APC"
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.19","","","","","","","fee schedule","16.85","113.09","APC"
"Cmv antibody igm","86645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.69","","","","","","","fee schedule","16.85","113.09","APC"
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.21","","","","","","","fee schedule","15.21","102.98",""
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.21","","","","","","","fee schedule","15.21","102.98",""
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.21","","","","","","","fee schedule","15.21","102.98",""
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.98","","","","","","","fee schedule","15.21","102.98",""
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.15","","","","","","","fee schedule","15.21","102.98",""
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.15","","","","","","","fee schedule","15.21","102.98",""
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.93","","","","","","","fee schedule","15.21","102.98","APC"
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.67","","","","","","","fee schedule","15.21","102.98","APC"
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.51","","","","","","","fee schedule","15.21","102.98","APC"
"Diphtheria antibody","86648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.97","","","","","","","fee schedule","15.21","102.98","APC"
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.04","","","","","","","fee schedule","13.19","92.04",""
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","92.04","APC"
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","92.04","APC"
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","92.04","APC"
"Encephalitis californ antbdy","86651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.04","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis east eqne anbdy","86652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.04","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis st louis antbody","86653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.04","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","92.04",""
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","92.04","APC"
"Encephaltis west eqne antbdy","86654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","92.04","APC"
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.03","","","","","","","fee schedule","13.03","85.65",""
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.03","","","","","","","fee schedule","13.03","85.65",""
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.03","","","","","","","fee schedule","13.03","85.65",""
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85.65","","","","","","","fee schedule","13.03","85.65",""
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.39","","","","","","","fee schedule","13.03","85.65",""
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.39","","","","","","","fee schedule","13.03","85.65",""
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.03","85.65","APC"
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.42","","","","","","","fee schedule","13.03","85.65","APC"
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.29","","","","","","","fee schedule","13.03","85.65","APC"
"Enterovirus antibody","86658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.68","","","","","","","fee schedule","13.03","85.65","APC"
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.12","","","","","","","fee schedule","13.12","96.28",""
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.12","","","","","","","fee schedule","13.12","96.28",""
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.12","","","","","","","fee schedule","13.12","96.28",""
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.28","","","","","","","fee schedule","13.12","96.28",""
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.56","","","","","","","fee schedule","13.12","96.28",""
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.56","","","","","","","fee schedule","13.12","96.28",""
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.74","","","","","","","fee schedule","13.12","96.28","APC"
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.51","","","","","","","fee schedule","13.12","96.28","APC"
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.38","","","","","","","fee schedule","13.12","96.28","APC"
"Epstein-barr antibody","86663","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.78","","","","","","","fee schedule","13.12","96.28","APC"
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.29","","","","","","","fee schedule","15.29","109.51",""
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.29","","","","","","","fee schedule","15.29","109.51",""
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.29","","","","","","","fee schedule","15.29","109.51",""
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","109.51","","","","","","","fee schedule","15.29","109.51",""
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.29","","","","","","","fee schedule","15.29","109.51",""
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.29","","","","","","","fee schedule","15.29","109.51",""
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.02","","","","","","","fee schedule","15.29","109.51","APC"
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.75","","","","","","","fee schedule","15.29","109.51","APC"
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.6","","","","","","","fee schedule","15.29","109.51","APC"
"Epstein-barr nuclear antigen","86664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.05","","","","","","","fee schedule","15.29","109.51","APC"
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.14","","","","","","","fee schedule","18.14","123.37",""
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.14","","","","","","","fee schedule","18.14","123.37",""
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.14","","","","","","","fee schedule","18.14","123.37",""
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","123.37","","","","","","","fee schedule","18.14","123.37",""
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.18","","","","","","","fee schedule","18.14","123.37",""
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.18","","","","","","","fee schedule","18.14","123.37",""
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19","","","","","","","fee schedule","18.14","123.37","APC"
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.68","","","","","","","fee schedule","18.14","123.37","APC"
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.5","","","","","","","fee schedule","18.14","123.37","APC"
"Epstein-barr capsid vca","86665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.05","","","","","","","fee schedule","18.14","123.37","APC"
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.18","","","","","","","fee schedule","10.18","70.09",""
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.18","","","","","","","fee schedule","10.18","70.09",""
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.18","","","","","","","fee schedule","10.18","70.09",""
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.48","","","","","","","fee schedule","10.18","70.09",""
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.09","","","","","","","fee schedule","10.18","70.09",""
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.48","","","","","","","fee schedule","10.18","70.09",""
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.18","70.09","APC"
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.49","","","","","","","fee schedule","10.18","70.09","APC"
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.38","","","","","","","fee schedule","10.18","70.09","APC"
"Ehrlichia Antibody","86666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.18","70.09","APC"
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.16","","","","","","","fee schedule","14.16","73.56",""
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.16","","","","","","","fee schedule","14.16","73.56",""
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.16","","","","","","","fee schedule","14.16","73.56",""
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.88","","","","","","","fee schedule","14.16","73.56",""
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","73.56","","","","","","","fee schedule","14.16","73.56",""
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.88","","","","","","","fee schedule","14.16","73.56",""
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.83","","","","","","","fee schedule","14.16","73.56","APC"
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.58","","","","","","","fee schedule","14.16","73.56","APC"
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.44","","","","","","","fee schedule","14.16","73.56","APC"
"Francisella tularensis","86668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.87","","","","","","","fee schedule","14.16","73.56","APC"
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.25","","","","","","","fee schedule","12.25","79.43",""
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.25","","","","","","","fee schedule","12.25","79.43",""
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.25","","","","","","","fee schedule","12.25","79.43",""
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","12.25","79.43",""
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.07","","","","","","","fee schedule","12.25","79.43",""
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.07","","","","","","","fee schedule","12.25","79.43",""
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.25","79.43","APC"
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.25","79.43","APC"
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.5","","","","","","","fee schedule","12.25","79.43","APC"
"Fungus nes antibody","86671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.86","","","","","","","fee schedule","12.25","79.43","APC"
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.72","","","","","","","fee schedule","14.72","107.47",""
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.72","","","","","","","fee schedule","14.72","107.47",""
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.72","","","","","","","fee schedule","14.72","107.47",""
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.47","","","","","","","fee schedule","14.72","107.47",""
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.3","","","","","","","fee schedule","14.72","107.47",""
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.3","","","","","","","fee schedule","14.72","107.47",""
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.42","","","","","","","fee schedule","14.72","107.47","APC"
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.16","","","","","","","fee schedule","14.72","107.47","APC"
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.01","","","","","","","fee schedule","14.72","107.47","APC"
"Giardia lamblia antibody","86674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.46","","","","","","","fee schedule","14.72","107.47","APC"
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.85","","","","","","","fee schedule","16.85","102.33",""
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.85","","","","","","","fee schedule","16.85","102.33",""
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.85","","","","","","","fee schedule","16.85","102.33",""
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.33","","","","","","","fee schedule","16.85","102.33",""
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.95","","","","","","","fee schedule","16.85","102.33",""
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.95","","","","","","","fee schedule","16.85","102.33",""
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.65","","","","","","","fee schedule","16.85","102.33","APC"
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.36","","","","","","","fee schedule","16.85","102.33","APC"
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.19","","","","","","","fee schedule","16.85","102.33","APC"
"Helicobacter pylori antibody","86677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.69","","","","","","","fee schedule","16.85","102.33","APC"
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.01","","","","","","","fee schedule","13.01","88.86",""
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.01","","","","","","","fee schedule","13.01","88.86",""
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.01","","","","","","","fee schedule","13.01","88.86",""
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.86","","","","","","","fee schedule","13.01","88.86",""
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.36","","","","","","","fee schedule","13.01","88.86",""
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.36","","","","","","","fee schedule","13.01","88.86",""
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.63","","","","","","","fee schedule","13.01","88.86","APC"
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.4","","","","","","","fee schedule","13.01","88.86","APC"
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.27","","","","","","","fee schedule","13.01","88.86","APC"
"Helminth antibody","86682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.66","","","","","","","fee schedule","13.01","88.86","APC"
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.84","","","","","","","fee schedule","15.84","110.42",""
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.84","","","","","","","fee schedule","15.84","110.42",""
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.84","","","","","","","fee schedule","15.84","110.42",""
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","110.42","","","","","","","fee schedule","15.84","110.42",""
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.24","","","","","","","fee schedule","15.84","110.42",""
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.24","","","","","","","fee schedule","15.84","110.42",""
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.59","","","","","","","fee schedule","15.84","110.42","APC"
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.32","","","","","","","fee schedule","15.84","110.42","APC"
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.16","","","","","","","fee schedule","15.84","110.42","APC"
"Hemophilus influenza antibdy","86684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.63","","","","","","","fee schedule","15.84","110.42","APC"
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.09","","","","","","","fee schedule","9.09","62.96",""
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.09","","","","","","","fee schedule","9.09","62.96",""
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.09","","","","","","","fee schedule","9.09","62.96",""
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","62.96","","","","","","","fee schedule","9.09","62.96",""
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.42","","","","","","","fee schedule","9.09","62.96",""
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.42","","","","","","","fee schedule","9.09","62.96",""
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.52","","","","","","","fee schedule","9.09","62.96","APC"
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.36","","","","","","","fee schedule","9.09","62.96","APC"
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.27","","","","","","","fee schedule","9.09","62.96","APC"
"Htlv-i antibody","86687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.54","","","","","","","fee schedule","9.09","62.96","APC"
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14","","","","","","","fee schedule","14","92.58",""
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14","","","","","","","fee schedule","14","92.58",""
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14","","","","","","","fee schedule","14","92.58",""
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.58","","","","","","","fee schedule","14","92.58",""
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.08","","","","","","","fee schedule","14","92.58",""
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.08","","","","","","","fee schedule","14","92.58",""
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.66","","","","","","","fee schedule","14","92.58","APC"
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.42","","","","","","","fee schedule","14","92.58","APC"
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.28","","","","","","","fee schedule","14","92.58","APC"
"Htlv-ii antibody","86688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.7","","","","","","","fee schedule","14","92.58","APC"
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.35","","","","","","","fee schedule","19.35","142.14",""
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.35","","","","","","","fee schedule","19.35","142.14",""
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.35","","","","","","","fee schedule","19.35","142.14",""
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.14","","","","","","","fee schedule","19.35","142.14",""
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.26","","","","","","","fee schedule","19.35","142.14",""
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.26","","","","","","","fee schedule","19.35","142.14",""
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.27","","","","","","","fee schedule","19.35","142.14","APC"
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.93","","","","","","","fee schedule","19.35","142.14","APC"
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.74","","","","","","","fee schedule","19.35","142.14","APC"
"Htlv/hiv confirmj antibody","86689","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.32","","","","","","","fee schedule","19.35","142.14","APC"
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.16","","","","","","","fee schedule","17.16","124.48",""
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.16","","","","","","","fee schedule","17.16","124.48",""
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.16","","","","","","","fee schedule","17.16","124.48",""
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.48","","","","","","","fee schedule","17.16","124.48",""
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29.5","","","","","","","fee schedule","17.16","124.48",""
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","29.5","","","","","","","fee schedule","17.16","124.48",""
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.98","","","","","","","fee schedule","17.16","124.48","APC"
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.67","","","","","","","fee schedule","17.16","124.48","APC"
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.5","","","","","","","fee schedule","17.16","124.48","APC"
"Hepatitis delta agent antbdy","86692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.02","","","","","","","fee schedule","17.16","124.48","APC"
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.39","","","","","","","fee schedule","14.39","105.96",""
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.39","","","","","","","fee schedule","14.39","105.96",""
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.39","","","","","","","fee schedule","14.39","105.96",""
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.96","","","","","","","fee schedule","14.39","105.96",""
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.74","","","","","","","fee schedule","14.39","105.96",""
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.74","","","","","","","fee schedule","14.39","105.96",""
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.07","","","","","","","fee schedule","14.39","105.96","APC"
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.82","","","","","","","fee schedule","14.39","105.96","APC"
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.68","","","","","","","fee schedule","14.39","105.96","APC"
"Herpes simplex nes antbdy","86694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.11","","","","","","","fee schedule","14.39","105.96","APC"
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","94.94",""
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","94.94",""
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","94.94",""
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","94.94","","","","","","","fee schedule","13.19","94.94",""
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","94.94",""
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","94.94",""
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","94.94","APC"
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","94.94","APC"
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","94.94","APC"
"Herpes simplex type 1 test","86695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","94.94","APC"
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.35","","","","","","","fee schedule","19.35","142.14",""
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.35","","","","","","","fee schedule","19.35","142.14",""
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.35","","","","","","","fee schedule","19.35","142.14",""
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.14","","","","","","","fee schedule","19.35","142.14",""
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.26","","","","","","","fee schedule","19.35","142.14",""
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.26","","","","","","","fee schedule","19.35","142.14",""
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.27","","","","","","","fee schedule","19.35","142.14","APC"
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.93","","","","","","","fee schedule","19.35","142.14","APC"
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.74","","","","","","","fee schedule","19.35","142.14","APC"
"Herpes simplex type 2 test","86696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.32","","","","","","","fee schedule","19.35","142.14","APC"
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.79","","","","","","","fee schedule","13.79","89.69",""
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.79","","","","","","","fee schedule","13.79","89.69",""
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.79","","","","","","","fee schedule","13.79","89.69",""
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.69","","","","","","","fee schedule","13.79","89.69",""
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.49","","","","","","","fee schedule","13.79","89.69",""
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.49","","","","","","","fee schedule","13.79","89.69",""
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.45","","","","","","","fee schedule","13.79","89.69","APC"
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.2","","","","","","","fee schedule","13.79","89.69","APC"
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.07","","","","","","","fee schedule","13.79","89.69","APC"
"Histoplasma antibody","86698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.48","","","","","","","fee schedule","13.79","89.69","APC"
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.89","","","","","","","fee schedule","8.89","65.8",""
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.89","","","","","","","fee schedule","8.89","65.8",""
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.89","","","","","","","fee schedule","8.89","65.8",""
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","65.8","","","","","","","fee schedule","8.89","65.8",""
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.26","","","","","","","fee schedule","8.89","65.8",""
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.26","","","","","","","fee schedule","8.89","65.8",""
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.31","","","","","","","fee schedule","8.89","65.8","APC"
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.16","","","","","","","fee schedule","8.89","65.8","APC"
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.07","","","","","","","fee schedule","8.89","65.8","APC"
"Hiv-1antibody","86701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.33","","","","","","","fee schedule","8.89","65.8","APC"
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.52","","","","","","","fee schedule","13.52","92.58",""
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.52","","","","","","","fee schedule","13.52","92.58",""
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.52","","","","","","","fee schedule","13.52","92.58",""
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.58","","","","","","","fee schedule","13.52","92.58",""
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.24","","","","","","","fee schedule","13.52","92.58",""
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.24","","","","","","","fee schedule","13.52","92.58",""
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.16","","","","","","","fee schedule","13.52","92.58","APC"
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.93","","","","","","","fee schedule","13.52","92.58","APC"
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.79","","","","","","","fee schedule","13.52","92.58","APC"
"Hiv-2 antibody","86702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.2","","","","","","","fee schedule","13.52","92.58","APC"
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.71","","","","","","","fee schedule","13.71","95.88",""
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.71","","","","","","","fee schedule","13.71","95.88",""
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.71","","","","","","","fee schedule","13.71","95.88",""
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.88","","","","","","","fee schedule","13.71","95.88",""
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.58","","","","","","","fee schedule","13.71","95.88",""
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.58","","","","","","","fee schedule","13.71","95.88",""
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.36","","","","","","","fee schedule","13.71","95.88","APC"
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.12","","","","","","","fee schedule","13.71","95.88","APC"
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.98","","","","","","","fee schedule","13.71","95.88","APC"
"Hiv-1/hiv-2 1 result antbdy","86703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.4","","","","","","","fee schedule","13.71","95.88","APC"
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","89.29",""
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","89.29",""
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","89.29",""
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.29","","","","","","","fee schedule","12.05","89.29",""
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.71","","","","","","","fee schedule","12.05","89.29",""
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.71","","","","","","","fee schedule","12.05","89.29",""
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","89.29","APC"
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","89.29","APC"
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","89.29","APC"
"Hep b core antibody total","86704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","89.29","APC"
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.77","","","","","","","fee schedule","11.77","87.19",""
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.77","","","","","","","fee schedule","11.77","87.19",""
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.77","","","","","","","fee schedule","11.77","87.19",""
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","87.19","","","","","","","fee schedule","11.77","87.19",""
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.23","","","","","","","fee schedule","11.77","87.19",""
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.23","","","","","","","fee schedule","11.77","87.19",""
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.33","","","","","","","fee schedule","11.77","87.19","APC"
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.12","","","","","","","fee schedule","11.77","87.19","APC"
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.01","","","","","","","fee schedule","11.77","87.19","APC"
"Hep b core antibody igm","86705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.36","","","","","","","fee schedule","11.77","87.19","APC"
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.74","","","","","","","fee schedule","10.74","79.55",""
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.74","","","","","","","fee schedule","10.74","79.55",""
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.74","","","","","","","fee schedule","10.74","79.55",""
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.55","","","","","","","fee schedule","10.74","79.55",""
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.46","","","","","","","fee schedule","10.74","79.55",""
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.46","","","","","","","fee schedule","10.74","79.55",""
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.25","","","","","","","fee schedule","10.74","79.55","APC"
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.74","79.55","APC"
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.74","79.55","APC"
"Hep b surface antibody","86706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.28","","","","","","","fee schedule","10.74","79.55","APC"
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.57","","","","","","","fee schedule","11.57","85.82",""
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.57","","","","","","","fee schedule","11.57","85.82",""
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.57","","","","","","","fee schedule","11.57","85.82",""
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85.82","","","","","","","fee schedule","11.57","85.82",""
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.88","","","","","","","fee schedule","11.57","85.82",""
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.88","","","","","","","fee schedule","11.57","85.82",""
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.12","","","","","","","fee schedule","11.57","85.82","APC"
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.92","","","","","","","fee schedule","11.57","85.82","APC"
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.8","","","","","","","fee schedule","11.57","85.82","APC"
"Hepatitis be antibody","86707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.15","","","","","","","fee schedule","11.57","85.82","APC"
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.39","","","","","","","fee schedule","12.39","92.58",""
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.39","","","","","","","fee schedule","12.39","92.58",""
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.39","","","","","","","fee schedule","12.39","92.58",""
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.58","","","","","","","fee schedule","12.39","92.58",""
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.3","","","","","","","fee schedule","12.39","92.58",""
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.3","","","","","","","fee schedule","12.39","92.58",""
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.98","","","","","","","fee schedule","12.39","92.58","APC"
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.76","","","","","","","fee schedule","12.39","92.58","APC"
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.64","","","","","","","fee schedule","12.39","92.58","APC"
"Hepatitis a antibody","86708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.01","","","","","","","fee schedule","12.39","92.58","APC"
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.26","","","","","","","fee schedule","11.26","82.79",""
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.26","","","","","","","fee schedule","11.26","82.79",""
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.26","","","","","","","fee schedule","11.26","82.79",""
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.34","","","","","","","fee schedule","11.26","82.79",""
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.79","","","","","","","fee schedule","11.26","82.79",""
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.34","","","","","","","fee schedule","11.26","82.79",""
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.79","","","","","","","fee schedule","11.26","82.79","APC"
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.6","","","","","","","fee schedule","11.26","82.79","APC"
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.49","","","","","","","fee schedule","11.26","82.79","APC"
"Hepatitis a igm antibody","86709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.82","","","","","","","fee schedule","11.26","82.79","APC"
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.55","","","","","","","fee schedule","13.55","96.36",""
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.55","","","","","","","fee schedule","13.55","96.36",""
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.55","","","","","","","fee schedule","13.55","96.36",""
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.3","","","","","","","fee schedule","13.55","96.36",""
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.36","","","","","","","fee schedule","13.55","96.36",""
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.3","","","","","","","fee schedule","13.55","96.36",""
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.19","","","","","","","fee schedule","13.55","96.36","APC"
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.96","","","","","","","fee schedule","13.55","96.36","APC"
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.55","96.36","APC"
"Influenza virus antibody","86710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.23","","","","","","","fee schedule","13.55","96.36","APC"
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.89","","","","","","","fee schedule","16.89","105.96",""
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.89","","","","","","","fee schedule","16.89","105.96",""
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.89","","","","","","","fee schedule","16.89","105.96",""
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.75","","","","","","","fee schedule","16.89","105.96",""
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.96","","","","","","","fee schedule","16.89","105.96",""
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.75","","","","","","","fee schedule","16.89","105.96",""
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.69","","","","","","","fee schedule","16.89","105.96","APC"
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.4","","","","","","","fee schedule","16.89","105.96","APC"
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.23","","","","","","","fee schedule","16.89","105.96","APC"
"John cunningham antibody","86711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.73","","","","","","","fee schedule","16.89","105.96","APC"
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.3","","","","","","","fee schedule","15.3","108.97",""
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.3","","","","","","","fee schedule","15.3","108.97",""
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.3","","","","","","","fee schedule","15.3","108.97",""
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.3","","","","","","","fee schedule","15.3","108.97",""
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","108.97","","","","","","","fee schedule","15.3","108.97",""
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.3","","","","","","","fee schedule","15.3","108.97",""
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.03","","","","","","","fee schedule","15.3","108.97","APC"
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.76","","","","","","","fee schedule","15.3","108.97","APC"
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.61","","","","","","","fee schedule","15.3","108.97","APC"
"Legionella antibody","86713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.07","","","","","","","fee schedule","15.3","108.97","APC"
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.25","","","","","","","fee schedule","12.25","81.11",""
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.25","","","","","","","fee schedule","12.25","81.11",""
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.25","","","","","","","fee schedule","12.25","81.11",""
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.06","","","","","","","fee schedule","12.25","81.11",""
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.11","","","","","","","fee schedule","12.25","81.11",""
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.06","","","","","","","fee schedule","12.25","81.11",""
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.25","81.11","APC"
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.25","81.11","APC"
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.5","","","","","","","fee schedule","12.25","81.11","APC"
"Leishmania antibody","86717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.86","","","","","","","fee schedule","12.25","81.11","APC"
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.2","","","","","","","fee schedule","16.2","86.45",""
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.2","","","","","","","fee schedule","16.2","86.45",""
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.2","","","","","","","fee schedule","16.2","86.45",""
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","16.2","86.45",""
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.45","","","","","","","fee schedule","16.2","86.45",""
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","16.2","86.45",""
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.97","","","","","","","fee schedule","16.2","86.45","APC"
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.69","","","","","","","fee schedule","16.2","86.45","APC"
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.52","","","","","","","fee schedule","16.2","86.45","APC"
"Leptospira antibody","86720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.01","","","","","","","fee schedule","16.2","86.45","APC"
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","91.99",""
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","91.99",""
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","91.99",""
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","91.99",""
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.99","","","","","","","fee schedule","13.19","91.99",""
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","91.99",""
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","91.99","APC"
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","91.99","APC"
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","91.99","APC"
"Listeria monocytogenes","86723","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","91.99","APC"
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.87","","","","","","","fee schedule","12.87","84.83",""
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.87","","","","","","","fee schedule","12.87","84.83",""
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.87","","","","","","","fee schedule","12.87","84.83",""
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.12","","","","","","","fee schedule","12.87","84.83",""
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","84.83","","","","","","","fee schedule","12.87","84.83",""
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.12","","","","","","","fee schedule","12.87","84.83",""
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.48","","","","","","","fee schedule","12.87","84.83","APC"
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.87","84.83","APC"
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.13","","","","","","","fee schedule","12.87","84.83","APC"
"Lymph choriomeningitis ab","86727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.51","","","","","","","fee schedule","12.87","84.83","APC"
"Lympho venereum antibody","86729","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.38","","","","","","","fee schedule","83.38","83.38",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15","","","","","","","fee schedule","15","91.68",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15","","","","","","","fee schedule","15","91.68",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15","","","","","","","fee schedule","15","91.68",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","15","91.68",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.68","","","","","","","fee schedule","15","91.68",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","15","91.68",""
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.71","","","","","","","fee schedule","15","91.68","APC"
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.45","","","","","","","fee schedule","15","91.68","APC"
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.3","","","","","","","fee schedule","15","91.68","APC"
"Mucormycosis antibody","86732","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.75","","","","","","","fee schedule","15","91.68","APC"
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.05","","","","","","","fee schedule","13.05","94.43",""
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.05","","","","","","","fee schedule","13.05","94.43",""
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.05","","","","","","","fee schedule","13.05","94.43",""
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.43","","","","","","","fee schedule","13.05","94.43",""
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","94.43","","","","","","","fee schedule","13.05","94.43",""
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.43","","","","","","","fee schedule","13.05","94.43",""
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.67","","","","","","","fee schedule","13.05","94.43","APC"
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.44","","","","","","","fee schedule","13.05","94.43","APC"
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.31","","","","","","","fee schedule","13.05","94.43","APC"
"Mumps antibody","86735","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.7","","","","","","","fee schedule","13.05","94.43","APC"
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.24","","","","","","","fee schedule","13.24","95.94",""
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.24","","","","","","","fee schedule","13.24","95.94",""
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.24","","","","","","","fee schedule","13.24","95.94",""
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.76","","","","","","","fee schedule","13.24","95.94",""
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.94","","","","","","","fee schedule","13.24","95.94",""
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.76","","","","","","","fee schedule","13.24","95.94",""
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.87","","","","","","","fee schedule","13.24","95.94","APC"
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.64","","","","","","","fee schedule","13.24","95.94","APC"
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.5","","","","","","","fee schedule","13.24","95.94","APC"
"Mycoplasma antibody","86738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.9","","","","","","","fee schedule","13.24","95.94","APC"
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","91.39",""
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","91.39",""
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","91.39",""
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","91.39",""
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.39","","","","","","","fee schedule","13.19","91.39",""
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","91.39",""
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","91.39","APC"
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","91.39","APC"
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","91.39","APC"
"Neisseria meningitidis","86741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","91.39","APC"
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.99","","","","","","","fee schedule","15.99","91.39",""
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.99","","","","","","","fee schedule","15.99","91.39",""
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.99","","","","","","","fee schedule","15.99","91.39",""
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","15.99","91.39",""
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.39","","","","","","","fee schedule","15.99","91.39",""
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","15.99","91.39",""
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.75","","","","","","","fee schedule","15.99","91.39","APC"
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.47","","","","","","","fee schedule","15.99","91.39","APC"
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.31","","","","","","","fee schedule","15.99","91.39","APC"
"Nocardia antibody","86744","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.79","","","","","","","fee schedule","15.99","91.39","APC"
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.03","","","","","","","fee schedule","15.03","107.89",""
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.03","","","","","","","fee schedule","15.03","107.89",""
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.03","","","","","","","fee schedule","15.03","107.89",""
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.84","","","","","","","fee schedule","15.03","107.89",""
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","107.89","","","","","","","fee schedule","15.03","107.89",""
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.84","","","","","","","fee schedule","15.03","107.89",""
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.74","","","","","","","fee schedule","15.03","107.89","APC"
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.48","","","","","","","fee schedule","15.03","107.89","APC"
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.33","","","","","","","fee schedule","15.03","107.89","APC"
"Parvovirus antibody","86747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.78","","","","","","","fee schedule","15.03","107.89","APC"
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","92.67",""
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","92.67",""
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","92.67",""
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","92.67",""
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","92.67","","","","","","","fee schedule","13.19","92.67",""
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","92.67",""
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","92.67","APC"
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","92.67","APC"
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","92.67","APC"
"Malaria antibody","86750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","92.67","APC"
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.39","","","","","","","fee schedule","12.39","80.37",""
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.39","","","","","","","fee schedule","12.39","80.37",""
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.39","","","","","","","fee schedule","12.39","80.37",""
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.3","","","","","","","fee schedule","12.39","80.37",""
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","80.37","","","","","","","fee schedule","12.39","80.37",""
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.3","","","","","","","fee schedule","12.39","80.37",""
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.98","","","","","","","fee schedule","12.39","80.37","APC"
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.76","","","","","","","fee schedule","12.39","80.37","APC"
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.64","","","","","","","fee schedule","12.39","80.37","APC"
"Protozoa antibody nos","86753","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.01","","","","","","","fee schedule","12.39","80.37","APC"
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.89","","","","","","","fee schedule","15.89","90.31",""
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.89","","","","","","","fee schedule","15.89","90.31",""
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.89","","","","","","","fee schedule","15.89","90.31",""
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.15","","","","","","","fee schedule","15.89","90.31",""
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","90.31","","","","","","","fee schedule","15.89","90.31",""
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.15","","","","","","","fee schedule","15.89","90.31",""
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.64","","","","","","","fee schedule","15.89","90.31","APC"
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.37","","","","","","","fee schedule","15.89","90.31","APC"
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.21","","","","","","","fee schedule","15.89","90.31","APC"
"Respiratory virus antibody","86756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.68","","","","","","","fee schedule","15.89","90.31","APC"
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.35","","","","","","","fee schedule","19.35","142.14",""
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.35","","","","","","","fee schedule","19.35","142.14",""
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.35","","","","","","","fee schedule","19.35","142.14",""
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.26","","","","","","","fee schedule","19.35","142.14",""
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.14","","","","","","","fee schedule","19.35","142.14",""
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.26","","","","","","","fee schedule","19.35","142.14",""
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.27","","","","","","","fee schedule","19.35","142.14","APC"
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.93","","","","","","","fee schedule","19.35","142.14","APC"
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.74","","","","","","","fee schedule","19.35","142.14","APC"
"Rickettsia Antibody","86757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.32","","","","","","","fee schedule","19.35","142.14","APC"
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.23","","","","","","","fee schedule","18.23","93.07",""
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.23","","","","","","","fee schedule","18.23","93.07",""
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.23","","","","","","","fee schedule","18.23","93.07",""
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","18.23","93.07",""
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.07","","","","","","","fee schedule","18.23","93.07",""
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","18.23","93.07",""
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.23","93.07","APC"
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.78","","","","","","","fee schedule","18.23","93.07","APC"
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.59","","","","","","","fee schedule","18.23","93.07","APC"
"Rotavirus antibody","86759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.14","","","","","","","fee schedule","18.23","93.07","APC"
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.39","","","","","","","fee schedule","14.39","105.96",""
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.39","","","","","","","fee schedule","14.39","105.96",""
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.39","","","","","","","fee schedule","14.39","105.96",""
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.74","","","","","","","fee schedule","14.39","105.96",""
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.96","","","","","","","fee schedule","14.39","105.96",""
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.74","","","","","","","fee schedule","14.39","105.96",""
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.07","","","","","","","fee schedule","14.39","105.96","APC"
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.82","","","","","","","fee schedule","14.39","105.96","APC"
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.68","","","","","","","fee schedule","14.39","105.96","APC"
"Rubella antibody","86762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.11","","","","","","","fee schedule","14.39","105.96","APC"
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.88","","","","","","","fee schedule","12.88","93.83",""
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.88","","","","","","","fee schedule","12.88","93.83",""
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.88","","","","","","","fee schedule","12.88","93.83",""
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.15","","","","","","","fee schedule","12.88","93.83",""
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.83","","","","","","","fee schedule","12.88","93.83",""
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.15","","","","","","","fee schedule","12.88","93.83",""
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.49","","","","","","","fee schedule","12.88","93.83","APC"
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.27","","","","","","","fee schedule","12.88","93.83","APC"
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.14","","","","","","","fee schedule","12.88","93.83","APC"
"Rubeola antibody","86765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.52","","","","","","","fee schedule","12.88","93.83","APC"
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","91.33",""
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","91.33",""
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","91.33",""
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","91.33",""
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.33","","","","","","","fee schedule","13.19","91.33",""
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","91.33",""
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","91.33","APC"
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","91.33","APC"
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","91.33","APC"
"Salmonella antibody","86768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","91.33","APC"
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.13","","","","","","","fee schedule","42.13","50.56",""
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.13","","","","","","","fee schedule","42.13","50.56",""
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.13","","","","","","","fee schedule","42.13","50.56",""
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50.56","","","","","","","fee schedule","42.13","50.56",""
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","50.56","","","","","","","fee schedule","42.13","50.56",""
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.13","50.56","APC"
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.39","","","","","","","fee schedule","42.13","50.56","APC"
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.97","","","","","","","fee schedule","42.13","50.56","APC"
"Sars-cov-2 covid-19 antibody","86769","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.24","","","","","","","fee schedule","42.13","50.56","APC"
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.48","","","","","","","fee schedule","22.67","94.34",""
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.48","","","","","","","fee schedule","22.67","94.34",""
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.48","","","","","","","fee schedule","22.67","94.34",""
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","22.67","94.34",""
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","94.34","","","","","","","fee schedule","22.67","94.34",""
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","22.67","94.34",""
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.64","","","","","","","fee schedule","22.67","94.34","APC"
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.21","","","","","","","fee schedule","22.67","94.34","APC"
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.97","","","","","","","fee schedule","22.67","94.34","APC"
"Shigella antibody","86771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.7","","","","","","","fee schedule","22.67","94.34","APC"
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.8","","","","","","","fee schedule","14.8","103.83",""
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.8","","","","","","","fee schedule","14.8","103.83",""
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.8","","","","","","","fee schedule","14.8","103.83",""
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.43","","","","","","","fee schedule","14.8","103.83",""
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","103.83","","","","","","","fee schedule","14.8","103.83",""
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.43","","","","","","","fee schedule","14.8","103.83",""
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.5","","","","","","","fee schedule","14.8","103.83","APC"
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.24","","","","","","","fee schedule","14.8","103.83","APC"
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.1","","","","","","","fee schedule","14.8","103.83","APC"
"Tetanus antibody","86774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.54","","","","","","","fee schedule","14.8","103.83","APC"
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.39","","","","","","","fee schedule","14.39","105.96",""
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.39","","","","","","","fee schedule","14.39","105.96",""
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.39","","","","","","","fee schedule","14.39","105.96",""
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.74","","","","","","","fee schedule","14.39","105.96",""
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.96","","","","","","","fee schedule","14.39","105.96",""
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.74","","","","","","","fee schedule","14.39","105.96",""
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.07","","","","","","","fee schedule","14.39","105.96","APC"
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.82","","","","","","","fee schedule","14.39","105.96","APC"
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.68","","","","","","","fee schedule","14.39","105.96","APC"
"Toxoplasma antibody","86777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.11","","","","","","","fee schedule","14.39","105.96","APC"
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.41","","","","","","","fee schedule","14.41","104.17",""
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.41","","","","","","","fee schedule","14.41","104.17",""
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.41","","","","","","","fee schedule","14.41","104.17",""
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.76","","","","","","","fee schedule","14.41","104.17",""
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","104.17","","","","","","","fee schedule","14.41","104.17",""
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.76","","","","","","","fee schedule","14.41","104.17",""
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.09","","","","","","","fee schedule","14.41","104.17","APC"
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.84","","","","","","","fee schedule","14.41","104.17","APC"
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.7","","","","","","","fee schedule","14.41","104.17","APC"
"Toxoplasma antibody igm","86778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.13","","","","","","","fee schedule","14.41","104.17","APC"
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.24","","","","","","","fee schedule","13.24","96.19",""
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.24","","","","","","","fee schedule","13.24","96.19",""
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.24","","","","","","","fee schedule","13.24","96.19",""
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.76","","","","","","","fee schedule","13.24","96.19",""
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.19","","","","","","","fee schedule","13.24","96.19",""
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.76","","","","","","","fee schedule","13.24","96.19",""
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.87","","","","","","","fee schedule","13.24","96.19","APC"
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.64","","","","","","","fee schedule","13.24","96.19","APC"
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.5","","","","","","","fee schedule","13.24","96.19","APC"
"Treponema pallidum","86780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.9","","","","","","","fee schedule","13.24","96.19","APC"
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.56","","","","","","","fee schedule","12.56","81.39",""
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.56","","","","","","","fee schedule","12.56","81.39",""
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.56","","","","","","","fee schedule","12.56","81.39",""
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.6","","","","","","","fee schedule","12.56","81.39",""
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","81.39","","","","","","","fee schedule","12.56","81.39",""
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.6","","","","","","","fee schedule","12.56","81.39",""
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.16","","","","","","","fee schedule","12.56","81.39","APC"
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.94","","","","","","","fee schedule","12.56","81.39","APC"
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.81","","","","","","","fee schedule","12.56","81.39","APC"
"Trichinella antibody","86784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.19","","","","","","","fee schedule","12.56","81.39","APC"
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.88","","","","","","","fee schedule","12.88","91.22",""
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.88","","","","","","","fee schedule","12.88","91.22",""
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.88","","","","","","","fee schedule","12.88","91.22",""
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","91.22","","","","","","","fee schedule","12.88","91.22",""
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.15","","","","","","","fee schedule","12.88","91.22",""
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.15","","","","","","","fee schedule","12.88","91.22",""
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.49","","","","","","","fee schedule","12.88","91.22","APC"
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.27","","","","","","","fee schedule","12.88","91.22","APC"
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.14","","","","","","","fee schedule","12.88","91.22","APC"
"Varicella-zoster antibody","86787","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.52","","","","","","","fee schedule","12.88","91.22","APC"
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.85","","","","","","","fee schedule","16.85","113.09",""
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.85","","","","","","","fee schedule","16.85","113.09",""
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.85","","","","","","","fee schedule","16.85","113.09",""
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","113.09","","","","","","","fee schedule","16.85","113.09",""
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.94","","","","","","","fee schedule","16.85","113.09",""
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.94","","","","","","","fee schedule","16.85","113.09",""
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.65","","","","","","","fee schedule","16.85","113.09","APC"
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.36","","","","","","","fee schedule","16.85","113.09","APC"
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.19","","","","","","","fee schedule","16.85","113.09","APC"
"West nile virus ab igm","86788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.69","","","","","","","fee schedule","16.85","113.09","APC"
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.39","","","","","","","fee schedule","14.39","105.96",""
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.39","","","","","","","fee schedule","14.39","105.96",""
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.39","","","","","","","fee schedule","14.39","105.96",""
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.96","","","","","","","fee schedule","14.39","105.96",""
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.74","","","","","","","fee schedule","14.39","105.96",""
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.74","","","","","","","fee schedule","14.39","105.96",""
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.07","","","","","","","fee schedule","14.39","105.96","APC"
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.82","","","","","","","fee schedule","14.39","105.96","APC"
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.68","","","","","","","fee schedule","14.39","105.96","APC"
"West Nile Virus Antibody","86789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.11","","","","","","","fee schedule","14.39","105.96","APC"
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.15","","","","","","","fee schedule","12.88","89.2",""
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.88","","","","","","","fee schedule","12.88","89.2",""
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.88","","","","","","","fee schedule","12.88","89.2",""
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.88","","","","","","","fee schedule","12.88","89.2",""
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.2","","","","","","","fee schedule","12.88","89.2",""
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.15","","","","","","","fee schedule","12.88","89.2",""
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.49","","","","","","","fee schedule","12.88","89.2","APC"
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.27","","","","","","","fee schedule","12.88","89.2","APC"
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.14","","","","","","","fee schedule","12.88","89.2","APC"
"Virus antibody nos","86790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.52","","","","","","","fee schedule","12.88","89.2","APC"
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.67","","","","","","","fee schedule","13.19","89.97",""
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.19","","","","","","","fee schedule","13.19","89.97",""
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.19","","","","","","","fee schedule","13.19","89.97",""
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.19","","","","","","","fee schedule","13.19","89.97",""
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.97","","","","","","","fee schedule","13.19","89.97",""
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.67","","","","","","","fee schedule","13.19","89.97",""
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.19","89.97","APC"
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.59","","","","","","","fee schedule","13.19","89.97","APC"
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.45","","","","","","","fee schedule","13.19","89.97","APC"
"Yersinia antibody","86793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.85","","","","","","","fee schedule","13.19","89.97","APC"
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.96","","","","","","","fee schedule","16.85","24.96",""
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.85","","","","","","","fee schedule","16.85","24.96",""
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.85","","","","","","","fee schedule","16.85","24.96",""
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.85","","","","","","","fee schedule","16.85","24.96",""
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.96","","","","","","","fee schedule","16.85","24.96",""
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.65","","","","","","","fee schedule","16.85","24.96","APC"
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.36","","","","","","","fee schedule","16.85","24.96","APC"
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.19","","","","","","","fee schedule","16.85","24.96","APC"
"Zika virus igm antibody","86794","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.69","","","","","","","fee schedule","16.85","24.96","APC"
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.34","","","","","","","fee schedule","15.91","113.63",""
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.91","","","","","","","fee schedule","15.91","113.63",""
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.91","","","","","","","fee schedule","15.91","113.63",""
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.91","","","","","","","fee schedule","15.91","113.63",""
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","113.63","","","","","","","fee schedule","15.91","113.63",""
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.34","","","","","","","fee schedule","15.91","113.63",""
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.67","","","","","","","fee schedule","15.91","113.63","APC"
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.39","","","","","","","fee schedule","15.91","113.63","APC"
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.23","","","","","","","fee schedule","15.91","113.63","APC"
"Thyroglobulin antibody","86800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.71","","","","","","","fee schedule","15.91","113.63","APC"
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.53","","","","","","","fee schedule","14.27","105.19",""
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.27","","","","","","","fee schedule","14.27","105.19",""
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.27","","","","","","","fee schedule","14.27","105.19",""
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.27","","","","","","","fee schedule","14.27","105.19",""
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","105.19","","","","","","","fee schedule","14.27","105.19",""
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.53","","","","","","","fee schedule","14.27","105.19",""
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.95","","","","","","","fee schedule","14.27","105.19","APC"
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.7","","","","","","","fee schedule","14.27","105.19","APC"
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.56","","","","","","","fee schedule","14.27","105.19","APC"
"Hepatitis c ab test","86803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.98","","","","","","","fee schedule","14.27","105.19","APC"
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.63","","","","","","","fee schedule","15.49","114.37",""
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.49","","","","","","","fee schedule","15.49","114.37",""
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.49","","","","","","","fee schedule","15.49","114.37",""
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.49","","","","","","","fee schedule","15.49","114.37",""
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","114.37","","","","","","","fee schedule","15.49","114.37",""
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.63","","","","","","","fee schedule","15.49","114.37",""
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.23","","","","","","","fee schedule","15.49","114.37","APC"
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.95","","","","","","","fee schedule","15.49","114.37","APC"
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.8","","","","","","","fee schedule","15.49","114.37","APC"
"Hep c ab test confirm","86804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.26","","","","","","","fee schedule","15.49","114.37","APC"
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","89.87","","","","","","","fee schedule","89.87","368.01",""
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","189.51","","","","","","","fee schedule","89.87","368.01",""
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","189.51","","","","","","","fee schedule","89.87","368.01",""
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","189.51","","","","","","","fee schedule","89.87","368.01",""
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","368.01","","","","","","","fee schedule","89.87","368.01",""
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","89.87","","","","","","","fee schedule","89.87","368.01",""
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","198.51","","","","","","","fee schedule","89.87","368.01","APC"
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","195.2","","","","","","","fee schedule","89.87","368.01","APC"
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","193.3","","","","","","","fee schedule","89.87","368.01","APC"
"Lymphocytotoxicity assay","86805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","198.99","","","","","","","fee schedule","89.87","368.01","APC"
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","81.79","","","","","","","fee schedule","47.59","332.73",""
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.59","","","","","","","fee schedule","47.59","332.73",""
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.59","","","","","","","fee schedule","47.59","332.73",""
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.59","","","","","","","fee schedule","47.59","332.73",""
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","332.73","","","","","","","fee schedule","47.59","332.73",""
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","81.79","","","","","","","fee schedule","47.59","332.73",""
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.85","","","","","","","fee schedule","47.59","332.73","APC"
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49.02","","","","","","","fee schedule","47.59","332.73","APC"
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.54","","","","","","","fee schedule","47.59","332.73","APC"
"Lymphocytotoxicity assay","86806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.97","","","","","","","fee schedule","47.59","332.73","APC"
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","68.02","","","","","","","fee schedule","68.02","279.46",""
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","78.65","","","","","","","fee schedule","68.02","279.46",""
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","78.65","","","","","","","fee schedule","68.02","279.46",""
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","78.65","","","","","","","fee schedule","68.02","279.46",""
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","279.46","","","","","","","fee schedule","68.02","279.46",""
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","68.02","","","","","","","fee schedule","68.02","279.46",""
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.39","","","","","","","fee schedule","68.02","279.46","APC"
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.01","","","","","","","fee schedule","68.02","279.46","APC"
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.22","","","","","","","fee schedule","68.02","279.46","APC"
"Cytotoxic antibody screening","86807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.58","","","","","","","fee schedule","68.02","279.46","APC"
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","51.01","","","","","","","fee schedule","29.68","212.35",""
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.68","","","","","","","fee schedule","29.68","212.35",""
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.68","","","","","","","fee schedule","29.68","212.35",""
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.68","","","","","","","fee schedule","29.68","212.35",""
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","212.35","","","","","","","fee schedule","29.68","212.35",""
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","51.01","","","","","","","fee schedule","29.68","212.35",""
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.09","","","","","","","fee schedule","29.68","212.35","APC"
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.57","","","","","","","fee schedule","29.68","212.35","APC"
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.27","","","","","","","fee schedule","29.68","212.35","APC"
"Cytotoxic antibody screening","86808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.16","","","","","","","fee schedule","29.68","212.35","APC"
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","44.35","","","","","","","fee schedule","25.81","192.98",""
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.81","","","","","","","fee schedule","25.81","192.98",""
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.81","","","","","","","fee schedule","25.81","192.98",""
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.81","","","","","","","fee schedule","25.81","192.98",""
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","192.98","","","","","","","fee schedule","25.81","192.98",""
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","44.35","","","","","","","fee schedule","25.81","192.98",""
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.04","","","","","","","fee schedule","25.81","192.98","APC"
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.58","","","","","","","fee schedule","25.81","192.98","APC"
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.33","","","","","","","fee schedule","25.81","192.98","APC"
"Hla typing a b or c","86812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.1","","","","","","","fee schedule","25.81","192.98","APC"
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","99.67","","","","","","","fee schedule","58","408.42",""
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58","","","","","","","fee schedule","58","408.42",""
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58","","","","","","","fee schedule","58","408.42",""
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","58","","","","","","","fee schedule","58","408.42",""
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","408.42","","","","","","","fee schedule","58","408.42",""
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","99.67","","","","","","","fee schedule","58","408.42",""
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.76","","","","","","","fee schedule","58","408.42","APC"
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.74","","","","","","","fee schedule","58","408.42","APC"
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.16","","","","","","","fee schedule","58","408.42","APC"
"Hla typing a b or c","86813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.9","","","","","","","fee schedule","58","408.42","APC"
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","47.88","","","","","","","fee schedule","30.17","208.29",""
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.17","","","","","","","fee schedule","30.17","208.29",""
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.17","","","","","","","fee schedule","30.17","208.29",""
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.17","","","","","","","fee schedule","30.17","208.29",""
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","208.29","","","","","","","fee schedule","30.17","208.29",""
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","47.88","","","","","","","fee schedule","30.17","208.29",""
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.6","","","","","","","fee schedule","30.17","208.29","APC"
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.08","","","","","","","fee schedule","30.17","208.29","APC"
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.77","","","","","","","fee schedule","30.17","208.29","APC"
"Hla typing dr/dq","86816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.68","","","","","","","fee schedule","30.17","208.29","APC"
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","110.66","","","","","","","fee schedule","106.14","473.09",""
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","106.14","","","","","","","fee schedule","106.14","473.09",""
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","106.14","","","","","","","fee schedule","106.14","473.09",""
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106.14","","","","","","","fee schedule","106.14","473.09",""
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","473.09","","","","","","","fee schedule","106.14","473.09",""
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","110.66","","","","","","","fee schedule","106.14","473.09",""
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","111.18","","","","","","","fee schedule","106.14","473.09","APC"
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","109.32","","","","","","","fee schedule","106.14","473.09","APC"
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","108.26","","","","","","","fee schedule","106.14","473.09","APC"
"Hla typing dr/dq","86817","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","111.45","","","","","","","fee schedule","106.14","473.09","APC"
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","97.04","","","","","","","fee schedule","36.56","412.94",""
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.56","","","","","","","fee schedule","36.56","412.94",""
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.56","","","","","","","fee schedule","36.56","412.94",""
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.56","","","","","","","fee schedule","36.56","412.94",""
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","412.94","","","","","","","fee schedule","36.56","412.94",""
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","97.04","","","","","","","fee schedule","36.56","412.94",""
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.3","","","","","","","fee schedule","36.56","412.94","APC"
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.66","","","","","","","fee schedule","36.56","412.94","APC"
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","36.56","412.94","APC"
"Lymphocyte culture mixed","86821","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","36.56","412.94","APC"
"Lymphocyte culture primed","86822","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","272.67","","","","","","","fee schedule","272.67","272.67",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","138.05","","","","","","","fee schedule","109.49","487.51",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","109.49","","","","","","","fee schedule","109.49","487.51",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","109.49","","","","","","","fee schedule","109.49","487.51",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","109.49","","","","","","","fee schedule","109.49","487.51",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","487.51","","","","","","","fee schedule","109.49","487.51",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","138.05","","","","","","","fee schedule","109.49","487.51",""
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","114.69","","","","","","","fee schedule","109.49","487.51","APC"
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","112.77","","","","","","","fee schedule","109.49","487.51","APC"
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","111.68","","","","","","","fee schedule","109.49","487.51","APC"
"Hla x-math non-cytotoxic","86825","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","114.96","","","","","","","fee schedule","109.49","487.51","APC"
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.02","","","","","","","fee schedule","36.53","162.53",""
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.53","","","","","","","fee schedule","36.53","162.53",""
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.53","","","","","","","fee schedule","36.53","162.53",""
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.53","","","","","","","fee schedule","36.53","162.53",""
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","162.53","","","","","","","fee schedule","36.53","162.53",""
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.02","","","","","","","fee schedule","36.53","162.53",""
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.27","","","","","","","fee schedule","36.53","162.53","APC"
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.63","","","","","","","fee schedule","36.53","162.53","APC"
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.26","","","","","","","fee schedule","36.53","162.53","APC"
"Hla x-match noncytotoxc addl","86826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.36","","","","","","","fee schedule","36.53","162.53","APC"
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","65.28","","","","","","","fee schedule","64.19","279.46",""
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.19","","","","","","","fee schedule","64.19","279.46",""
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.19","","","","","","","fee schedule","64.19","279.46",""
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.19","","","","","","","fee schedule","64.19","279.46",""
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","279.46","","","","","","","fee schedule","64.19","279.46",""
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","65.28","","","","","","","fee schedule","64.19","279.46",""
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.24","","","","","","","fee schedule","64.19","279.46","APC"
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.12","","","","","","","fee schedule","64.19","279.46","APC"
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.47","","","","","","","fee schedule","64.19","279.46","APC"
"Hla class i&ii antibody qual","86828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.4","","","","","","","fee schedule","64.19","279.46","APC"
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","48.96","","","","","","","fee schedule","48.96","212.35",""
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","64.19","","","","","","","fee schedule","48.96","212.35",""
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.19","","","","","","","fee schedule","48.96","212.35",""
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.19","","","","","","","fee schedule","48.96","212.35",""
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","212.35","","","","","","","fee schedule","48.96","212.35",""
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","48.96","","","","","","","fee schedule","48.96","212.35",""
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.24","","","","","","","fee schedule","48.96","212.35","APC"
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.12","","","","","","","fee schedule","48.96","212.35","APC"
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.47","","","","","","","fee schedule","48.96","212.35","APC"
"Hla class i/ii antibody qual","86829","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.4","","","","","","","fee schedule","48.96","212.35","APC"
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","133.19","","","","","","","fee schedule","95.52","591.57",""
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95.52","","","","","","","fee schedule","95.52","591.57",""
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.52","","","","","","","fee schedule","95.52","591.57",""
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","95.52","","","","","","","fee schedule","95.52","591.57",""
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","591.57","","","","","","","fee schedule","95.52","591.57",""
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","133.19","","","","","","","fee schedule","95.52","591.57",""
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.06","","","","","","","fee schedule","95.52","591.57","APC"
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","98.39","","","","","","","fee schedule","95.52","591.57","APC"
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","97.43","","","","","","","fee schedule","95.52","591.57","APC"
"Hla class i phenotype qual","86830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","100.3","","","","","","","fee schedule","95.52","591.57","APC"
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","114.16","","","","","","","fee schedule","81.88","507.08",""
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","81.88","","","","","","","fee schedule","81.88","507.08",""
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","81.88","","","","","","","fee schedule","81.88","507.08",""
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","81.88","","","","","","","fee schedule","81.88","507.08",""
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","507.08","","","","","","","fee schedule","81.88","507.08",""
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","114.16","","","","","","","fee schedule","81.88","507.08",""
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","85.77","","","","","","","fee schedule","81.88","507.08","APC"
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","84.34","","","","","","","fee schedule","81.88","507.08","APC"
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","83.52","","","","","","","fee schedule","81.88","507.08","APC"
"Hla class ii phenotype qual","86831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","85.97","","","","","","","fee schedule","81.88","507.08","APC"
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.28","","","","","","","fee schedule","209.28","929.62",""
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","323.75","","","","","","","fee schedule","209.28","929.62",""
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","323.75","","","","","","","fee schedule","209.28","929.62",""
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","323.75","","","","","","","fee schedule","209.28","929.62",""
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","929.62","","","","","","","fee schedule","209.28","929.62",""
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.28","","","","","","","fee schedule","209.28","929.62",""
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","339.13","","","","","","","fee schedule","209.28","929.62","APC"
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","333.46","","","","","","","fee schedule","209.28","929.62","APC"
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","330.22","","","","","","","fee schedule","209.28","929.62","APC"
"Hla class i high defin qual","86832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","339.94","","","","","","","fee schedule","209.28","929.62","APC"
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","190.26","","","","","","","fee schedule","190.26","845.13",""
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","325.8","","","","","","","fee schedule","190.26","845.13",""
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","325.8","","","","","","","fee schedule","190.26","845.13",""
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","325.8","","","","","","","fee schedule","190.26","845.13",""
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","845.13","","","","","","","fee schedule","190.26","845.13",""
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","190.26","","","","","","","fee schedule","190.26","845.13",""
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","341.28","","","","","","","fee schedule","190.26","845.13","APC"
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","335.57","","","","","","","fee schedule","190.26","845.13","APC"
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","332.32","","","","","","","fee schedule","190.26","845.13","APC"
"Hla class ii high defin qual","86833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","342.09","","","","","","","fee schedule","190.26","845.13","APC"
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","589.79","","","","","","","fee schedule","357.56","2619.67",""
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","357.56","","","","","","","fee schedule","357.56","2619.67",""
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","357.56","","","","","","","fee schedule","357.56","2619.67",""
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","357.56","","","","","","","fee schedule","357.56","2619.67",""
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2619.67","","","","","","","fee schedule","357.56","2619.67",""
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","589.79","","","","","","","fee schedule","357.56","2619.67",""
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","374.54","","","","","","","fee schedule","357.56","2619.67","APC"
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","368.29","","","","","","","fee schedule","357.56","2619.67","APC"
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","364.71","","","","","","","fee schedule","357.56","2619.67","APC"
"Hla class i semiquant panel","86834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","375.44","","","","","","","fee schedule","357.56","2619.67","APC"
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","532.72","","","","","","","fee schedule","322.96","2366.15",""
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","322.96","","","","","","","fee schedule","322.96","2366.15",""
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","322.96","","","","","","","fee schedule","322.96","2366.15",""
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","322.96","","","","","","","fee schedule","322.96","2366.15",""
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2366.15","","","","","","","fee schedule","322.96","2366.15",""
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","532.72","","","","","","","fee schedule","322.96","2366.15",""
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","338.3","","","","","","","fee schedule","322.96","2366.15","APC"
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","332.65","","","","","","","fee schedule","322.96","2366.15","APC"
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","329.42","","","","","","","fee schedule","322.96","2366.15","APC"
"Hla class ii semiquant panel","86835","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","339.11","","","","","","","fee schedule","322.96","2366.15","APC"
"Immunology procedure","86849","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.77","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.77","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","195","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.77","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","201","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","196","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","93.07","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","9.77","201",""
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","9.77","201","APC 277.30"
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","9.77","201","APC 296.56"
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","9.77","201","APC 308.91"
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","9.77","201","APC"
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","9.77","201","APC"
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","9.77","201","APC"
"RBC antibody screen","86850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","9.77","201","APC"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.2","","","","","","","fee schedule","30.2","588.18",""
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.11","","","","","","","fee schedule","30.2","588.18",""
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.2","","","","","","","fee schedule","30.2","588.18",""
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","30.2","588.18","APC 277.30"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","30.2","588.18","APC 296.56"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","30.2","588.18","APC 308.91"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","30.2","588.18","APC"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","30.2","588.18","APC"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","30.2","588.18","APC"
"RBC antibody elution","86860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","30.2","588.18","APC"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.2","","","","","","","fee schedule","30.2","1237.5",""
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","163.75","","","","","","","fee schedule","30.2","1237.5",""
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.2","","","","","","","fee schedule","30.2","1237.5",""
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","30.2","1237.5","APC 277.30"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","30.2","1237.5","APC 296.56"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","30.2","1237.5","APC 308.91"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","30.2","1237.5","APC"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","30.2","1237.5","APC"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","30.2","1237.5","APC"
"RBC antibody identification","86870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","30.2","1237.5","APC"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.24","","","","","","","fee schedule","5.39","203.66",""
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.39","","","","","","","fee schedule","5.39","203.66",""
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.39","","","","","","","fee schedule","5.39","203.66",""
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.39","","","","","","","fee schedule","5.39","203.66",""
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","39.87","","","","","","","fee schedule","5.39","203.66",""
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.24","","","","","","","fee schedule","5.39","203.66",""
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","5.39","203.66","APC 277.30"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","5.39","203.66","APC 296.56"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","5.39","203.66","APC 308.91"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","5.39","203.66","APC"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","5.39","203.66","APC"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","5.39","203.66","APC"
"Coombs test direct","86880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","5.39","203.66","APC"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.84","","","","","","","fee schedule","5.72","588.18",""
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.72","","","","","","","fee schedule","5.72","588.18",""
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.72","","","","","","","fee schedule","5.72","588.18",""
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.72","","","","","","","fee schedule","5.72","588.18",""
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","42.23","","","","","","","fee schedule","5.72","588.18",""
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.84","","","","","","","fee schedule","5.72","588.18",""
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","5.72","588.18","APC 277.30"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","5.72","588.18","APC 296.56"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","5.72","588.18","APC 308.91"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","5.72","588.18","APC"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","5.72","588.18","APC"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","5.72","588.18","APC"
"Coombs test indirect qual","86885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","5.72","588.18","APC"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","588.18",""
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","588.18",""
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","588.18",""
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","588.18",""
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.65","","","","","","","fee schedule","5.18","588.18",""
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","588.18",""
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","5.18","588.18","APC 277.30"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","5.18","588.18","APC 296.56"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","5.18","588.18","APC 308.91"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","5.18","588.18","APC"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","5.18","588.18","APC"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","5.18","588.18","APC"
"Coombs test indirect titer","86886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","5.18","588.18","APC"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.72","","","","","","","fee schedule","59.72","588.18",""
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","375.9","","","","","","","fee schedule","59.72","588.18",""
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.72","","","","","","","fee schedule","59.72","588.18",""
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","59.72","588.18","APC 277.30"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","59.72","588.18","APC 296.56"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","59.72","588.18","APC 308.91"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","59.72","588.18","APC"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","59.72","588.18","APC"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","59.72","588.18","APC"
"Autologous blood process","86890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","59.72","588.18","APC"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","2781.52",""
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","532.24","","","","","","","fee schedule","17.76","2781.52",""
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","2781.52",""
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","17.76","2781.52","APC 277.30"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","17.76","2781.52","APC 296.56"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","17.76","2781.52","APC 308.91"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","17.76","2781.52","APC"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","17.76","2781.52","APC"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","17.76","2781.52","APC"
"Autologous blood op salvage","86891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","17.76","2781.52","APC"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.12","","","","","","","fee schedule","2.99","459.34",""
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.99","","","","","","","fee schedule","2.99","459.34",""
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.99","","","","","","","fee schedule","2.99","459.34",""
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.99","","","","","","","fee schedule","2.99","459.34",""
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","22.38","","","","","","","fee schedule","2.99","459.34",""
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.12","","","","","","","fee schedule","2.99","459.34",""
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","2.99","459.34","APC 277.30"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","2.99","459.34","APC 296.56"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","2.99","459.34","APC 308.91"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","2.99","459.34","APC"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","2.99","459.34","APC"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","2.99","459.34","APC"
"Blood typing serologic abo","86900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","2.99","459.34","APC"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5.12","","","","","","","fee schedule","2.99","128.95",""
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.99","","","","","","","fee schedule","2.99","128.95",""
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.99","","","","","","","fee schedule","2.99","128.95",""
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.99","","","","","","","fee schedule","2.99","128.95",""
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","22.38","","","","","","","fee schedule","2.99","128.95",""
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5.12","","","","","","","fee schedule","2.99","128.95",""
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","2.99","128.95","APC 277.30"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","2.99","128.95","APC 296.56"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","2.99","128.95","APC 308.91"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","2.99","128.95","APC"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","2.99","128.95","APC"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","2.99","128.95","APC"
"Blood typing serologic rh(d)","86901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","2.99","128.95","APC"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.46","","","","","","","fee schedule","6.35","1237.5",""
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.35","","","","","","","fee schedule","6.35","1237.5",""
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.35","","","","","","","fee schedule","6.35","1237.5",""
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.35","","","","","","","fee schedule","6.35","1237.5",""
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.58","","","","","","","fee schedule","6.35","1237.5",""
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.46","","","","","","","fee schedule","6.35","1237.5",""
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","6.35","1237.5","APC 277.30"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","6.35","1237.5","APC 296.56"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","6.35","1237.5","APC 308.91"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","6.35","1237.5","APC"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","6.35","1237.5","APC"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","6.35","1237.5","APC"
"Blood type antigen donor ea","86902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","6.35","1237.5","APC"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.34","","","","","","","fee schedule","16.34","203.66",""
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.34","","","","","","","fee schedule","16.34","203.66",""
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.34","","","","","","","fee schedule","16.34","203.66",""
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.34","","","","","","","fee schedule","16.34","203.66",""
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","67.31","","","","","","","fee schedule","16.34","203.66",""
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.34","","","","","","","fee schedule","16.34","203.66",""
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","16.34","203.66","APC 277.30"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","16.34","203.66","APC 296.56"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","16.34","203.66","APC 308.91"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","16.34","203.66","APC"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","16.34","203.66","APC"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","16.34","203.66","APC"
"Blood typing patient serum","86904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","16.34","203.66","APC"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.58","","","","","","","fee schedule","3.83","1237.5",""
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.83","","","","","","","fee schedule","3.83","1237.5",""
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.83","","","","","","","fee schedule","3.83","1237.5",""
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.83","","","","","","","fee schedule","3.83","1237.5",""
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","27.58","","","","","","","fee schedule","3.83","1237.5",""
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.58","","","","","","","fee schedule","3.83","1237.5",""
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","3.83","1237.5","APC 277.30"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","3.83","1237.5","APC 296.56"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","3.83","1237.5","APC 308.91"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","3.83","1237.5","APC"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","3.83","1237.5","APC"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","3.83","1237.5","APC"
"Blood typing rbc antigens","86905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","3.83","1237.5","APC"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.32","","","","","","","fee schedule","7.75","128.95",""
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.75","","","","","","","fee schedule","7.75","128.95",""
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.75","","","","","","","fee schedule","7.75","128.95",""
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.75","","","","","","","fee schedule","7.75","128.95",""
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","56.89","","","","","","","fee schedule","7.75","128.95",""
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.32","","","","","","","fee schedule","7.75","128.95",""
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","7.75","128.95","APC 277.30"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","7.75","128.95","APC 296.56"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","7.75","128.95","APC 308.91"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","7.75","128.95","APC"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","7.75","128.95","APC"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","7.75","128.95","APC"
"Bld typing serologic rh phnt","86906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","7.75","128.95","APC"
"Blood typing paternity test","86910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.92","","","","","","","fee schedule","19.92","96.79",""
"Blood typing paternity test","86910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.79","","","","","","","fee schedule","19.92","96.79",""
"Blood typing paternity test","86910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.92","","","","","","","fee schedule","19.92","96.79",""
"Blood typing antigen system","86911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.32","","","","","","","fee schedule","17.32","83.75",""
"Blood typing antigen system","86911","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","83.75","","","","","","","fee schedule","17.32","83.75",""
"Blood typing antigen system","86911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.32","","","","","","","fee schedule","17.32","83.75",""
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.12","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test spin","86920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.11","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test incubate","86921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.2","","","","","","","fee schedule","30.2","588.18",""
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","141.49","","","","","","","fee schedule","30.2","588.18",""
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.2","","","","","","","fee schedule","30.2","588.18",""
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","30.2","588.18","APC 277.30"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","30.2","588.18","APC 296.56"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","30.2","588.18","APC 308.91"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","30.2","588.18","APC"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","30.2","588.18","APC"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","30.2","588.18","APC"
"Compatibility test antiglob","86922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","30.2","588.18","APC"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.02","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Compatibility test electric","86923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","74.49","","","","","","","fee schedule","17.76","588.18",""
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Plasma fresh frozen","86927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.72","","","","","","","fee schedule","59.72","588.18",""
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","442.9","","","","","","","fee schedule","59.72","588.18",""
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.72","","","","","","","fee schedule","59.72","588.18",""
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","59.72","588.18","APC 277.30"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","59.72","588.18","APC 296.56"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","59.72","588.18","APC 308.91"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood prep","86930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.72","","","","","","","fee schedule","59.72","588.18",""
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","333.16","","","","","","","fee schedule","59.72","588.18",""
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.72","","","","","","","fee schedule","59.72","588.18",""
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","59.72","588.18","APC 277.30"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","59.72","588.18","APC 296.56"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","59.72","588.18","APC 308.91"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood thaw","86931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","59.72","588.18","APC"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.72","","","","","","","fee schedule","37.17","375.9",""
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","375.9","","","","","","","fee schedule","37.17","375.9",""
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.72","","","","","","","fee schedule","37.17","375.9",""
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","375.9","APC 277.30"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","375.9","APC 296.56"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","375.9","APC 308.91"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","375.9","APC"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","375.9","APC"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","375.9","APC"
"Frozen blood freeze/thaw","86932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","375.9","APC"
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.09","","","","","","","fee schedule","8.77","57.91",""
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.77","","","","","","","fee schedule","8.77","57.91",""
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.77","","","","","","","fee schedule","8.77","57.91",""
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.77","","","","","","","fee schedule","8.77","57.91",""
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","57.91","","","","","","","fee schedule","8.77","57.91",""
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.09","","","","","","","fee schedule","8.77","57.91",""
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.19","","","","","","","fee schedule","8.77","57.91","APC"
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.03","","","","","","","fee schedule","8.77","57.91","APC"
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.95","","","","","","","fee schedule","8.77","57.91","APC"
"Hemolysins/agglutinins auto","86940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.21","","","","","","","fee schedule","8.77","57.91","APC"
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.82","","","","","","","fee schedule","12.11","87.84",""
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.11","","","","","","","fee schedule","12.11","87.84",""
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.11","","","","","","","fee schedule","12.11","87.84",""
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.11","","","","","","","fee schedule","12.11","87.84",""
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","87.84","","","","","","","fee schedule","12.11","87.84",""
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.82","","","","","","","fee schedule","12.11","87.84",""
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.11","87.84","APC"
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.47","","","","","","","fee schedule","12.11","87.84","APC"
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.35","","","","","","","fee schedule","12.11","87.84","APC"
"Hemolysins/agglutinins","86941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.72","","","","","","","fee schedule","12.11","87.84","APC"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","128.95",""
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.67","","","","","","","fee schedule","17.76","128.95",""
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","128.95",""
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","17.76","128.95","APC 277.30"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","17.76","128.95","APC 296.56"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","17.76","128.95","APC 308.91"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","17.76","128.95","APC"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","17.76","128.95","APC"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","17.76","128.95","APC"
"Blood product/irradiation","86945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","17.76","128.95","APC"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","288.46","","","","","","","fee schedule","17.76","588.18",""
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Leukacyte transfusion","86950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.7","","","","","","","fee schedule","17.76","588.18",""
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Vol reduction of blood/prod","86960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.2","","","","","","","fee schedule","30.2","588.18",""
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.7","","","","","","","fee schedule","30.2","588.18",""
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.2","","","","","","","fee schedule","30.2","588.18",""
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","30.2","588.18","APC 277.30"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","30.2","588.18","APC 296.56"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","30.2","588.18","APC 308.91"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","30.2","588.18","APC"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","30.2","588.18","APC"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","30.2","588.18","APC"
"Pooling blood platelets","86965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","30.2","588.18","APC"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","203.66",""
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","111.67","","","","","","","fee schedule","17.76","203.66",""
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","203.66",""
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","17.76","203.66","APC 277.30"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","17.76","203.66","APC 296.56"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","17.76","203.66","APC 308.91"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","17.76","203.66","APC"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","17.76","203.66","APC"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","17.76","203.66","APC"
"Rbc pretx incubatj w/chemicl","86970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","17.76","203.66","APC"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","89.29","","","","","","","fee schedule","17.76","588.18",""
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/enzymes","86971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","154.5","","","","","","","fee schedule","17.76","588.18",""
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc pretx incubatj w/density","86972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.2","","","","","","","fee schedule","30.2","1542.27",""
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","119.11","","","","","","","fee schedule","30.2","1542.27",""
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.2","","","","","","","fee schedule","30.2","1542.27",""
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","30.2","1542.27","APC 277.30"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","30.2","1542.27","APC 296.56"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","30.2","1542.27","APC 308.91"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","30.2","1542.27","APC"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","30.2","1542.27","APC"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","30.2","1542.27","APC"
"Rbc serum pretx incubj drugs","86975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","30.2","1542.27","APC"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","132.12",""
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.12","","","","","","","fee schedule","17.76","132.12",""
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","132.12",""
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","17.76","132.12","APC 277.30"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","17.76","132.12","APC 296.56"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","17.76","132.12","APC 308.91"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","17.76","132.12","APC"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","17.76","132.12","APC"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","17.76","132.12","APC"
"Rbc serum pretx id dilution","86976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","17.76","132.12","APC"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.72","","","","","","","fee schedule","59.72","588.18",""
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.12","","","","","","","fee schedule","59.72","588.18",""
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.72","","","","","","","fee schedule","59.72","588.18",""
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","59.72","588.18","APC 277.30"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","59.72","588.18","APC 296.56"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","59.72","588.18","APC 308.91"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","59.72","588.18","APC"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","59.72","588.18","APC"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","59.72","588.18","APC"
"Rbc serum pretx incubj/inhib","86977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","59.72","588.18","APC"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.2","","","","","","","fee schedule","30.2","203.66",""
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.12","","","","","","","fee schedule","30.2","203.66",""
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.2","","","","","","","fee schedule","30.2","203.66",""
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","30.2","203.66","APC 277.30"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","30.2","203.66","APC 296.56"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","30.2","203.66","APC 308.91"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","30.2","203.66","APC"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","30.2","203.66","APC"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","30.2","203.66","APC"
"Rbc pretreatment serum","86978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","30.2","203.66","APC"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","588.18",""
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.79","","","","","","","fee schedule","17.76","588.18",""
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","588.18",""
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","17.76","588.18","APC 277.30"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","17.76","588.18","APC 296.56"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","17.76","588.18","APC 308.91"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","17.76","588.18","APC"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","17.76","588.18","APC"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","17.76","588.18","APC"
"Split blood or products","86985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","17.76","588.18","APC"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.76","","","","","","","fee schedule","17.76","99.86",""
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","98.24","","","","","","","fee schedule","17.76","99.86",""
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.76","","","","","","","fee schedule","17.76","99.86",""
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","17.76","99.86","APC 277.30"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","17.76","99.86","APC 296.56"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","17.76","99.86","APC 308.91"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","17.76","99.86","APC"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","17.76","99.86","APC"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","17.76","99.86","APC"
"Transfusion procedure","86999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","17.76","99.86","APC"
"Small animal inoculation","87001","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","90.99","","","","","","","fee schedule","90.99","90.99",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.93","","","","","","","fee schedule","16.84","124.87",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.84","","","","","","","fee schedule","16.84","124.87",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.84","","","","","","","fee schedule","16.84","124.87",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.84","","","","","","","fee schedule","16.84","124.87",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.87","","","","","","","fee schedule","16.84","124.87",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.93","","","","","","","fee schedule","16.84","124.87",""
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.64","","","","","","","fee schedule","16.84","124.87","APC"
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.35","","","","","","","fee schedule","16.84","124.87","APC"
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.18","","","","","","","fee schedule","16.84","124.87","APC"
"Small animal inoculation","87003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.68","","","","","","","fee schedule","16.84","124.87","APC"
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.48","","","","","","","fee schedule","6.68","47.29",""
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.68","","","","","","","fee schedule","6.68","47.29",""
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.68","","","","","","","fee schedule","6.68","47.29",""
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.68","","","","","","","fee schedule","6.68","47.29",""
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.29","","","","","","","fee schedule","6.68","47.29",""
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.48","","","","","","","fee schedule","6.68","47.29",""
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7","","","","","","","fee schedule","6.68","47.29","APC"
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.88","","","","","","","fee schedule","6.68","47.29","APC"
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.81","","","","","","","fee schedule","6.68","47.29","APC"
"Specimen infect agnt concntj","87015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.01","","","","","","","fee schedule","6.68","47.29","APC"
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.75","","","","","","","fee schedule","10.32","75.06",""
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.32","","","","","","","fee schedule","10.32","75.06",""
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.32","","","","","","","fee schedule","10.32","75.06",""
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.32","","","","","","","fee schedule","10.32","75.06",""
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.06","","","","","","","fee schedule","10.32","75.06",""
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.75","","","","","","","fee schedule","10.32","75.06",""
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.81","","","","","","","fee schedule","10.32","75.06","APC"
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.63","","","","","","","fee schedule","10.32","75.06","APC"
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.53","","","","","","","fee schedule","10.32","75.06","APC"
"Blood culture for bacteria","87040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.84","","","","","","","fee schedule","10.32","75.06","APC"
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.21","","","","","","","fee schedule","9.44","68.5",""
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.44","","","","","","","fee schedule","9.44","68.5",""
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.44","","","","","","","fee schedule","9.44","68.5",""
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.44","","","","","","","fee schedule","9.44","68.5",""
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","68.5","","","","","","","fee schedule","9.44","68.5",""
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.21","","","","","","","fee schedule","9.44","68.5",""
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.89","","","","","","","fee schedule","9.44","68.5","APC"
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.72","","","","","","","fee schedule","9.44","68.5","APC"
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.63","","","","","","","fee schedule","9.44","68.5","APC"
"Feces culture aerobic bact","87045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.44","68.5","APC"
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.21","","","","","","","fee schedule","9.44","68.5",""
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.44","","","","","","","fee schedule","9.44","68.5",""
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.44","","","","","","","fee schedule","9.44","68.5",""
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.44","","","","","","","fee schedule","9.44","68.5",""
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","68.5","","","","","","","fee schedule","9.44","68.5",""
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.21","","","","","","","fee schedule","9.44","68.5",""
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.89","","","","","","","fee schedule","9.44","68.5","APC"
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.72","","","","","","","fee schedule","9.44","68.5","APC"
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.63","","","","","","","fee schedule","9.44","68.5","APC"
"Stool cultr aerobic bact ea","87046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.91","","","","","","","fee schedule","9.44","68.5","APC"
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.81","","","","","","","fee schedule","8.62","63.9",""
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.62","","","","","","","fee schedule","8.62","63.9",""
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.62","","","","","","","fee schedule","8.62","63.9",""
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.62","","","","","","","fee schedule","8.62","63.9",""
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.9","","","","","","","fee schedule","8.62","63.9",""
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.81","","","","","","","fee schedule","8.62","63.9",""
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.03","","","","","","","fee schedule","8.62","63.9","APC"
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.88","","","","","","","fee schedule","8.62","63.9","APC"
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.79","","","","","","","fee schedule","8.62","63.9","APC"
"Culture othr specimn aerobic","87070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.05","","","","","","","fee schedule","8.62","63.9","APC"
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.21","","","","","","","fee schedule","9.89","68.5",""
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.89","","","","","","","fee schedule","9.89","68.5",""
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.89","","","","","","","fee schedule","9.89","68.5",""
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.89","","","","","","","fee schedule","9.89","68.5",""
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","68.5","","","","","","","fee schedule","9.89","68.5",""
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.21","","","","","","","fee schedule","9.89","68.5",""
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.36","","","","","","","fee schedule","9.89","68.5","APC"
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.19","","","","","","","fee schedule","9.89","68.5","APC"
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.09","","","","","","","fee schedule","9.89","68.5","APC"
"Culture aerobic quant other","87071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.38","","","","","","","fee schedule","9.89","68.5","APC"
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.21","","","","","","","fee schedule","9.66","68.5",""
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.66","","","","","","","fee schedule","9.66","68.5",""
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.66","","","","","","","fee schedule","9.66","68.5",""
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.66","","","","","","","fee schedule","9.66","68.5",""
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","68.5","","","","","","","fee schedule","9.66","68.5",""
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.21","","","","","","","fee schedule","9.66","68.5",""
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.12","","","","","","","fee schedule","9.66","68.5","APC"
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.95","","","","","","","fee schedule","9.66","68.5","APC"
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.85","","","","","","","fee schedule","9.66","68.5","APC"
"Culture Bacteria Anaerobic","87073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.14","","","","","","","fee schedule","9.66","68.5","APC"
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.26","","","","","","","fee schedule","9.47","69.15",""
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.47","","","","","","","fee schedule","9.47","69.15",""
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.47","","","","","","","fee schedule","9.47","69.15",""
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.47","","","","","","","fee schedule","9.47","69.15",""
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.15","","","","","","","fee schedule","9.47","69.15",""
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.26","","","","","","","fee schedule","9.47","69.15",""
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.92","","","","","","","fee schedule","9.47","69.15","APC"
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.75","","","","","","","fee schedule","9.47","69.15","APC"
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.66","","","","","","","fee schedule","9.47","69.15","APC"
"Cultr bacteria except blood","87075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.94","","","","","","","fee schedule","9.47","69.15","APC"
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.88","","","","","","","fee schedule","8.08","58.22",""
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.08","","","","","","","fee schedule","8.08","58.22",""
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.08","","","","","","","fee schedule","8.08","58.22",""
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.08","","","","","","","fee schedule","8.08","58.22",""
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.22","","","","","","","fee schedule","8.08","58.22",""
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.88","","","","","","","fee schedule","8.08","58.22",""
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.46","","","","","","","fee schedule","8.08","58.22","APC"
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.32","","","","","","","fee schedule","8.08","58.22","APC"
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.24","","","","","","","fee schedule","8.08","58.22","APC"
"Culture anaerobe ident each","87076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.48","","","","","","","fee schedule","8.08","58.22","APC"
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.88","","","","","","","fee schedule","8.08","58.22",""
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.08","","","","","","","fee schedule","8.08","58.22",""
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.08","","","","","","","fee schedule","8.08","58.22",""
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.08","","","","","","","fee schedule","8.08","58.22",""
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","58.22","","","","","","","fee schedule","8.08","58.22",""
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.88","","","","","","","fee schedule","8.08","58.22",""
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.46","","","","","","","fee schedule","8.08","58.22","APC"
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.32","","","","","","","fee schedule","8.08","58.22","APC"
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.24","","","","","","","fee schedule","8.08","58.22","APC"
"Culture Aerobic Identify","87077","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.48","","","","","","","fee schedule","8.08","58.22","APC"
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.4","","","","","","","fee schedule","6.63","47.29",""
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.63","","","","","","","fee schedule","6.63","47.29",""
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.63","","","","","","","fee schedule","6.63","47.29",""
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.63","","","","","","","fee schedule","6.63","47.29",""
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.29","","","","","","","fee schedule","6.63","47.29",""
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.4","","","","","","","fee schedule","6.63","47.29",""
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.94","","","","","","","fee schedule","6.63","47.29","APC"
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.83","","","","","","","fee schedule","6.63","47.29","APC"
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.76","","","","","","","fee schedule","6.63","47.29","APC"
"Culture screen only","87081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.96","","","","","","","fee schedule","6.63","47.29","APC"
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.81","","","","","","","fee schedule","14.81","61.34",""
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.07","","","","","","","fee schedule","14.81","61.34",""
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.07","","","","","","","fee schedule","14.81","61.34",""
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.07","","","","","","","fee schedule","14.81","61.34",""
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","61.34","","","","","","","fee schedule","14.81","61.34",""
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.81","","","","","","","fee schedule","14.81","61.34",""
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.36","","","","","","","fee schedule","14.81","61.34","APC"
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.88","","","","","","","fee schedule","14.81","61.34","APC"
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.61","","","","","","","fee schedule","14.81","61.34","APC"
"Culture of specimen by kit","87084","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.42","","","","","","","fee schedule","14.81","61.34","APC"
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.88","","","","","","","fee schedule","8.07","59.07",""
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.07","","","","","","","fee schedule","8.07","59.07",""
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.07","","","","","","","fee schedule","8.07","59.07",""
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.07","","","","","","","fee schedule","8.07","59.07",""
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.07","","","","","","","fee schedule","8.07","59.07",""
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.88","","","","","","","fee schedule","8.07","59.07",""
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.45","","","","","","","fee schedule","8.07","59.07","APC"
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.31","","","","","","","fee schedule","8.07","59.07","APC"
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.23","","","","","","","fee schedule","8.07","59.07","APC"
"Urine culture/colony count","87086","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.47","","","","","","","fee schedule","8.07","59.07","APC"
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.92","","","","","","","fee schedule","8.09","56.49",""
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.09","","","","","","","fee schedule","8.09","56.49",""
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.09","","","","","","","fee schedule","8.09","56.49",""
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.09","","","","","","","fee schedule","8.09","56.49",""
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","56.49","","","","","","","fee schedule","8.09","56.49",""
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.92","","","","","","","fee schedule","8.09","56.49",""
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.47","","","","","","","fee schedule","8.09","56.49","APC"
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.33","","","","","","","fee schedule","8.09","56.49","APC"
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.25","","","","","","","fee schedule","8.09","56.49","APC"
"Urine bacteria culture","87088","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.49","","","","","","","fee schedule","8.09","56.49","APC"
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.26","","","","","","","fee schedule","7.71","55.72",""
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.71","","","","","","","fee schedule","7.71","55.72",""
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.71","","","","","","","fee schedule","7.71","55.72",""
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.71","","","","","","","fee schedule","7.71","55.72",""
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","55.72","","","","","","","fee schedule","7.71","55.72",""
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.26","","","","","","","fee schedule","7.71","55.72",""
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.08","","","","","","","fee schedule","7.71","55.72","APC"
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.94","","","","","","","fee schedule","7.71","55.72","APC"
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.86","","","","","","","fee schedule","7.71","55.72","APC"
"Skin fungi culture","87101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.1","","","","","","","fee schedule","7.71","55.72","APC"
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.44","","","","","","","fee schedule","8.41","61",""
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.41","","","","","","","fee schedule","8.41","61",""
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.41","","","","","","","fee schedule","8.41","61",""
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.41","","","","","","","fee schedule","8.41","61",""
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","61","","","","","","","fee schedule","8.41","61",""
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.44","","","","","","","fee schedule","8.41","61",""
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.81","","","","","","","fee schedule","8.41","61","APC"
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.66","","","","","","","fee schedule","8.41","61","APC"
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.41","61","APC"
"Fungus isolation culture","87102","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.83","","","","","","","fee schedule","8.41","61","APC"
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.5","","","","","","","fee schedule","15.5","66.65",""
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.46","","","","","","","fee schedule","15.5","66.65",""
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.46","","","","","","","fee schedule","15.5","66.65",""
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.46","","","","","","","fee schedule","15.5","66.65",""
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","66.65","","","","","","","fee schedule","15.5","66.65",""
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.5","","","","","","","fee schedule","15.5","66.65",""
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.43","","","","","","","fee schedule","15.5","66.65","APC"
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.07","","","","","","","fee schedule","15.5","66.65","APC"
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.87","","","","","","","fee schedule","15.5","66.65","APC"
"Blood fungus culture","87103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.48","","","","","","","fee schedule","15.5","66.65","APC"
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.75","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.32","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.32","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.32","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","73.7","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.75","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.81","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.63","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.53","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification yeast","87106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.84","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.75","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.32","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.32","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.32","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","73.7","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.75","","","","","","","fee schedule","10.32","73.7",""
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.81","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.63","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.53","","","","","","","fee schedule","10.32","73.7","APC"
"Fungi identification mold","87107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.84","","","","","","","fee schedule","10.32","73.7","APC"
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.45","","","","","","","fee schedule","15.39","106.3",""
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.39","","","","","","","fee schedule","15.39","106.3",""
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.39","","","","","","","fee schedule","15.39","106.3",""
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.39","","","","","","","fee schedule","15.39","106.3",""
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.3","","","","","","","fee schedule","15.39","106.3",""
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.45","","","","","","","fee schedule","15.39","106.3",""
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.12","","","","","","","fee schedule","15.39","106.3","APC"
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.85","","","","","","","fee schedule","15.39","106.3","APC"
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.7","","","","","","","fee schedule","15.39","106.3","APC"
"Mycoplasma","87109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.16","","","","","","","fee schedule","15.39","106.3","APC"
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.67","","","","","","","fee schedule","19.6","135.67",""
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.6","","","","","","","fee schedule","19.6","135.67",""
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.6","","","","","","","fee schedule","19.6","135.67",""
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.6","","","","","","","fee schedule","19.6","135.67",""
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","135.67","","","","","","","fee schedule","19.6","135.67",""
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.67","","","","","","","fee schedule","19.6","135.67",""
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.53","","","","","","","fee schedule","19.6","135.67","APC"
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.19","","","","","","","fee schedule","19.6","135.67","APC"
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.99","","","","","","","fee schedule","19.6","135.67","APC"
"Chlamydia culture","87110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.58","","","","","","","fee schedule","19.6","135.67","APC"
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.58","","","","","","","fee schedule","10.8","76.85",""
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.8","","","","","","","fee schedule","10.8","76.85",""
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.8","","","","","","","fee schedule","10.8","76.85",""
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.8","","","","","","","fee schedule","10.8","76.85",""
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","76.85","","","","","","","fee schedule","10.8","76.85",""
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.58","","","","","","","fee schedule","10.8","76.85",""
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.31","","","","","","","fee schedule","10.8","76.85","APC"
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.12","","","","","","","fee schedule","10.8","76.85","APC"
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.02","","","","","","","fee schedule","10.8","76.85","APC"
"Mycobacteria culture","87116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.34","","","","","","","fee schedule","10.8","76.85","APC"
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.8","","","","","","","fee schedule","14.61","79.69",""
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.61","","","","","","","fee schedule","14.61","79.69",""
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.61","","","","","","","fee schedule","14.61","79.69",""
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.61","","","","","","","fee schedule","14.61","79.69",""
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.69","","","","","","","fee schedule","14.61","79.69",""
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.8","","","","","","","fee schedule","14.61","79.69",""
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.3","","","","","","","fee schedule","14.61","79.69","APC"
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.05","","","","","","","fee schedule","14.61","79.69","APC"
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.9","","","","","","","fee schedule","14.61","79.69","APC"
"Mycobacteric identification","87118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.34","","","","","","","fee schedule","14.61","79.69","APC"
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.58","","","","","","","fee schedule","5.57","40.81",""
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.57","","","","","","","fee schedule","5.57","40.81",""
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.57","","","","","","","fee schedule","5.57","40.81",""
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.57","","","","","","","fee schedule","5.57","40.81",""
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.81","","","","","","","fee schedule","5.57","40.81",""
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.58","","","","","","","fee schedule","5.57","40.81",""
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.83","","","","","","","fee schedule","5.57","40.81","APC"
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.74","","","","","","","fee schedule","5.57","40.81","APC"
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.68","","","","","","","fee schedule","5.57","40.81","APC"
"Culture type immunofluoresc","87140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.85","","","","","","","fee schedule","5.57","40.81","APC"
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21.54","","","","","","","fee schedule","12.52","86.85",""
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.52","","","","","","","fee schedule","12.52","86.85",""
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.52","","","","","","","fee schedule","12.52","86.85",""
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.52","","","","","","","fee schedule","12.52","86.85",""
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.85","","","","","","","fee schedule","12.52","86.85",""
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21.54","","","","","","","fee schedule","12.52","86.85",""
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.11","","","","","","","fee schedule","12.52","86.85","APC"
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.9","","","","","","","fee schedule","12.52","86.85","APC"
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.77","","","","","","","fee schedule","12.52","86.85","APC"
"Culture typing glc/hplc","87143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.15","","","","","","","fee schedule","12.52","86.85","APC"
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.89","","","","","","","fee schedule","5.18","37.69",""
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.18","","","","","","","fee schedule","5.18","37.69",""
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.18","","","","","","","fee schedule","5.18","37.69",""
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.18","","","","","","","fee schedule","5.18","37.69",""
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.69","","","","","","","fee schedule","5.18","37.69",""
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.89","","","","","","","fee schedule","5.18","37.69",""
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.18","37.69","APC"
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.18","37.69","APC"
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.18","37.69","APC"
"Culture type immunologic","87147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.18","37.69","APC"
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Dna/rna direct probe","87149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Dna/rna amplified probe","87150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.74","","","","","","","fee schedule","7.74","38.88",""
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.74","","","","","","","fee schedule","7.74","38.88",""
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.74","","","","","","","fee schedule","7.74","38.88",""
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.88","","","","","","","fee schedule","7.74","38.88",""
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.99","","","","","","","fee schedule","7.74","38.88",""
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.99","","","","","","","fee schedule","7.74","38.88",""
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.11","","","","","","","fee schedule","7.74","38.88","APC"
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.97","","","","","","","fee schedule","7.74","38.88","APC"
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.89","","","","","","","fee schedule","7.74","38.88","APC"
"Culture Type Pulse Field Gel","87152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.13","","","","","","","fee schedule","7.74","38.88","APC"
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.36","","","","","","","fee schedule","115.36","835.7",""
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","115.36","","","","","","","fee schedule","115.36","835.7",""
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","115.36","","","","","","","fee schedule","115.36","835.7",""
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","835.7","","","","","","","fee schedule","115.36","835.7",""
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","198.26","","","","","","","fee schedule","115.36","835.7",""
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","198.26","","","","","","","fee schedule","115.36","835.7",""
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","120.84","","","","","","","fee schedule","115.36","835.7","APC"
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","118.82","","","","","","","fee schedule","115.36","835.7","APC"
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117.67","","","","","","","fee schedule","115.36","835.7","APC"
"Dna/rna sequencing","87153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","121.13","","","","","","","fee schedule","115.36","835.7","APC"
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","218.06","","","","","","","fee schedule","218.06","261.67",""
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","218.06","","","","","","","fee schedule","218.06","261.67",""
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","218.06","","","","","","","fee schedule","218.06","261.67",""
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","261.67","","","","","","","fee schedule","218.06","261.67",""
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","261.67","","","","","","","fee schedule","218.06","261.67",""
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","228.42","","","","","","","fee schedule","218.06","261.67","APC"
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","224.6","","","","","","","fee schedule","218.06","261.67","APC"
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","222.42","","","","","","","fee schedule","218.06","261.67","APC"
"Cul typ id bld pthgn 6+ trgt","87154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","228.96","","","","","","","fee schedule","218.06","261.67","APC"
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.74","","","","","","","fee schedule","7.74","38.88",""
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.74","","","","","","","fee schedule","7.74","38.88",""
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.74","","","","","","","fee schedule","7.74","38.88",""
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","38.88","","","","","","","fee schedule","7.74","38.88",""
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.99","","","","","","","fee schedule","7.74","38.88",""
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.99","","","","","","","fee schedule","7.74","38.88",""
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.11","","","","","","","fee schedule","7.74","38.88","APC"
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.97","","","","","","","fee schedule","7.74","38.88","APC"
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.89","","","","","","","fee schedule","7.74","38.88","APC"
"Culture typing added method","87158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.13","","","","","","","fee schedule","7.74","38.88","APC"
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.74","","","","","","","fee schedule","10.74","70.46",""
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.74","","","","","","","fee schedule","10.74","70.46",""
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.74","","","","","","","fee schedule","10.74","70.46",""
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","70.46","","","","","","","fee schedule","10.74","70.46",""
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.46","","","","","","","fee schedule","10.74","70.46",""
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.46","","","","","","","fee schedule","10.74","70.46",""
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.25","","","","","","","fee schedule","10.74","70.46","APC"
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.74","70.46","APC"
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.74","70.46","APC"
"Dark field examination","87164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.28","","","","","","","fee schedule","10.74","70.46","APC"
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.3","","","","","","","fee schedule","11.3","75.23",""
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.3","","","","","","","fee schedule","11.3","75.23",""
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.3","","","","","","","fee schedule","11.3","75.23",""
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.23","","","","","","","fee schedule","11.3","75.23",""
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.42","","","","","","","fee schedule","11.3","75.23",""
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.42","","","","","","","fee schedule","11.3","75.23",""
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.84","","","","","","","fee schedule","11.3","75.23","APC"
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.64","","","","","","","fee schedule","11.3","75.23","APC"
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.53","","","","","","","fee schedule","11.3","75.23","APC"
"Dark field examination","87166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.87","","","","","","","fee schedule","11.3","75.23","APC"
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","31.64",""
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","31.64",""
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","31.64",""
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.64","","","","","","","fee schedule","4.27","31.64",""
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.27","31.64",""
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.27","31.64",""
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","31.64","APC"
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","31.64","APC"
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","31.64","APC"
"Macroscopic Exam Arthropod","87168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","31.64","APC"
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.31","","","","","","","fee schedule","4.31","31.64",""
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.31","","","","","","","fee schedule","4.31","31.64",""
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.31","","","","","","","fee schedule","4.31","31.64",""
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.64","","","","","","","fee schedule","4.31","31.64",""
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.31","31.64",""
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.31","31.64",""
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.51","","","","","","","fee schedule","4.31","31.64","APC"
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.31","31.64","APC"
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.31","31.64","APC"
"Macroscopic exam parasite","87169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.53","","","","","","","fee schedule","4.31","31.64","APC"
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","31.64",""
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","31.64",""
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","31.64",""
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.64","","","","","","","fee schedule","4.27","31.64",""
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.27","31.64",""
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.27","31.64",""
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","31.64","APC"
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","31.64","APC"
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","31.64","APC"
"Pinworm Exam","87172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","31.64","APC"
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.88","","","","","","","fee schedule","5.88","43.51",""
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.88","","","","","","","fee schedule","5.88","43.51",""
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.88","","","","","","","fee schedule","5.88","43.51",""
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","43.51","","","","","","","fee schedule","5.88","43.51",""
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.12","","","","","","","fee schedule","5.88","43.51",""
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.12","","","","","","","fee schedule","5.88","43.51",""
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.16","","","","","","","fee schedule","5.88","43.51","APC"
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.06","","","","","","","fee schedule","5.88","43.51","APC"
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6","","","","","","","fee schedule","5.88","43.51","APC"
"Tissue homogenization cultr","87176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.17","","","","","","","fee schedule","5.88","43.51","APC"
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.9","","","","","","","fee schedule","8.9","65.23",""
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.9","","","","","","","fee schedule","8.9","65.23",""
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.9","","","","","","","fee schedule","8.9","65.23",""
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","65.23","","","","","","","fee schedule","8.9","65.23",""
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.29","","","","","","","fee schedule","8.9","65.23",""
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.29","","","","","","","fee schedule","8.9","65.23",""
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.32","","","","","","","fee schedule","8.9","65.23","APC"
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.17","","","","","","","fee schedule","8.9","65.23","APC"
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.08","","","","","","","fee schedule","8.9","65.23","APC"
"Ova and parasites smears","87177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.35","","","","","","","fee schedule","8.9","65.23","APC"
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.75","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.75","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.75","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","28.03","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.98","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.89","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.84","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible diffuse","87181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.99","","","","","","","fee schedule","4.75","28.03","APC"
"Sc std carbapenem resist gen","87183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.79","36.84","APC"
"Sc std carbapenem resist gen","87183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.79","36.84","APC"
"Sc std carbapenem resist gen","87183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.79","36.84","APC"
"Sc std carbapenem resist gen","87183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.79","36.84","APC"
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.48","","","","","","","fee schedule","7.48","51.26",""
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.48","","","","","","","fee schedule","7.48","51.26",""
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.48","","","","","","","fee schedule","7.48","51.26",""
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","51.26","","","","","","","fee schedule","7.48","51.26",""
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.86","","","","","","","fee schedule","7.48","51.26",""
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.86","","","","","","","fee schedule","7.48","51.26",""
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.84","","","","","","","fee schedule","7.48","51.26","APC"
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.7","","","","","","","fee schedule","7.48","51.26","APC"
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.63","","","","","","","fee schedule","7.48","51.26","APC"
"Microbe susceptible disk","87184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.85","","","","","","","fee schedule","7.48","51.26","APC"
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.75","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.75","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.75","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","28.03","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","4.75","28.03",""
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.98","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.89","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.84","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible enzyme","87185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.99","","","","","","","fee schedule","4.75","28.03","APC"
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.65","","","","","","","fee schedule","8.65","63.05",""
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.65","","","","","","","fee schedule","8.65","63.05",""
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.65","","","","","","","fee schedule","8.65","63.05",""
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","63.05","","","","","","","fee schedule","8.65","63.05",""
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.86","","","","","","","fee schedule","8.65","63.05",""
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.86","","","","","","","fee schedule","8.65","63.05",""
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.06","","","","","","","fee schedule","8.65","63.05","APC"
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.91","","","","","","","fee schedule","8.65","63.05","APC"
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.82","","","","","","","fee schedule","8.65","63.05","APC"
"Microbe susceptible mic","87186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.08","","","","","","","fee schedule","8.65","63.05","APC"
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40.17","","","","","","","fee schedule","17.81","72.87",""
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","40.17","","","","","","","fee schedule","17.81","72.87",""
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40.17","","","","","","","fee schedule","17.81","72.87",""
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","72.87","","","","","","","fee schedule","17.81","72.87",""
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.81","","","","","","","fee schedule","17.81","72.87",""
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.81","","","","","","","fee schedule","17.81","72.87",""
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.08","","","","","","","fee schedule","17.81","72.87","APC"
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.38","","","","","","","fee schedule","17.81","72.87","APC"
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.97","","","","","","","fee schedule","17.81","72.87","APC"
"Microbe susceptible mlc","87187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.18","","","","","","","fee schedule","17.81","72.87","APC"
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.64","","","","","","","fee schedule","6.64","47.46",""
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.64","","","","","","","fee schedule","6.64","47.46",""
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.64","","","","","","","fee schedule","6.64","47.46",""
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","47.46","","","","","","","fee schedule","6.64","47.46",""
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.4","","","","","","","fee schedule","6.64","47.46",""
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.4","","","","","","","fee schedule","6.64","47.46",""
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.96","","","","","","","fee schedule","6.64","47.46","APC"
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.84","","","","","","","fee schedule","6.64","47.46","APC"
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.77","","","","","","","fee schedule","6.64","47.46","APC"
"Microbe suscept macrobroth","87188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.97","","","","","","","fee schedule","6.64","47.46","APC"
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.31","","","","","","","fee schedule","7.31","39.02",""
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.31","","","","","","","fee schedule","7.31","39.02",""
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.31","","","","","","","fee schedule","7.31","39.02",""
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","39.02","","","","","","","fee schedule","7.31","39.02",""
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.72","","","","","","","fee schedule","7.31","39.02",""
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.72","","","","","","","fee schedule","7.31","39.02",""
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.66","","","","","","","fee schedule","7.31","39.02","APC"
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.53","","","","","","","fee schedule","7.31","39.02","APC"
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.46","","","","","","","fee schedule","7.31","39.02","APC"
"Microbe suscept mycobacteri","87190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.68","","","","","","","fee schedule","7.31","39.02","APC"
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.02","","","","","","","fee schedule","15.02","102.92",""
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.02","","","","","","","fee schedule","15.02","102.92",""
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.02","","","","","","","fee schedule","15.02","102.92",""
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","102.92","","","","","","","fee schedule","15.02","102.92",""
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.82","","","","","","","fee schedule","15.02","102.92",""
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.82","","","","","","","fee schedule","15.02","102.92",""
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.73","","","","","","","fee schedule","15.02","102.92","APC"
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.47","","","","","","","fee schedule","15.02","102.92","APC"
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.32","","","","","","","fee schedule","15.02","102.92","APC"
"Bactericidal level serum","87197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.77","","","","","","","fee schedule","15.02","102.92","APC"
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","31.33",""
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","31.33",""
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","31.33",""
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.33","","","","","","","fee schedule","4.27","31.33",""
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.27","31.33",""
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.27","31.33",""
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","31.33","APC"
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","31.33","APC"
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","31.33","APC"
"Smear gram stain","87205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","31.33","APC"
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.39","","","","","","","fee schedule","5.39","39.31",""
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.39","","","","","","","fee schedule","5.39","39.31",""
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.39","","","","","","","fee schedule","5.39","39.31",""
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.24","","","","","","","fee schedule","5.39","39.31",""
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","39.31","","","","","","","fee schedule","5.39","39.31",""
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.24","","","","","","","fee schedule","5.39","39.31",""
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.65","","","","","","","fee schedule","5.39","39.31","APC"
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.55","","","","","","","fee schedule","5.39","39.31","APC"
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.5","","","","","","","fee schedule","5.39","39.31","APC"
"Smear fluorescent/acid stai","87206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.66","","","","","","","fee schedule","5.39","39.31","APC"
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.99","","","","","","","fee schedule","5.99","43.51",""
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.99","","","","","","","fee schedule","5.99","43.51",""
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.99","","","","","","","fee schedule","5.99","43.51",""
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.3","","","","","","","fee schedule","5.99","43.51",""
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","43.51","","","","","","","fee schedule","5.99","43.51",""
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.3","","","","","","","fee schedule","5.99","43.51",""
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.27","","","","","","","fee schedule","5.99","43.51","APC"
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.17","","","","","","","fee schedule","5.99","43.51","APC"
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.11","","","","","","","fee schedule","5.99","43.51","APC"
"Smear special stain","87207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.29","","","","","","","fee schedule","5.99","43.51","APC"
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.98","","","","","","","fee schedule","17.98","130.61",""
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.98","","","","","","","fee schedule","17.98","130.61",""
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.98","","","","","","","fee schedule","17.98","130.61",""
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.89","","","","","","","fee schedule","17.98","130.61",""
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","130.61","","","","","","","fee schedule","17.98","130.61",""
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.89","","","","","","","fee schedule","17.98","130.61",""
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.83","","","","","","","fee schedule","17.98","130.61","APC"
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.52","","","","","","","fee schedule","17.98","130.61","APC"
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.34","","","","","","","fee schedule","17.98","130.61","APC"
"Smear complex stain","87209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.88","","","","","","","fee schedule","17.98","130.61","APC"
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.82","","","","","","","fee schedule","5.82","31.64",""
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.82","","","","","","","fee schedule","5.82","31.64",""
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.82","","","","","","","fee schedule","5.82","31.64",""
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","5.82","31.64",""
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.64","","","","","","","fee schedule","5.82","31.64",""
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","5.82","31.64",""
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.1","","","","","","","fee schedule","5.82","31.64","APC"
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.99","","","","","","","fee schedule","5.82","31.64","APC"
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.94","","","","","","","fee schedule","5.82","31.64","APC"
"Smear wet mount saline/ink","87210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.11","","","","","","","fee schedule","5.82","31.64","APC"
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","30.79",""
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","30.79",""
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","30.79",""
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.27","30.79",""
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","30.79","","","","","","","fee schedule","4.27","30.79",""
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.27","30.79",""
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","30.79","APC"
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","30.79","APC"
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","30.79","APC"
"Tissue exam for fungi","87220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","30.79","APC"
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.74","","","","","","","fee schedule","19.74","137.51",""
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.74","","","","","","","fee schedule","19.74","137.51",""
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.74","","","","","","","fee schedule","19.74","137.51",""
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.94","","","","","","","fee schedule","19.74","137.51",""
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","137.51","","","","","","","fee schedule","19.74","137.51",""
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.94","","","","","","","fee schedule","19.74","137.51",""
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.68","","","","","","","fee schedule","19.74","137.51","APC"
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.33","","","","","","","fee schedule","19.74","137.51","APC"
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.13","","","","","","","fee schedule","19.74","137.51","APC"
"Assay toxin or antitoxin","87230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.73","","","","","","","fee schedule","19.74","137.51","APC"
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.56","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.56","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.56","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.61","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.48","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.61","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.49","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.15","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.95","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculate eggs/animal","87250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.54","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.07","","","","","","","fee schedule","26.07","185.62",""
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.07","","","","","","","fee schedule","26.07","185.62",""
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.07","","","","","","","fee schedule","26.07","185.62",""
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","44.8","","","","","","","fee schedule","26.07","185.62",""
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","185.62","","","","","","","fee schedule","26.07","185.62",""
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","44.8","","","","","","","fee schedule","26.07","185.62",""
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.31","","","","","","","fee schedule","26.07","185.62","APC"
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.85","","","","","","","fee schedule","26.07","185.62","APC"
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.59","","","","","","","fee schedule","26.07","185.62","APC"
"Virus inoculation tissue","87252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.37","","","","","","","fee schedule","26.07","185.62","APC"
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.2","","","","","","","fee schedule","20.2","138.45",""
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.2","","","","","","","fee schedule","20.2","138.45",""
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.2","","","","","","","fee schedule","20.2","138.45",""
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.72","","","","","","","fee schedule","20.2","138.45",""
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","138.45","","","","","","","fee schedule","20.2","138.45",""
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.72","","","","","","","fee schedule","20.2","138.45",""
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.16","","","","","","","fee schedule","20.2","138.45","APC"
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.81","","","","","","","fee schedule","20.2","138.45","APC"
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.6","","","","","","","fee schedule","20.2","138.45","APC"
"Virus inoculate tissue addl","87253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.21","","","","","","","fee schedule","20.2","138.45","APC"
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.56","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.56","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.56","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.61","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.48","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.61","","","","","","","fee schedule","19.56","142.48",""
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.49","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.15","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.95","","","","","","","fee schedule","19.56","142.48","APC"
"Virus inoculation shell via","87254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.54","","","","","","","fee schedule","19.56","142.48","APC"
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.86","","","","","","","fee schedule","33.86","246.17",""
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.86","","","","","","","fee schedule","33.86","246.17",""
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","33.86","","","","","","","fee schedule","33.86","246.17",""
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.2","","","","","","","fee schedule","33.86","246.17",""
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","246.17","","","","","","","fee schedule","33.86","246.17",""
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.2","","","","","","","fee schedule","33.86","246.17",""
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.47","","","","","","","fee schedule","33.86","246.17","APC"
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.88","","","","","","","fee schedule","33.86","246.17","APC"
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.54","","","","","","","fee schedule","33.86","246.17","APC"
"Genet virus isolate hsv","87255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.55","","","","","","","fee schedule","33.86","246.17","APC"
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.43","","","","","","","fee schedule","14.43","86.99",""
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.43","","","","","","","fee schedule","14.43","86.99",""
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.43","","","","","","","fee schedule","14.43","86.99",""
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","14.43","86.99",""
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","14.43","86.99",""
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","14.43","86.99",""
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.12","","","","","","","fee schedule","14.43","86.99","APC"
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.86","","","","","","","fee schedule","14.43","86.99","APC"
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.72","","","","","","","fee schedule","14.43","86.99","APC"
"Adenovirus ag if","87260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.15","","","","","","","fee schedule","14.43","86.99","APC"
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Pertussis ag if","87265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.42","","","","","","","fee schedule","13.42","86.99",""
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.42","86.99",""
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.42","86.99",""
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.42","86.99",""
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.42","86.99","APC"
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.42","86.99","APC"
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.42","86.99","APC"
"Enterovirus antibody dfa","87267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.09","","","","","","","fee schedule","13.42","86.99","APC"
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.61","","","","","","","fee schedule","13.61","86.99",""
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.61","","","","","","","fee schedule","13.61","86.99",""
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.61","","","","","","","fee schedule","13.61","86.99",""
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.61","86.99",""
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.61","86.99",""
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.61","86.99",""
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.26","","","","","","","fee schedule","13.61","86.99","APC"
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.02","","","","","","","fee schedule","13.61","86.99","APC"
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.61","86.99","APC"
"Giardia ag if","87269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.29","","","","","","","fee schedule","13.61","86.99","APC"
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Chlamydia trachomatis ag if","87270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.42","","","","","","","fee schedule","13.42","86.99",""
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.42","86.99",""
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.42","86.99",""
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.42","86.99",""
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.42","86.99","APC"
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.42","86.99","APC"
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.42","86.99","APC"
"Cytomegalovirus dfa","87271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.09","","","","","","","fee schedule","13.42","86.99","APC"
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Cryptosporidium ag if","87272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 2 ag if","87273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Herpes simplex 1 ag if","87274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","12.25","86.99",""
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.25","","","","","","","fee schedule","12.25","86.99",""
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.25","","","","","","","fee schedule","12.25","86.99",""
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.25","","","","","","","fee schedule","12.25","86.99",""
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","12.25","86.99",""
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","12.25","86.99",""
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.25","86.99","APC"
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.25","86.99","APC"
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.5","","","","","","","fee schedule","12.25","86.99","APC"
"Influenza b ag if","87275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.86","","","","","","","fee schedule","12.25","86.99","APC"
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.07","86.99",""
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.07","","","","","","","fee schedule","16.07","86.99",""
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.07","","","","","","","fee schedule","16.07","86.99",""
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.07","","","","","","","fee schedule","16.07","86.99",""
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.07","86.99",""
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.07","86.99",""
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.83","","","","","","","fee schedule","16.07","86.99","APC"
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.55","","","","","","","fee schedule","16.07","86.99","APC"
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.39","","","","","","","fee schedule","16.07","86.99","APC"
"Influenza a ag if","87276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.87","","","","","","","fee schedule","16.07","86.99","APC"
"Legionella micdadei ag if","87277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","86.99","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","15.6","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.6","","","","","","","fee schedule","15.6","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.6","","","","","","","fee schedule","15.6","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.6","","","","","","","fee schedule","15.6","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","15.6","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","15.6","86.99",""
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.34","","","","","","","fee schedule","15.6","86.99","APC"
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.07","","","","","","","fee schedule","15.6","86.99","APC"
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.91","","","","","","","fee schedule","15.6","86.99","APC"
"Legion pneumophilia ag if","87278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.38","","","","","","","fee schedule","15.6","86.99","APC"
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.43","86.99",""
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.43","","","","","","","fee schedule","16.43","86.99",""
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.43","","","","","","","fee schedule","16.43","86.99",""
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.43","","","","","","","fee schedule","16.43","86.99",""
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.43","86.99",""
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.43","86.99",""
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.21","","","","","","","fee schedule","16.43","86.99","APC"
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.92","","","","","","","fee schedule","16.43","86.99","APC"
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.76","","","","","","","fee schedule","16.43","86.99","APC"
"Parainfluenza ag if","87279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.25","","","","","","","fee schedule","16.43","86.99","APC"
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.42","86.99",""
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.42","","","","","","","fee schedule","13.42","86.99",""
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.42","86.99",""
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.42","86.99",""
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.42","86.99","APC"
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.42","86.99","APC"
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.42","86.99","APC"
"Respiratory syncytial ag if","87280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.09","","","","","","","fee schedule","13.42","86.99","APC"
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Pneumocystis carinii ag if","87281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","20.62","86.99",""
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60.8","","","","","","","fee schedule","20.62","86.99",""
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60.8","","","","","","","fee schedule","20.62","86.99",""
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60.8","","","","","","","fee schedule","20.62","86.99",""
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","20.62","86.99",""
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","20.62","86.99",""
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.69","","","","","","","fee schedule","20.62","86.99","APC"
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.62","","","","","","","fee schedule","20.62","86.99","APC"
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.02","","","","","","","fee schedule","20.62","86.99","APC"
"Rubeola ag if","87283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63.84","","","","","","","fee schedule","20.62","86.99","APC"
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","12.18","86.99",""
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.18","","","","","","","fee schedule","12.18","86.99",""
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.18","","","","","","","fee schedule","12.18","86.99",""
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.18","","","","","","","fee schedule","12.18","86.99",""
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","12.18","86.99",""
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","12.18","86.99",""
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.76","","","","","","","fee schedule","12.18","86.99","APC"
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.55","","","","","","","fee schedule","12.18","86.99","APC"
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.42","","","","","","","fee schedule","12.18","86.99","APC"
"Treponema pallidum ag if","87285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.79","","","","","","","fee schedule","12.18","86.99","APC"
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.42","86.99",""
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.42","","","","","","","fee schedule","13.42","86.99",""
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.42","86.99",""
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.42","86.99",""
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.42","86.99","APC"
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.42","86.99","APC"
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.42","86.99","APC"
"Varicella zoster ag if","87290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.09","","","","","","","fee schedule","13.42","86.99","APC"
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.1","86.99",""
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.1","","","","","","","fee schedule","16.1","86.99",""
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.1","","","","","","","fee schedule","16.1","86.99",""
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.1","","","","","","","fee schedule","16.1","86.99",""
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.1","86.99",""
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.1","86.99",""
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.86","","","","","","","fee schedule","16.1","86.99","APC"
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.58","","","","","","","fee schedule","16.1","86.99","APC"
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.42","","","","","","","fee schedule","16.1","86.99","APC"
"Antibody detection nos if","87299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.9","","","","","","","fee schedule","16.1","86.99","APC"
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detection polyval if","87300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Adenovirus ag ia","87301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Aspergillus ag ia","87305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","15","86.99",""
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15","","","","","","","fee schedule","15","86.99",""
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15","","","","","","","fee schedule","15","86.99",""
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15","","","","","","","fee schedule","15","86.99",""
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","15","86.99",""
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","15","86.99",""
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.71","","","","","","","fee schedule","15","86.99","APC"
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.45","","","","","","","fee schedule","15","86.99","APC"
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.3","","","","","","","fee schedule","15","86.99","APC"
"Chylmd trach ag ia","87320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.75","","","","","","","fee schedule","15","86.99","APC"
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Clostridium ag ia","87324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.42","86.99",""
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.42","","","","","","","fee schedule","13.42","86.99",""
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.42","","","","","","","fee schedule","13.42","86.99",""
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.42","86.99",""
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.42","86.99",""
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.06","","","","","","","fee schedule","13.42","86.99","APC"
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.82","","","","","","","fee schedule","13.42","86.99","APC"
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.42","86.99","APC"
"Cryptococcus neoform ag ia","87327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.09","","","","","","","fee schedule","13.42","86.99","APC"
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.82","86.99",""
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.82","","","","","","","fee schedule","13.82","86.99",""
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.82","","","","","","","fee schedule","13.82","86.99",""
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.82","","","","","","","fee schedule","13.82","86.99",""
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.82","86.99",""
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.82","86.99",""
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.48","","","","","","","fee schedule","13.82","86.99","APC"
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.23","","","","","","","fee schedule","13.82","86.99","APC"
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.1","","","","","","","fee schedule","13.82","86.99","APC"
"Cryptosporidium ag ia","87328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.51","","","","","","","fee schedule","13.82","86.99","APC"
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Giardia ag ia","87329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Cytomegalovirus ag ia","87332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","12.66","86.99",""
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.66","","","","","","","fee schedule","12.66","86.99",""
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.66","","","","","","","fee schedule","12.66","86.99",""
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.66","","","","","","","fee schedule","12.66","86.99",""
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","12.66","86.99",""
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","12.66","86.99",""
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.26","","","","","","","fee schedule","12.66","86.99","APC"
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.04","","","","","","","fee schedule","12.66","86.99","APC"
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.91","","","","","","","fee schedule","12.66","86.99","APC"
"E coli 0157 ag ia","87335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.29","","","","","","","fee schedule","12.66","86.99","APC"
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16","86.99",""
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16","","","","","","","fee schedule","16","86.99",""
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16","","","","","","","fee schedule","16","86.99",""
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16","","","","","","","fee schedule","16","86.99",""
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16","86.99",""
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16","86.99",""
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.76","","","","","","","fee schedule","16","86.99","APC"
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.48","","","","","","","fee schedule","16","86.99","APC"
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.32","","","","","","","fee schedule","16","86.99","APC"
"Entamoeb hist dispr ag ia","87336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.8","","","","","","","fee schedule","16","86.99","APC"
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Entamoeb hist group ag ia","87337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","24.72","","","","","","","fee schedule","14.38","95.88",""
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.38","","","","","","","fee schedule","14.38","95.88",""
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.38","","","","","","","fee schedule","14.38","95.88",""
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.38","","","","","","","fee schedule","14.38","95.88",""
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","24.72","","","","","","","fee schedule","14.38","95.88",""
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","95.88","","","","","","","fee schedule","14.38","95.88",""
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.06","","","","","","","fee schedule","14.38","95.88","APC"
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.81","","","","","","","fee schedule","14.38","95.88","APC"
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.67","","","","","","","fee schedule","14.38","95.88","APC"
"Hpylori stool ia","87338","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.1","","","","","","","fee schedule","14.38","95.88","APC"
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16","86.99",""
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16","","","","","","","fee schedule","16","86.99",""
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16","","","","","","","fee schedule","16","86.99",""
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16","","","","","","","fee schedule","16","86.99",""
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16","86.99",""
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16","86.99",""
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.76","","","","","","","fee schedule","16","86.99","APC"
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.48","","","","","","","fee schedule","16","86.99","APC"
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.32","","","","","","","fee schedule","16","86.99","APC"
"H pylori ag ia","87339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.8","","","","","","","fee schedule","16","86.99","APC"
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.75","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.33","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.33","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.33","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.75","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.83","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.82","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.64","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.54","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.85","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.75","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.33","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.33","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.33","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.75","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","75.83","","","","","","","fee schedule","10.33","75.83",""
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.82","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.64","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.54","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis b surface ag ia","87341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.85","","","","","","","fee schedule","10.33","75.83","APC"
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.81","","","","","","","fee schedule","11.53","85.65",""
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.53","","","","","","","fee schedule","11.53","85.65",""
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.53","","","","","","","fee schedule","11.53","85.65",""
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.53","","","","","","","fee schedule","11.53","85.65",""
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.81","","","","","","","fee schedule","11.53","85.65",""
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","85.65","","","","","","","fee schedule","11.53","85.65",""
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.53","85.65","APC"
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.53","85.65","APC"
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.76","","","","","","","fee schedule","11.53","85.65","APC"
"Hepatitis be ag ia","87350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.53","85.65","APC"
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28.22","","","","","","","fee schedule","18.36","117.06",""
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.36","","","","","","","fee schedule","18.36","117.06",""
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.36","","","","","","","fee schedule","18.36","117.06",""
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.36","","","","","","","fee schedule","18.36","117.06",""
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","28.22","","","","","","","fee schedule","18.36","117.06",""
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","117.06","","","","","","","fee schedule","18.36","117.06",""
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.23","","","","","","","fee schedule","18.36","117.06","APC"
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.36","117.06","APC"
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.73","","","","","","","fee schedule","18.36","117.06","APC"
"Hepatitis delta ag ia","87380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.28","","","","","","","fee schedule","18.36","117.06","APC"
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.25","86.99",""
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.25","","","","","","","fee schedule","13.25","86.99",""
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.25","","","","","","","fee schedule","13.25","86.99",""
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.25","","","","","","","fee schedule","13.25","86.99",""
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.25","86.99",""
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.25","86.99",""
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.88","","","","","","","fee schedule","13.25","86.99","APC"
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.25","86.99","APC"
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.52","","","","","","","fee schedule","13.25","86.99","APC"
"Histoplasma capsul ag ia","87385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.91","","","","","","","fee schedule","13.25","86.99","APC"
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","40.94","","","","","","","fee schedule","24.08","174.04",""
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.08","","","","","","","fee schedule","24.08","174.04",""
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.08","","","","","","","fee schedule","24.08","174.04",""
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.08","","","","","","","fee schedule","24.08","174.04",""
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","40.94","","","","","","","fee schedule","24.08","174.04",""
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","174.04","","","","","","","fee schedule","24.08","174.04",""
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.22","","","","","","","fee schedule","24.08","174.04","APC"
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.8","","","","","","","fee schedule","24.08","174.04","APC"
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.56","","","","","","","fee schedule","24.08","174.04","APC"
"Hiv-1 ag w/hiv-1 & hiv-2 ab","87389","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.28","","","","","","","fee schedule","24.08","174.04","APC"
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.32","","","","","","","fee schedule","24.06","124.02",""
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.06","","","","","","","fee schedule","24.06","124.02",""
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.06","","","","","","","fee schedule","24.06","124.02",""
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.06","","","","","","","fee schedule","24.06","124.02",""
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.32","","","","","","","fee schedule","24.06","124.02",""
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.02","","","","","","","fee schedule","24.06","124.02",""
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.2","","","","","","","fee schedule","24.06","124.02","APC"
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.78","","","","","","","fee schedule","24.06","124.02","APC"
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.54","","","","","","","fee schedule","24.06","124.02","APC"
"Hiv-1 ag ia","87390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.26","","","","","","","fee schedule","24.06","124.02","APC"
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.32","","","","","","","fee schedule","21.9","124.02",""
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.9","","","","","","","fee schedule","21.9","124.02",""
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.9","","","","","","","fee schedule","21.9","124.02",""
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.9","","","","","","","fee schedule","21.9","124.02",""
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.32","","","","","","","fee schedule","21.9","124.02",""
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","124.02","","","","","","","fee schedule","21.9","124.02",""
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.94","","","","","","","fee schedule","21.9","124.02","APC"
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.56","","","","","","","fee schedule","21.9","124.02","APC"
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.34","","","","","","","fee schedule","21.9","124.02","APC"
"Hiv-2 ag ia","87391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23","","","","","","","fee schedule","21.9","124.02","APC"
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","14.13","86.99",""
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.13","","","","","","","fee schedule","14.13","86.99",""
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.13","","","","","","","fee schedule","14.13","86.99",""
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.13","","","","","","","fee schedule","14.13","86.99",""
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","14.13","86.99",""
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","14.13","86.99",""
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.8","","","","","","","fee schedule","14.13","86.99","APC"
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.55","","","","","","","fee schedule","14.13","86.99","APC"
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.41","","","","","","","fee schedule","14.13","86.99","APC"
"Influenza a/b ag ia","87400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.84","","","","","","","fee schedule","14.13","86.99","APC"
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.91","86.99",""
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.91","","","","","","","fee schedule","13.91","86.99",""
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.91","","","","","","","fee schedule","13.91","86.99",""
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.91","","","","","","","fee schedule","13.91","86.99",""
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.91","86.99",""
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.91","86.99",""
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.57","","","","","","","fee schedule","13.91","86.99","APC"
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.33","","","","","","","fee schedule","13.91","86.99","APC"
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.19","","","","","","","fee schedule","13.91","86.99","APC"
"Resp syncytial ag ia","87420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.61","","","","","","","fee schedule","13.91","86.99","APC"
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Rotavirus ag ia","87425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","54.44","","","","","","","fee schedule","35.33","54.44",""
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.33","","","","","","","fee schedule","35.33","54.44",""
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.33","","","","","","","fee schedule","35.33","54.44",""
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.33","","","","","","","fee schedule","35.33","54.44",""
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","54.44","","","","","","","fee schedule","35.33","54.44",""
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37.01","","","","","","","fee schedule","35.33","54.44","APC"
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.39","","","","","","","fee schedule","35.33","54.44","APC"
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36.04","","","","","","","fee schedule","35.33","54.44","APC"
"Coronavirus ag ia","87426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.1","","","","","","","fee schedule","35.33","54.44","APC"
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Shiga-like toxin ag ia","87427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","88.28","","","","","","","fee schedule","70.29","88.28",""
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.29","","","","","","","fee schedule","70.29","88.28",""
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.29","","","","","","","fee schedule","70.29","88.28",""
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.29","","","","","","","fee schedule","70.29","88.28",""
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","88.28","","","","","","","fee schedule","70.29","88.28",""
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.63","","","","","","","fee schedule","70.29","88.28","APC"
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.4","","","","","","","fee schedule","70.29","88.28","APC"
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.7","","","","","","","fee schedule","70.29","88.28","APC"
"Sarscov & inf vir a&b ag ia","87428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.8","","","","","","","fee schedule","70.29","88.28","APC"
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.81","86.99",""
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.81","","","","","","","fee schedule","16.81","86.99",""
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.81","","","","","","","fee schedule","16.81","86.99",""
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.81","","","","","","","fee schedule","16.81","86.99",""
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.81","86.99",""
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.81","86.99",""
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.61","","","","","","","fee schedule","16.81","86.99","APC"
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.31","","","","","","","fee schedule","16.81","86.99","APC"
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.15","","","","","","","fee schedule","16.81","86.99","APC"
"Strep a ag ia","87430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.65","","","","","","","fee schedule","16.81","86.99","APC"
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","11.98","86.99",""
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","86.99",""
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","86.99",""
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","11.98","86.99",""
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","11.98","86.99",""
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detect nos ia mult","87449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","86.99","APC"
"Ag detect nos ia single","87450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.47","","","","","","","fee schedule","64.47","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","16.48","","","","","","","fee schedule","10.51","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.51","","","","","","","fee schedule","10.51","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.51","","","","","","","fee schedule","10.51","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.51","","","","","","","fee schedule","10.51","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","64.47","","","","","","","fee schedule","10.51","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","16.48","","","","","","","fee schedule","10.51","64.47",""
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.01","","","","","","","fee schedule","10.51","64.47","APC"
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.83","","","","","","","fee schedule","10.51","64.47","APC"
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.72","","","","","","","fee schedule","10.51","64.47","APC"
"Ag detect polyval ia mult","87451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.04","","","","","","","fee schedule","10.51","64.47","APC"
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.06","","","","","","","fee schedule","18.06","26.59",""
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.32","","","","","","","fee schedule","18.06","26.59",""
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.32","","","","","","","fee schedule","18.06","26.59",""
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.32","","","","","","","fee schedule","18.06","26.59",""
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.06","","","","","","","fee schedule","18.06","26.59",""
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.52","","","","","","","fee schedule","18.06","26.59","APC"
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.08","","","","","","","fee schedule","18.06","26.59","APC"
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.83","","","","","","","fee schedule","18.06","26.59","APC"
"Hepatitis b surface ag quan","87467","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.59","","","","","","","fee schedule","18.06","26.59","APC"
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","35.09","42.11",""
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","42.11",""
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","35.09","42.11",""
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","42.11","APC"
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","42.11","APC"
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","42.11","APC"
"Anaplsma phgcytophlm amp prb","87468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","42.11","APC"
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","35.09","42.11",""
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","42.11",""
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","35.09","42.11",""
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","42.11","APC"
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","42.11","APC"
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","42.11","APC"
"Babesia microti amp prb","87469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","42.11","APC"
"Bartonella dna dir probe","87470","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","146.86","146.86",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Bartonella dna amp probe","87471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Bartonella dna quant","87472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Lyme dis dna dir probe","87475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Lyme dis dna amp probe","87476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Lyme dis dna quant","87477","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","300.19","","","","","","","fee schedule","300.19","300.19",""
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","35.09","42.11",""
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","42.11",""
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","35.09","42.11",""
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","42.11","APC"
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","42.11","APC"
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","42.11","APC"
"Borrelia miyamotoi amp prb","87478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","42.11","APC"
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Candida dna dir probe","87480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Candida dna amp probe","87481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","55.74","293.46",""
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.74","","","","","","","fee schedule","55.74","293.46",""
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","55.74","","","","","","","fee schedule","55.74","293.46",""
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","55.74","","","","","","","fee schedule","55.74","293.46",""
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","55.74","293.46",""
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","55.74","293.46",""
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.39","","","","","","","fee schedule","55.74","293.46","APC"
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.41","","","","","","","fee schedule","55.74","293.46","APC"
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.85","","","","","","","fee schedule","55.74","293.46","APC"
"Candida dna quant","87482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.53","","","","","","","fee schedule","55.74","293.46","APC"
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","686.06","","","","","","","fee schedule","416.78","686.06",""
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","686.06",""
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","686.06",""
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","686.06",""
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","686.06","","","","","","","fee schedule","416.78","686.06",""
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","686.06","APC"
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","686.06","APC"
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","686.06","APC"
"Cns dna amp probe type 12-25","87483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","686.06","APC"
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","35.09","42.11",""
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","42.11",""
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","42.11",""
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","35.09","42.11",""
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","42.11","APC"
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","42.11","APC"
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","42.11","APC"
"Ehrlicha chaffeensis amp prb","87484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","42.11","APC"
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Chylmd pneum dna dir probe","87485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd pneum dna amp probe","87486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Chylmd pneum dna quant","87487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","22.75","146.86",""
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.75","","","","","","","fee schedule","22.75","146.86",""
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.75","","","","","","","fee schedule","22.75","146.86",""
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.75","","","","","","","fee schedule","22.75","146.86",""
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","22.75","146.86",""
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","22.75","146.86",""
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.83","","","","","","","fee schedule","22.75","146.86","APC"
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.43","","","","","","","fee schedule","22.75","146.86","APC"
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.2","","","","","","","fee schedule","22.75","146.86","APC"
"Chylmd trach dna dir probe","87490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.89","","","","","","","fee schedule","22.75","146.86","APC"
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd trach dna amp probe","87491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.08","","","","","","","fee schedule","53.47","231.23",""
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","53.47","","","","","","","fee schedule","53.47","231.23",""
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","53.47","","","","","","","fee schedule","53.47","231.23",""
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","53.47","","","","","","","fee schedule","53.47","231.23",""
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","231.23","","","","","","","fee schedule","53.47","231.23",""
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.08","","","","","","","fee schedule","53.47","231.23",""
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","56.01","","","","","","","fee schedule","53.47","231.23","APC"
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","55.07","","","","","","","fee schedule","53.47","231.23","APC"
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","54.54","","","","","","","fee schedule","53.47","231.23","APC"
"Chylmd trach dna quant","87492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56.14","","","","","","","fee schedule","53.47","231.23","APC"
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","37.27","249.69",""
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","37.27","","","","","","","fee schedule","37.27","249.69",""
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.27","","","","","","","fee schedule","37.27","249.69",""
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.27","","","","","","","fee schedule","37.27","249.69",""
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","37.27","249.69",""
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","37.27","249.69",""
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.04","","","","","","","fee schedule","37.27","249.69","APC"
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.27","249.69","APC"
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.02","","","","","","","fee schedule","37.27","249.69","APC"
"C diff amplified probe","87493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.13","","","","","","","fee schedule","37.27","249.69","APC"
"Chlmy trch&neisra gonor mult","87494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.51","","","","","","","fee schedule","71.58","73.69","APC"
"Chlmy trch&neisra gonor mult","87494","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.29","","","","","","","fee schedule","71.58","73.69","APC"
"Chlmy trch&neisra gonor mult","87494","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.58","","","","","","","fee schedule","71.58","73.69","APC"
"Chlmy trch&neisra gonor mult","87494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.69","","","","","","","fee schedule","71.58","73.69","APC"
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","30.03","146.86",""
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.03","","","","","","","fee schedule","30.03","146.86",""
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.03","","","","","","","fee schedule","30.03","146.86",""
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.03","","","","","","","fee schedule","30.03","146.86",""
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","30.03","146.86",""
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","30.03","146.86",""
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.46","","","","","","","fee schedule","30.03","146.86","APC"
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.93","","","","","","","fee schedule","30.03","146.86","APC"
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.63","","","","","","","fee schedule","30.03","146.86","APC"
"Cytomeg dna dir probe","87495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.53","","","","","","","fee schedule","30.03","146.86","APC"
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Cytomeg dna amp probe","87496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Cytomeg dna quant","87497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Enterovirus probe&revrs trns","87498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Vanomycin dna amp probe","87500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","86.66","","","","","","","fee schedule","51.31","357.75",""
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.31","","","","","","","fee schedule","51.31","357.75",""
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.31","","","","","","","fee schedule","51.31","357.75",""
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.31","","","","","","","fee schedule","51.31","357.75",""
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","86.66","","","","","","","fee schedule","51.31","357.75",""
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","357.75","","","","","","","fee schedule","51.31","357.75",""
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.75","","","","","","","fee schedule","51.31","357.75","APC"
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.85","","","","","","","fee schedule","51.31","357.75","APC"
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.34","","","","","","","fee schedule","51.31","357.75","APC"
"Influenza dna amp prob 1+","87501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.88","","","","","","","fee schedule","51.31","357.75","APC"
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","143.7","","","","","","","fee schedule","95.8","600.32",""
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95.8","","","","","","","fee schedule","95.8","600.32",""
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.8","","","","","","","fee schedule","95.8","600.32",""
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","95.8","","","","","","","fee schedule","95.8","600.32",""
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","143.7","","","","","","","fee schedule","95.8","600.32",""
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","600.32","","","","","","","fee schedule","95.8","600.32",""
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.35","","","","","","","fee schedule","95.8","600.32","APC"
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","98.67","","","","","","","fee schedule","95.8","600.32","APC"
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","97.72","","","","","","","fee schedule","95.8","600.32","APC"
"Influenza dna amp probe","87502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","100.59","","","","","","","fee schedule","95.8","600.32","APC"
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","35.06","","","","","","","fee schedule","29.22","144.7",""
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.22","","","","","","","fee schedule","29.22","144.7",""
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.22","","","","","","","fee schedule","29.22","144.7",""
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.22","","","","","","","fee schedule","29.22","144.7",""
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35.06","","","","","","","fee schedule","29.22","144.7",""
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","144.7","","","","","","","fee schedule","29.22","144.7",""
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.61","","","","","","","fee schedule","29.22","144.7","APC"
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.1","","","","","","","fee schedule","29.22","144.7","APC"
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.8","","","","","","","fee schedule","29.22","144.7","APC"
"Influenza dna amp prob addl","87503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.68","","","","","","","fee schedule","29.22","144.7","APC"
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","209.5","","","","","","","fee schedule","128.29","209.5",""
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","128.29","","","","","","","fee schedule","128.29","209.5",""
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","128.29","","","","","","","fee schedule","128.29","209.5",""
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.29","","","","","","","fee schedule","128.29","209.5",""
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","209.5","","","","","","","fee schedule","128.29","209.5",""
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","134.38","","","","","","","fee schedule","128.29","209.5","APC"
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.14","","","","","","","fee schedule","128.29","209.5","APC"
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","130.86","","","","","","","fee schedule","128.29","209.5","APC"
"Nfct agent detection gi","87505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","134.7","","","","","","","fee schedule","128.29","209.5","APC"
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","348.54","","","","","","","fee schedule","262.99","348.54",""
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","262.99","","","","","","","fee schedule","262.99","348.54",""
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","262.99","","","","","","","fee schedule","262.99","348.54",""
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","262.99","","","","","","","fee schedule","262.99","348.54",""
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","348.54","","","","","","","fee schedule","262.99","348.54",""
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.48","","","","","","","fee schedule","262.99","348.54","APC"
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","270.88","","","","","","","fee schedule","262.99","348.54","APC"
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","268.25","","","","","","","fee schedule","262.99","348.54","APC"
"Iadna-dna/rna probe tq 6-11","87506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","276.14","","","","","","","fee schedule","262.99","348.54","APC"
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","680.62","","","","","","","fee schedule","416.78","680.62",""
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","680.62",""
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","680.62",""
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","680.62",""
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","680.62","","","","","","","fee schedule","416.78","680.62",""
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","680.62","APC"
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","680.62","APC"
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","680.62","APC"
"Iadna-dna/rna probe tq 12-25","87507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","680.62","APC"
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Gardner vag dna dir probe","87510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Gardner vag dna amp probe","87511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","41.76","293.46",""
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.76","","","","","","","fee schedule","41.76","293.46",""
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","41.76","293.46",""
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","41.76","293.46",""
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.74","","","","","","","fee schedule","41.76","293.46","APC"
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.01","","","","","","","fee schedule","41.76","293.46","APC"
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.6","","","","","","","fee schedule","41.76","293.46","APC"
"Gardner vag dna quant","87512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.85","","","","","","","fee schedule","41.76","293.46","APC"
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","36.84",""
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","36.84",""
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","36.84",""
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","36.84","APC"
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","36.84","APC"
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","36.84","APC"
"H pylri clrthmcn rst amp prb","87513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","36.84","APC"
"Hepatitis b dna dir probe","87515","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","146.86","146.86",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis b dna amp probe","87516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis b dna quant","87517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","31.22","146.86",""
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.22","","","","","","","fee schedule","31.22","146.86",""
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.22","","","","","","","fee schedule","31.22","146.86",""
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","31.22","","","","","","","fee schedule","31.22","146.86",""
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","31.22","146.86",""
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","31.22","146.86",""
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.7","","","","","","","fee schedule","31.22","146.86","APC"
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.16","","","","","","","fee schedule","31.22","146.86","APC"
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.84","","","","","","","fee schedule","31.22","146.86","APC"
"Hepatitis c rna dir probe","87520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.78","","","","","","","fee schedule","31.22","146.86","APC"
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis c probe&rvrs trnsc","87521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis c revrs trnscrpj","87522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","51.41","","","","","","","fee schedule","42.84","51.41",""
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","51.41",""
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","51.41",""
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","51.41",""
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","51.41","","","","","","","fee schedule","42.84","51.41",""
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","51.41","APC"
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","51.41","APC"
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","51.41","APC"
"Hepatitis d quantification","87523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","51.41","APC"
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","29.8","146.86",""
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.8","","","","","","","fee schedule","29.8","146.86",""
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.8","","","","","","","fee schedule","29.8","146.86",""
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","29.8","","","","","","","fee schedule","29.8","146.86",""
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","29.8","146.86",""
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","29.8","146.86",""
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.22","","","","","","","fee schedule","29.8","146.86","APC"
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.69","","","","","","","fee schedule","29.8","146.86","APC"
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.4","","","","","","","fee schedule","29.8","146.86","APC"
"Hepatitis g dna dir probe","87525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.29","","","","","","","fee schedule","29.8","146.86","APC"
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","39.26","249.69",""
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.26","","","","","","","fee schedule","39.26","249.69",""
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.26","","","","","","","fee schedule","39.26","249.69",""
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.26","","","","","","","fee schedule","39.26","249.69",""
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","39.26","249.69",""
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","39.26","249.69",""
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.12","","","","","","","fee schedule","39.26","249.69","APC"
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.44","","","","","","","fee schedule","39.26","249.69","APC"
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.05","","","","","","","fee schedule","39.26","249.69","APC"
"Hepatitis g dna amp probe","87526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.22","","","","","","","fee schedule","39.26","249.69","APC"
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","41.76","293.46",""
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.76","","","","","","","fee schedule","41.76","293.46",""
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","41.76","293.46",""
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","41.76","293.46",""
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.74","","","","","","","fee schedule","41.76","293.46","APC"
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.01","","","","","","","fee schedule","41.76","293.46","APC"
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.6","","","","","","","fee schedule","41.76","293.46","APC"
"Hepatitis g dna quant","87527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.85","","","","","","","fee schedule","41.76","293.46","APC"
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Hsv dna dir probe","87528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Hsv dna amp probe","87529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Hsv dna quant","87530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","34.46","146.86",""
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58","","","","","","","fee schedule","34.46","146.86",""
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58","","","","","","","fee schedule","34.46","146.86",""
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","58","","","","","","","fee schedule","34.46","146.86",""
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","34.46","146.86",""
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","34.46","146.86",""
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.76","","","","","","","fee schedule","34.46","146.86","APC"
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.74","","","","","","","fee schedule","34.46","146.86","APC"
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.16","","","","","","","fee schedule","34.46","146.86","APC"
"Hhv-6 dna dir probe","87531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.9","","","","","","","fee schedule","34.46","146.86","APC"
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Hhv-6 dna amp probe","87532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","41.76","293.46",""
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.76","","","","","","","fee schedule","41.76","293.46",""
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","41.76","293.46",""
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","41.76","293.46",""
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.74","","","","","","","fee schedule","41.76","293.46","APC"
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.01","","","","","","","fee schedule","41.76","293.46","APC"
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.6","","","","","","","fee schedule","41.76","293.46","APC"
"Hhv-6 dna quant","87533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.85","","","","","","","fee schedule","41.76","293.46","APC"
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","21.92","146.86",""
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.92","","","","","","","fee schedule","21.92","146.86",""
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.92","","","","","","","fee schedule","21.92","146.86",""
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.92","","","","","","","fee schedule","21.92","146.86",""
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","21.92","146.86",""
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","21.92","146.86",""
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.96","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.58","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.36","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-1 dna dir probe","87534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.02","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-1 probe&reverse trnscrpj","87535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","146.26","","","","","","","fee schedule","85.1","600.26",""
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","85.1","","","","","","","fee schedule","85.1","600.26",""
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.1","","","","","","","fee schedule","85.1","600.26",""
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","85.1","","","","","","","fee schedule","85.1","600.26",""
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","600.26","","","","","","","fee schedule","85.1","600.26",""
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","146.26","","","","","","","fee schedule","85.1","600.26",""
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","89.14","","","","","","","fee schedule","85.1","600.26","APC"
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.65","","","","","","","fee schedule","85.1","600.26","APC"
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.8","","","","","","","fee schedule","85.1","600.26","APC"
"Hiv-1 quant&revrse trnscrpj","87536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.36","","","","","","","fee schedule","85.1","600.26","APC"
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","21.92","146.86",""
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.92","","","","","","","fee schedule","21.92","146.86",""
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.92","","","","","","","fee schedule","21.92","146.86",""
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.92","","","","","","","fee schedule","21.92","146.86",""
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","21.92","146.86",""
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","21.92","146.86",""
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.96","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.58","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.36","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-2 dna dir probe","87537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.02","","","","","","","fee schedule","21.92","146.86","APC"
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-2 probe&revrse trnscripj","87538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","58.62","300.19",""
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.62","","","","","","","fee schedule","58.62","300.19",""
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58.62","","","","","","","fee schedule","58.62","300.19",""
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","58.62","","","","","","","fee schedule","58.62","300.19",""
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","300.19","","","","","","","fee schedule","58.62","300.19",""
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","58.62","300.19",""
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","61.4","","","","","","","fee schedule","58.62","300.19","APC"
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","60.38","","","","","","","fee schedule","58.62","300.19","APC"
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.79","","","","","","","fee schedule","58.62","300.19","APC"
"Hiv-2 quant&revrse trnscripj","87539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","61.55","","","","","","","fee schedule","58.62","300.19","APC"
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Legion pneumo dna dir prob","87540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Legion pneumo dna amp prob","87541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","41.76","293.46",""
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.76","","","","","","","fee schedule","41.76","293.46",""
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","41.76","293.46",""
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","41.76","293.46",""
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.74","","","","","","","fee schedule","41.76","293.46","APC"
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.01","","","","","","","fee schedule","41.76","293.46","APC"
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.6","","","","","","","fee schedule","41.76","293.46","APC"
"Legion pneumo dna quant","87542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.85","","","","","","","fee schedule","41.76","293.46","APC"
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Mycobacteria dna dir probe","87550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","48.24","249.69",""
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","48.24","","","","","","","fee schedule","48.24","249.69",""
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","48.24","","","","","","","fee schedule","48.24","249.69",""
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","48.24","","","","","","","fee schedule","48.24","249.69",""
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","48.24","249.69",""
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","48.24","249.69",""
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50.53","","","","","","","fee schedule","48.24","249.69","APC"
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49.69","","","","","","","fee schedule","48.24","249.69","APC"
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.2","","","","","","","fee schedule","48.24","249.69","APC"
"Mycobacteria dna amp probe","87551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50.65","","","","","","","fee schedule","48.24","249.69","APC"
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"Mycobacteria dna quant","87552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","26.88","146.86",""
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.88","","","","","","","fee schedule","26.88","146.86",""
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.88","","","","","","","fee schedule","26.88","146.86",""
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.88","","","","","","","fee schedule","26.88","146.86",""
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","26.88","146.86",""
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","26.88","146.86",""
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.16","","","","","","","fee schedule","26.88","146.86","APC"
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.69","","","","","","","fee schedule","26.88","146.86","APC"
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.42","","","","","","","fee schedule","26.88","146.86","APC"
"M.tuberculo dna dir probe","87555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.22","","","","","","","fee schedule","26.88","146.86","APC"
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","41.68","249.69",""
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.68","","","","","","","fee schedule","41.68","249.69",""
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.68","","","","","","","fee schedule","41.68","249.69",""
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.68","","","","","","","fee schedule","41.68","249.69",""
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","41.68","249.69",""
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","41.68","249.69",""
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.66","","","","","","","fee schedule","41.68","249.69","APC"
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.93","","","","","","","fee schedule","41.68","249.69","APC"
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.51","","","","","","","fee schedule","41.68","249.69","APC"
"M.tuberculo dna amp probe","87556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.76","","","","","","","fee schedule","41.68","249.69","APC"
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"M.tuberculo dna quant","87557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","27.29","146.86",""
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.29","","","","","","","fee schedule","27.29","146.86",""
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.29","","","","","","","fee schedule","27.29","146.86",""
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.29","","","","","","","fee schedule","27.29","146.86",""
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","27.29","146.86",""
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","27.29","146.86",""
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.59","","","","","","","fee schedule","27.29","146.86","APC"
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.11","","","","","","","fee schedule","27.29","146.86","APC"
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.84","","","","","","","fee schedule","27.29","146.86","APC"
"M.avium-intra dna dir prob","87560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.65","","","","","","","fee schedule","27.29","146.86","APC"
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"M.avium-intra dna amp prob","87561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","310.78",""
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","310.78",""
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","310.78",""
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","310.78",""
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","42.84","310.78",""
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","310.78",""
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","310.78","APC"
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","310.78","APC"
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","310.78","APC"
"M.avium-intra dna quant","87562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","310.78","APC"
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.11","","","","","","","fee schedule","35.09","42.11",""
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","42.11",""
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","42.11",""
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","42.11",""
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.11","","","","","","","fee schedule","35.09","42.11",""
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","42.11","APC"
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","42.11","APC"
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","42.11","APC"
"M. genitalium amp probe","87563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","42.11","APC"
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","76.77","","","","","","","fee schedule","76.77","80.61",""
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","76.77","","","","","","","fee schedule","76.77","80.61",""
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","76.77","","","","","","","fee schedule","76.77","80.61",""
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","80.42","","","","","","","fee schedule","76.77","80.61","APC"
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","79.07","","","","","","","fee schedule","76.77","80.61","APC"
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","78.31","","","","","","","fee schedule","76.77","80.61","APC"
"Mtb rifampin rst amp prb tq","87564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","80.61","","","","","","","fee schedule","76.77","80.61","APC"
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"M.pneumon dna dir probe","87580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"M.pneumon dna amp probe","87581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","71.75","317.75",""
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","302.62","","","","","","","fee schedule","71.75","317.75",""
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","302.62","","","","","","","fee schedule","71.75","317.75",""
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","302.62","","","","","","","fee schedule","71.75","317.75",""
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","71.75","317.75",""
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","71.75","317.75",""
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","316.99","","","","","","","fee schedule","71.75","317.75","APC"
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","311.7","","","","","","","fee schedule","71.75","317.75","APC"
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","308.67","","","","","","","fee schedule","71.75","317.75","APC"
"M.pneumon dna quant","87582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","317.75","","","","","","","fee schedule","71.75","317.75","APC"
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","26.88","146.86",""
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.88","","","","","","","fee schedule","26.88","146.86",""
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.88","","","","","","","fee schedule","26.88","146.86",""
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.88","","","","","","","fee schedule","26.88","146.86",""
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","26.88","146.86",""
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","26.88","146.86",""
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.16","","","","","","","fee schedule","26.88","146.86","APC"
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.69","","","","","","","fee schedule","26.88","146.86","APC"
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.42","","","","","","","fee schedule","26.88","146.86","APC"
"N.gonorrhoeae dna dir prob","87590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.22","","","","","","","fee schedule","26.88","146.86","APC"
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"N.gonorrhoeae dna amp prob","87591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","292.78",""
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","292.78",""
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","292.78",""
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","292.78",""
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","292.78","","","","","","","fee schedule","42.84","292.78",""
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","292.78",""
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","292.78","APC"
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","292.78","APC"
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","292.78","APC"
"N.gonorrhoeae dna quant","87592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","292.78","APC"
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","61.4","","","","","","","fee schedule","51.31","61.4",""
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.31","","","","","","","fee schedule","51.31","61.4",""
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.31","","","","","","","fee schedule","51.31","61.4",""
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.31","","","","","","","fee schedule","51.31","61.4",""
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","61.4","","","","","","","fee schedule","51.31","61.4",""
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.75","","","","","","","fee schedule","51.31","61.4","APC"
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.85","","","","","","","fee schedule","51.31","61.4","APC"
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.34","","","","","","","fee schedule","51.31","61.4","APC"
"Orthopoxvirus amp prb each","87593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.88","","","","","","","fee schedule","51.31","61.4","APC"
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","36.84",""
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","36.84",""
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","36.84",""
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","36.84","APC"
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","36.84","APC"
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","36.84","APC"
"Pneumcysts jirovecii amp prb","87594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","36.84","APC"
"Hpv, dna, dir probe","87620","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","146.86","146.86",""
"Hpv, dna, amp probe","87621","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","249.69","249.69",""
"Hpv, dna, quant","87622","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","293.46","293.46",""
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","57.31","","","","","","","fee schedule","35.09","57.31",""
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","57.31",""
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","57.31",""
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","57.31",""
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","57.31","","","","","","","fee schedule","35.09","57.31",""
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv low-risk types","87623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","57.31","","","","","","","fee schedule","35.09","57.31",""
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","57.31",""
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","57.31",""
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","57.31",""
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","57.31","","","","","","","fee schedule","35.09","57.31",""
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv high-risk types","87624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","57.31","APC"
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","57.31","","","","","","","fee schedule","40.55","57.31",""
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40.55","","","","","","","fee schedule","40.55","57.31",""
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","40.55","","","","","","","fee schedule","40.55","57.31",""
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40.55","","","","","","","fee schedule","40.55","57.31",""
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","57.31","","","","","","","fee schedule","40.55","57.31",""
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.48","","","","","","","fee schedule","40.55","57.31","APC"
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.77","","","","","","","fee schedule","40.55","57.31","APC"
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.36","","","","","","","fee schedule","40.55","57.31","APC"
"Hpv types 16 & 18 only","87625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.58","","","","","","","fee schedule","40.55","57.31","APC"
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.2","","","","","","","fee schedule","70.2","73.71",""
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.2","","","","","","","fee schedule","70.2","73.71",""
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.2","","","","","","","fee schedule","70.2","73.71",""
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.53","","","","","","","fee schedule","70.2","73.71","APC"
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.31","","","","","","","fee schedule","70.2","73.71","APC"
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.6","","","","","","","fee schedule","70.2","73.71","APC"
"Hpv sep hi-rsk typ&pool rslt","87626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.71","","","","","","","fee schedule","70.2","73.71","APC"
"Jt spc pthgn&rx rsist gen26+","87627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","712.06","","","","","","","fee schedule","693.37","713.76","APC"
"Jt spc pthgn&rx rsist gen26+","87627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","700.16","","","","","","","fee schedule","693.37","713.76","APC"
"Jt spc pthgn&rx rsist gen26+","87627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.37","","","","","","","fee schedule","693.37","713.76","APC"
"Jt spc pthgn&rx rsist gen26+","87627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.76","","","","","","","fee schedule","693.37","713.76","APC"
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","211.61","","","","","","","fee schedule","142.63","900.25",""
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","900.25",""
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","900.25",""
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","900.25",""
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","900.25","","","","","","","fee schedule","142.63","900.25",""
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","211.61","","","","","","","fee schedule","142.63","900.25",""
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","900.25","APC"
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","900.25","APC"
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","900.25","APC"
"Resp virus 3-5 targets","87631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","900.25","APC"
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","352.04","","","","","","","fee schedule","218.06","1492.9",""
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","218.06","","","","","","","fee schedule","218.06","1492.9",""
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","218.06","","","","","","","fee schedule","218.06","1492.9",""
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","218.06","","","","","","","fee schedule","218.06","1492.9",""
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1492.9","","","","","","","fee schedule","218.06","1492.9",""
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","352.04","","","","","","","fee schedule","218.06","1492.9",""
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","228.42","","","","","","","fee schedule","218.06","1492.9","APC"
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","224.6","","","","","","","fee schedule","218.06","1492.9","APC"
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","222.42","","","","","","","fee schedule","218.06","1492.9","APC"
"Resp virus 6-11 targets","87632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","228.96","","","","","","","fee schedule","218.06","1492.9","APC"
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","687.49","","","","","","","fee schedule","416.78","2917.28",""
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.78","","","","","","","fee schedule","416.78","2917.28",""
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","416.78","","","","","","","fee schedule","416.78","2917.28",""
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","416.78","","","","","","","fee schedule","416.78","2917.28",""
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2917.28","","","","","","","fee schedule","416.78","2917.28",""
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","687.49","","","","","","","fee schedule","416.78","2917.28",""
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.58","","","","","","","fee schedule","416.78","2917.28","APC"
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.28","","","","","","","fee schedule","416.78","2917.28","APC"
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.12","","","","","","","fee schedule","416.78","2917.28","APC"
"Resp virus 12-25 targets","87633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.62","","","","","","","fee schedule","416.78","2917.28","APC"
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","103.99","","","","","","","fee schedule","70.2","103.99",""
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.2","","","","","","","fee schedule","70.2","103.99",""
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.2","","","","","","","fee schedule","70.2","103.99",""
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.2","","","","","","","fee schedule","70.2","103.99",""
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","103.99","","","","","","","fee schedule","70.2","103.99",""
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.53","","","","","","","fee schedule","70.2","103.99","APC"
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.31","","","","","","","fee schedule","70.2","103.99","APC"
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.6","","","","","","","fee schedule","70.2","103.99","APC"
"Rsv dna/rna amp probe","87634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.71","","","","","","","fee schedule","70.2","103.99","APC"
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","61.57","","","","","","","fee schedule","51.31","61.57",""
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.31","","","","","","","fee schedule","51.31","61.57",""
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.31","","","","","","","fee schedule","51.31","61.57",""
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.31","","","","","","","fee schedule","51.31","61.57",""
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","61.57","","","","","","","fee schedule","51.31","61.57",""
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.75","","","","","","","fee schedule","51.31","61.57","APC"
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.85","","","","","","","fee schedule","51.31","61.57","APC"
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.34","","","","","","","fee schedule","51.31","61.57","APC"
"Sars-cov-2 covid-19 amp prb","87635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.88","","","","","","","fee schedule","51.31","61.57","APC"
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.12","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.12","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2 & inf a&b amp prb","87636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","171.12","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.63","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","142.63","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","171.12","","","","","","","fee schedule","142.63","171.12",""
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","149.4","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.91","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","145.48","","","","","","","fee schedule","142.63","171.12","APC"
"Sarscov2&inf a&b&rsv amp prb","87637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","149.76","","","","","","","fee schedule","142.63","171.12","APC"
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Staph a dna amp probe","87640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Mr-staph dna amp probe","87641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Strep a dna dir probe","87650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Strep a dna amp probe","87651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","71.75","","","","","","","fee schedule","41.76","293.46",""
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.76","","","","","","","fee schedule","41.76","293.46",""
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.76","","","","","","","fee schedule","41.76","293.46",""
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.46","","","","","","","fee schedule","41.76","293.46",""
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","71.75","","","","","","","fee schedule","41.76","293.46",""
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.74","","","","","","","fee schedule","41.76","293.46","APC"
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.01","","","","","","","fee schedule","41.76","293.46","APC"
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.6","","","","","","","fee schedule","41.76","293.46","APC"
"Strep a dna quant","87652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.85","","","","","","","fee schedule","41.76","293.46","APC"
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Strep b dna amp probe","87653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","20.05","146.86",""
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.05","","","","","","","fee schedule","20.05","146.86",""
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.05","","","","","","","fee schedule","20.05","146.86",""
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","20.05","146.86",""
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","20.05","146.86",""
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21","","","","","","","fee schedule","20.05","146.86","APC"
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.65","","","","","","","fee schedule","20.05","146.86","APC"
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.45","","","","","","","fee schedule","20.05","146.86","APC"
"Trichomonas vagin dir probe","87660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.05","","","","","","","fee schedule","20.05","146.86","APC"
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","57.44","","","","","","","fee schedule","35.09","57.44",""
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","57.44",""
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","57.44",""
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","57.44",""
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","57.44","","","","","","","fee schedule","35.09","57.44",""
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","57.44","APC"
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","57.44","APC"
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","57.44","APC"
"Trichomonas vaginalis amplif","87661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","57.44","APC"
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","76.02","","","","","","","fee schedule","51.31","76.02",""
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.31","","","","","","","fee schedule","51.31","76.02",""
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.31","","","","","","","fee schedule","51.31","76.02",""
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.31","","","","","","","fee schedule","51.31","76.02",""
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","76.02","","","","","","","fee schedule","51.31","76.02",""
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.75","","","","","","","fee schedule","51.31","76.02","APC"
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.85","","","","","","","fee schedule","51.31","76.02","APC"
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.34","","","","","","","fee schedule","51.31","76.02","APC"
"Zika virus dna/rna amp probe","87662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.88","","","","","","","fee schedule","51.31","76.02","APC"
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.46","","","","","","","fee schedule","30.03","146.86",""
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.03","","","","","","","fee schedule","30.03","146.86",""
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.03","","","","","","","fee schedule","30.03","146.86",""
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.03","","","","","","","fee schedule","30.03","146.86",""
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","146.86","","","","","","","fee schedule","30.03","146.86",""
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.46","","","","","","","fee schedule","30.03","146.86",""
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.46","","","","","","","fee schedule","30.03","146.86","APC"
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.93","","","","","","","fee schedule","30.03","146.86","APC"
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.63","","","","","","","fee schedule","30.03","146.86","APC"
"Detect agent nos dna dir","87797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.53","","","","","","","fee schedule","30.03","146.86","APC"
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","60.32","","","","","","","fee schedule","35.09","249.69",""
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","249.69",""
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","249.69",""
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","249.69","","","","","","","fee schedule","35.09","249.69",""
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60.32","","","","","","","fee schedule","35.09","249.69",""
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","249.69","APC"
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","249.69","APC"
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","249.69","APC"
"Detect agent nos dna amp","87798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","249.69","APC"
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","73.62","","","","","","","fee schedule","42.84","314.64",""
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.84","","","","","","","fee schedule","42.84","314.64",""
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.84","","","","","","","fee schedule","42.84","314.64",""
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.84","","","","","","","fee schedule","42.84","314.64",""
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","314.64","","","","","","","fee schedule","42.84","314.64",""
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","73.62","","","","","","","fee schedule","42.84","314.64",""
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.87","","","","","","","fee schedule","42.84","314.64","APC"
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.13","","","","","","","fee schedule","42.84","314.64","APC"
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.7","","","","","","","fee schedule","42.84","314.64","APC"
"Detect agent nos dna quant","87799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.98","","","","","","","fee schedule","42.84","314.64","APC"
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","68.94","","","","","","","fee schedule","43.67","293.8",""
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.67","","","","","","","fee schedule","43.67","293.8",""
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.67","","","","","","","fee schedule","43.67","293.8",""
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.67","","","","","","","fee schedule","43.67","293.8",""
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","293.8","","","","","","","fee schedule","43.67","293.8",""
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","68.94","","","","","","","fee schedule","43.67","293.8",""
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45.74","","","","","","","fee schedule","43.67","293.8","APC"
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.98","","","","","","","fee schedule","43.67","293.8","APC"
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.54","","","","","","","fee schedule","43.67","293.8","APC"
"Detect agnt mult dna direc","87800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45.85","","","","","","","fee schedule","43.67","293.8","APC"
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","120.65","","","","","","","fee schedule","70.2","499.33",""
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.2","","","","","","","fee schedule","70.2","499.33",""
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.2","","","","","","","fee schedule","70.2","499.33",""
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.2","","","","","","","fee schedule","70.2","499.33",""
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","499.33","","","","","","","fee schedule","70.2","499.33",""
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","120.65","","","","","","","fee schedule","70.2","499.33",""
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.53","","","","","","","fee schedule","70.2","499.33","APC"
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.31","","","","","","","fee schedule","70.2","499.33","APC"
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.6","","","","","","","fee schedule","70.2","499.33","APC"
"Detect agnt mult dna ampli","87801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.71","","","","","","","fee schedule","70.2","499.33","APC"
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","12.73","86.99",""
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.73","","","","","","","fee schedule","12.73","86.99",""
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.73","","","","","","","fee schedule","12.73","86.99",""
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.73","","","","","","","fee schedule","12.73","86.99",""
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","12.73","86.99",""
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","12.73","86.99",""
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.33","","","","","","","fee schedule","12.73","86.99","APC"
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.11","","","","","","","fee schedule","12.73","86.99","APC"
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.98","","","","","","","fee schedule","12.73","86.99","APC"
"Strep b assay w/optic","87802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.37","","","","","","","fee schedule","12.73","86.99","APC"
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16","86.99",""
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16","","","","","","","fee schedule","16","86.99",""
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16","","","","","","","fee schedule","16","86.99",""
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16","","","","","","","fee schedule","16","86.99",""
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16","86.99",""
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16","86.99",""
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.76","","","","","","","fee schedule","16","86.99","APC"
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.48","","","","","","","fee schedule","16","86.99","APC"
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.32","","","","","","","fee schedule","16","86.99","APC"
"Clostridium toxin a w/optic","87803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.8","","","","","","","fee schedule","16","86.99","APC"
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.55","86.99",""
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.55","","","","","","","fee schedule","16.55","86.99",""
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.55","","","","","","","fee schedule","16.55","86.99",""
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.55","","","","","","","fee schedule","16.55","86.99",""
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.55","86.99",""
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.55","86.99",""
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.34","","","","","","","fee schedule","16.55","86.99","APC"
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.05","","","","","","","fee schedule","16.55","86.99","APC"
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.88","","","","","","","fee schedule","16.55","86.99","APC"
"Influenza assay w/optic","87804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.38","","","","","","","fee schedule","16.55","86.99","APC"
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.32","","","","","","","fee schedule","32.77","39.32",""
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.77","","","","","","","fee schedule","32.77","39.32",""
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","32.77","","","","","","","fee schedule","32.77","39.32",""
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.77","","","","","","","fee schedule","32.77","39.32",""
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.32","","","","","","","fee schedule","32.77","39.32",""
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34.33","","","","","","","fee schedule","32.77","39.32","APC"
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.75","","","","","","","fee schedule","32.77","39.32","APC"
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.43","","","","","","","fee schedule","32.77","39.32","APC"
"Hiv antigen w/hiv antibodies","87806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34.41","","","","","","","fee schedule","32.77","39.32","APC"
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","13.1","86.99",""
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.1","","","","","","","fee schedule","13.1","86.99",""
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.1","","","","","","","fee schedule","13.1","86.99",""
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.1","","","","","","","fee schedule","13.1","86.99",""
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","13.1","86.99",""
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","13.1","86.99",""
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.72","","","","","","","fee schedule","13.1","86.99","APC"
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.49","","","","","","","fee schedule","13.1","86.99","APC"
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.36","","","","","","","fee schedule","13.1","86.99","APC"
"Rsv assay w/optic","87807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.76","","","","","","","fee schedule","13.1","86.99","APC"
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","15.29","86.99",""
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.29","","","","","","","fee schedule","15.29","86.99",""
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.29","","","","","","","fee schedule","15.29","86.99",""
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.29","","","","","","","fee schedule","15.29","86.99",""
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","15.29","86.99",""
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","15.29","86.99",""
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.02","","","","","","","fee schedule","15.29","86.99","APC"
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.75","","","","","","","fee schedule","15.29","86.99","APC"
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.6","","","","","","","fee schedule","15.29","86.99","APC"
"Trichomonas assay w/optic","87808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.05","","","","","","","fee schedule","15.29","86.99","APC"
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","20.62","86.99",""
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.76","","","","","","","fee schedule","20.62","86.99",""
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.76","","","","","","","fee schedule","20.62","86.99",""
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.76","","","","","","","fee schedule","20.62","86.99",""
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","20.62","86.99",""
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","20.62","86.99",""
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.79","","","","","","","fee schedule","20.62","86.99","APC"
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.41","","","","","","","fee schedule","20.62","86.99","APC"
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.2","","","","","","","fee schedule","20.62","86.99","APC"
"Adenovirus assay w/optic","87809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.85","","","","","","","fee schedule","20.62","86.99","APC"
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","20.62","86.99",""
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.29","","","","","","","fee schedule","20.62","86.99",""
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.29","","","","","","","fee schedule","20.62","86.99",""
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.29","","","","","","","fee schedule","20.62","86.99",""
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","20.62","86.99",""
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","20.62","86.99",""
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.97","","","","","","","fee schedule","20.62","86.99","APC"
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.35","","","","","","","fee schedule","20.62","86.99","APC"
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36","","","","","","","fee schedule","20.62","86.99","APC"
"Chylmd trach assay w/optic","87810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.05","","","","","","","fee schedule","20.62","86.99","APC"
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","49.78","","","","","","","fee schedule","41.38","49.78",""
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.38","","","","","","","fee schedule","41.38","49.78",""
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.38","","","","","","","fee schedule","41.38","49.78",""
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","41.38","","","","","","","fee schedule","41.38","49.78",""
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","49.78","","","","","","","fee schedule","41.38","49.78",""
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.35","","","","","","","fee schedule","41.38","49.78","APC"
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.62","","","","","","","fee schedule","41.38","49.78","APC"
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.21","","","","","","","fee schedule","41.38","49.78","APC"
"Sars-cov-2 covid19 w/optic","87811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.45","","","","","","","fee schedule","41.38","49.78","APC"
"Sarscov2&inf typ a&b w/optic","87812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.02","","","","","","","fee schedule","75.97","78.2","APC"
"Sarscov2&inf typ a&b w/optic","87812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.71","","","","","","","fee schedule","75.97","78.2","APC"
"Sarscov2&inf typ a&b w/optic","87812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","75.97","","","","","","","fee schedule","75.97","78.2","APC"
"Sarscov2&inf typ a&b w/optic","87812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.2","","","","","","","fee schedule","75.97","78.2","APC"
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","20.62","86.99",""
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.56","","","","","","","fee schedule","20.62","86.99",""
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.56","","","","","","","fee schedule","20.62","86.99",""
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.56","","","","","","","fee schedule","20.62","86.99",""
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","20.62","86.99",""
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","20.62","86.99",""
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.73","","","","","","","fee schedule","20.62","86.99","APC"
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.3","","","","","","","fee schedule","20.62","86.99","APC"
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.05","","","","","","","fee schedule","20.62","86.99","APC"
"N. gonorrhoeae assay w/optic","87850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.79","","","","","","","fee schedule","20.62","86.99","APC"
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.53","86.99",""
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.53","","","","","","","fee schedule","16.53","86.99",""
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.53","","","","","","","fee schedule","16.53","86.99",""
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.53","","","","","","","fee schedule","16.53","86.99",""
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.53","86.99",""
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.53","86.99",""
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.32","","","","","","","fee schedule","16.53","86.99","APC"
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.03","","","","","","","fee schedule","16.53","86.99","APC"
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.86","","","","","","","fee schedule","16.53","86.99","APC"
"Strep a assay w/optic","87880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.36","","","","","","","fee schedule","16.53","86.99","APC"
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.62","","","","","","","fee schedule","16.07","86.99",""
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.07","","","","","","","fee schedule","16.07","86.99",""
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.07","","","","","","","fee schedule","16.07","86.99",""
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.07","","","","","","","fee schedule","16.07","86.99",""
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","86.99","","","","","","","fee schedule","16.07","86.99",""
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.62","","","","","","","fee schedule","16.07","86.99",""
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.83","","","","","","","fee schedule","16.07","86.99","APC"
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.55","","","","","","","fee schedule","16.07","86.99","APC"
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.39","","","","","","","fee schedule","16.07","86.99","APC"
"Agent nos assay w/optic","87899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.87","","","","","","","fee schedule","16.07","86.99","APC"
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","224.03","","","","","","","fee schedule","130.35","928.34",""
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","130.35","","","","","","","fee schedule","130.35","928.34",""
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","130.35","","","","","","","fee schedule","130.35","928.34",""
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","130.35","","","","","","","fee schedule","130.35","928.34",""
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","928.34","","","","","","","fee schedule","130.35","928.34",""
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","224.03","","","","","","","fee schedule","130.35","928.34",""
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.54","","","","","","","fee schedule","130.35","928.34","APC"
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","134.26","","","","","","","fee schedule","130.35","928.34","APC"
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.96","","","","","","","fee schedule","130.35","928.34","APC"
"Phenotype infect agent drug","87900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.87","","","","","","","fee schedule","130.35","928.34","APC"
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","442.48","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1717.77","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","442.48","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","269.68","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","265.17","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","262.6","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hiv reverse t","87901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","270.32","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","442.48","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1717.77","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","442.48","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","269.68","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","265.17","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","262.6","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna/rna hep c","87902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","270.32","","","","","","","fee schedule","257.45","1717.77","APC"
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","839.86","","","","","","","fee schedule","488.66","3563.83",""
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","488.66","","","","","","","fee schedule","488.66","3563.83",""
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","488.66","","","","","","","fee schedule","488.66","3563.83",""
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","488.66","","","","","","","fee schedule","488.66","3563.83",""
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3563.83","","","","","","","fee schedule","488.66","3563.83",""
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","839.86","","","","","","","fee schedule","488.66","3563.83",""
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","511.87","","","","","","","fee schedule","488.66","3563.83","APC"
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","503.32","","","","","","","fee schedule","488.66","3563.83","APC"
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","498.43","","","","","","","fee schedule","488.66","3563.83","APC"
"Phenotype dna hiv w/culture","87903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","513.09","","","","","","","fee schedule","488.66","3563.83","APC"
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","44.8","","","","","","","fee schedule","26.07","185.62",""
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.07","","","","","","","fee schedule","26.07","185.62",""
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.07","","","","","","","fee schedule","26.07","185.62",""
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.07","","","","","","","fee schedule","26.07","185.62",""
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","185.62","","","","","","","fee schedule","26.07","185.62",""
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","44.8","","","","","","","fee schedule","26.07","185.62",""
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.31","","","","","","","fee schedule","26.07","185.62","APC"
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.85","","","","","","","fee schedule","26.07","185.62","APC"
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.59","","","","","","","fee schedule","26.07","185.62","APC"
"Phenotype dna hiv w/clt add","87904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.37","","","","","","","fee schedule","26.07","185.62","APC"
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21","","","","","","","fee schedule","12.22","87.44",""
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.22","","","","","","","fee schedule","12.22","87.44",""
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.22","","","","","","","fee schedule","12.22","87.44",""
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.22","","","","","","","fee schedule","12.22","87.44",""
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","87.44","","","","","","","fee schedule","12.22","87.44",""
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","21","","","","","","","fee schedule","12.22","87.44",""
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.8","","","","","","","fee schedule","12.22","87.44","APC"
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.59","","","","","","","fee schedule","12.22","87.44","APC"
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.46","","","","","","","fee schedule","12.22","87.44","APC"
"Sialidase enzyme assay","87905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.83","","","","","","","fee schedule","12.22","87.44","APC"
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","217.37","","","","","","","fee schedule","128.73","858.84",""
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","128.73","","","","","","","fee schedule","128.73","858.84",""
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","128.73","","","","","","","fee schedule","128.73","858.84",""
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.73","","","","","","","fee schedule","128.73","858.84",""
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","858.84","","","","","","","fee schedule","128.73","858.84",""
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","217.37","","","","","","","fee schedule","128.73","858.84",""
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","134.84","","","","","","","fee schedule","128.73","858.84","APC"
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.59","","","","","","","fee schedule","128.73","858.84","APC"
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.3","","","","","","","fee schedule","128.73","858.84","APC"
"Genotype dna/rna hiv","87906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.17","","","","","","","fee schedule","128.73","858.84","APC"
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","424.66","","","","","","","fee schedule","257.45","1717.77",""
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1717.77","","","","","","","fee schedule","257.45","1717.77",""
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","424.66","","","","","","","fee schedule","257.45","1717.77",""
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","269.68","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","265.17","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","262.6","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype cytomegalovirus","87910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","270.32","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","424.66","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","257.45","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1717.77","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","424.66","","","","","","","fee schedule","257.45","1717.77",""
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","269.68","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","265.17","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","262.6","","","","","","","fee schedule","257.45","1717.77","APC"
"Genotype dna hepatitis b","87912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","270.32","","","","","","","fee schedule","257.45","1717.77","APC"
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","308.94","","","","","","","fee schedule","257.45","308.94",""
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","257.45","","","","","","","fee schedule","257.45","308.94",""
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","257.45","","","","","","","fee schedule","257.45","308.94",""
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","257.45","","","","","","","fee schedule","257.45","308.94",""
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","308.94","","","","","","","fee schedule","257.45","308.94",""
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","269.68","","","","","","","fee schedule","257.45","308.94","APC"
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","265.17","","","","","","","fee schedule","257.45","308.94","APC"
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","262.6","","","","","","","fee schedule","257.45","308.94","APC"
"Nfct agt gntyp alys sarscov2","87913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","270.32","","","","","","","fee schedule","257.45","308.94","APC"
"Microbiology procedure","87999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"Autopsy (necropsy) gross","88000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","236.42","","","","","","","fee schedule","236.42","1269.25",""
"Autopsy (necropsy) gross","88000","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1269.25","","","","","","","fee schedule","236.42","1269.25",""
"Autopsy (necropsy) gross","88000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","236.42","","","","","","","fee schedule","236.42","1269.25",""
"Autopsy (necropsy) gross","88005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","271.93","","","","","","","fee schedule","271.93","1481.32",""
"Autopsy (necropsy) gross","88005","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1481.32","","","","","","","fee schedule","271.93","1481.32",""
"Autopsy (necropsy) gross","88005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","271.93","","","","","","","fee schedule","271.93","1481.32",""
"Autopsy (necropsy) gross","88007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","295.75","","","","","","","fee schedule","295.75","1552.06",""
"Autopsy (necropsy) gross","88007","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1552.06","","","","","","","fee schedule","295.75","1552.06",""
"Autopsy (necropsy) gross","88007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","295.75","","","","","","","fee schedule","295.75","1552.06",""
"Autopsy (necropsy) gross","88012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","212.62","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) gross","88012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1269.25","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) gross","88012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","212.62","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) gross","88014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","212.62","","","","","","","fee schedule","212.62","1163.12",""
"Autopsy (necropsy) gross","88014","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1163.12","","","","","","","fee schedule","212.62","1163.12",""
"Autopsy (necropsy) gross","88014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","212.62","","","","","","","fee schedule","212.62","1163.12",""
"Autopsy (necropsy) gross","88016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","271.93","","","","","","","fee schedule","271.93","1622.75",""
"Autopsy (necropsy) gross","88016","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1622.75","","","","","","","fee schedule","271.93","1622.75",""
"Autopsy (necropsy) gross","88016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","271.93","","","","","","","fee schedule","271.93","1622.75",""
"Autopsy (necropsy) complete","88020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","366.34","","","","","","","fee schedule","366.34","2186.66",""
"Autopsy (necropsy) complete","88020","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2186.66","","","","","","","fee schedule","366.34","2186.66",""
"Autopsy (necropsy) complete","88020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","366.34","","","","","","","fee schedule","366.34","2186.66",""
"Autopsy (necropsy) complete","88025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","401.84","","","","","","","fee schedule","401.84","2115.94",""
"Autopsy (necropsy) complete","88025","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2115.94","","","","","","","fee schedule","401.84","2115.94",""
"Autopsy (necropsy) complete","88025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","401.84","","","","","","","fee schedule","401.84","2115.94",""
"Autopsy (necropsy) complete","88027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","437.34","","","","","","","fee schedule","437.34","2257.4",""
"Autopsy (necropsy) complete","88027","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2257.4","","","","","","","fee schedule","437.34","2257.4",""
"Autopsy (necropsy) complete","88027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","437.34","","","","","","","fee schedule","437.34","2257.4",""
"Autopsy (necropsy) complete","88028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","212.62","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) complete","88028","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1269.25","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) complete","88028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","212.62","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) complete","88029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","212.62","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) complete","88029","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1269.25","","","","","","","fee schedule","212.62","1269.25",""
"Autopsy (necropsy) complete","88029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","212.62","","","","","","","fee schedule","212.62","1269.25",""
"Limited autopsy","88036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","118.21","","","","","","","fee schedule","118.21","634.57",""
"Limited autopsy","88036","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","634.57","","","","","","","fee schedule","118.21","634.57",""
"Limited autopsy","88036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","118.21","","","","","","","fee schedule","118.21","634.57",""
"Limited autopsy","88037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","94.39","","","","","","","fee schedule","94.39","563.91",""
"Limited autopsy","88037","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","563.91","","","","","","","fee schedule","94.39","563.91",""
"Limited autopsy","88037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","94.39","","","","","","","fee schedule","94.39","563.91",""
"Forensic autopsy (necropsy)","88040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","591.06","","","","","","","fee schedule","591.06","3526.54",""
"Forensic autopsy (necropsy)","88040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3526.54","","","","","","","fee schedule","591.06","3526.54",""
"Forensic autopsy (necropsy)","88040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","591.06","","","","","","","fee schedule","591.06","3526.54",""
"Coroners autopsy (necropsy)","88045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.33","","","","","","","fee schedule","59.33","353.61",""
"Coroners autopsy (necropsy)","88045","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","353.61","","","","","","","fee schedule","59.33","353.61",""
"Coroners autopsy (necropsy)","88045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.33","","","","","","","fee schedule","59.33","353.61",""
"Necropsy (autopsy) procedure","88099","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","260.54",""
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","260.54","","","","","","","fee schedule","20.08","260.54",""
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","260.54",""
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","20.08","260.54","APC 277.30"
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","20.08","260.54","APC 296.56"
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","20.08","260.54","APC 308.91"
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","20.08","260.54","APC"
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","20.08","260.54","APC"
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","20.08","260.54","APC"
"Cytopath fl nongyn smears","88104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","20.08","260.54","APC"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","362.87",""
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","362.87","","","","","","","fee schedule","20.08","362.87",""
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","362.87",""
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","20.08","362.87","APC 277.30"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","20.08","362.87","APC 296.56"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","20.08","362.87","APC 308.91"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","20.08","362.87","APC"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","20.08","362.87","APC"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","20.08","362.87","APC"
"Cytopath fl nongyn filter","88106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","20.08","362.87","APC"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","310.78",""
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","310.78","","","","","","","fee schedule","20.08","310.78",""
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","310.78",""
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","20.08","310.78","APC 277.30"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","20.08","310.78","APC 296.56"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","20.08","310.78","APC 308.91"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","20.08","310.78","APC"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","20.08","310.78","APC"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","20.08","310.78","APC"
"Cytopath concentrate tech","88108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","20.08","310.78","APC"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","280.99",""
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","280.99","","","","","","","fee schedule","42.88","280.99",""
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","280.99",""
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","280.99","APC 277.30"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","280.99","APC 296.56"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","280.99","APC 308.91"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","280.99","APC"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","280.99","APC"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","280.99","APC"
"Cytopath cell enhance tech","88112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","280.99","APC"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","67.7","","","","","","","fee schedule","67.7","3087.39",""
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3087.39","","","","","","","fee schedule","67.7","3087.39",""
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","67.7","","","","","","","fee schedule","67.7","3087.39",""
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","67.7","3087.39","APC 277.30"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","67.7","3087.39","APC 296.56"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","67.7","3087.39","APC 308.91"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","67.7","3087.39","APC"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","67.7","3087.39","APC"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","67.7","3087.39","APC"
"Cytp urne 3-5 probes ea spec","88120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","67.7","3087.39","APC"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","67.7","","","","","","","fee schedule","67.7","2782.15",""
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2782.15","","","","","","","fee schedule","67.7","2782.15",""
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","67.7","","","","","","","fee schedule","67.7","2782.15",""
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","67.7","2782.15","APC 277.30"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","67.7","2782.15","APC 296.56"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","67.7","2782.15","APC 308.91"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","67.7","2782.15","APC"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","67.7","2782.15","APC"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","67.7","2782.15","APC"
"Cytp urine 3-5 probes cmptr","88121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","67.7","2782.15","APC"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","179.91",""
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.11","","","","","","","fee schedule","20.08","179.91",""
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","179.91",""
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","20.08","179.91","APC 277.30"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","20.08","179.91","APC 296.56"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","20.08","179.91","APC 308.91"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","20.08","179.91","APC"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","20.08","179.91","APC"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","20.08","179.91","APC"
"Forensic cytopathology","88125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","20.08","179.91","APC"
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25.87","","","","","","","fee schedule","17.98","112.86",""
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.98","","","","","","","fee schedule","17.98","112.86",""
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.98","","","","","","","fee schedule","17.98","112.86",""
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.98","","","","","","","fee schedule","17.98","112.86",""
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","112.86","","","","","","","fee schedule","17.98","112.86",""
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","25.87","","","","","","","fee schedule","17.98","112.86",""
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.83","","","","","","","fee schedule","17.98","112.86","APC"
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.52","","","","","","","fee schedule","17.98","112.86","APC"
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.34","","","","","","","fee schedule","17.98","112.86","APC"
"Sex chromatin identification","88130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.88","","","","","","","fee schedule","17.98","112.86","APC"
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.74","","","","","","","fee schedule","7.99","56.2",""
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.99","","","","","","","fee schedule","7.99","56.2",""
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.99","","","","","","","fee schedule","7.99","56.2",""
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.99","","","","","","","fee schedule","7.99","56.2",""
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","56.2","","","","","","","fee schedule","7.99","56.2",""
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.74","","","","","","","fee schedule","7.99","56.2",""
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.37","","","","","","","fee schedule","7.99","56.2","APC"
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.23","","","","","","","fee schedule","7.99","56.2","APC"
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.15","","","","","","","fee schedule","7.99","56.2","APC"
"Sex chromatin identification","88140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.39","","","","","","","fee schedule","7.99","56.2","APC"
"Cytopath c/v interpret","88141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.26","","","","","","","fee schedule","38.26","173.13",""
"Cytopath c/v interpret","88141","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","173.13","","","","","","","fee schedule","38.26","173.13",""
"Cytopath c/v interpret","88141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.26","","","","","","","fee schedule","38.26","173.13",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.82","","","","","","","fee schedule","20.26","144.5",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.26","","","","","","","fee schedule","20.26","144.5",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.26","","","","","","","fee schedule","20.26","144.5",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.26","","","","","","","fee schedule","20.26","144.5",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","144.5","","","","","","","fee schedule","20.26","144.5",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.82","","","","","","","fee schedule","20.26","144.5",""
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.22","","","","","","","fee schedule","20.26","144.5","APC"
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.87","","","","","","","fee schedule","20.26","144.5","APC"
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.67","","","","","","","fee schedule","20.26","144.5","APC"
"Cytopath c/v thin layer","88142","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.27","","","","","","","fee schedule","20.26","144.5","APC"
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.82","","","","","","","fee schedule","23.04","142.31",""
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.04","","","","","","","fee schedule","23.04","142.31",""
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.04","","","","","","","fee schedule","23.04","142.31",""
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.04","","","","","","","fee schedule","23.04","142.31",""
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","142.31","","","","","","","fee schedule","23.04","142.31",""
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.82","","","","","","","fee schedule","23.04","142.31",""
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.13","","","","","","","fee schedule","23.04","142.31","APC"
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.73","","","","","","","fee schedule","23.04","142.31","APC"
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.5","","","","","","","fee schedule","23.04","142.31","APC"
"Cytopath c/v thin layer redo","88143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.19","","","","","","","fee schedule","23.04","142.31","APC"
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.56","","","","","","","fee schedule","19.56","82.45",""
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","50.56","","","","","","","fee schedule","19.56","82.45",""
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.56","","","","","","","fee schedule","19.56","82.45",""
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","50.56","","","","","","","fee schedule","19.56","82.45",""
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","82.45","","","","","","","fee schedule","19.56","82.45",""
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.56","","","","","","","fee schedule","19.56","82.45",""
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52.96","","","","","","","fee schedule","19.56","82.45","APC"
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.08","","","","","","","fee schedule","19.56","82.45","APC"
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.57","","","","","","","fee schedule","19.56","82.45","APC"
"Cytopath c/v automated","88147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.09","","","","","","","fee schedule","19.56","82.45","APC"
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.12","","","","","","","fee schedule","18.19","98.89",""
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.19","98.89",""
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.19","98.89",""
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.19","98.89",""
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","98.89","","","","","","","fee schedule","18.19","98.89",""
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.12","","","","","","","fee schedule","18.19","98.89",""
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.19","98.89","APC"
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.19","98.89","APC"
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.19","98.89","APC"
"Cytopath c/v auto rescreen","88148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.19","98.89","APC"
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v manual","88150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.64","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.64","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.64","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.95","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.47","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.19","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v auto redo","88152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.02","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.03","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.03","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.03","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.17","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.75","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.51","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v redo","88153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.23","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath c/v select","88154","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","79.43","79.43",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.3","","","","","","","fee schedule","10.3","44.02",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.65","","","","","","","fee schedule","10.3","44.02",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.65","","","","","","","fee schedule","10.3","44.02",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.65","","","","","","","fee schedule","10.3","44.02",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.02","","","","","","","fee schedule","10.3","44.02",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.3","","","","","","","fee schedule","10.3","44.02",""
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.35","","","","","","","fee schedule","10.3","44.02","APC"
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.09","","","","","","","fee schedule","10.3","44.02","APC"
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.94","","","","","","","fee schedule","10.3","44.02","APC"
"Cytopath c/v index add-on","88155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.38","","","","","","","fee schedule","10.3","44.02","APC"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","208.46",""
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","208.46","","","","","","","fee schedule","20.08","208.46",""
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","208.46",""
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","20.08","208.46","APC 277.30"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","20.08","208.46","APC 296.56"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","20.08","208.46","APC 308.91"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","20.08","208.46","APC"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","20.08","208.46","APC"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","20.08","208.46","APC"
"Cytopath smear other source","88160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","20.08","208.46","APC"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","197.27",""
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","197.27",""
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","197.27","","","","","","","fee schedule","20.08","197.27",""
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","20.08","197.27","APC 277.30"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","20.08","197.27","APC 296.56"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","20.08","197.27","APC 308.91"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","20.08","197.27","APC"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","20.08","197.27","APC"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","20.08","197.27","APC"
"Cytopath smear other source","88161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","20.08","197.27","APC"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","312.63",""
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","312.63",""
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","312.63","","","","","","","fee schedule","42.88","312.63",""
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","312.63","APC 277.30"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","312.63","APC 296.56"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","312.63","APC 308.91"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","312.63","APC"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","312.63","APC"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","312.63","APC"
"Cytopath smear other source","88162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","312.63","APC"
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v manual","88164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.22","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.22","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.22","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.23","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.49","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.06","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v redo","88165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.33","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v auto redo","88166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","79.43","","","","","","","fee schedule","18.16","79.43",""
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.16","79.43","APC"
"Cytopath tbs c/v select","88167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.16","79.43","APC"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.02","","","","","","","fee schedule","42.88","588.18",""
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Cytp dx eval fna 1st ea site","88172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","437.36",""
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","437.36",""
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","437.36","","","","","","","fee schedule","42.88","437.36",""
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","437.36","APC 277.30"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","437.36","APC 296.56"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","437.36","APC 308.91"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","437.36","APC"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","437.36","APC"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","437.36","APC"
"Cytopath eval fna report","88173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","437.36","APC"
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.72","","","","","","","fee schedule","25.37","151.23",""
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.37","","","","","","","fee schedule","25.37","151.23",""
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.37","","","","","","","fee schedule","25.37","151.23",""
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.37","","","","","","","fee schedule","25.37","151.23",""
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.72","","","","","","","fee schedule","25.37","151.23",""
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","151.23","","","","","","","fee schedule","25.37","151.23",""
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.58","","","","","","","fee schedule","25.37","151.23","APC"
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.13","","","","","","","fee schedule","25.37","151.23","APC"
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.88","","","","","","","fee schedule","25.37","151.23","APC"
"Cytopath c/v auto in fluid","88174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.64","","","","","","","fee schedule","25.37","151.23","APC"
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45.53","","","","","","","fee schedule","26.61","186.64",""
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.61","","","","","","","fee schedule","26.61","186.64",""
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.61","","","","","","","fee schedule","26.61","186.64",""
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.61","","","","","","","fee schedule","26.61","186.64",""
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45.53","","","","","","","fee schedule","26.61","186.64",""
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","186.64","","","","","","","fee schedule","26.61","186.64",""
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.87","","","","","","","fee schedule","26.61","186.64","APC"
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.41","","","","","","","fee schedule","26.61","186.64","APC"
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.14","","","","","","","fee schedule","26.61","186.64","APC"
"Cytopath c/v auto fluid redo","88175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.94","","","","","","","fee schedule","26.61","186.64","APC"
"Cytp fna eval ea addl","88177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.25","","","","","","","fee schedule","13.25","42.86",""
"Cytp fna eval ea addl","88177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.25","","","","","","","fee schedule","13.25","42.86",""
"Cytp fna eval ea addl","88177","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","42.86","","","","","","","fee schedule","13.25","42.86",""
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","405.72",""
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","405.72",""
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","405.72","","","","","","","fee schedule","42.88","405.72",""
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","405.72","APC 277.30"
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","405.72","APC 296.56"
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","405.72","APC 308.91"
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","405.72","APC"
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","405.72","APC"
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","405.72","APC"
"Cell marker study","88182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","405.72","APC"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","1237.5",""
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","1237.5",""
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","485.73","","","","","","","fee schedule","20.08","1237.5",""
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","20.08","1237.5","APC 277.30"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","20.08","1237.5","APC 296.56"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","20.08","1237.5","APC 308.91"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","20.08","1237.5","APC"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","20.08","1237.5","APC"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","20.08","1237.5","APC"
"Flowcytometry/ tc 1 marker","88184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","20.08","1237.5","APC"
"Flowcytometry/tc add-on","88185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","295.98",""
"Flowcytometry/tc add-on","88185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","295.98",""
"Flowcytometry/tc add-on","88185","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","295.98","","","","","","","fee schedule","20.08","295.98",""
"Flowcytometry/read 2-8","88187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","375.9",""
"Flowcytometry/read 2-8","88187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","375.9",""
"Flowcytometry/read 2-8","88187","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","375.9","","","","","","","fee schedule","12.5","375.9",""
"Flowcytometry/read 9-15","88188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","480.13",""
"Flowcytometry/read 9-15","88188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","480.13",""
"Flowcytometry/read 9-15","88188","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","480.13","","","","","","","fee schedule","42.88","480.13",""
"Flowcytometry/read 16 & >","88189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","582.48",""
"Flowcytometry/read 16 & >","88189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","582.48",""
"Flowcytometry/read 16 & >","88189","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","582.48","","","","","","","fee schedule","42.88","582.48",""
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","179.91",""
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","179.91",""
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","12.5","179.91",""
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","12.5","179.91","APC 277.30"
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","12.5","179.91","APC 296.56"
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","12.5","179.91","APC 308.91"
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","12.5","179.91","APC"
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","12.5","179.91","APC"
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","12.5","179.91","APC"
"Cytopathology procedure","88199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","12.5","179.91","APC"
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","200.23","","","","","","","fee schedule","116.49","686.74",""
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.49","","","","","","","fee schedule","116.49","686.74",""
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","116.49","","","","","","","fee schedule","116.49","686.74",""
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","116.49","","","","","","","fee schedule","116.49","686.74",""
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","200.23","","","","","","","fee schedule","116.49","686.74",""
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","686.74","","","","","","","fee schedule","116.49","686.74",""
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","122.02","","","","","","","fee schedule","116.49","686.74","APC"
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","119.98","","","","","","","fee schedule","116.49","686.74","APC"
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","118.82","","","","","","","fee schedule","116.49","686.74","APC"
"Tissue culture lymphocyte","88230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","122.31","","","","","","","fee schedule","116.49","686.74","APC"
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","241.88","","","","","","","fee schedule","140.73","881.71",""
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","140.73","","","","","","","fee schedule","140.73","881.71",""
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","140.73","","","","","","","fee schedule","140.73","881.71",""
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","140.73","","","","","","","fee schedule","140.73","881.71",""
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","241.88","","","","","","","fee schedule","140.73","881.71",""
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","881.71","","","","","","","fee schedule","140.73","881.71",""
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","147.41","","","","","","","fee schedule","140.73","881.71","APC"
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","144.95","","","","","","","fee schedule","140.73","881.71","APC"
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","143.54","","","","","","","fee schedule","140.73","881.71","APC"
"Tissue culture skin/biopsy","88233","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","147.77","","","","","","","fee schedule","140.73","881.71","APC"
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","253.09","","","","","","","fee schedule","150.3","889.97",""
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150.3","","","","","","","fee schedule","150.3","889.97",""
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","150.3","","","","","","","fee schedule","150.3","889.97",""
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150.3","","","","","","","fee schedule","150.3","889.97",""
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","253.09","","","","","","","fee schedule","150.3","889.97",""
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","889.97","","","","","","","fee schedule","150.3","889.97",""
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.44","","","","","","","fee schedule","150.3","889.97","APC"
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.81","","","","","","","fee schedule","150.3","889.97","APC"
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153.31","","","","","","","fee schedule","150.3","889.97","APC"
"Tissue culture placenta","88235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.82","","","","","","","fee schedule","150.3","889.97","APC"
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","217.09","","","","","","","fee schedule","143.75","781.51",""
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","143.75","","","","","","","fee schedule","143.75","781.51",""
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","143.75","","","","","","","fee schedule","143.75","781.51",""
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","143.75","","","","","","","fee schedule","143.75","781.51",""
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","217.09","","","","","","","fee schedule","143.75","781.51",""
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","781.51","","","","","","","fee schedule","143.75","781.51",""
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","150.58","","","","","","","fee schedule","143.75","781.51","APC"
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","148.06","","","","","","","fee schedule","143.75","781.51","APC"
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","146.62","","","","","","","fee schedule","143.75","781.51","APC"
"Tissue culture bone marrow","88237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","150.94","","","","","","","fee schedule","143.75","781.51","APC"
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","253.56","","","","","","","fee schedule","147.52","968.07",""
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","147.52","","","","","","","fee schedule","147.52","968.07",""
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","147.52","","","","","","","fee schedule","147.52","968.07",""
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","147.52","","","","","","","fee schedule","147.52","968.07",""
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","253.56","","","","","","","fee schedule","147.52","968.07",""
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","968.07","","","","","","","fee schedule","147.52","968.07",""
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","154.53","","","","","","","fee schedule","147.52","968.07","APC"
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","151.95","","","","","","","fee schedule","147.52","968.07","APC"
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","150.47","","","","","","","fee schedule","147.52","968.07","APC"
"Tissue culture tumor","88239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","154.9","","","","","","","fee schedule","147.52","968.07","APC"
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.36","","","","","","","fee schedule","13.07","69.15",""
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.07","","","","","","","fee schedule","13.07","69.15",""
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.07","","","","","","","fee schedule","13.07","69.15",""
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.07","","","","","","","fee schedule","13.07","69.15",""
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.36","","","","","","","fee schedule","13.07","69.15",""
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.15","","","","","","","fee schedule","13.07","69.15",""
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.07","69.15","APC"
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.46","","","","","","","fee schedule","13.07","69.15","APC"
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.33","","","","","","","fee schedule","13.07","69.15","APC"
"Cell cryopreserve/storage","88240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.72","","","","","","","fee schedule","13.07","69.15","APC"
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.36","","","","","","","fee schedule","12.09","69.15",""
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.09","","","","","","","fee schedule","12.09","69.15",""
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.09","","","","","","","fee schedule","12.09","69.15",""
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.09","","","","","","","fee schedule","12.09","69.15",""
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.36","","","","","","","fee schedule","12.09","69.15",""
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.15","","","","","","","fee schedule","12.09","69.15",""
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.66","","","","","","","fee schedule","12.09","69.15","APC"
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.45","","","","","","","fee schedule","12.09","69.15","APC"
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.33","","","","","","","fee schedule","12.09","69.15","APC"
"Frozen cell preparation","88241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.09","69.15","APC"
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","255.86","","","","","","","fee schedule","173.17","1033.02",""
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","173.17","","","","","","","fee schedule","173.17","1033.02",""
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","173.17","","","","","","","fee schedule","173.17","1033.02",""
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.17","","","","","","","fee schedule","173.17","1033.02",""
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","255.86","","","","","","","fee schedule","173.17","1033.02",""
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1033.02","","","","","","","fee schedule","173.17","1033.02",""
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","181.4","","","","","","","fee schedule","173.17","1033.02","APC"
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","178.37","","","","","","","fee schedule","173.17","1033.02","APC"
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","176.63","","","","","","","fee schedule","173.17","1033.02","APC"
"Chromosome analysis 20-25","88245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","181.83","","","","","","","fee schedule","173.17","1033.02","APC"
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","297.65","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","173.17","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","173.17","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.17","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","297.65","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1271.61","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","181.4","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","178.37","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","176.63","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 50-100","88248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","181.83","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","297.65","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","173.17","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","173.17","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.17","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","297.65","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1271.61","","","","","","","fee schedule","173.17","1271.61",""
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","181.4","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","178.37","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","176.63","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 100","88249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","181.83","","","","","","","fee schedule","173.17","1271.61","APC"
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","303.77","","","","","","","fee schedule","264.34","1327.64",""
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","264.34","","","","","","","fee schedule","264.34","1327.64",""
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","264.34","","","","","","","fee schedule","264.34","1327.64",""
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","264.34","","","","","","","fee schedule","264.34","1327.64",""
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","303.77","","","","","","","fee schedule","264.34","1327.64",""
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1327.64","","","","","","","fee schedule","264.34","1327.64",""
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","276.9","","","","","","","fee schedule","264.34","1327.64","APC"
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","272.27","","","","","","","fee schedule","264.34","1327.64","APC"
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","269.63","","","","","","","fee schedule","264.34","1327.64","APC"
"Chromosome analysis 5","88261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","277.56","","","","","","","fee schedule","264.34","1327.64","APC"
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","214.24","","","","","","","fee schedule","125.49","937.09",""
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","125.49","","","","","","","fee schedule","125.49","937.09",""
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","125.49","","","","","","","fee schedule","125.49","937.09",""
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","125.49","","","","","","","fee schedule","125.49","937.09",""
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","214.24","","","","","","","fee schedule","125.49","937.09",""
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","937.09","","","","","","","fee schedule","125.49","937.09",""
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.45","","","","","","","fee schedule","125.49","937.09","APC"
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.25","","","","","","","fee schedule","125.49","937.09","APC"
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128","","","","","","","fee schedule","125.49","937.09","APC"
"Chromosome analysis 15-20","88262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.76","","","","","","","fee schedule","125.49","937.09","APC"
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","258.3","","","","","","","fee schedule","150.29","1087.83",""
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150.29","","","","","","","fee schedule","150.29","1087.83",""
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","150.29","","","","","","","fee schedule","150.29","1087.83",""
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150.29","","","","","","","fee schedule","150.29","1087.83",""
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","258.3","","","","","","","fee schedule","150.29","1087.83",""
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1087.83","","","","","","","fee schedule","150.29","1087.83",""
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.43","","","","","","","fee schedule","150.29","1087.83","APC"
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.8","","","","","","","fee schedule","150.29","1087.83","APC"
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153.3","","","","","","","fee schedule","150.29","1087.83","APC"
"Chromosome analysis 45","88263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.8","","","","","","","fee schedule","150.29","1087.83","APC"
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","214.24","","","","","","","fee schedule","144.61","937.09",""
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","144.61","","","","","","","fee schedule","144.61","937.09",""
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","144.61","","","","","","","fee schedule","144.61","937.09",""
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","144.61","","","","","","","fee schedule","144.61","937.09",""
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","214.24","","","","","","","fee schedule","144.61","937.09",""
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","937.09","","","","","","","fee schedule","144.61","937.09",""
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","151.48","","","","","","","fee schedule","144.61","937.09","APC"
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","148.95","","","","","","","fee schedule","144.61","937.09","APC"
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","147.5","","","","","","","fee schedule","144.61","937.09","APC"
"Chromosome analysis 20-25","88264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","151.84","","","","","","","fee schedule","144.61","937.09","APC"
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","308.98","","","","","","","fee schedule","188.57","1344.37",""
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","188.57","","","","","","","fee schedule","188.57","1344.37",""
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","188.57","","","","","","","fee schedule","188.57","1344.37",""
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","188.57","","","","","","","fee schedule","188.57","1344.37",""
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","308.98","","","","","","","fee schedule","188.57","1344.37",""
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1344.37","","","","","","","fee schedule","188.57","1344.37",""
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","197.53","","","","","","","fee schedule","188.57","1344.37","APC"
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","194.23","","","","","","","fee schedule","188.57","1344.37","APC"
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","192.34","","","","","","","fee schedule","188.57","1344.37","APC"
"Chromosome analys placenta","88267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","198","","","","","","","fee schedule","188.57","1344.37","APC"
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","285.86","","","","","","","fee schedule","173.66","1211.86",""
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","173.66","","","","","","","fee schedule","173.66","1211.86",""
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","173.66","","","","","","","fee schedule","173.66","1211.86",""
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.66","","","","","","","fee schedule","173.66","1211.86",""
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","285.86","","","","","","","fee schedule","173.66","1211.86",""
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1211.86","","","","","","","fee schedule","173.66","1211.86",""
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","181.91","","","","","","","fee schedule","173.66","1211.86","APC"
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","178.87","","","","","","","fee schedule","173.66","1211.86","APC"
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","177.13","","","","","","","fee schedule","173.66","1211.86","APC"
"Chromosome analys amniotic","88269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","182.34","","","","","","","fee schedule","173.66","1211.86","APC"
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.82","","","","","","","fee schedule","21.42","145.92",""
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.42","","","","","","","fee schedule","21.42","145.92",""
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.42","","","","","","","fee schedule","21.42","145.92",""
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.42","","","","","","","fee schedule","21.42","145.92",""
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.82","","","","","","","fee schedule","21.42","145.92",""
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","145.92","","","","","","","fee schedule","21.42","145.92",""
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.44","","","","","","","fee schedule","21.42","145.92","APC"
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.06","","","","","","","fee schedule","21.42","145.92","APC"
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.85","","","","","","","fee schedule","21.42","145.92","APC"
"Cytogenetics dna probe","88271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.49","","","","","","","fee schedule","21.42","145.92","APC"
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.02","","","","","","","fee schedule","40.7","191.19",""
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","40.7","","","","","","","fee schedule","40.7","191.19",""
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","40.7","","","","","","","fee schedule","40.7","191.19",""
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40.7","","","","","","","fee schedule","40.7","191.19",""
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.02","","","","","","","fee schedule","40.7","191.19",""
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","191.19","","","","","","","fee schedule","40.7","191.19",""
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.63","","","","","","","fee schedule","40.7","191.19","APC"
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.92","","","","","","","fee schedule","40.7","191.19","APC"
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.51","","","","","","","fee schedule","40.7","191.19","APC"
"Cytogenetics 3-5","88272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.74","","","","","","","fee schedule","40.7","191.19","APC"
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55.22","","","","","","","fee schedule","34.81","232.34",""
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.81","","","","","","","fee schedule","34.81","232.34",""
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.81","","","","","","","fee schedule","34.81","232.34",""
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.81","","","","","","","fee schedule","34.81","232.34",""
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","55.22","","","","","","","fee schedule","34.81","232.34",""
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","232.34","","","","","","","fee schedule","34.81","232.34",""
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.46","","","","","","","fee schedule","34.81","232.34","APC"
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.85","","","","","","","fee schedule","34.81","232.34","APC"
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.51","","","","","","","fee schedule","34.81","232.34","APC"
"Cytogenetics 10-30","88273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.55","","","","","","","fee schedule","34.81","232.34","APC"
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.83","","","","","","","fee schedule","42.38","255.15",""
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.38","","","","","","","fee schedule","42.38","255.15",""
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42.38","","","","","","","fee schedule","42.38","255.15",""
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.38","","","","","","","fee schedule","42.38","255.15",""
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.83","","","","","","","fee schedule","42.38","255.15",""
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","255.15","","","","","","","fee schedule","42.38","255.15",""
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.39","","","","","","","fee schedule","42.38","255.15","APC"
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.65","","","","","","","fee schedule","42.38","255.15","APC"
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.23","","","","","","","fee schedule","42.38","255.15","APC"
"Cytogenetics 25-99","88274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.5","","","","","","","fee schedule","42.38","255.15","APC"
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","69.02","","","","","","","fee schedule","51.19","294.03",""
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.19","","","","","","","fee schedule","51.19","294.03",""
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.19","","","","","","","fee schedule","51.19","294.03",""
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.19","","","","","","","fee schedule","51.19","294.03",""
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","69.02","","","","","","","fee schedule","51.19","294.03",""
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","294.03","","","","","","","fee schedule","51.19","294.03",""
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.62","","","","","","","fee schedule","51.19","294.03","APC"
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.73","","","","","","","fee schedule","51.19","294.03","APC"
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.21","","","","","","","fee schedule","51.19","294.03","APC"
"Cytogenetics 100-300","88275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.75","","","","","","","fee schedule","51.19","294.03","APC"
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.14","","","","","","","fee schedule","33.47","188.77",""
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.47","","","","","","","fee schedule","33.47","188.77",""
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.47","","","","","","","fee schedule","33.47","188.77",""
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","33.47","","","","","","","fee schedule","33.47","188.77",""
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.14","","","","","","","fee schedule","33.47","188.77",""
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","188.77","","","","","","","fee schedule","33.47","188.77",""
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.06","","","","","","","fee schedule","33.47","188.77","APC"
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.47","","","","","","","fee schedule","33.47","188.77","APC"
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.14","","","","","","","fee schedule","33.47","188.77","APC"
"Chromosome karyotype study","88280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.14","","","","","","","fee schedule","33.47","188.77","APC"
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","117.9","","","","","","","fee schedule","68.6","409.98",""
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","68.6","","","","","","","fee schedule","68.6","409.98",""
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","68.6","","","","","","","fee schedule","68.6","409.98",""
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","68.6","","","","","","","fee schedule","68.6","409.98",""
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","117.9","","","","","","","fee schedule","68.6","409.98",""
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","409.98","","","","","","","fee schedule","68.6","409.98",""
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","71.86","","","","","","","fee schedule","68.6","409.98","APC"
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","70.66","","","","","","","fee schedule","68.6","409.98","APC"
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","69.97","","","","","","","fee schedule","68.6","409.98","APC"
"Chromosome banding study","88283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","72.03","","","","","","","fee schedule","68.6","409.98","APC"
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","32.65","","","","","","","fee schedule","26.91","140.13",""
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.91","","","","","","","fee schedule","26.91","140.13",""
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.91","","","","","","","fee schedule","26.91","140.13",""
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.91","","","","","","","fee schedule","26.91","140.13",""
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","32.65","","","","","","","fee schedule","26.91","140.13",""
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","140.13","","","","","","","fee schedule","26.91","140.13",""
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.19","","","","","","","fee schedule","26.91","140.13","APC"
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.72","","","","","","","fee schedule","26.91","140.13","APC"
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.45","","","","","","","fee schedule","26.91","140.13","APC"
"Chromosome count additional","88285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.26","","","","","","","fee schedule","26.91","140.13","APC"
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","59.18","","","","","","","fee schedule","34.43","231.09",""
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.43","","","","","","","fee schedule","34.43","231.09",""
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.43","","","","","","","fee schedule","34.43","231.09",""
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.43","","","","","","","fee schedule","34.43","231.09",""
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","59.18","","","","","","","fee schedule","34.43","231.09",""
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","231.09","","","","","","","fee schedule","34.43","231.09",""
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.07","","","","","","","fee schedule","34.43","231.09","APC"
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.46","","","","","","","fee schedule","34.43","231.09","APC"
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.12","","","","","","","fee schedule","34.43","231.09","APC"
"Chromosome study additional","88289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.15","","","","","","","fee schedule","34.43","231.09","APC"
"Cyto/molecular report","88291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.21","","","","","","","fee schedule","34.21","167.45",""
"Cyto/molecular report","88291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.21","","","","","","","fee schedule","34.21","167.45",""
"Cyto/molecular report","88291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","167.45","","","","","","","fee schedule","34.21","167.45",""
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","179.91",""
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","179.91",""
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","12.5","179.91",""
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","12.5","179.91","APC 277.30"
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","12.5","179.91","APC 296.56"
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","12.5","179.91","APC 308.91"
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","12.5","179.91","APC"
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","12.5","179.91","APC"
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","12.5","179.91","APC"
"Cytogenetic study","88299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","12.5","179.91","APC"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","99.86",""
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","99.86",""
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","55.86","","","","","","","fee schedule","20.08","99.86",""
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","20.08","99.86","APC 277.30"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","20.08","99.86","APC 296.56"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","20.08","99.86","APC 308.91"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","20.08","99.86","APC"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","20.08","99.86","APC"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","20.08","99.86","APC"
"Surgical path gross","88300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","20.08","99.86","APC"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","132.12",""
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","132.12",""
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","132.12","","","","","","","fee schedule","20.08","132.12",""
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","20.08","132.12","APC 277.30"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","20.08","132.12","APC 296.56"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","20.08","132.12","APC 308.91"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","20.08","132.12","APC"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","20.08","132.12","APC"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","20.08","132.12","APC"
"Tissue exam by pathologist","88302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","20.08","132.12","APC"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","182.36",""
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","182.36",""
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","182.36","","","","","","","fee schedule","42.88","182.36",""
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","182.36","APC 277.30"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","182.36","APC 296.56"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","182.36","APC 308.91"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","182.36",""
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","182.36",""
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","182.36","","","","","","","fee schedule","42.88","182.36",""
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","182.36","APC 277.30"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","182.36","APC 296.56"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","182.36","APC 308.91"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","182.36","APC"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1178.03","","","","","","","fee schedule","64.93","1237.5",""
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","64.93","1237.5","APC 277.30"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","64.93","1237.5","APC 296.56"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","64.93","1237.5","APC 308.91"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","64.93","1237.5","APC"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","64.93","1237.5","APC"
"Tissue exam by pathologist","88307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1665.6","","","","","","","fee schedule","64.93","2781.52",""
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","64.93","2781.52","APC 277.30"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","64.93","2781.52","APC 296.56"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","64.93","2781.52","APC 308.91"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","64.93","2781.52","APC"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","64.93","2781.52","APC"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","64.93","2781.52","APC"
"Tissue exam by pathologist","88309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","64.93","2781.52","APC"
"Decalcify tissue","88311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","44.7",""
"Decalcify tissue","88311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","44.7",""
"Decalcify tissue","88311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","44.7","","","","","","","fee schedule","12.5","44.7",""
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","388.94",""
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","388.94",""
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","388.94","","","","","","","fee schedule","20.08","388.94",""
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","20.08","388.94","APC 277.30"
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","20.08","388.94","APC 296.56"
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","20.08","388.94","APC 308.91"
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","20.08","388.94","APC"
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","20.08","388.94","APC"
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","20.08","388.94","APC"
"Special stains group 1","88312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","20.08","388.94","APC"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","459.34",""
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","459.34",""
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","305.24","","","","","","","fee schedule","20.08","459.34",""
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","20.08","459.34","APC 277.30"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","20.08","459.34","APC 296.56"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","20.08","459.34","APC 308.91"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","20.08","459.34","APC"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","20.08","459.34","APC"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","20.08","459.34","APC"
"Special stains group 2","88313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","20.08","459.34","APC"
"Histochemical stains add-on","88314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","320.1",""
"Histochemical stains add-on","88314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","320.1",""
"Histochemical stains add-on","88314","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","320.1","","","","","","","fee schedule","20.08","320.1",""
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","329.38","","","","","","","fee schedule","64.93","2781.52",""
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","64.93","2781.52","APC 277.30"
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","64.93","2781.52","APC 296.56"
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","64.93","2781.52","APC 308.91"
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","64.93","2781.52","APC"
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","64.93","2781.52","APC"
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","64.93","2781.52","APC"
"Enzyme histochemistry","88319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","64.93","2781.52","APC"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","455.91",""
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","455.91",""
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","455.91","","","","","","","fee schedule","20.08","455.91",""
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","20.08","455.91","APC 277.30"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","20.08","455.91","APC 296.56"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","20.08","455.91","APC 308.91"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","20.08","455.91","APC"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","20.08","455.91","APC"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","20.08","455.91","APC"
"Microslide consultation","88321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","20.08","455.91","APC"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","320.1",""
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","320.1",""
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","320.1","","","","","","","fee schedule","42.88","320.1",""
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","42.88","320.1","APC 277.30"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","42.88","320.1","APC 296.56"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","42.88","320.1","APC 308.91"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","42.88","320.1","APC"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","42.88","320.1","APC"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","42.88","320.1","APC"
"Microslide consultation","88323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","42.88","320.1","APC"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","705.34",""
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","705.34","","","","","","","fee schedule","64.93","705.34",""
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","705.34",""
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","705.34","APC 277.30"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","705.34","APC 296.56"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","705.34","APC 308.91"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","705.34","APC"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","705.34","APC"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","705.34","APC"
"Comprehensive review of data","88325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","705.34","APC"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","203.66",""
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","195.42","","","","","","","fee schedule","20.08","203.66",""
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","203.66",""
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","20.08","203.66","APC 277.30"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","20.08","203.66","APC 296.56"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","20.08","203.66","APC 308.91"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","20.08","203.66","APC"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","20.08","203.66","APC"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","20.08","203.66","APC"
"Path consult introp","88329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","20.08","203.66","APC"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","210.3","","","","","","","fee schedule","42.88","588.18",""
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Path consult intraop 1 bloc","88331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Path consult intraop addl","88332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","72.65",""
"Path consult intraop addl","88332","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","72.65","","","","","","","fee schedule","20.08","72.65",""
"Path consult intraop addl","88332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","72.65",""
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","2781.52",""
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","234.53","","","","","","","fee schedule","20.08","2781.52",""
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","2781.52",""
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","20.08","2781.52","APC 277.30"
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","20.08","2781.52","APC 296.56"
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","20.08","2781.52","APC 308.91"
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","20.08","2781.52","APC"
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","20.08","2781.52","APC"
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","20.08","2781.52","APC"
"Intraop cyto path consult 1","88333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","20.08","2781.52","APC"
"Intraop cyto path consult 2","88334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","148.87",""
"Intraop cyto path consult 2","88334","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","148.87","","","","","","","fee schedule","20.08","148.87",""
"Intraop cyto path consult 2","88334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","148.87",""
"Immunohisto antb addl slide","88341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","54.56","","","","","","","fee schedule","54.56","54.56",""
"Immunohisto antb addl slide","88341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","54.56","","","","","","","fee schedule","54.56","54.56",""
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","400.13","","","","","","","fee schedule","42.88","588.18",""
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Immunohisto antb 1st stain","88342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","92.36","","","","","","","fee schedule","92.36","1237.5",""
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","92.36","","","","","","","fee schedule","92.36","1237.5",""
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","92.36","1237.5","APC 277.30"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","92.36","1237.5","APC 296.56"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","92.36","1237.5","APC 308.91"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","92.36","1237.5","APC"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","92.36","1237.5","APC"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","92.36","1237.5","APC"
"Immunohisto antibody slide","88344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","92.36","1237.5","APC"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","368.49","","","","","","","fee schedule","42.88","588.18",""
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Immunofluor antb 1st stain","88346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Immunofluorescent study","88347","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","225.18","","","","","","","fee schedule","225.18","225.18",""
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","197.77","","","","","","","fee schedule","197.77","3561.9",""
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3561.9","","","","","","","fee schedule","197.77","3561.9",""
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","197.77","","","","","","","fee schedule","197.77","3561.9",""
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","197.77","3561.9","APC 277.30"
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","197.77","3561.9","APC 296.56"
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","197.77","3561.9","APC 308.91"
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","197.77","3561.9","APC"
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","197.77","3561.9","APC"
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","197.77","3561.9","APC"
"Electron microscopy","88348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","197.77","3561.9","APC"
"Scanning electron microscopy","88349","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","2173.57","","","","","","","fee schedule","2173.57","2173.57",""
"Immunofluor antb addl stain","88350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","52.45","","","","","","","fee schedule","52.45","52.45",""
"Immunofluor antb addl stain","88350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","52.45","","","","","","","fee schedule","52.45","52.45",""
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","547.13","","","","","","","fee schedule","42.88","588.18",""
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis skeletal muscle","88355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","818.89",""
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","818.89","","","","","","","fee schedule","51.86","818.89",""
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","818.89",""
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","818.89","APC 277.30"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","818.89","APC 296.56"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","818.89","APC 308.91"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","818.89","APC"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","818.89","APC"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","818.89","APC"
"Analysis nerve","88356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","818.89","APC"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","210.3","","","","","","","fee schedule","42.88","588.18",""
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Analysis tumor","88358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","42.88","588.18",""
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","409.41","","","","","","","fee schedule","42.88","588.18",""
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","42.88","588.18",""
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","42.88","588.18","APC 277.30"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","42.88","588.18","APC 296.56"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","42.88","588.18","APC 308.91"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","42.88","588.18","APC"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","42.88","588.18","APC"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","42.88","588.18","APC"
"Tumor immunohistochem/manual","88360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","42.88","588.18","APC"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","543.43","","","","","","","fee schedule","64.93","1237.5",""
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","64.93","1237.5","APC 277.30"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","64.93","1237.5","APC 296.56"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","64.93","1237.5","APC 308.91"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","64.93","1237.5","APC"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","64.93","1237.5","APC"
"Tumor immunohistochem/comput","88361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1109.19","","","","","","","fee schedule","64.93","2781.52",""
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","64.93","2781.52","APC 277.30"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","64.93","2781.52","APC 296.56"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","64.93","2781.52","APC 308.91"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","64.93","2781.52","APC"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","64.93","2781.52","APC"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","64.93","2781.52","APC"
"Nerve teasing preparations","88362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","64.93","2781.52","APC"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.25","","","","","","","fee schedule","13.25","106.02",""
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","106.02","","","","","","","fee schedule","13.25","106.02",""
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.25","","","","","","","fee schedule","13.25","106.02",""
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","13.25","106.02","APC 277.30"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","13.25","106.02","APC 296.56"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","13.25","106.02","APC 308.91"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","13.25","106.02","APC"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","13.25","106.02","APC"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","13.25","106.02","APC"
"Xm archive tissue molec anal","88363","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","13.25","106.02","APC"
"Insitu hybridization (fish)","88364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","84.2","","","","","","","fee schedule","84.2","84.2",""
"Insitu hybridization (fish)","88364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","84.2","","","","","","","fee schedule","84.2","84.2",""
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","658.82",""
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","658.82","","","","","","","fee schedule","64.93","658.82",""
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","658.82",""
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","658.82","APC 277.30"
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","658.82","APC 296.56"
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","658.82","APC 308.91"
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","658.82","APC"
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","658.82","APC"
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","658.82","APC"
"Insitu hybridization (fish)","88365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","658.82","APC"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","103.54","","","","","","","fee schedule","103.54","588.18",""
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","103.54","","","","","","","fee schedule","103.54","588.18",""
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","103.54","588.18","APC 277.30"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","103.54","588.18","APC 296.56"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","103.54","588.18","APC 308.91"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","103.54","588.18","APC"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","103.54","588.18","APC"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","103.54","588.18","APC"
"Insitu hybridization (fish)","88366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","103.54","588.18","APC"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","1084.97","","","","","","","fee schedule","64.93","1237.5",""
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","64.93","1237.5","APC 277.30"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","64.93","1237.5","APC 296.56"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","64.93","1237.5","APC 308.91"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization auto","88367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","932.37","","","","","","","fee schedule","64.93","1237.5",""
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","1237.5",""
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","64.93","1237.5","APC 277.30"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","64.93","1237.5","APC 296.56"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","64.93","1237.5","APC 308.91"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","64.93","1237.5","APC"
"Insitu hybridization manual","88368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","64.93","1237.5","APC"
"M/phmtrc alysishquant/semiq","88369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","58.43","","","","","","","fee schedule","58.43","58.43",""
"M/phmtrc alysishquant/semiq","88369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","58.43","","","","","","","fee schedule","58.43","58.43",""
"Protein western blot tissue","88371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38.2","","","","","","","fee schedule","22.23","156.68",""
"Protein western blot tissue","88371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.23","","","","","","","fee schedule","22.23","156.68",""
"Protein western blot tissue","88371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.23","","","","","","","fee schedule","22.23","156.68",""
"Protein western blot tissue","88371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.23","","","","","","","fee schedule","22.23","156.68",""
"Protein western blot tissue","88371","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","156.68","","","","","","","fee schedule","22.23","156.68",""
"Protein western blot tissue","88371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","38.2","","","","","","","fee schedule","22.23","156.68",""
"Protein analysis w/probe","88372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.1","","","","","","","fee schedule","26.22","164.52",""
"Protein analysis w/probe","88372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.22","","","","","","","fee schedule","26.22","164.52",""
"Protein analysis w/probe","88372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.22","","","","","","","fee schedule","26.22","164.52",""
"Protein analysis w/probe","88372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.22","","","","","","","fee schedule","26.22","164.52",""
"Protein analysis w/probe","88372","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","164.52","","","","","","","fee schedule","26.22","164.52",""
"Protein analysis w/probe","88372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.1","","","","","","","fee schedule","26.22","164.52",""
"M/phmtrc alys ishquant/semiq","88373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","46.82","","","","","","","fee schedule","46.82","46.82",""
"M/phmtrc alys ishquant/semiq","88373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","46.82","","","","","","","fee schedule","46.82","46.82",""
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","220.34","","","","","","","fee schedule","169.55","588.18",""
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","220.34","","","","","","","fee schedule","169.55","588.18",""
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","169.55","588.18","APC 277.30"
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","169.55","588.18","APC 296.56"
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","169.55","588.18","APC 308.91"
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","169.55","588.18","APC"
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","169.55","588.18","APC"
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","169.55","588.18","APC"
"M/phmtrc alys ishquant/semiq","88374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","169.55","588.18","APC"
"Optical endomicroscpy interp","88375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.25","","","","","","","fee schedule","15.25","69.49",""
"Optical endomicroscpy interp","88375","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","15.25","69.49",""
"Optical endomicroscpy interp","88375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.25","","","","","","","fee schedule","15.25","69.49",""
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","220.34","","","","","","","fee schedule","169.55","588.18",""
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","220.34","","","","","","","fee schedule","169.55","588.18",""
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","169.55","588.18","APC 277.30"
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","169.55","588.18","APC 296.56"
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","169.55","588.18","APC 308.91"
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","169.55","588.18","APC"
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","169.55","588.18","APC"
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","169.55","588.18","APC"
"M/phmtrc alys ishquant/semiq","88377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","169.55","588.18","APC"
"Microdissection laser","88380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","132.4","","","","","","","fee schedule","132.4","470.84",""
"Microdissection laser","88380","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","470.84","","","","","","","fee schedule","132.4","470.84",""
"Microdissection laser","88380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","132.4","","","","","","","fee schedule","132.4","470.84",""
"Microdissection manual","88381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","126.82","","","","","","","fee schedule","126.82","558.37",""
"Microdissection manual","88381","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","558.37","","","","","","","fee schedule","126.82","558.37",""
"Microdissection manual","88381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","126.82","","","","","","","fee schedule","126.82","558.37",""
"Tiss exam molecular study","88387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.74","","","","","","","fee schedule","7.74","33.48",""
"Tiss exam molecular study","88387","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.48","","","","","","","fee schedule","7.74","33.48",""
"Tiss exam molecular study","88387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.74","","","","","","","fee schedule","7.74","33.48",""
"Tiss ex molecul study add-on","88388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.75","","","","","","","fee schedule","10.75","52.11",""
"Tiss ex molecul study add-on","88388","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","52.11","","","","","","","fee schedule","10.75","52.11",""
"Tiss ex molecul study add-on","88388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.75","","","","","","","fee schedule","10.75","52.11",""
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","179.91",""
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","12.5","179.91",""
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","179.91",""
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","12.5","179.91","APC 277.30"
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","12.5","179.91","APC 296.56"
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","12.5","179.91","APC 308.91"
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","12.5","179.91","APC"
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","12.5","179.91","APC"
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","12.5","179.91","APC"
"Surgical pathology procedure","88399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","12.5","179.91","APC"
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.63","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.18","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.63","","","","","","","fee schedule","5.02","37.18",""
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.26","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.17","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.12","","","","","","","fee schedule","5.02","37.18","APC"
"Bilirubin total transcut","88720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.27","","","","","","","fee schedule","5.02","37.18","APC"
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.63","","","","","","","fee schedule","5.02","37.18",""
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.02","","","","","","","fee schedule","5.02","37.18",""
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.02","","","","","","","fee schedule","5.02","37.18",""
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.18","","","","","","","fee schedule","5.02","37.18",""
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.63","","","","","","","fee schedule","5.02","37.18",""
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.26","","","","","","","fee schedule","5.02","37.18","APC"
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.17","","","","","","","fee schedule","5.02","37.18","APC"
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.12","","","","","","","fee schedule","5.02","37.18","APC"
"Hgb quant transcutaneous","88738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.27","","","","","","","fee schedule","5.02","37.18","APC"
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.63","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.37","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.37","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.37","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.18","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.63","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.82","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.65","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.56","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous carboxyhb","88740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.84","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.63","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.37","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.37","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.37","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.18","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.63","","","","","","","fee schedule","8.63","37.18",""
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.82","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.65","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.56","","","","","","","fee schedule","8.63","37.18","APC"
"Transcutaneous methb","88741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.84","","","","","","","fee schedule","8.63","37.18","APC"
"In vivo lab service","88749","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","37.32","","","","","","","fee schedule","37.32","37.32",""
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","588.18",""
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","357.3","","","","","","","fee schedule","12.5","588.18",""
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","588.18",""
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","12.5","588.18","APC 277.30"
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","12.5","588.18","APC 296.56"
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","12.5","588.18","APC 308.91"
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","12.5","588.18","APC"
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","12.5","588.18","APC"
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","12.5","588.18","APC"
"Chct for mal hyperthermia","89049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","12.5","588.18","APC"
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.12","","","","","","","fee schedule","4.72","33.26",""
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.72","","","","","","","fee schedule","4.72","33.26",""
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.72","","","","","","","fee schedule","4.72","33.26",""
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.72","","","","","","","fee schedule","4.72","33.26",""
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","33.26","","","","","","","fee schedule","4.72","33.26",""
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.12","","","","","","","fee schedule","4.72","33.26",""
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.94","","","","","","","fee schedule","4.72","33.26","APC"
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.86","","","","","","","fee schedule","4.72","33.26","APC"
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.81","","","","","","","fee schedule","4.72","33.26","APC"
"Body fluid cell count","89050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.96","","","","","","","fee schedule","4.72","33.26","APC"
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.47","","","","","","","fee schedule","5.6","40.56",""
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.6","","","","","","","fee schedule","5.6","40.56",""
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.6","","","","","","","fee schedule","5.6","40.56",""
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.6","","","","","","","fee schedule","5.6","40.56",""
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","40.56","","","","","","","fee schedule","5.6","40.56",""
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.47","","","","","","","fee schedule","5.6","40.56",""
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.87","","","","","","","fee schedule","5.6","40.56","APC"
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.77","","","","","","","fee schedule","5.6","40.56","APC"
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.71","","","","","","","fee schedule","5.6","40.56","APC"
"Body fluid cell count","89051","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.88","","","","","","","fee schedule","5.6","40.56","APC"
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.27","31.33",""
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","31.33",""
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","31.33",""
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","31.33",""
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","31.33","","","","","","","fee schedule","4.27","31.33",""
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.27","31.33",""
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","31.33","APC"
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","31.33","APC"
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","31.33","APC"
"Leukocyte assessment fecal","89055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","31.33","APC"
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.29","","","","","","","fee schedule","7.33","53.16",""
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.33","","","","","","","fee schedule","7.33","53.16",""
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.33","","","","","","","fee schedule","7.33","53.16",""
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.33","","","","","","","fee schedule","7.33","53.16",""
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","53.16","","","","","","","fee schedule","7.33","53.16",""
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.29","","","","","","","fee schedule","7.33","53.16",""
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.68","","","","","","","fee schedule","7.33","53.16","APC"
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.55","","","","","","","fee schedule","7.33","53.16","APC"
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.48","","","","","","","fee schedule","7.33","53.16","APC"
"Exam synovial fluid crystals","89060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.7","","","","","","","fee schedule","7.33","53.16","APC"
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.43","","","","","","","fee schedule","5.88","30.56",""
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.88","","","","","","","fee schedule","5.88","30.56",""
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.88","","","","","","","fee schedule","5.88","30.56",""
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.88","","","","","","","fee schedule","5.88","30.56",""
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","30.56","","","","","","","fee schedule","5.88","30.56",""
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.43","","","","","","","fee schedule","5.88","30.56",""
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.16","","","","","","","fee schedule","5.88","30.56","APC"
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.06","","","","","","","fee schedule","5.88","30.56","APC"
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6","","","","","","","fee schedule","5.88","30.56","APC"
"Specimen fat stain","89125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.17","","","","","","","fee schedule","5.88","30.56","APC"
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.34","","","","","","","fee schedule","4.85","26.53",""
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.85","","","","","","","fee schedule","4.85","26.53",""
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.85","","","","","","","fee schedule","4.85","26.53",""
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.85","","","","","","","fee schedule","4.85","26.53",""
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","26.53","","","","","","","fee schedule","4.85","26.53",""
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.34","","","","","","","fee schedule","4.85","26.53",""
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.08","","","","","","","fee schedule","4.85","26.53","APC"
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5","","","","","","","fee schedule","4.85","26.53","APC"
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.95","","","","","","","fee schedule","4.85","26.53","APC"
"Exam feces for meat fibers","89160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.09","","","","","","","fee schedule","4.85","26.53","APC"
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.16","","","","","","","fee schedule","5.79","34.68",""
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.79","","","","","","","fee schedule","5.79","34.68",""
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.79","","","","","","","fee schedule","5.79","34.68",""
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.79","","","","","","","fee schedule","5.79","34.68",""
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","34.68","","","","","","","fee schedule","5.79","34.68",""
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.16","","","","","","","fee schedule","5.79","34.68",""
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.07","","","","","","","fee schedule","5.79","34.68","APC"
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.96","","","","","","","fee schedule","5.79","34.68","APC"
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.91","","","","","","","fee schedule","5.79","34.68","APC"
"Nasal smear for eosinophils","89190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.08","","","","","","","fee schedule","5.79","34.68","APC"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.08","","","","","","","fee schedule","20.08","588.18",""
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","96.79","","","","","","","fee schedule","20.08","588.18",""
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.08","","","","","","","fee schedule","20.08","588.18",""
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","20.08","588.18","APC 277.30"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","20.08","588.18","APC 296.56"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","20.08","588.18","APC 308.91"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","20.08","588.18","APC"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","20.08","588.18","APC"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","20.08","588.18","APC"
"Sputum specimen collection","89220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","20.08","588.18","APC"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","42.88","","","","","","","fee schedule","13.06","179.91",""
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13.06","","","","","","","fee schedule","13.06","179.91",""
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42.88","","","","","","","fee schedule","13.06","179.91",""
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","13.06","179.91","APC 277.30"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","13.06","179.91","APC 296.56"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","13.06","179.91","APC 308.91"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","13.06","179.91","APC"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","13.06","179.91","APC"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","13.06","179.91","APC"
"Collect sweat for test","89230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","13.06","179.91","APC"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","179.91",""
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","69.49","","","","","","","fee schedule","12.5","179.91",""
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","179.91",""
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","12.5","179.91","APC 277.30"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","12.5","179.91","APC 296.56"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","12.5","179.91","APC 308.91"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","12.5","179.91","APC"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","12.5","179.91","APC"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","12.5","179.91","APC"
"Pathology lab procedure","89240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","12.5","179.91","APC"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","5798.77",""
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5798.77","","","","","","","fee schedule","64.93","5798.77",""
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","5798.77",""
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","5798.77","APC 277.30"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","5798.77","APC 296.56"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","5798.77","APC 308.91"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","5798.77","APC"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","5798.77","APC"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","5798.77","APC"
"Cultr oocyte/embryo <4 days","89250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","5798.77","APC"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","6031.45",""
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","6031.45","","","","","","","fee schedule","64.93","6031.45",""
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","6031.45",""
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","6031.45","APC 277.30"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","6031.45","APC 296.56"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","6031.45","APC 308.91"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","6031.45","APC"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","6031.45","APC"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","6031.45","APC"
"Cultr oocyte/embryo <4 days","89251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","6031.45","APC"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Embryo hatching","89253","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Oocyte identification","89254","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","330.63",""
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","51.86","330.63",""
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","330.63",""
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","330.63","APC 277.30"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","330.63","APC 296.56"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","330.63","APC 308.91"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","330.63","APC"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","330.63","APC"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","330.63","APC"
"Prepare embryo for transfer","89255","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","330.63","APC"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","179.91",""
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.17","","","","","","","fee schedule","51.86","179.91",""
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","179.91",""
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","179.91","APC 277.30"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","179.91","APC 296.56"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","179.91","APC 308.91"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","179.91","APC"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","179.91","APC"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","179.91","APC"
"Sperm identification","89257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","179.91","APC"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","2781.52",""
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","64.93","2781.52","APC 277.30"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","64.93","2781.52","APC 296.56"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","64.93","2781.52","APC 308.91"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","64.93","2781.52","APC"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","64.93","2781.52","APC"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","64.93","2781.52","APC"
"Cryopreservation embryo(s)","89258","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","64.93","2781.52","APC"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","128.17","","","","","","","fee schedule","64.93","588.18",""
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Cryopreservation sperm","89259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","208.46",""
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","208.46","","","","","","","fee schedule","51.86","208.46",""
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","208.46",""
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","208.46","APC 277.30"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","208.46","APC 296.56"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","208.46","APC 308.91"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation simple","89260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","208.46",""
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","208.46","","","","","","","fee schedule","51.86","208.46",""
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","208.46",""
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","208.46","APC 277.30"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","208.46","APC 296.56"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","208.46","APC 308.91"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","208.46","APC"
"Sperm isolation complex","89261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","208.46","APC"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","330.63",""
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","51.86","330.63",""
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","330.63",""
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","330.63","APC 277.30"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","330.63","APC 296.56"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","330.63","APC 308.91"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","330.63","APC"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","330.63","APC"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","330.63","APC"
"Identify sperm tissue","89264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","330.63","APC"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Insemination of oocytes","89268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","2781.52",""
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","64.93","2781.52","APC 277.30"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","64.93","2781.52","APC 296.56"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","64.93","2781.52","APC 308.91"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","64.93","2781.52","APC"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","64.93","2781.52","APC"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","64.93","2781.52","APC"
"Extended culture of oocytes","89272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","64.93","2781.52","APC"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","208.46","","","","","","","fee schedule","64.93","2781.52",""
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","2781.52",""
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2496.9","","","","","","","fee schedule","64.93","2781.52","APC 277.30"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2670.32","","","","","","","fee schedule","64.93","2781.52","APC 296.56"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2781.52","","","","","","","fee schedule","64.93","2781.52","APC 308.91"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","823.43","","","","","","","fee schedule","64.93","2781.52","APC"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","809.67","","","","","","","fee schedule","64.93","2781.52","APC"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","801.81","","","","","","","fee schedule","64.93","2781.52","APC"
"Assist oocyte fertilization","89280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","825.39","","","","","","","fee schedule","64.93","2781.52","APC"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Assist oocyte fertilization","89281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Biopsy oocyte polar body","89291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15.32","","","","","","","fee schedule","9.84","60.35",""
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.84","","","","","","","fee schedule","9.84","60.35",""
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.84","","","","","","","fee schedule","9.84","60.35",""
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.84","","","","","","","fee schedule","9.84","60.35",""
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","60.35","","","","","","","fee schedule","9.84","60.35",""
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","15.32","","","","","","","fee schedule","9.84","60.35",""
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.31","","","","","","","fee schedule","9.84","60.35","APC"
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.14","","","","","","","fee schedule","9.84","60.35","APC"
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.04","","","","","","","fee schedule","9.84","60.35","APC"
"Semen analysis w/huhner","89300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.33","","","","","","","fee schedule","9.84","60.35","APC"
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","14.8","","","","","","","fee schedule","8.61","59.84",""
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.61","","","","","","","fee schedule","8.61","59.84",""
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.61","","","","","","","fee schedule","8.61","59.84",""
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.61","","","","","","","fee schedule","8.61","59.84",""
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","59.84","","","","","","","fee schedule","8.61","59.84",""
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14.8","","","","","","","fee schedule","8.61","59.84",""
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.02","","","","","","","fee schedule","8.61","59.84","APC"
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.87","","","","","","","fee schedule","8.61","59.84","APC"
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.78","","","","","","","fee schedule","8.61","59.84","APC"
"Semen analysis w/count","89310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.04","","","","","","","fee schedule","8.61","59.84","APC"
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.71","","","","","","","fee schedule","12.31","88.3",""
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.31","","","","","","","fee schedule","12.31","88.3",""
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.31","","","","","","","fee schedule","12.31","88.3",""
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.31","","","","","","","fee schedule","12.31","88.3",""
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.3","","","","","","","fee schedule","12.31","88.3",""
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.71","","","","","","","fee schedule","12.31","88.3",""
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.89","","","","","","","fee schedule","12.31","88.3","APC"
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.68","","","","","","","fee schedule","12.31","88.3","APC"
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.56","","","","","","","fee schedule","12.31","88.3","APC"
"Semen anal vol/count/mot","89320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.93","","","","","","","fee schedule","12.31","88.3","APC"
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.71","","","","","","","fee schedule","12.05","88.3",""
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","88.3",""
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.05","","","","","","","fee schedule","12.05","88.3",""
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.05","","","","","","","fee schedule","12.05","88.3",""
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","88.3","","","","","","","fee schedule","12.05","88.3",""
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.71","","","","","","","fee schedule","12.05","88.3",""
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.62","","","","","","","fee schedule","12.05","88.3","APC"
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.41","","","","","","","fee schedule","12.05","88.3","APC"
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.29","","","","","","","fee schedule","12.05","88.3","APC"
"Semen anal sperm detection","89321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.05","88.3","APC"
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.64","","","","","","","fee schedule","15.5","115.28",""
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.5","","","","","","","fee schedule","15.5","115.28",""
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.5","","","","","","","fee schedule","15.5","115.28",""
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.5","","","","","","","fee schedule","15.5","115.28",""
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","115.28","","","","","","","fee schedule","15.5","115.28",""
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.64","","","","","","","fee schedule","15.5","115.28",""
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.24","","","","","","","fee schedule","15.5","115.28","APC"
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.96","","","","","","","fee schedule","15.5","115.28","APC"
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.81","","","","","","","fee schedule","15.5","115.28","APC"
"Semen anal strict criteria","89322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.28","","","","","","","fee schedule","15.5","115.28","APC"
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.35","","","","","","","fee schedule","10.67","77.33",""
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.67","","","","","","","fee schedule","10.67","77.33",""
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.67","","","","","","","fee schedule","10.67","77.33",""
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.67","","","","","","","fee schedule","10.67","77.33",""
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","77.33","","","","","","","fee schedule","10.67","77.33",""
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.35","","","","","","","fee schedule","10.67","77.33",""
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.18","","","","","","","fee schedule","10.67","77.33","APC"
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.99","","","","","","","fee schedule","10.67","77.33","APC"
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.88","","","","","","","fee schedule","10.67","77.33","APC"
"Sperm antibody test","89325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.2","","","","","","","fee schedule","10.67","77.33","APC"
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.04","","","","","","","fee schedule","19.59","151.23",""
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.59","","","","","","","fee schedule","19.59","151.23",""
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.59","","","","","","","fee schedule","19.59","151.23",""
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.59","","","","","","","fee schedule","19.59","151.23",""
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","151.23","","","","","","","fee schedule","19.59","151.23",""
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.04","","","","","","","fee schedule","19.59","151.23",""
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.52","","","","","","","fee schedule","19.59","151.23","APC"
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.18","","","","","","","fee schedule","19.59","151.23","APC"
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.98","","","","","","","fee schedule","19.59","151.23","APC"
"Sperm evaluation test","89329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.57","","","","","","","fee schedule","19.59","151.23","APC"
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.02","","","","","","","fee schedule","10.38","73.56",""
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.38","","","","","","","fee schedule","10.38","73.56",""
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.38","","","","","","","fee schedule","10.38","73.56",""
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.38","","","","","","","fee schedule","10.38","73.56",""
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","73.56","","","","","","","fee schedule","10.38","73.56",""
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.02","","","","","","","fee schedule","10.38","73.56",""
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.87","","","","","","","fee schedule","10.38","73.56","APC"
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.69","","","","","","","fee schedule","10.38","73.56","APC"
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.59","","","","","","","fee schedule","10.38","73.56","APC"
"Evaluation cervical mucus","89330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.9","","","","","","","fee schedule","10.38","73.56","APC"
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.67","","","","","","","fee schedule","19.59","144.5",""
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.59","","","","","","","fee schedule","19.59","144.5",""
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.59","","","","","","","fee schedule","19.59","144.5",""
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.59","","","","","","","fee schedule","19.59","144.5",""
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","144.5","","","","","","","fee schedule","19.59","144.5",""
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.67","","","","","","","fee schedule","19.59","144.5",""
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.52","","","","","","","fee schedule","19.59","144.5","APC"
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.18","","","","","","","fee schedule","19.59","144.5","APC"
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.98","","","","","","","fee schedule","19.59","144.5","APC"
"Retrograde ejaculation anal","89331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.57","","","","","","","fee schedule","19.59","144.5","APC"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","330.63",""
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","51.86","330.63",""
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","330.63",""
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","330.63","APC 277.30"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","330.63","APC 296.56"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","330.63","APC 308.91"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","330.63","APC"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","330.63","APC"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","330.63","APC"
"Cryopreserve testicular tiss","89335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","330.63","APC"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","220.34","","","","","","","fee schedule","169.55","588.18",""
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","220.34","","","","","","","fee schedule","169.55","588.18",""
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","169.55","588.18","APC 277.30"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","169.55","588.18","APC 296.56"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","169.55","588.18","APC 308.91"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","169.55","588.18","APC"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","169.55","588.18","APC"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","169.55","588.18","APC"
"Cryopreservation oocyte(s)","89337","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","169.55","588.18","APC"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year embryo(s)","89342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year sperm/semen","89343","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year reprod tissue","89344","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Storage/year oocyte(s)","89346","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved embryo","89352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","51.86","330.63",""
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","51.86","330.63",""
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","51.86","330.63",""
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","51.86","330.63","APC 277.30"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","51.86","330.63","APC 296.56"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","51.86","330.63","APC 308.91"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","51.86","330.63","APC"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","51.86","330.63","APC"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","51.86","330.63","APC"
"Thawing cryopresrved sperm","89353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","51.86","330.63","APC"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Thaw cryoprsvrd reprod tiss","89354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","64.93","","","","","","","fee schedule","64.93","588.18",""
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","330.63","","","","","","","fee schedule","64.93","588.18",""
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","64.93","","","","","","","fee schedule","64.93","588.18",""
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","528","","","","","","","fee schedule","64.93","588.18","APC 277.30"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","564.67","","","","","","","fee schedule","64.93","588.18","APC 296.56"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","588.18","","","","","","","fee schedule","64.93","588.18","APC 308.91"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.12","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.21","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.55","","","","","","","fee schedule","64.93","588.18","APC"
"Thawing cryopresrved oocyte","89356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.54","","","","","","","fee schedule","64.93","588.18","APC"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.5","","","","","","","fee schedule","12.5","179.91",""
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.5","","","","","","","fee schedule","12.5","179.91",""
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.5","","","","","","","fee schedule","12.5","179.91","APC 277.30"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.72","","","","","","","fee schedule","12.5","179.91","APC 296.56"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.91","","","","","","","fee schedule","12.5","179.91","APC 308.91"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.26","","","","","","","fee schedule","12.5","179.91","APC"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.37","","","","","","","fee schedule","12.5","179.91","APC"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.86","","","","","","","fee schedule","12.5","179.91","APC"
"Unlisted reprod med lab proc","89398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.39","","","","","","","fee schedule","12.5","179.91","APC"
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","415.5","","","","","","","fee schedule","136.88","462.54",""
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","444.24","","","","","","","fee schedule","136.88","462.54",""
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","462.54","","","","","","","fee schedule","136.88","462.54",""
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","140.57","","","","","","","fee schedule","136.88","462.54","APC"
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","138.22","","","","","","","fee schedule","136.88","462.54","APC"
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","136.88","","","","","","","fee schedule","136.88","462.54","APC"
"Hep b ig im","90371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","140.9","","","","","","","fee schedule","136.88","462.54","APC"
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","847.28","","","","","","","fee schedule","285.45","943.2",""
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","905.9","","","","","","","fee schedule","285.45","943.2",""
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","943.2","","","","","","","fee schedule","285.45","943.2",""
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","293.15","","","","","","","fee schedule","285.45","943.2","APC"
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","288.25","","","","","","","fee schedule","285.45","943.2","APC"
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","285.45","","","","","","","fee schedule","285.45","943.2","APC"
"Rabies ig im/sc","90375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","293.85","","","","","","","fee schedule","285.45","943.2","APC"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1104.48","","","","","","","fee schedule","359.49","1247.09",""
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1180.89","","","","","","","fee schedule","359.49","1247.09",""
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1229.51","","","","","","","fee schedule","359.49","1247.09",""
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1119.47","","","","","","","fee schedule","359.49","1247.09","APC 277.30"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1197.23","","","","","","","fee schedule","359.49","1247.09","APC 296.56"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1247.09","","","","","","","fee schedule","359.49","1247.09","APC 308.91"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","369.18","","","","","","","fee schedule","359.49","1247.09","APC"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","363.01","","","","","","","fee schedule","359.49","1247.09","APC"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","359.49","","","","","","","fee schedule","359.49","1247.09","APC"
"Rabies ig heat treated","90376","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","370.06","","","","","","","fee schedule","359.49","1247.09","APC"
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","753.98","","","","","","","fee schedule","226.69","839.33",""
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","806.14","","","","","","","fee schedule","226.69","839.33",""
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","839.33","","","","","","","fee schedule","226.69","839.33",""
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","232.8","","","","","","","fee schedule","226.69","839.33","APC"
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","228.91","","","","","","","fee schedule","226.69","839.33","APC"
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","226.69","","","","","","","fee schedule","226.69","839.33","APC"
"Rabies ig ht&sol human im/sc","90377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","233.36","","","","","","","fee schedule","226.69","839.33","APC"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2289.19","","","","","","","fee schedule","445.48","2548.34",""
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2447.56","","","","","","","fee schedule","445.48","2548.34",""
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2548.34","","","","","","","fee schedule","445.48","2548.34",""
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1387.27","","","","","","","fee schedule","445.48","2548.34","APC 277.30"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1483.63","","","","","","","fee schedule","445.48","2548.34","APC 296.56"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1545.41","","","","","","","fee schedule","445.48","2548.34","APC 308.91"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","457.5","","","","","","","fee schedule","445.48","2548.34","APC"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","449.85","","","","","","","fee schedule","445.48","2548.34","APC"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","445.48","","","","","","","fee schedule","445.48","2548.34","APC"
"Rsv mab im 50mg","90378","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","458.59","","","","","","","fee schedule","445.48","2548.34","APC"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7504.48","","","","","","","fee schedule","2409.06","8357.15",""
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8023.66","","","","","","","fee schedule","2409.06","8357.15",""
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8354.05","","","","","","","fee schedule","2409.06","8357.15",""
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7501.99","","","","","","","fee schedule","2409.06","8357.15","APC 277.30"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8023.04","","","","","","","fee schedule","2409.06","8357.15","APC 296.56"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8357.15","","","","","","","fee schedule","2409.06","8357.15","APC 308.91"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2474.01","","","","","","","fee schedule","2409.06","8357.15","APC"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2432.68","","","","","","","fee schedule","2409.06","8357.15","APC"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2409.06","","","","","","","fee schedule","2409.06","8357.15","APC"
"Varicella-zoster ig im","90396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2479.91","","","","","","","fee schedule","2409.06","8357.15","APC"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","532","","","","","","","fee schedule","71.65","547",""
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","547","","","","","","","fee schedule","71.65","547",""
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","534","","","","","","","fee schedule","71.65","547",""
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","547","APC 277.30"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","547","APC 296.56"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","547","APC 308.91"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","547","APC"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","547","APC"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","547","APC"
"Immunization admin","90471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","547","APC"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Immune admin oral/nasal","90473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.01","0.04",""
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.01","0.04",""
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.01","0.04",""
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.01","0.04","APC 277.30"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.01","0.04","APC 296.56"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.01","0.04","APC 308.91"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Smallpox&monkeypox vac 0.5ml","90611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.01","0.04",""
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.01","0.04",""
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.01","0.04",""
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.01","0.04","APC 277.30"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.01","0.04","APC 296.56"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.01","0.04","APC 308.91"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Vaccinia vrs vac 0.3 ml perq","90622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.01","","","","","","","fee schedule","0.01","0.04","APC"
"Iiv adjuvant vaccine im","90653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","265.5","","","","","","","fee schedule","265.5","295.55",""
"Iiv adjuvant vaccine im","90653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","283.87","","","","","","","fee schedule","265.5","295.55",""
"Iiv adjuvant vaccine im","90653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","295.55","","","","","","","fee schedule","265.5","295.55",""
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","71.07","","","","","","","fee schedule","71.07","79.12",""
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","75.99","","","","","","","fee schedule","71.07","79.12",""
"Iiv3 vacc no prsv 0.5 ml im","90656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","79.12","","","","","","","fee schedule","71.07","79.12",""
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.76","","","","","","","fee schedule","34.76","38.69",""
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.16","","","","","","","fee schedule","34.76","38.69",""
"Iiv3 vaccine splt 0.25 ml im","90657","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.69","","","","","","","fee schedule","34.76","38.69",""
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","69.51","","","","","","","fee schedule","69.51","77.38",""
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","74.32","","","","","","","fee schedule","69.51","77.38",""
"Iiv3 vaccine splt 0.5 ml im","90658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","77.38","","","","","","","fee schedule","69.51","77.38",""
"Laiv3 vaccine intranasal","90660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.81","","","","","","","fee schedule","91.81","102.2",""
"Laiv3 vaccine intranasal","90660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","98.16","","","","","","","fee schedule","91.81","102.2",""
"Laiv3 vaccine intranasal","90660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","102.2","","","","","","","fee schedule","91.81","102.2",""
"Cciiv3 vac no prsv 0.5 ml im","90661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","117.18","","","","","","","fee schedule","117.18","130.45",""
"Cciiv3 vac no prsv 0.5 ml im","90661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","125.29","","","","","","","fee schedule","117.18","130.45",""
"Cciiv3 vac no prsv 0.5 ml im","90661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","130.45","","","","","","","fee schedule","117.18","130.45",""
"Iiv no prsv increased ag im","90662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","265.5","","","","","","","fee schedule","265.5","295.55",""
"Iiv no prsv increased ag im","90662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","283.87","","","","","","","fee schedule","265.5","295.55",""
"Iiv no prsv increased ag im","90662","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","295.55","","","","","","","fee schedule","265.5","295.55",""
"Pcv13 vaccine im","90670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","820.41","","","","","","","fee schedule","820.41","913.28",""
"Pcv13 vaccine im","90670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","877.17","","","","","","","fee schedule","820.41","913.28",""
"Pcv13 vaccine im","90670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","913.28","","","","","","","fee schedule","820.41","913.28",""
"Pcv15 vaccine im","90671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","830.46","","","","","","","fee schedule","830.46","924.47",""
"Pcv15 vaccine im","90671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","887.91","","","","","","","fee schedule","830.46","924.47",""
"Pcv15 vaccine im","90671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","924.47","","","","","","","fee schedule","830.46","924.47",""
"Laiv4 vaccine intranasal","90672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","77.91","","","","","","","fee schedule","77.91","86.73",""
"Laiv4 vaccine intranasal","90672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","83.3","","","","","","","fee schedule","77.91","86.73",""
"Laiv4 vaccine intranasal","90672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","86.73","","","","","","","fee schedule","77.91","86.73",""
"Riv3 vaccine no preserv im","90673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","265.5","","","","","","","fee schedule","265.5","295.55",""
"Riv3 vaccine no preserv im","90673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","283.87","","","","","","","fee schedule","265.5","295.55",""
"Riv3 vaccine no preserv im","90673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","295.55","","","","","","","fee schedule","265.5","295.55",""
"Cciiv4 vac no prsv 0.5 ml im","90674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95.72","","","","","","","fee schedule","95.72","106.55",""
"Cciiv4 vac no prsv 0.5 ml im","90674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102.34","","","","","","","fee schedule","95.72","106.55",""
"Cciiv4 vac no prsv 0.5 ml im","90674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106.55","","","","","","","fee schedule","95.72","106.55",""
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","992.26","","","","","","","fee schedule","319.95","1104.59",""
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1060.9","","","","","","","fee schedule","319.95","1104.59",""
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1104.59","","","","","","","fee schedule","319.95","1104.59",""
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","328.58","","","","","","","fee schedule","319.95","1104.59","APC"
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","323.09","","","","","","","fee schedule","319.95","1104.59","APC"
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","319.95","","","","","","","fee schedule","319.95","1104.59","APC"
"Rabies vaccine im","90675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","329.36","","","","","","","fee schedule","319.95","1104.59","APC"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","841.01","","","","","","","fee schedule","241.6","936.22",""
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","899.2","","","","","","","fee schedule","241.6","936.22",""
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","936.22","","","","","","","fee schedule","241.6","936.22",""
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","752.35","","","","","","","fee schedule","241.6","936.22","APC 277.30"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","804.61","","","","","","","fee schedule","241.6","936.22","APC 296.56"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","838.11","","","","","","","fee schedule","241.6","936.22","APC 308.91"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","248.11","","","","","","","fee schedule","241.6","936.22","APC"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","243.97","","","","","","","fee schedule","241.6","936.22","APC"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","241.6","","","","","","","fee schedule","241.6","936.22","APC"
"Rabies vaccine id","90676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","248.7","","","","","","","fee schedule","241.6","936.22","APC"
"Pcv20 vaccine im","90677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","995.02","","","","","","","fee schedule","995.02","1107.67",""
"Pcv20 vaccine im","90677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1063.86","","","","","","","fee schedule","995.02","1107.67",""
"Pcv20 vaccine im","90677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1107.67","","","","","","","fee schedule","995.02","1107.67",""
"Riv4 vacc recombinant dna im","90682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","205.14","","","","","","","fee schedule","205.14","228.37",""
"Riv4 vacc recombinant dna im","90682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","219.33","","","","","","","fee schedule","205.14","228.37",""
"Riv4 vacc recombinant dna im","90682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","228.37","","","","","","","fee schedule","205.14","228.37",""
"Pcv21 vaccine im","90684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1042.69","","","","","","","fee schedule","1042.69","1160.73",""
"Pcv21 vaccine im","90684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1114.83","","","","","","","fee schedule","1042.69","1160.73",""
"Pcv21 vaccine im","90684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1160.73","","","","","","","fee schedule","1042.69","1160.73",""
"Iiv4 vacc no prsv 0.5 ml im","90686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.74","","","","","","","fee schedule","62.74","69.84",""
"Iiv4 vacc no prsv 0.5 ml im","90686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.08","","","","","","","fee schedule","62.74","69.84",""
"Iiv4 vacc no prsv 0.5 ml im","90686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","69.84","","","","","","","fee schedule","62.74","69.84",""
"Iiv4 vaccine splt 0.25 ml im","90687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.32","","","","","","","fee schedule","29.32","32.64",""
"Iiv4 vaccine splt 0.25 ml im","90687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.35","","","","","","","fee schedule","29.32","32.64",""
"Iiv4 vaccine splt 0.25 ml im","90687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.64","","","","","","","fee schedule","29.32","32.64",""
"Iiv4 vaccine splt 0.5 ml im","90688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.64","","","","","","","fee schedule","58.64","65.28",""
"Iiv4 vaccine splt 0.5 ml im","90688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.7","","","","","","","fee schedule","58.64","65.28",""
"Iiv4 vaccine splt 0.5 ml im","90688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","65.28","","","","","","","fee schedule","58.64","65.28",""
"Vacc aiiv4 no prsrv 0.5ml im","90694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","216.18","","","","","","","fee schedule","216.18","240.65",""
"Vacc aiiv4 no prsrv 0.5ml im","90694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","231.13","","","","","","","fee schedule","216.18","240.65",""
"Vacc aiiv4 no prsrv 0.5ml im","90694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","240.65","","","","","","","fee schedule","216.18","240.65",""
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","424.43","","","","","","","fee schedule","424.43","472.48",""
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","453.8","","","","","","","fee schedule","424.43","472.48",""
"Ppsv23 vacc 2 yrs+ subq/im","90732","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","472.48","","","","","","","fee schedule","424.43","472.48",""
"Hepb vacc 2 dose adult im","90739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","564.64","","","","","","","fee schedule","564.64","628.56",""
"Hepb vacc 2 dose adult im","90739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","603.7","","","","","","","fee schedule","564.64","628.56",""
"Hepb vacc 2 dose adult im","90739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","628.56","","","","","","","fee schedule","564.64","628.56",""
"Hepb vacc 3 dose immunsup im","90740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","522.86","","","","","","","fee schedule","522.86","582.05",""
"Hepb vacc 3 dose immunsup im","90740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","559.03","","","","","","","fee schedule","522.86","582.05",""
"Hepb vacc 3 dose immunsup im","90740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","582.05","","","","","","","fee schedule","522.86","582.05",""
"Hepb vacc 2 dose adolesc im","90743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","238.98","","","","","","","fee schedule","238.98","266.03",""
"Hepb vacc 2 dose adolesc im","90743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","255.51","","","","","","","fee schedule","238.98","266.03",""
"Hepb vacc 2 dose adolesc im","90743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","266.03","","","","","","","fee schedule","238.98","266.03",""
"Hepb vacc 3 dose ped/adol im","90744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","100.71","","","","","","","fee schedule","100.71","112.11",""
"Hepb vacc 3 dose ped/adol im","90744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","107.68","","","","","","","fee schedule","100.71","112.11",""
"Hepb vacc 3 dose ped/adol im","90744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","112.11","","","","","","","fee schedule","100.71","112.11",""
"Hepb vaccine 3 dose adult im","90746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.81","","","","","","","fee schedule","223.81","249.15",""
"Hepb vaccine 3 dose adult im","90746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","239.29","","","","","","","fee schedule","223.81","249.15",""
"Hepb vaccine 3 dose adult im","90746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","249.15","","","","","","","fee schedule","223.81","249.15",""
"Hepb vacc 4 dose immunsup im","90747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","447.59","","","","","","","fee schedule","447.59","498.26",""
"Hepb vacc 4 dose immunsup im","90747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","478.55","","","","","","","fee schedule","447.59","498.26",""
"Hepb vacc 4 dose immunsup im","90747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","498.26","","","","","","","fee schedule","447.59","498.26",""
"Cciiv4 vacc abx free im","90756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","90.69","","","","","","","fee schedule","90.69","100.96",""
"Cciiv4 vacc abx free im","90756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","96.97","","","","","","","fee schedule","90.69","100.96",""
"Cciiv4 vacc abx free im","90756","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","100.96","","","","","","","fee schedule","90.69","100.96",""
"Hep b vac 3ag 10mcg 3 dos im","90759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","234.75","","","","","","","fee schedule","234.75","261.32",""
"Hep b vac 3ag 10mcg 3 dos im","90759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","250.99","","","","","","","fee schedule","234.75","261.32",""
"Hep b vac 3ag 10mcg 3 dos im","90759","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","261.32","","","","","","","fee schedule","234.75","261.32",""
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx plan","90867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Tcranial magn stim tx deli","90868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Tcran magn stim redetemine","90869","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Electroconvulsive therapy","90870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Psychiatric service/therapy","90899","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Biofeedback train any meth","90901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17","","","","","","","fee schedule","16.55","17.04","APC"
"Biofeedback train any meth","90901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.72","","","","","","","fee schedule","16.55","17.04","APC"
"Biofeedback train any meth","90901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.55","","","","","","","fee schedule","16.55","17.04","APC"
"Biofeedback train any meth","90901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.04","","","","","","","fee schedule","16.55","17.04","APC"
"Bfb training 1st 15 min","90912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.57","","","","","","","fee schedule","37.56","38.66","APC"
"Bfb training 1st 15 min","90912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.92","","","","","","","fee schedule","37.56","38.66","APC"
"Bfb training 1st 15 min","90912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.56","","","","","","","fee schedule","37.56","38.66","APC"
"Bfb training 1st 15 min","90912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.66","","","","","","","fee schedule","37.56","38.66","APC"
"Bfb training ea addl 15 min","90913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.67","","","","","","","fee schedule","21.1","21.72","APC"
"Bfb training ea addl 15 min","90913","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.31","","","","","","","fee schedule","21.1","21.72","APC"
"Bfb training ea addl 15 min","90913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.1","","","","","","","fee schedule","21.1","21.72","APC"
"Bfb training ea addl 15 min","90913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.72","","","","","","","fee schedule","21.1","21.72","APC"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2126.97","","","","","","","fee schedule","683.02","2369.43","APC 277.30"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2274.7","","","","","","","fee schedule","683.02","2369.43","APC 296.56"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2369.43","","","","","","","fee schedule","683.02","2369.43","APC 308.91"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","701.43","","","","","","","fee schedule","683.02","2369.43","APC"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","689.72","","","","","","","fee schedule","683.02","2369.43","APC"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","683.02","","","","","","","fee schedule","683.02","2369.43","APC"
"Hemodialysis one evaluation","90935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","703.11","","","","","","","fee schedule","683.02","2369.43","APC"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1293.15","","","","","","","fee schedule","415.26","1440.55","APC 277.30"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1382.96","","","","","","","fee schedule","415.26","1440.55","APC 296.56"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1440.55","","","","","","","fee schedule","415.26","1440.55","APC 308.91"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","426.45","","","","","","","fee schedule","415.26","1440.55","APC"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","419.33","","","","","","","fee schedule","415.26","1440.55","APC"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","415.26","","","","","","","fee schedule","415.26","1440.55","APC"
"Dialysis one evaluation","90945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","427.47","","","","","","","fee schedule","415.26","1440.55","APC"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Esophagus motility study","91010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Esophgl motil w/stim/perfus","91013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Esophgl motil w/stim/perfus","91013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Gastric motility studies","91020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Duodenal motility study","91022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Acid perfusion of esophagus","91030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Gastroesophageal reflux test","91034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","854.62","2964.71",""
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","854.62","2964.71",""
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"G-esoph reflx tst w/electrod","91035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","2633",""
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","2633",""
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","2633","APC 277.30"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","2633","APC 296.56"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","2633","APC 308.91"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","2633","APC"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","2633","APC"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","2633","APC"
"Esoph imped function test","91037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","2633","APC"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Esoph imped funct test > 1hr","91038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Esoph balloon distension tst","91040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","2633",""
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","2633",""
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","2633","APC 277.30"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","2633","APC 296.56"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","2633","APC 308.91"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","2633","APC"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","2633","APC"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","2633","APC"
"Breath hydrogen/methane test","91065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","2633","APC"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Gi tract capsule endoscopy","91110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Esophageal Capsule Endoscopy","91111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","902.63","5790",""
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","902.63","5790",""
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2810.86","","","","","","","fee schedule","902.63","5790","APC 277.30"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3006.09","","","","","","","fee schedule","902.63","5790","APC 296.56"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3131.27","","","","","","","fee schedule","902.63","5790","APC 308.91"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","926.97","","","","","","","fee schedule","902.63","5790","APC"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","911.48","","","","","","","fee schedule","902.63","5790","APC"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","902.63","","","","","","","fee schedule","902.63","5790","APC"
"Gi wireless capsule measure","91112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","929.18","","","","","","","fee schedule","902.63","5790","APC"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3210.58","APC 277.30"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3210.58","APC 296.56"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3210.58","APC 308.91"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3210.58","APC"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3210.58","APC"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3210.58","APC"
"Gi trc img intral colon i&r","91113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3210.58","APC"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","2633",""
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","2633",""
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","2633","APC 277.30"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","2633","APC 296.56"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","2633","APC 308.91"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","2633","APC"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","2633","APC"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","2633","APC"
"Colon motility 6 hr study","91117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","2633","APC"
"Rectal sensation test","91120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Rectal sensation test","91120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Anal pressure record","91122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","279","2633",""
"Anal pressure record","91122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","279","","","","","","","fee schedule","279","2633",""
"Anal pressure record","91122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","279","2633",""
"Anal pressure record","91122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","287","","","","","","","fee schedule","279","2633",""
"Anal pressure record","91122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","280","","","","","","","fee schedule","279","2633",""
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Rct snsatn tone&cmplianc std","91124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Anrct mano rct snsatn&balo","91125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","2633",""
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","2633",""
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","2633","APC 277.30"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","2633","APC 296.56"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","2633","APC 308.91"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","2633","APC"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","2633","APC"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","2633","APC"
"Electrogastrography","91132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","2633","APC"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","132.41","2633",""
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","132.41","2633",""
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","2633","APC 277.30"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","2633","APC 296.56"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","2633","APC 308.91"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","2633","APC"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","2633","APC"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","2633","APC"
"Electrogastrography W/Test","91133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","2633","APC"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Liver elastography","91200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","2633",""
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","2633",""
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","2633","APC 277.30"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","2633","APC 296.56"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","2633","APC 308.91"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","2633","APC"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","2633","APC"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","2633","APC"
"Gastroenterology procedure","91299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","2633","APC"
"Coronavirus vaccine 5","91304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","513.7","","","","","","","fee schedule","513.7","571.85",""
"Coronavirus vaccine 5","91304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","549.24","","","","","","","fee schedule","513.7","571.85",""
"Coronavirus vaccine 5","91304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","571.85","","","","","","","fee schedule","513.7","571.85",""
"Sarscov2 vac 3mcg trs-suc im","91318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","208.45","","","","","","","fee schedule","208.45","232.05",""
"Sarscov2 vac 3mcg trs-suc im","91318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","222.87","","","","","","","fee schedule","208.45","232.05",""
"Sarscov2 vac 3mcg trs-suc im","91318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","232.05","","","","","","","fee schedule","208.45","232.05",""
"Sarscv2 vac 10mcg trs-suc im","91319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","279.14","","","","","","","fee schedule","279.14","310.74",""
"Sarscv2 vac 10mcg trs-suc im","91319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","298.45","","","","","","","fee schedule","279.14","310.74",""
"Sarscv2 vac 10mcg trs-suc im","91319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","310.74","","","","","","","fee schedule","279.14","310.74",""
"Sarscv2 vac 30mcg trs-suc im","91320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","495.76","","","","","","","fee schedule","495.76","551.89",""
"Sarscv2 vac 30mcg trs-suc im","91320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","530.06","","","","","","","fee schedule","495.76","551.89",""
"Sarscv2 vac 30mcg trs-suc im","91320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","551.89","","","","","","","fee schedule","495.76","551.89",""
"Sarscov2 vac 25 mcg/.25ml im","91321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","467.65","","","","","","","fee schedule","467.65","520.59",""
"Sarscov2 vac 25 mcg/.25ml im","91321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","500","","","","","","","fee schedule","467.65","520.59",""
"Sarscov2 vac 25 mcg/.25ml im","91321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","520.59","","","","","","","fee schedule","467.65","520.59",""
"Sarscov2 vac 50 mcg/0.5ml im","91322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","514.05","","","","","","","fee schedule","514.05","572.24",""
"Sarscov2 vac 50 mcg/0.5ml im","91322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","549.61","","","","","","","fee schedule","514.05","572.24",""
"Sarscov2 vac 50 mcg/0.5ml im","91322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","572.24","","","","","","","fee schedule","514.05","572.24",""
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam new patient","92004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam establish patient","92012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Eye exam&tx estab pt 1/>vst","92014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"New eye exam & treatment","92018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2366.07","14111",""
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2366.07","14111",""
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7368.11","","","","","","","fee schedule","2366.07","14111","APC 277.30"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7879.87","","","","","","","fee schedule","2366.07","14111","APC 296.56"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8208.02","","","","","","","fee schedule","2366.07","14111","APC 308.91"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.86","","","","","","","fee schedule","2366.07","14111","APC"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.27","","","","","","","fee schedule","2366.07","14111","APC"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2366.07","","","","","","","fee schedule","2366.07","14111","APC"
"Eye exam & treatment","92019","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.66","","","","","","","fee schedule","2366.07","14111","APC"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Special eye evaluation","92020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Corneal Topography","92025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Special eye evaluation","92060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Orthop traing supvj phys/qhp","92066","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92081","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92082","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Visual field examination(s)","92083","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Cmptr ophth dx img ant segmt","92132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","41","","","","","","","fee schedule","41","203.66",""
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","43","","","","","","","fee schedule","41","203.66",""
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","41","","","","","","","fee schedule","41","203.66",""
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","41","203.66","APC 277.30"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","41","203.66","APC 296.56"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","41","203.66","APC 308.91"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","41","203.66","APC"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","41","203.66","APC"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","41","203.66","APC"
"Cmptr ophth img optic nerve","92133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","41","203.66","APC"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Cptr ophth dx img post segmt","92134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ophthalmic biometry","92136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Cptrz oph img pst sg rta oct","92137","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Corneal hysteresis deter","92145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd rta draw uni/bi","92201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Opscpy extnd on/mac draw","92202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Remote dx retinal imaging","92227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Remote retinal imaging mgmt","92228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Img rta detc/mntr ds poc aly","92229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Eye exam with photos","92230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein angrph uni/bi","92235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Icg angiography uni/bi","92240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Fluorescein icg angiography","92242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Eye exam with photos","92250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ophthalmoscopy/dynamometry","92260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Eye muscle evaluation","92265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Electro-oculography","92270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Full field erg w/i&r","92273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Multifocal erg w/i&r","92274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Color vision examination","92283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Dark adaptation eye exam","92284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Eye photography","92285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Internal eye photography","92287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Contact lens fitting","92311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Contact lens fitting","92313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 1 eye","92315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Rx cntact lens aphakia 2 eye","92316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Rx corneoscleral cntact lens","92317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Modification of contact lens","92325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Replacement of contact lens","92326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl monofocl","92352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Fit aphakia spectcl multifoc","92353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles single system","92354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Fit spectacles compound lens","92355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Aphakia prosth service temp","92358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Repair & adjust spectacles","92371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Eye service or procedure","92499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","536.74","2633",""
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","536.74","2633",""
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1671.44","","","","","","","fee schedule","536.74","2633","APC 277.30"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1787.54","","","","","","","fee schedule","536.74","2633","APC 296.56"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1861.98","","","","","","","fee schedule","536.74","2633","APC 308.91"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","551.21","","","","","","","fee schedule","536.74","2633","APC"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","542","","","","","","","fee schedule","536.74","2633","APC"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","536.74","","","","","","","fee schedule","536.74","2633","APC"
"Ear and throat examination","92502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","552.53","","","","","","","fee schedule","536.74","2633","APC"
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","106","","","","","","","fee schedule","77.02","110",""
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","102.09","","","","","","","fee schedule","77.02","110",""
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","110","","","","","","","fee schedule","77.02","110",""
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","102.09","","","","","","","fee schedule","77.02","110",""
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","106","","","","","","","fee schedule","77.02","110",""
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","102.09","","","","","","","fee schedule","77.02","110",""
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.1","","","","","","","fee schedule","77.02","110","APC"
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.78","","","","","","","fee schedule","77.02","110","APC"
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.02","","","","","","","fee schedule","77.02","110","APC"
"Speech/hearing therapy","92507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.29","","","","","","","fee schedule","77.02","110","APC"
"Speech/hearing therapy","92508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.86","","","","","","","fee schedule","24.2","24.92","APC"
"Speech/hearing therapy","92508","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.44","","","","","","","fee schedule","24.2","24.92","APC"
"Speech/hearing therapy","92508","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.2","","","","","","","fee schedule","24.2","24.92","APC"
"Speech/hearing therapy","92508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.92","","","","","","","fee schedule","24.2","24.92","APC"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","618.61","","","","","","","fee schedule","198.65","689.12","APC 277.30"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","661.57","","","","","","","fee schedule","198.65","689.12","APC 296.56"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","689.12","","","","","","","fee schedule","198.65","689.12","APC 308.91"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204","","","","","","","fee schedule","198.65","689.12","APC"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.6","","","","","","","fee schedule","198.65","689.12","APC"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.65","","","","","","","fee schedule","198.65","689.12","APC"
"Nasopharyngoscopy","92511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.49","","","","","","","fee schedule","198.65","689.12","APC"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Nasal function studies","92512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Facial nerve function test","92516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r cervical","92517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp test i&r ocular","92518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Vemp tst i&r cervical&ocular","92519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Laryngeal function studies","92520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Evaluation of speech fluency","92521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","138.46","","","","","","","fee schedule","134.82","138.79","APC"
"Evaluation of speech fluency","92521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","136.15","","","","","","","fee schedule","134.82","138.79","APC"
"Evaluation of speech fluency","92521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","134.82","","","","","","","fee schedule","134.82","138.79","APC"
"Evaluation of speech fluency","92521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","138.79","","","","","","","fee schedule","134.82","138.79","APC"
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","228","","","","","","","fee schedule","112.92","234",""
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","234","","","","","","","fee schedule","112.92","234",""
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","228","","","","","","","fee schedule","112.92","234",""
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","115.97","","","","","","","fee schedule","112.92","234","APC"
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","114.03","","","","","","","fee schedule","112.92","234","APC"
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","112.92","","","","","","","fee schedule","112.92","234","APC"
"Evaluate speech production","92522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","116.25","","","","","","","fee schedule","112.92","234","APC"
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","228","","","","","","","fee schedule","228","253.95",""
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","253.95","","","","","","","fee schedule","228","253.95",""
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","234","","","","","","","fee schedule","228","253.95",""
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","253.95","","","","","","","fee schedule","228","253.95",""
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","228","","","","","","","fee schedule","228","253.95",""
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","253.95","","","","","","","fee schedule","228","253.95",""
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","235.37","","","","","","","fee schedule","228","253.95","APC"
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","231.44","","","","","","","fee schedule","228","253.95","APC"
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","229.19","","","","","","","fee schedule","228","253.95","APC"
"Speech sound lang comprehen","92523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","235.94","","","","","","","fee schedule","228","253.95","APC"
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","333","","","","","","","fee schedule","110.68","343",""
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","343","","","","","","","fee schedule","110.68","343",""
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","334","","","","","","","fee schedule","110.68","343",""
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","113.66","","","","","","","fee schedule","110.68","343","APC"
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","111.77","","","","","","","fee schedule","110.68","343","APC"
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","110.68","","","","","","","fee schedule","110.68","343","APC"
"Behavral qualit analys voice","92524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","113.94","","","","","","","fee schedule","110.68","343","APC"
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","134","","","","","","","fee schedule","85.08","138",""
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","111.23","","","","","","","fee schedule","85.08","138",""
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","138","","","","","","","fee schedule","85.08","138",""
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","111.23","","","","","","","fee schedule","85.08","138",""
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","134","","","","","","","fee schedule","85.08","138",""
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","111.23","","","","","","","fee schedule","85.08","138",""
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","87.37","","","","","","","fee schedule","85.08","138","APC"
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","85.91","","","","","","","fee schedule","85.08","138","APC"
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","85.08","","","","","","","fee schedule","85.08","138","APC"
"Oral function therapy","92526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","87.58","","","","","","","fee schedule","85.08","138","APC"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Caloric vstblr test w/rec","92537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Caloric vstblr test w/rec","92538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Basic vestibular evaluation","92540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Spontaneous nystagmus test","92541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Positional nystagmus test","92542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Optokinetic nystagmus test","92544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Oscillating tracking test","92545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Sinusoidal rotational test","92546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Posturography","92548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Cdp-sot 6 cond w/i&r mct&adt","92549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","27.44","","","","","","","fee schedule","27.44","745.45",""
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","27.44","","","","","","","fee schedule","27.44","745.45",""
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","27.44","","","","","","","fee schedule","27.44","745.45",""
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","27.44","745.45","APC 277.30"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","27.44","745.45","APC 296.56"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","27.44","745.45","APC 308.91"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","27.44","745.45","APC"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","27.44","745.45","APC"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","27.44","745.45","APC"
"Tympanometry & reflex thresh","92550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","27.44","745.45","APC"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","40.46","","","","","","","fee schedule","40.46","459.34",""
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","40.46","","","","","","","fee schedule","40.46","459.34",""
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","40.46","","","","","","","fee schedule","40.46","459.34",""
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","40.46","459.34","APC 277.30"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","40.46","459.34","APC 296.56"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","40.46","459.34","APC 308.91"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","40.46","459.34","APC"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","40.46","459.34","APC"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","40.46","459.34","APC"
"Pure tone audiometry air","92552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","40.46","459.34","APC"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Audiometry air & bone","92553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Speech threshold audiometry","92555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Speech audiometry complete","92556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","42.58","","","","","","","fee schedule","42.58","444.23",""
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","42.58","","","","","","","fee schedule","42.58","444.23",""
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","42.58","","","","","","","fee schedule","42.58","444.23",""
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","42.58","444.23","APC 277.30"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","42.58","444.23","APC 296.56"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","42.58","444.23","APC 308.91"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","42.58","444.23","APC"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","42.58","444.23","APC"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","42.58","444.23","APC"
"Comprehensive hearing test","92557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","42.58","444.23","APC"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Loudness balance test","92562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Tone decay hearing test","92563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Stenger test pure tone","92565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","14.19","","","","","","","fee schedule","14.19","128.95",""
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","14.19","","","","","","","fee schedule","14.19","128.95",""
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","14.19","","","","","","","fee schedule","14.19","128.95",""
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","14.19","128.95","APC 277.30"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","14.19","128.95","APC 296.56"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","14.19","128.95","APC 308.91"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","14.19","128.95","APC"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","14.19","128.95","APC"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","14.19","128.95","APC"
"Tympanometry","92567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","14.19","128.95","APC"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Acoustic refl threshold tst","92568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Acoustic immitance testing","92570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Filtered speech hearing test","92571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Staggered spondaic word test","92572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Sensorineural acuity test","92575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Synthetic sentence test","92576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Stenger test speech","92577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Visual audiometry (vra)","92579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Conditioning play audiometry","92582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Select picture audiometry","92583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Electrocochleography","92584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Evoked auditory test limited","92587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Evoked auditory tst complete","92588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ear protector evaluation","92596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Oral speech device eval","92597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.8","","","","","","","fee schedule","71.86","73.97","APC"
"Oral speech device eval","92597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.56","","","","","","","fee schedule","71.86","73.97","APC"
"Oral speech device eval","92597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.86","","","","","","","fee schedule","71.86","73.97","APC"
"Oral speech device eval","92597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.97","","","","","","","fee schedule","71.86","73.97","APC"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam <7","92601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Cochlear implt f/up exam 7/>","92603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Reprogram cochlear implt 7/>","92604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","165.11","","","","","","","fee schedule","123.55","165.11",""
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","165.11","","","","","","","fee schedule","123.55","165.11",""
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","165.11","","","","","","","fee schedule","123.55","165.11",""
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","126.88","","","","","","","fee schedule","123.55","165.11","APC"
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","124.76","","","","","","","fee schedule","123.55","165.11","APC"
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","123.55","","","","","","","fee schedule","123.55","165.11","APC"
"Ex for speech device rx 1hr","92607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","127.19","","","","","","","fee schedule","123.55","165.11","APC"
"Ex for speech device rx addl","92608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.6","","","","","","","fee schedule","48.3","49.72","APC"
"Ex for speech device rx addl","92608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.77","","","","","","","fee schedule","48.3","49.72","APC"
"Ex for speech device rx addl","92608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.3","","","","","","","fee schedule","48.3","49.72","APC"
"Ex for speech device rx addl","92608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.72","","","","","","","fee schedule","48.3","49.72","APC"
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","142.74","","","","","","","fee schedule","103.59","142.74",""
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","142.74","","","","","","","fee schedule","103.59","142.74",""
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","142.74","","","","","","","fee schedule","103.59","142.74",""
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.38","","","","","","","fee schedule","103.59","142.74","APC"
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","104.61","","","","","","","fee schedule","103.59","142.74","APC"
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","103.59","","","","","","","fee schedule","103.59","142.74","APC"
"Use of speech device service","92609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","106.64","","","","","","","fee schedule","103.59","142.74","APC"
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","147","","","","","","","fee schedule","58.6","151",""
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","151","","","","","","","fee schedule","58.6","151",""
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","147","","","","","","","fee schedule","58.6","151",""
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.18","","","","","","","fee schedule","58.6","151","APC"
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.17","","","","","","","fee schedule","58.6","151","APC"
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.6","","","","","","","fee schedule","58.6","151","APC"
"Evaluate swallowing function","92610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.32","","","","","","","fee schedule","58.6","151","APC"
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","462","","","","","","","fee schedule","92.04","475",""
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","475","","","","","","","fee schedule","92.04","475",""
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","463","","","","","","","fee schedule","92.04","475",""
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","94.53","","","","","","","fee schedule","92.04","475","APC"
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","92.95","","","","","","","fee schedule","92.04","475","APC"
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","92.04","","","","","","","fee schedule","92.04","475","APC"
"Motion fluoroscopy/swallow","92611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","94.75","","","","","","","fee schedule","92.04","475","APC"
"Endoscopy swallow (fees) vid","92612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","55.97","","","","","","","fee schedule","54.5","56.1","APC"
"Endoscopy swallow (fees) vid","92612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","55.03","","","","","","","fee schedule","54.5","56.1","APC"
"Endoscopy swallow (fees) vid","92612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","54.5","","","","","","","fee schedule","54.5","56.1","APC"
"Endoscopy swallow (fees) vid","92612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56.1","","","","","","","fee schedule","54.5","56.1","APC"
"Laryngoscopic sensory vid","92614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","55.87","","","","","","","fee schedule","54.41","56.01","APC"
"Laryngoscopic sensory vid","92614","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","54.94","","","","","","","fee schedule","54.41","56.01","APC"
"Laryngoscopic sensory vid","92614","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","54.41","","","","","","","fee schedule","54.41","56.01","APC"
"Laryngoscopic sensory vid","92614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56.01","","","","","","","fee schedule","54.41","56.01","APC"
"Fees w/laryngeal sense test","92616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.61","","","","","","","fee schedule","80.44","82.8","APC"
"Fees w/laryngeal sense test","92616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.23","","","","","","","fee schedule","80.44","82.8","APC"
"Fees w/laryngeal sense test","92616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.44","","","","","","","fee schedule","80.44","82.8","APC"
"Fees w/laryngeal sense test","92616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.8","","","","","","","fee schedule","80.44","82.8","APC"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Auditory function 60 min","92620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Dx aly aud oi snd prcsr 1st","92622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Tinnitus assessment","92625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Eval aud rehab status","92626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Aud brainstem implt programg","92640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Aep hearing status deter i&r","92651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Aep thrshld est mlt freq i&r","92652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Aep neurodiagnostic i&r","92653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Ent procedure/service","92700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31373","","","","","","","fee schedule","5664.24","31373",""
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28517","","","","","","","fee schedule","5664.24","31373",""
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","31373","APC 277.30"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","31373","APC 296.56"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","31373","APC 308.91"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","31373","APC"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","31373","APC"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","31373","APC"
"Prq cardiac angioplast 1 art","92920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","31373","APC"
"Prq cardiac angio addl art","92921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31373","","","","","","","fee schedule","28517","31373",""
"Prq cardiac angio addl art","92921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28517","","","","","","","fee schedule","28517","31373",""
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31373","","","","","","","fee schedule","11488.76","39855.12",""
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28517","","","","","","","fee schedule","11488.76","39855.12",""
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card angio/athrect 1 art","92924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card angio/athrect addl","92925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31373","","","","","","","fee schedule","28517","31373",""
"Prq card angio/athrect addl","92925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","28517","","","","","","","fee schedule","28517","31373",""
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","11488.76","39855.12",""
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","11488.76","39855.12",""
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card stent w/angio 1 vsl","92928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card stent w/angio addl","92929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","33527","36886",""
"Prq card stent w/angio addl","92929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","33527","36886",""
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq tcat plmt ntrac st 2+les","92930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","18243.62","63288.08",""
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","18243.62","63288.08",""
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq card stent/ath/angio","92933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Prq card stent/ath/angio","92934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","33527","36886",""
"Prq card stent/ath/angio","92934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","33527","36886",""
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","11488.76","39855.12",""
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","11488.76","39855.12",""
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq revasc byp graft 1 vsl","92937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq revasc byp graft addl","92938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","33527","36886",""
"Prq revasc byp graft addl","92938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","33527","36886",""
"Prq card revasc mi 1 vsl","92941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","33527","36886",""
"Prq card revasc mi 1 vsl","92941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","33527","36886",""
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","11488.76","39855.12",""
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","11488.76","39855.12",""
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card revasc chronic 1vsl","92943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq card revasc chronic addl","92944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36886","","","","","","","fee schedule","33527","36886",""
"Prq card revasc chronic addl","92944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33527","","","","","","","fee schedule","33527","36886",""
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Prq trl rvs ch occ ant&rtrgr","92945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","214.89","2633",""
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","214.89","2633",""
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","2633","APC 277.30"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","2633","APC 296.56"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","2633","APC 308.91"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","2633","APC"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","2633","APC"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","2633","APC"
"Heart/lung resuscitation cpr","92950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","2633","APC"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","657.77","3880",""
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","657.77","3880",""
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2048.35","","","","","","","fee schedule","657.77","3880","APC 277.30"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2190.62","","","","","","","fee schedule","657.77","3880","APC 296.56"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2281.84","","","","","","","fee schedule","657.77","3880","APC 308.91"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","675.5","","","","","","","fee schedule","657.77","3880","APC"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","664.22","","","","","","","fee schedule","657.77","3880","APC"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","657.77","","","","","","","fee schedule","657.77","3880","APC"
"Temporary external pacing","92953","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","677.12","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1489","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1532","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1495","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2048.35","","","","","","","fee schedule","657.77","3880","APC 277.30"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2190.62","","","","","","","fee schedule","657.77","3880","APC 296.56"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2281.84","","","","","","","fee schedule","657.77","3880","APC 308.91"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","675.5","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","664.22","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","657.77","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric ext","92960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","677.12","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","657.77","3880",""
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2048.35","","","","","","","fee schedule","657.77","3880","APC 277.30"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2190.62","","","","","","","fee schedule","657.77","3880","APC 296.56"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2281.84","","","","","","","fee schedule","657.77","3880","APC 308.91"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","675.5","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","664.22","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","657.77","","","","","","","fee schedule","657.77","3880","APC"
"Cardioversion electric int","92961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","677.12","","","","","","","fee schedule","657.77","3880","APC"
"Cardioassist internal","92970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cardioassist internal","92970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cardioassist external","92971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cardioassist external","92971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Prq coronary mech thrombect","92973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Prq coronary mech thrombect","92973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Cath place cardio brachytx","92974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Cath place cardio brachytx","92974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Dissolve clot heart vessel","92975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Dissolve clot heart vessel","92975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Dissolve clot heart vessel","92977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Dissolve clot heart vessel","92977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Endoluminl ivus oct c 1st","92978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Endoluminl ivus oct c 1st","92978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Endoluminl ivus oct c ea","92979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Endoluminl ivus oct c ea","92979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5664.24","29398",""
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5664.24","29398",""
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17638.85","","","","","","","fee schedule","5664.24","29398","APC 277.30"
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18863.96","","","","","","","fee schedule","5664.24","29398","APC 296.56"
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19649.53","","","","","","","fee schedule","5664.24","29398","APC 308.91"
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5816.95","","","","","","","fee schedule","5664.24","29398","APC"
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5719.77","","","","","","","fee schedule","5664.24","29398","APC"
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5664.24","","","","","","","fee schedule","5664.24","29398","APC"
"Revision of aortic valve","92986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5830.83","","","","","","","fee schedule","5664.24","29398","APC"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","11488.76","39855.12",""
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","11488.76","39855.12",""
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of mitral valve","92987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","11488.76","39855.12",""
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","11488.76","39855.12",""
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revision of pulmonary valve","92990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","11488.76","39855.12",""
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","11488.76","39855.12",""
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Pul art balloon repr percut","92997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Pul art balloon repr percut","92998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Pul art balloon repr percut","92998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","207","","","","","","","fee schedule","58.71","213",""
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","213","","","","","","","fee schedule","58.71","213",""
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","208","","","","","","","fee schedule","58.71","213",""
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","213","APC 277.30"
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","213","APC 296.56"
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","213","APC 308.91"
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","213","APC"
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","213","APC"
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","213","APC"
"Electrocardiogram tracing","93005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","213","APC"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1006","","","","","","","fee schedule","214.89","1035",""
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1035","","","","","","","fee schedule","214.89","1035",""
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1011","","","","","","","fee schedule","214.89","1035",""
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","1035","APC 277.30"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","1035","APC 296.56"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","1035","APC 308.91"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","1035","APC"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","1035","APC"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","1035","APC"
"Cardiovascular stress test","93017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","1035","APC"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Cardiac drug stress test","93024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Microvolt t-wave assess","93025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Rhythm ecg tracing","93041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Art pressure waveform analys","93050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip wo","93145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Interrog crtd sins bat ip w/","93146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","123","","","","","","","fee schedule","123","459.34",""
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","127","","","","","","","fee schedule","123","459.34",""
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","123","","","","","","","fee schedule","123","459.34",""
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","123","459.34","APC 277.30"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","123","459.34","APC 296.56"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","123","459.34","APC 308.91"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","123","459.34","APC"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","123","459.34","APC"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","123","459.34","APC"
"Ecg monit/reprt up to 48 hrs","93225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","123","459.34","APC"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","353","","","","","","","fee schedule","58.71","363",""
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","363","","","","","","","fee schedule","58.71","363",""
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","354","","","","","","","fee schedule","58.71","363",""
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","363","APC 277.30"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","363","APC 296.56"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","363","APC 308.91"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","363","APC"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","363","APC"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","363","APC"
"Ecg monit/reprt up to 48 hrs","93226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","363","APC"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Remote 30 day ecg tech supp","93229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>48hr<7d recording","93242","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>48hr<7d scan a/r","93243","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>7d<15d recording","93246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ext ecg>7d<15d scan a/r","93247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg dev eval impltbl sys","93260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrogate subq defib","93261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr wrls p-art prs snr","93264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Remote 30 day ecg rev/report","93270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","474","","","","","","","fee schedule","94.61","488",""
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","488","","","","","","","fee schedule","94.61","488",""
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","475","","","","","","","fee schedule","94.61","488",""
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","294.64","","","","","","","fee schedule","94.61","488","APC 277.30"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","315.1","","","","","","","fee schedule","94.61","488","APC 296.56"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","328.22","","","","","","","fee schedule","94.61","488","APC 308.91"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","97.17","","","","","","","fee schedule","94.61","488","APC"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","95.54","","","","","","","fee schedule","94.61","488","APC"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","94.61","","","","","","","fee schedule","94.61","488","APC"
"Ecg/monitoring and analysis","93271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","97.4","","","","","","","fee schedule","94.61","488","APC"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"ECG/signal-averaged","93278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval sngl","93279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","228","","","","","","","fee schedule","37.14","234",""
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","234","","","","","","","fee schedule","37.14","234",""
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","228","","","","","","","fee schedule","37.14","234",""
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","234","APC 277.30"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","234","APC 296.56"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","234","APC 308.91"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","234","APC"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","234","APC"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","234","APC"
"Pm device progr eval dual","93280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","234","APC"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device progr eval multi","93281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","134","","","","","","","fee schedule","37.14","138",""
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","138","","","","","","","fee schedule","37.14","138",""
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","134","","","","","","","fee schedule","37.14","138",""
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","138","APC 277.30"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","138","APC 296.56"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","138","APC 308.91"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","138","APC"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","138","APC"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","138","APC"
"Prgrmg eval implantable dfb","93282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","138","APC"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","139","","","","","","","fee schedule","37.14","143",""
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","143","","","","","","","fee schedule","37.14","143",""
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","140","","","","","","","fee schedule","37.14","143",""
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","143","APC 277.30"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","143","APC 296.56"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","143","APC 308.91"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","143","APC"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","143","APC"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","143","APC"
"Prgrmg eval implantable dfb","93283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","143","APC"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Prgrmg eval implantable dfb","93284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device eval progr","93285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","44","","","","","","","fee schedule","37.14","128.85",""
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","46","","","","","","","fee schedule","37.14","128.85",""
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","44","","","","","","","fee schedule","37.14","128.85",""
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm device eval in person","93288","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Interrog device eval heart","93289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device eval","93290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Ilr device interrogate","93291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Wcd device interrogate","93292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm phone r-strip device eval","93293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","85","","","","","","","fee schedule","37.14","128.85",""
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","87","","","","","","","fee schedule","37.14","128.85",""
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","86","","","","","","","fee schedule","37.14","128.85",""
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Pm/icd remote tech serv","93296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Icm device interrogat remote","93297","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Ilr device interrogat remote","93298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transthoracic","93304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1196","","","","","","","fee schedule","543.79","1886.44",""
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1231","","","","","","","fee schedule","543.79","1886.44",""
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1202","","","","","","","fee schedule","543.79","1886.44",""
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Tte w/doppler complete","93306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Tte w/o doppler complete","93307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","936","","","","","","","fee schedule","237.46","964",""
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","964","","","","","","","fee schedule","237.46","964",""
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","940","","","","","","","fee schedule","237.46","964",""
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","964","APC 277.30"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","964","APC 296.56"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","964","APC 308.91"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","964","APC"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","964","APC"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","964","APC"
"Tte f-up or lmtd","93308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","964","APC"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1692","","","","","","","fee schedule","543.79","1886.44",""
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1741","","","","","","","fee schedule","543.79","1886.44",""
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1698","","","","","","","fee schedule","543.79","1886.44",""
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo transesophageal","93316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Echo Transesophageal Intraop","93318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1382","","","","","","","fee schedule","543.79","1886.44",""
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1422","","","","","","","fee schedule","543.79","1886.44",""
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1389","","","","","","","fee schedule","543.79","1886.44",""
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte only","93350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Stress tte complete","93351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"Right heart cath","93451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"Left hrt cath w/ventrclgrphy","93452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath w/ventriclgrphy","93453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary artery angio s&i","93454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"Coronary art/grft angio s&i","93455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt coronary artery angio","93456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt art/grft angio","93457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt artery/ventricle angio","93458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt art/grft angio","93459","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt art/ventricle angio","93461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt cath trnsptl puncture","93462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"L hrt cath trnsptl puncture","93462","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"L hrt cath trnsptl puncture","93462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Drug admin & hemodynmic meas","93463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Drug admin & hemodynmic meas","93463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Exercise w/hemodynamic meas","93464","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Exercise w/hemodynamic meas","93464","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","1566.6","5434.61",""
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1566.6","5434.61",""
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","1566.6","5434.61",""
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4878.5","","","","","","","fee schedule","1566.6","5434.61","APC 277.30"
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5217.33","","","","","","","fee schedule","1566.6","5434.61","APC 296.56"
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5434.61","","","","","","","fee schedule","1566.6","5434.61","APC 308.91"
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1608.83","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1581.96","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1566.6","","","","","","","fee schedule","1566.6","5434.61","APC"
"Insert/place heart catheter","93503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1612.67","","","","","","","fee schedule","1566.6","5434.61","APC"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","3142.32","19040",""
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3142.32","19040",""
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","3142.32","19040",""
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9785.42","","","","","","","fee schedule","3142.32","19040","APC 277.30"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10465.07","","","","","","","fee schedule","3142.32","19040","APC 296.56"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10900.88","","","","","","","fee schedule","3142.32","19040","APC 308.91"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3227.04","","","","","","","fee schedule","3142.32","19040","APC"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3173.13","","","","","","","fee schedule","3142.32","19040","APC"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3142.32","","","","","","","fee schedule","3142.32","19040","APC"
"Biopsy of heart lining","93505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3234.74","","","","","","","fee schedule","3142.32","19040","APC"
"Rt heart cath congenital","93530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"R & l heart cath congenital","93531","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"R & l heart cath congenital","93532","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"R & l heart cath congenital","93533","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Inject congenital card cath","93563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Inject congenital card cath","93563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Inject hrt congntl art/grft","93564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Inject hrt congntl art/grft","93564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Inject l ventr/atrial angio","93565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Inject l ventr/atrial angio","93565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Inject r ventr/atrial angio","93566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Inject r ventr/atrial angio","93566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Inject suprvlv aortography","93567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Inject suprvlv aortography","93567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Inject pulm art hrt cath","93568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Inject pulm art hrt cath","93568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Njx cth slct p-art angrp uni","93569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Njx cth slct p-art angrp uni","93569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Heart flow reserve measure","93571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Heart flow reserve measure","93571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Heart flow reserve measure","93572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Heart flow reserve measure","93572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Njx cath slct p-art angrp bi","93573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Njx cath slct p-art angrp bi","93573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Njx cath slct pulm vn angrph","93574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Njx cath slct pulm vn angrph","93574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Njx cath slct p angrph mapca","93575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Njx cath slct p angrph mapca","93575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","18243.62","63288.08",""
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","18243.62","63288.08",""
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of asd","93580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","18243.62","63288.08",""
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","18243.62","63288.08",""
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Transcath closure of vsd","93581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","42343","","","","","","","fee schedule","18243.62","63288.08",""
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","38218","","","","","","","fee schedule","18243.62","63288.08",""
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath closure pda","93582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath septal reduxn","93583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq transcath septal reduxn","93583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","18243.62","63288.08",""
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","18243.62","63288.08",""
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls mitral","93590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","18243.62","63288.08",""
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","18243.62","63288.08",""
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath cls aortic","93591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Perq transcath closure each","93592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Perq transcath closure each","93592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd nml nt cnj","93593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R hrt cath chd abnl nt cnj","93594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"L hrt cath chd nm/abn nt cnj","93595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd nml nt cnj","93596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","3226.37","23971",""
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10047.14","","","","","","","fee schedule","3226.37","23971","APC 277.30"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10744.97","","","","","","","fee schedule","3226.37","23971","APC 296.56"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11192.43","","","","","","","fee schedule","3226.37","23971","APC 308.91"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3313.35","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3258","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3226.37","","","","","","","fee schedule","3226.37","23971","APC"
"R&l hrt cath chd abnl nt cnj","93597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3321.26","","","","","","","fee schedule","3226.37","23971","APC"
"Car outp meas drg cath chd","93598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Car outp meas drg cath chd","93598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Bundle of His recording","93600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial recording","93602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","1211.69","27559",""
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","1211.69","27559",""
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","27559","APC 277.30"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","27559","APC 296.56"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","27559","APC 308.91"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","27559","APC"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","27559","APC"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","27559","APC"
"Right ventricular recording","93603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","27559","APC"
"Map tachycardia add-on","93609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Map tachycardia add-on","93609","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Intra-atrial pacing","93610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Intraventricular pacing","93612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophys map 3d add-on","93613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Electrophys map 3d add-on","93613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","1211.69","27559",""
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","1211.69","27559",""
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","27559","APC 277.30"
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","27559","APC 296.56"
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","27559","APC 308.91"
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","1211.69","27559",""
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","1211.69","27559",""
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","27559","APC 277.30"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","27559","APC 296.56"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","27559","APC 308.91"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","27559","APC"
"Esophageal recording","93616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","27559","APC"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","1211.69","27559",""
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","1211.69","27559",""
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","27559","APC 277.30"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","27559","APC 296.56"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","27559","APC 308.91"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","27559","APC"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","27559","APC"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","27559","APC"
"Heart rhythm pacing","93618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","27559","APC"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiology evaluation","93621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Stimulation pacing heart","93623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Stimulation pacing heart","93623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","7762.21","27559",""
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","7762.21","27559",""
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","27559","APC 277.30"
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","27559","APC 296.56"
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","27559","APC 308.91"
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","27559","APC"
"Electrophysiologic study","93624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","27559","APC"
"Heart pacing mapping","93631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Heart pacing mapping","93631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Evaluation heart device","93640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Evaluation heart device","93640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","1211.69","27559",""
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","1211.69","27559",""
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3773.3","","","","","","","fee schedule","1211.69","27559","APC 277.30"
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4035.38","","","","","","","fee schedule","1211.69","27559","APC 296.56"
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4203.43","","","","","","","fee schedule","1211.69","27559","APC 308.91"
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.36","","","","","","","fee schedule","1211.69","27559","APC"
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.57","","","","","","","fee schedule","1211.69","27559","APC"
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.69","","","","","","","fee schedule","1211.69","27559","APC"
"Electrophysiology evaluation","93642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.33","","","","","","","fee schedule","1211.69","27559","APC"
"Electrophysiology evaluation","93644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27559","","","","","","","fee schedule","25050","27559",""
"Electrophysiology evaluation","93644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","25050","","","","","","","fee schedule","25050","27559",""
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17227","","","","","","","fee schedule","7762.21","26927.53",""
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15654","","","","","","","fee schedule","7762.21","26927.53",""
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24172.1","","","","","","","fee schedule","7762.21","26927.53","APC 277.30"
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25850.99","","","","","","","fee schedule","7762.21","26927.53","APC 296.56"
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26927.53","","","","","","","fee schedule","7762.21","26927.53","APC 308.91"
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7971.49","","","","","","","fee schedule","7762.21","26927.53","APC"
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7838.31","","","","","","","fee schedule","7762.21","26927.53","APC"
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7762.21","","","","","","","fee schedule","7762.21","26927.53","APC"
"Ablate heart dysrhythm focus","93650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7990.51","","","","","","","fee schedule","7762.21","26927.53","APC"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17227","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","31936","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15654","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","32853","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","32059","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","81004.39","","","","","","","fee schedule","15654","90238.25","APC 277.30"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","86630.59","","","","","","","fee schedule","15654","90238.25","APC 296.56"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","90238.25","","","","","","","fee schedule","15654","90238.25","APC 308.91"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26713.67","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26267.38","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26012.36","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate supravent arrhyt","93653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26777.43","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17227","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","31936","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15654","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","32853","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","32059","","","","","","","fee schedule","15654","90238.25",""
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","81004.39","","","","","","","fee schedule","15654","90238.25","APC 277.30"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","86630.59","","","","","","","fee schedule","15654","90238.25","APC 296.56"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","90238.25","","","","","","","fee schedule","15654","90238.25","APC 308.91"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26713.67","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26267.38","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26012.36","","","","","","","fee schedule","15654","90238.25","APC"
"Ep & ablate ventric tachy","93654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26777.43","","","","","","","fee schedule","15654","90238.25","APC"
"Ablate arrhythmia add on","93655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17227","","","","","","","fee schedule","15654","17227",""
"Ablate arrhythmia add on","93655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15654","","","","","","","fee schedule","15654","17227",""
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17227","","","","","","","fee schedule","15654","90238.25",""
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15654","","","","","","","fee schedule","15654","90238.25",""
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","81004.39","","","","","","","fee schedule","15654","90238.25","APC 277.30"
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","86630.59","","","","","","","fee schedule","15654","90238.25","APC 296.56"
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","90238.25","","","","","","","fee schedule","15654","90238.25","APC 308.91"
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26713.67","","","","","","","fee schedule","15654","90238.25","APC"
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26267.38","","","","","","","fee schedule","15654","90238.25","APC"
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26012.36","","","","","","","fee schedule","15654","90238.25","APC"
"Tx atrial fib pulm vein isol","93656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26777.43","","","","","","","fee schedule","15654","90238.25","APC"
"Tx l/r atrial fib addl","93657","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17227","","","","","","","fee schedule","15654","17227",""
"Tx l/r atrial fib addl","93657","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","15654","","","","","","","fee schedule","15654","17227",""
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","371.37","2633",""
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","653","","","","","","","fee schedule","371.37","2633",""
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","371.37","2633",""
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","672","","","","","","","fee schedule","371.37","2633",""
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","656","","","","","","","fee schedule","371.37","2633",""
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","2633","APC 277.30"
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","2633","APC 296.56"
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","2633","APC 308.91"
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","2633","APC"
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","2633","APC"
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","2633","APC"
"Tilt table evaluation","93660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","2633","APC"
"Intracardiac Ecg (Ice)","93662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Intracardiac Ecg (Ice)","93662","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Peripheral Vascular Rehab","93668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Bioimpedance cv analysis","93701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Bis xtracell fluid analysis","93702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Temperature gradient studies","93740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.66","2633",""
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.66","2633",""
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.86","","","","","","","fee schedule","305.66","2633","APC 277.30"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.97","","","","","","","fee schedule","305.66","2633","APC 296.56"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1060.36","","","","","","","fee schedule","305.66","2633","APC 308.91"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.9","","","","","","","fee schedule","305.66","2633","APC"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.66","","","","","","","fee schedule","305.66","2633","APC"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.66","","","","","","","fee schedule","305.66","2633","APC"
"Set-up cardiovert-defibrill","93745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.65","","","","","","","fee schedule","305.66","2633","APC"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","94.61","2633",""
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","94.61","2633",""
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","294.64","","","","","","","fee schedule","94.61","2633","APC 277.30"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","315.1","","","","","","","fee schedule","94.61","2633","APC 296.56"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","328.22","","","","","","","fee schedule","94.61","2633","APC 308.91"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","97.17","","","","","","","fee schedule","94.61","2633","APC"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","95.54","","","","","","","fee schedule","94.61","2633","APC"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","94.61","","","","","","","fee schedule","94.61","2633","APC"
"Interrogation vad in person","93750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","97.4","","","","","","","fee schedule","94.61","2633","APC"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP recording","93786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Ambulatory BP analysis","93788","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","399.5","","","","","","","fee schedule","128.29","445.04","APC 277.30"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","427.25","","","","","","","fee schedule","128.29","445.04","APC 296.56"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","445.04","","","","","","","fee schedule","128.29","445.04","APC 308.91"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.75","","","","","","","fee schedule","128.29","445.04","APC"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.55","","","","","","","fee schedule","128.29","445.04","APC"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.29","","","","","","","fee schedule","128.29","445.04","APC"
"Cardiac rehab","93797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.06","","","","","","","fee schedule","128.29","445.04","APC"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","99","","","","","","","fee schedule","99","445.04",""
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","101","","","","","","","fee schedule","99","445.04",""
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","100","","","","","","","fee schedule","99","445.04",""
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","399.5","","","","","","","fee schedule","99","445.04","APC 277.30"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","427.25","","","","","","","fee schedule","99","445.04","APC 296.56"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","445.04","","","","","","","fee schedule","99","445.04","APC 308.91"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.75","","","","","","","fee schedule","99","445.04","APC"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.55","","","","","","","fee schedule","99","445.04","APC"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.29","","","","","","","fee schedule","99","445.04","APC"
"Cardiac rehab/monitor","93798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.06","","","","","","","fee schedule","99","445.04","APC"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","128.06","2633",""
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","128.06","2633",""
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","2633","APC 277.30"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","2633","APC 296.56"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","2633","APC 308.91"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","2633","APC"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","2633","APC"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","2633","APC"
"Cardiovascular procedure","93799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","2633","APC"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","748","","","","","","","fee schedule","237.46","823.75",""
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","770","","","","","","","fee schedule","237.46","823.75",""
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","750","","","","","","","fee schedule","237.46","823.75",""
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Extracranial bilat study","93880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Extracranial uni/ltd study","93882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Intracranial complete study","93886","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Intracranial limited study","93888","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/o inj","93892","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Tcd emboli detect w/inj","93893","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","166","","","","","","","fee schedule","132.41","459.34",""
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","170","","","","","","","fee schedule","132.41","459.34",""
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","167","","","","","","","fee schedule","132.41","459.34",""
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Upr/l xtremity art 2 levels","93922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","512","","","","","","","fee schedule","214.89","745.45",""
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","527","","","","","","","fee schedule","214.89","745.45",""
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","514","","","","","","","fee schedule","214.89","745.45",""
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Upr/lxtr art stdy 3+ lvls","93923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","408","","","","","","","fee schedule","214.89","745.45",""
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","419","","","","","","","fee schedule","214.89","745.45",""
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","409","","","","","","","fee schedule","214.89","745.45",""
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Lwr xtr vasc stdy bilat","93924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","642","","","","","","","fee schedule","237.46","823.75",""
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","661","","","","","","","fee schedule","237.46","823.75",""
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","644","","","","","","","fee schedule","237.46","823.75",""
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Lower extremity study","93925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","612","","","","","","","fee schedule","104.04","630",""
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","630","","","","","","","fee schedule","104.04","630",""
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","615","","","","","","","fee schedule","104.04","630",""
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","630","APC 277.30"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","630","APC 296.56"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","630","APC 308.91"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","630","APC"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","630","APC"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","630","APC"
"Lower extremity study","93926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","630","APC"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Upper extremity study","93930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Upper extremity study","93931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1013","","","","","","","fee schedule","237.46","1041",""
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1041","","","","","","","fee schedule","237.46","1041",""
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1016","","","","","","","fee schedule","237.46","1041",""
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","1041","APC 277.30"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","1041","APC 296.56"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","1041","APC 308.91"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","1041","APC"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","1041","APC"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","1041","APC"
"Extremity study","93970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","1041","APC"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","442","","","","","","","fee schedule","104.04","455",""
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","455","","","","","","","fee schedule","104.04","455",""
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","444","","","","","","","fee schedule","104.04","455",""
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","455","APC 277.30"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","455","APC 296.56"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","455","APC 308.91"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","455","APC"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","455","APC"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","455","APC"
"Extremity study","93971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","455","APC"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","873","","","","","","","fee schedule","237.46","899",""
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","899","","","","","","","fee schedule","237.46","899",""
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","876","","","","","","","fee schedule","237.46","899",""
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","899","APC 277.30"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","899","APC 296.56"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","899","APC 308.91"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","899","APC"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","899","APC"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","899","APC"
"Vascular study","93975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","899","APC"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1015","","","","","","","fee schedule","104.04","1044",""
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1044","","","","","","","fee schedule","104.04","1044",""
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1019","","","","","","","fee schedule","104.04","1044",""
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","1044","APC 277.30"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","1044","APC 296.56"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","1044","APC 308.91"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","1044","APC"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","1044","APC"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","1044","APC"
"Vascular study","93976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","1044","APC"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","545","","","","","","","fee schedule","237.46","823.75",""
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","561","","","","","","","fee schedule","237.46","823.75",""
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","547","","","","","","","fee schedule","237.46","823.75",""
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Vascular study","93978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Vascular study","93979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Penile vascular study","93981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Dup-scan hemo compl bi std","93985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Dup-scan hemo compl uni std","93986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","742","","","","","","","fee schedule","104.04","763",""
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","763","","","","","","","fee schedule","104.04","763",""
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","745","","","","","","","fee schedule","104.04","763",""
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","763","APC 277.30"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","763","APC 296.56"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","763","APC 308.91"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","763","APC"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","763","APC"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","763","APC"
"Doppler flow testing","93990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","763","APC"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Noninvas vasc dx study proc","93998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1914.6","","","","","","","fee schedule","614.82","2132.85","APC 277.30"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2047.58","","","","","","","fee schedule","614.82","2132.85","APC 296.56"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2132.85","","","","","","","fee schedule","614.82","2132.85","APC 308.91"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","631.4","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","620.85","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","614.82","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat init day","94002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","632.91","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1914.6","","","","","","","fee schedule","614.82","2132.85","APC 277.30"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2047.58","","","","","","","fee schedule","614.82","2132.85","APC 296.56"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2132.85","","","","","","","fee schedule","614.82","2132.85","APC 308.91"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","631.4","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","620.85","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","614.82","","","","","","","fee schedule","614.82","2132.85","APC"
"Vent mgmt inpat subq day","94003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","632.91","","","","","","","fee schedule","614.82","2132.85","APC"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","332","","","","","","","fee schedule","214.89","745.45",""
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","341","","","","","","","fee schedule","214.89","745.45",""
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","333","","","","","","","fee schedule","214.89","745.45",""
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Breathing capacity test","94010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Spirometry up to 2 yrs old","94011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Spirmtry w/brnchdil inf-2 yr","94012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Meas lung vol thru 2 yrs","94013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Patient recorded spirometry","94014","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Patient recorded spirometry","94015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Review patient spirometry","94016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.56","","","","","","","fee schedule","24.89","25.62","APC"
"Review patient spirometry","94016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.13","","","","","","","fee schedule","24.89","25.62","APC"
"Review patient spirometry","94016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.89","","","","","","","fee schedule","24.89","25.62","APC"
"Review patient spirometry","94016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.62","","","","","","","fee schedule","24.89","25.62","APC"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","657","","","","","","","fee schedule","371.37","1288.29",""
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","675","","","","","","","fee schedule","371.37","1288.29",""
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","659","","","","","","","fee schedule","371.37","1288.29",""
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","659","","","","","","","fee schedule","371.37","1288.29",""
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","678","","","","","","","fee schedule","371.37","1288.29",""
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","661","","","","","","","fee schedule","371.37","1288.29",""
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Evaluation of wheezing","94070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Vital capacity test","94150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Lung function test (MBC/MVV)","94200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Respiratory flow volume loop","94375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Hypoxia response curve","94450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/report","94452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Hast w/oxygen titrate","94453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","756","APC 277.30"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","756","APC 296.56"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","756","APC 308.91"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","756","APC"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","756","APC"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","756","APC"
"Surfactant Admin Thru Tube","94610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","756","APC"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Exercise tst brncspsm","94617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","485","","","","","","","fee schedule","132.41","499",""
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","499","","","","","","","fee schedule","132.41","499",""
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","487","","","","","","","fee schedule","132.41","499",""
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","499","APC 277.30"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","499","APC 296.56"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","499","APC 308.91"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","499","APC"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","499","APC"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","499","APC"
"Pulmonary stress testing","94618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","499","APC"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Exercise tst brncspsm wo ecg","94619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Pulmonary stress test/simple","94620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","640","","","","","","","fee schedule","640","658",""
"Pulmonary stress test/simple","94620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","658","","","","","","","fee schedule","640","658",""
"Pulmonary stress test/simple","94620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","642","","","","","","","fee schedule","640","658",""
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","597","","","","","","","fee schedule","371.37","1288.29",""
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","614","","","","","","","fee schedule","371.37","1288.29",""
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","599","","","","","","","fee schedule","371.37","1288.29",""
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm stress test/complex","94621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/o mntr","94625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Phy/qhp op pulm rhb w/mntr","94626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","756","APC 277.30"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","756","APC 296.56"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","756","APC 308.91"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","756","APC"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","756","APC"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","756","APC"
"Airway inhalation treatment","94640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","756","APC"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","756","APC 277.30"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","756","APC 296.56"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","756","APC 308.91"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","756","APC"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","756","APC"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","756","APC"
"Aerosol inhalation treatment","94642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","756","APC"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Cbt 1st hour","94644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","756","APC 277.30"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","756","APC 296.56"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","756","APC 308.91"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","756","APC"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","756","APC"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","756","APC"
"Pos airway pressure cpap","94660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","756","APC"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","756","APC 277.30"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","756","APC 296.56"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","756","APC 308.91"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","756","APC"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","756","APC"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","756","APC"
"Evaluate pt use of inhaler","94664","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","756","APC"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94667","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Chest wall manipulation","94668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","678.64","","","","","","","fee schedule","217.93","756","APC 277.30"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","725.77","","","","","","","fee schedule","217.93","756","APC 296.56"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","756","","","","","","","fee schedule","217.93","756","APC 308.91"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","223.8","","","","","","","fee schedule","217.93","756","APC"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.06","","","","","","","fee schedule","217.93","756","APC"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","217.93","","","","","","","fee schedule","217.93","756","APC"
"Mechanical chest wall oscill","94669","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.34","","","","","","","fee schedule","217.93","756","APC"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Exhaled air analysis o2","94680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Exhaled air analysis o2/co2","94681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Exhaled air analysis","94690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","975","","","","","","","fee schedule","371.37","1288.29",""
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1003","","","","","","","fee schedule","371.37","1288.29",""
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","979","","","","","","","fee schedule","371.37","1288.29",""
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm funct tst plethysmograp","94726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1145","","","","","","","fee schedule","214.89","1179",""
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1179","","","","","","","fee schedule","214.89","1179",""
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1149","","","","","","","fee schedule","214.89","1179",""
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","1179","APC 277.30"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","1179","APC 296.56"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","1179","APC 308.91"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","1179","APC"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","1179","APC"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","1179","APC"
"Pulm function test by gas","94727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","1179","APC"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Pulm funct test oscillometry","94728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Measure blood oxygen level","94762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Exhaled carbon dioxide test","94770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","136","","","","","","","fee schedule","136","139",""
"Exhaled carbon dioxide test","94770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","139","","","","","","","fee schedule","136","139",""
"Exhaled carbon dioxide test","94770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","136","","","","","","","fee schedule","136","139",""
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Breath recording infant","94772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec hk-up","94775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Ped home apnea rec downld","94776","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Car seat/bed test 60 min","94780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Pulmonary service/procedure","94799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Percut allergy skin tests","95004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Exhaled Nitric Oxide Meas","95012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Perq & icut allg test venoms","95017","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Perq&ic allg test drugs/biol","95018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Icut allergy test drug/bug","95024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Icut allergy titrate-airborn","95027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Icut allergy test-delayed","95028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Allergy patch tests","95044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Photo patch test","95052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Photosensitivity tests","95056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Eye allergy tests","95060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Nose allergy test","95065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Bronchial allergy tests","95070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Ingest challenge ini 120 min","95076","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy one injection","95115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Immunotherapy injections","95117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95149","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Antigen therapy services","95170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Rapid desensitization","95180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Allergy immunology services","95199","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Cont gluc mntr pt prov eqp","95249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Glucose monitoring cont","95250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg cont rec w/vid eeg tech","95700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12 hr unmntr","95705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg wo vid 2-12hr intmt mntr","95706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg w/o vid 2-12hr cont mntr","95707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg wo vid ea 12-26hr unmntr","95708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr intmt","95709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg w/o vid ea 12-26hr cont","95710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Veeg 2-12 hr unmonitored","95711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr intmt mntr","95712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg 2-12 hr cont mntr","95713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26 hr unmntr","95714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26hr intmt mntr","95715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Veeg ea 12-26hr cont mntr","95716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs 4/> paramtrs","95782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom <6 yrs cpap/bilvl","95783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Slp stdy unattended","95800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Slp stdy unatnd w/anal","95801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Actigraphy testing","95803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","878","","","","","","","fee schedule","854.62","2964.71",""
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","903","","","","","","","fee schedule","854.62","2964.71",""
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","881","","","","","","","fee schedule","854.62","2964.71",""
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Multiple sleep latency test","95805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1128","","","","","","","fee schedule","214.89","1162",""
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1162","","","","","","","fee schedule","214.89","1162",""
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1133","","","","","","","fee schedule","214.89","1162",""
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","1162","APC 277.30"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","1162","APC 296.56"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","1162","APC 308.91"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","1162","APC"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","1162","APC"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","1162","APC"
"Sleep study unatt&resp efft","95806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","1162","APC"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Sleep study attended","95807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom any age 1-3> param","95808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1853","","","","","","","fee schedule","854.62","2964.71",""
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1906","","","","","","","fee schedule","854.62","2964.71",""
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1860","","","","","","","fee schedule","854.62","2964.71",""
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/> yrs 4/> param","95810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2516","","","","","","","fee schedule","854.62","2964.71",""
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2588","","","","","","","fee schedule","854.62","2964.71",""
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2524","","","","","","","fee schedule","854.62","2964.71",""
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Polysom 6/>yrs cpap 4/> parm","95811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg 41-60 minutes","95812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg over 1 hour","95813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","790","","","","","","","fee schedule","214.89","813",""
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","813","","","","","","","fee schedule","214.89","813",""
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","792","","","","","","","fee schedule","214.89","813",""
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","813","APC 277.30"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","813","APC 296.56"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","813","APC 308.91"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","813","APC"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","813","APC"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","813","APC"
"Eeg awake and drowsy","95816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","813","APC"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","847","","","","","","","fee schedule","214.89","871",""
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","871","","","","","","","fee schedule","214.89","871",""
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","850","","","","","","","fee schedule","214.89","871",""
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","871","APC 277.30"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","871","APC 296.56"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","871","APC 308.91"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","871","APC"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","871","APC"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","871","APC"
"Eeg awake and asleep","95819","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","871","APC"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg coma or sleep only","95822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Eeg cerebral death only","95824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Ecog impltd brn npgt <=30 d","95836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Range of motion measurements","95851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.87","","","","","","","fee schedule","6.69","6.89","APC"
"Range of motion measurements","95851","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.76","","","","","","","fee schedule","6.69","6.89","APC"
"Range of motion measurements","95851","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.69","","","","","","","fee schedule","6.69","6.89","APC"
"Range of motion measurements","95851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.89","","","","","","","fee schedule","6.69","6.89","APC"
"Range of motion measurements","95852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.12","","","","","","","fee schedule","4.99","5.13","APC"
"Range of motion measurements","95852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.04","","","","","","","fee schedule","4.99","5.13","APC"
"Range of motion measurements","95852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.99","","","","","","","fee schedule","4.99","5.13","APC"
"Range of motion measurements","95852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.13","","","","","","","fee schedule","4.99","5.13","APC"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Cholinesterase challenge","95857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test one limb","95860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test 2 limbs","95861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 3 limbs","95863","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test 4 limbs","95864","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test larynx","95865","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test hemidiaphragm","95866","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerv unilat","95867","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test cran nerve bilat","95868","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test thor paraspinal","95869","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test nonparaspinal","95870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Muscle test one fiber","95872","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Limb exercise test","95875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Motor &/ sens nrve cndj test","95905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Nvr cndj tst 1-2 studies","95907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 3-4 studies","95908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj tst 5-6 studies","95909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 7-8 studies","95910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 9-10 studies","95911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 11-12 studies","95912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrv cndj test 13/> studies","95913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Quan puplmtry phy/qhp uni/bi","95919","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Autonomic nrv parasym inervj","95921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv adrenrg inervj","95922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Autonomic nrv syst funj test","95923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Ans parasymp & symp w/tilt","95924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Somatosensory testing","95927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked uppr limbs","95928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"C motor evoked lwr limbs","95929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Visual evoked potential test","95930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Blink reflex test","95933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Neuromuscular junction test","95937","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Somatosensory testing","95938","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"C motor evoked upr&lwr limbs","95939","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Ambulatory eeg monitoring","95950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1054","","","","","","","fee schedule","1054","1084",""
"Ambulatory eeg monitoring","95950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1084","","","","","","","fee schedule","1054","1084",""
"Ambulatory eeg monitoring","95950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1058","","","","","","","fee schedule","1054","1084",""
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"EEG monitoring/giving drugs","95954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"EEG monitoring/function test","95958","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Electrode stimulation brain","95961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg spontaneous","95965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Meg evoked single","95966","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Analyze neurostim no prog","95970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Alys smpl cn npgt prgrmg","95976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Io anal gast n-stim subsq","95981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Io ga n-stim subsq w/reprog","95982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","328.72","2633",""
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","328.72","2633",""
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","2633","APC 277.30"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","2633","APC 296.56"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","2633","APC 308.91"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","2633","APC"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","2633","APC"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","2633","APC"
"Spin/brain pump refil & main","95990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","2633","APC"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","305.48","2633",""
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","305.48","2633",""
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","951.28","","","","","","","fee schedule","305.48","2633","APC 277.30"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1017.35","","","","","","","fee schedule","305.48","2633","APC 296.56"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1059.72","","","","","","","fee schedule","305.48","2633","APC 308.91"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","313.71","","","","","","","fee schedule","305.48","2633","APC"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.47","","","","","","","fee schedule","305.48","2633","APC"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.48","","","","","","","fee schedule","305.48","2633","APC"
"Spin/brain pump refil & main","95991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.46","","","","","","","fee schedule","305.48","2633","APC"
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","48.54","","","","","","","fee schedule","30.04","48.54",""
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","48.54","","","","","","","fee schedule","30.04","48.54",""
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","48.54","","","","","","","fee schedule","30.04","48.54",""
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.85","","","","","","","fee schedule","30.04","48.54","APC"
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.33","","","","","","","fee schedule","30.04","48.54","APC"
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.04","","","","","","","fee schedule","30.04","48.54","APC"
"Canalith repositioning proc","95992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.92","","","","","","","fee schedule","30.04","48.54","APC"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Neurological procedure","95999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Motion analysis video/3d","96000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Motion test w/ft press meas","96001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Dynamic surface emg","96002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Assessment of aphasia","96105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.64","","","","","","","fee schedule","98","100.88","APC"
"Assessment of aphasia","96105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","98.96","","","","","","","fee schedule","98","100.88","APC"
"Assessment of aphasia","96105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","98","","","","","","","fee schedule","98","100.88","APC"
"Assessment of aphasia","96105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","100.88","","","","","","","fee schedule","98","100.88","APC"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","166.28","","","","","","","fee schedule","128.06","444.23",""
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","166.28","","","","","","","fee schedule","128.06","444.23",""
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","166.28","","","","","","","fee schedule","128.06","444.23",""
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"Devel tst phys/qhp 1st hr","96112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Devel tst phys/qhp ea addl","96113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","75.98","","","","","","","fee schedule","75.98","75.98",""
"Devel tst phys/qhp ea addl","96113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","75.98","","","","","","","fee schedule","75.98","75.98",""
"Devel tst phys/qhp ea addl","96113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","75.98","","","","","","","fee schedule","75.98","75.98",""
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Neurobehavioral status exam","96116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Cognitive test by hc pro","96125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.55","","","","","","","fee schedule","103.75","106.81","APC"
"Cognitive test by hc pro","96125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","104.77","","","","","","","fee schedule","103.75","106.81","APC"
"Cognitive test by hc pro","96125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","103.75","","","","","","","fee schedule","103.75","106.81","APC"
"Cognitive test by hc pro","96125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","106.81","","","","","","","fee schedule","103.75","106.81","APC"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Brief emotional/behav assmt","96127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Psycl tst eval phys/qhp 1st","96130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Nrpsyc tst eval phys/qhp 1st","96132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Psycl/nrpsyc tst phy/qhp 1st","96136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","1542.27","APC 277.30"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","1542.27","APC 296.56"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","1542.27","APC 308.91"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","1542.27","APC"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","1542.27","APC"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","1542.27","APC"
"Psycl/nrpsyc tech 1st","96138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","1542.27","APC"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Psycl/nrpsyc tst auto result","96146","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Pt-focused hlth risk assmt","96160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Caregiver health risk assmt","96161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj grp 1st 30","96164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hlth bhv ivntj fam 1st 30","96167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Mlt fam grp bhv train 1st 60","96202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.04","","","","","","","fee schedule","17.56","18.08","APC"
"Mlt fam grp bhv train 1st 60","96202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.74","","","","","","","fee schedule","17.56","18.08","APC"
"Mlt fam grp bhv train 1st 60","96202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.56","","","","","","","fee schedule","17.56","18.08","APC"
"Mlt fam grp bhv train 1st 60","96202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.08","","","","","","","fee schedule","17.56","18.08","APC"
"Mlt fam grp bhv train ea add","96203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.13","","","","","","","fee schedule","5","5.14","APC"
"Mlt fam grp bhv train ea add","96203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.05","","","","","","","fee schedule","5","5.14","APC"
"Mlt fam grp bhv train ea add","96203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5","","","","","","","fee schedule","5","5.14","APC"
"Mlt fam grp bhv train ea add","96203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.14","","","","","","","fee schedule","5","5.14","APC"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1045","","","","","","","fee schedule","211.68","1075",""
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1075","","","","","","","fee schedule","211.68","1075",""
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1050","","","","","","","fee schedule","211.68","1075",""
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","1075","APC 277.30"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","1075","APC 296.56"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","1075","APC 308.91"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","1075","APC"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","1075","APC"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","1075","APC"
"Hydration iv infusion init","96360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","1075","APC"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Hydrate iv infusion add-on","96361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag iv inf init","96365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/proph/diag iv inf addon","96366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Tx/proph/dg addl seq iv inf","96367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Sc ther infusion up to 1 hr","96369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Sc ther infusion addl hr","96370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Sc ther infusion reset pump","96371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Ther/proph/diag inj sc/im","96372","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj ia","96373","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Ther/proph/diag inj iv push","96374","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Tx/pro/dx inj new drug addon","96375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Applicaton on-body injector","96377","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Ther/prop/diag inj/inf proc","96379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo anti-neopl sq/im","96401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo hormon antineopl sq/im","96402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo intralesional up to 7","96405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Chemo intralesional over 7","96406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv push sngl drug","96409","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv push addl drug","96411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv infusion 1 hr","96413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infusion addl hr","96415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo prolong infuse w/pump","96416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo iv infus each addl seq","96417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia push tecnique","96420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia infusion up to 1 hr","96422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Chemo ia infuse each addl hr","96423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy infusion method","96425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy intracavitary","96440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotx admn prtl cavity","96446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy into cns","96450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint portable pump","96521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Refill/maint pump/resvr syst","96522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Irrig drug delivery device","96523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemotherapy injection","96542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Intraop hipec px 1st 60 min","96547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Intraop hipec px 1st 60 min","96547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Ntraop hipec px ea add 30min","96548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Ntraop hipec px ea add 30min","96548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Chemotherapy unspecified","96549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","2633",""
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","2633",""
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","2633","APC 277.30"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","2633","APC 296.56"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","2633","APC 308.91"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","2633","APC"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","2633","APC"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","2633","APC"
"Photodynamic tx skin","96567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","2633","APC"
"Photodynmc tx 30 min add-on","96570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Photodynmc tx 30 min add-on","96570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Photodynamic tx addl 15 min","96571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Photodynamic tx addl 15 min","96571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","2633",""
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","2633",""
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","2633","APC 277.30"
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","2633","APC 296.56"
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","2633","APC 308.91"
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","2633","APC"
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","2633","APC"
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","2633","APC"
"Pdt dstr prmlg les phys/qhp","96573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","2633","APC"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","2633",""
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","2633",""
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","2633","APC 277.30"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","2633","APC 296.56"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","2633","APC 308.91"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","2633","APC"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","2633","APC"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","2633","APC"
"Dbrdmt prmlg les w/pdt","96574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","2633","APC"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Ultraviolet light therapy","96900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-B","96910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","203.66","APC 277.30"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","203.66","APC 296.56"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","203.66","APC 308.91"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy with UV-A","96912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","203.66","APC"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Photochemotherapy uv-a or b","96913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","692.67","APC 277.30"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","692.67","APC 296.56"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","692.67","APC 308.91"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin < 250 sq cm","96920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","692.67","APC 277.30"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","692.67","APC 296.56"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","692.67","APC 308.91"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin 250-500 sq cm","96921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","692.67","APC"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Laser tx skin >500 sq cm","96922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","692.67","APC 277.30"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","692.67","APC 296.56"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","692.67","APC 308.91"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","692.67","APC"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","692.67","APC"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","692.67","APC"
"Dermatological procedure","96999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","692.67","APC"
"Hot or cold packs therapy","97010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","7.73","","","","","","","fee schedule","7.73","7.73",""
"Hot or cold packs therapy","97010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","7.73","","","","","","","fee schedule","7.73","7.73",""
"Hot or cold packs therapy","97010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","7.73","","","","","","","fee schedule","7.73","7.73",""
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","21.06","","","","","","","fee schedule","14.44","21.06",""
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","21.06","","","","","","","fee schedule","14.44","21.06",""
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","21.06","","","","","","","fee schedule","14.44","21.06",""
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.83","","","","","","","fee schedule","14.44","21.06","APC"
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.58","","","","","","","fee schedule","14.44","21.06","APC"
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.44","","","","","","","fee schedule","14.44","21.06","APC"
"Mechanical traction therapy","97012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.87","","","","","","","fee schedule","14.44","21.06","APC"
"Electric stimulation therapy","97014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","20.56","","","","","","","fee schedule","20.56","20.56",""
"Electric stimulation therapy","97014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","20.56","","","","","","","fee schedule","20.56","20.56",""
"Electric stimulation therapy","97014","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","20.56","","","","","","","fee schedule","20.56","20.56",""
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","25.1","","","","","","","fee schedule","12.07","25.1",""
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","25.1","","","","","","","fee schedule","12.07","25.1",""
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","25.1","","","","","","","fee schedule","12.07","25.1",""
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.39","","","","","","","fee schedule","12.07","25.1","APC"
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.18","","","","","","","fee schedule","12.07","25.1","APC"
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.07","","","","","","","fee schedule","12.07","25.1","APC"
"Vasopneumatic device therapy","97016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.42","","","","","","","fee schedule","12.07","25.1","APC"
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","14.1","","","","","","","fee schedule","5.97","14.1",""
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","14.1","","","","","","","fee schedule","5.97","14.1",""
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","14.1","","","","","","","fee schedule","5.97","14.1",""
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.13","","","","","","","fee schedule","5.97","14.1","APC"
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.03","","","","","","","fee schedule","5.97","14.1","APC"
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.97","","","","","","","fee schedule","5.97","14.1","APC"
"Paraffin bath therapy","97018","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.14","","","","","","","fee schedule","5.97","14.1","APC"
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","30.56","","","","","","","fee schedule","15.75","30.56",""
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","30.56","","","","","","","fee schedule","15.75","30.56",""
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","30.56","","","","","","","fee schedule","15.75","30.56",""
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.17","","","","","","","fee schedule","15.75","30.56","APC"
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.9","","","","","","","fee schedule","15.75","30.56","APC"
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.75","","","","","","","fee schedule","15.75","30.56","APC"
"Whirlpool therapy","97022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.21","","","","","","","fee schedule","15.75","30.56","APC"
"Diathermy eg microwave","97024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.5","","","","","","","fee schedule","7.3","7.52","APC"
"Diathermy eg microwave","97024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.37","","","","","","","fee schedule","7.3","7.52","APC"
"Diathermy eg microwave","97024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.3","","","","","","","fee schedule","7.3","7.52","APC"
"Diathermy eg microwave","97024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.52","","","","","","","fee schedule","7.3","7.52","APC"
"Infrared therapy","97026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.82","","","","","","","fee schedule","6.64","6.84","APC"
"Infrared therapy","97026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.71","","","","","","","fee schedule","6.64","6.84","APC"
"Infrared therapy","97026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.64","","","","","","","fee schedule","6.64","6.84","APC"
"Infrared therapy","97026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.84","","","","","","","fee schedule","6.64","6.84","APC"
"Ultraviolet therapy","97028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.55","","","","","","","fee schedule","8.32","8.57","APC"
"Ultraviolet therapy","97028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.4","","","","","","","fee schedule","8.32","8.57","APC"
"Ultraviolet therapy","97028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.32","","","","","","","fee schedule","8.32","8.57","APC"
"Ultraviolet therapy","97028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.57","","","","","","","fee schedule","8.32","8.57","APC"
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","24.7","","","","","","","fee schedule","14.79","24.7",""
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","24.7","","","","","","","fee schedule","14.79","24.7",""
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","24.7","","","","","","","fee schedule","14.79","24.7",""
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.19","","","","","","","fee schedule","14.79","24.7","APC"
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.94","","","","","","","fee schedule","14.79","24.7","APC"
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.79","","","","","","","fee schedule","14.79","24.7","APC"
"Electrical stimulation","97032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.23","","","","","","","fee schedule","14.79","24.7","APC"
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","28.35","","","","","","","fee schedule","19.15","28.35",""
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","28.35","","","","","","","fee schedule","19.15","28.35",""
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","28.35","","","","","","","fee schedule","19.15","28.35",""
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.66","","","","","","","fee schedule","19.15","28.35","APC"
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.33","","","","","","","fee schedule","19.15","28.35","APC"
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.15","","","","","","","fee schedule","19.15","28.35","APC"
"Electric current therapy","97033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.71","","","","","","","fee schedule","19.15","28.35","APC"
"Contrast bath therapy","97034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.48","","","","","","","fee schedule","14.1","14.51","APC"
"Contrast bath therapy","97034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.23","","","","","","","fee schedule","14.1","14.51","APC"
"Contrast bath therapy","97034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.1","","","","","","","fee schedule","14.1","14.51","APC"
"Contrast bath therapy","97034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.51","","","","","","","fee schedule","14.1","14.51","APC"
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","16.48","","","","","","","fee schedule","14.42","16.48",""
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","16.48","","","","","","","fee schedule","14.42","16.48",""
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","16.48","","","","","","","fee schedule","14.42","16.48",""
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.81","","","","","","","fee schedule","14.42","16.48","APC"
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.56","","","","","","","fee schedule","14.42","16.48","APC"
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.42","","","","","","","fee schedule","14.42","16.48","APC"
"Ultrasound therapy","97035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.85","","","","","","","fee schedule","14.42","16.48","APC"
"Hydrotherapy","97036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.83","","","","","","","fee schedule","34.89","35.92","APC"
"Hydrotherapy","97036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.24","","","","","","","fee schedule","34.89","35.92","APC"
"Hydrotherapy","97036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.89","","","","","","","fee schedule","34.89","35.92","APC"
"Hydrotherapy","97036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.92","","","","","","","fee schedule","34.89","35.92","APC"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Appl modality 1+lllt po pain","97037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","42.08","","","","","","","fee schedule","29.3","42.08",""
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","42.08","","","","","","","fee schedule","29.3","42.08",""
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","42.08","","","","","","","fee schedule","29.3","42.08",""
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.09","","","","","","","fee schedule","29.3","42.08","APC"
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.59","","","","","","","fee schedule","29.3","42.08","APC"
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.3","","","","","","","fee schedule","29.3","42.08","APC"
"Therapeutic exercises","97110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.17","","","","","","","fee schedule","29.3","42.08","APC"
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","43.9","","","","","","","fee schedule","33.02","43.9",""
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","43.9","","","","","","","fee schedule","33.02","43.9",""
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","43.9","","","","","","","fee schedule","33.02","43.9",""
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.91","","","","","","","fee schedule","33.02","43.9","APC"
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.34","","","","","","","fee schedule","33.02","43.9","APC"
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.02","","","","","","","fee schedule","33.02","43.9","APC"
"Neuromuscular reeducation","97112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.99","","","","","","","fee schedule","33.02","43.9","APC"
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","55.77","","","","","","","fee schedule","37.35","55.77",""
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","55.77","","","","","","","fee schedule","37.35","55.77",""
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","55.77","","","","","","","fee schedule","37.35","55.77",""
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.36","","","","","","","fee schedule","37.35","55.77","APC"
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.72","","","","","","","fee schedule","37.35","55.77","APC"
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.35","","","","","","","fee schedule","37.35","55.77","APC"
"Aquatic therapy/exercises","97113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.45","","","","","","","fee schedule","37.35","55.77","APC"
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","36.63","","","","","","","fee schedule","29.3","36.63",""
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","36.63","","","","","","","fee schedule","29.3","36.63",""
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","36.63","","","","","","","fee schedule","29.3","36.63",""
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.09","","","","","","","fee schedule","29.3","36.63","APC"
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.59","","","","","","","fee schedule","29.3","36.63","APC"
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.3","","","","","","","fee schedule","29.3","36.63","APC"
"Gait training therapy","97116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.17","","","","","","","fee schedule","29.3","36.63","APC"
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","33.87","","","","","","","fee schedule","29.92","33.87",""
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","33.87","","","","","","","fee schedule","29.92","33.87",""
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","33.87","","","","","","","fee schedule","29.92","33.87",""
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.72","","","","","","","fee schedule","29.92","33.87","APC"
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.21","","","","","","","fee schedule","29.92","33.87","APC"
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.92","","","","","","","fee schedule","29.92","33.87","APC"
"Massage therapy","97124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.8","","","","","","","fee schedule","29.92","33.87","APC"
"Ther ivntj 1st 15 min","97129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.49","","","","","","","fee schedule","19.95","20.54","APC"
"Ther ivntj 1st 15 min","97129","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.15","","","","","","","fee schedule","19.95","20.54","APC"
"Ther ivntj 1st 15 min","97129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.95","","","","","","","fee schedule","19.95","20.54","APC"
"Ther ivntj 1st 15 min","97129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.54","","","","","","","fee schedule","19.95","20.54","APC"
"Ther ivntj ea addl 15 min","97130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.7","19.25","APC"
"Ther ivntj ea addl 15 min","97130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.88","","","","","","","fee schedule","18.7","19.25","APC"
"Ther ivntj ea addl 15 min","97130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.7","","","","","","","fee schedule","18.7","19.25","APC"
"Ther ivntj ea addl 15 min","97130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.25","","","","","","","fee schedule","18.7","19.25","APC"
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","38.92","","","","","","","fee schedule","27.95","38.92",""
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","38.92","","","","","","","fee schedule","27.95","38.92",""
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","38.92","","","","","","","fee schedule","27.95","38.92",""
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.7","","","","","","","fee schedule","27.95","38.92","APC"
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.22","","","","","","","fee schedule","27.95","38.92","APC"
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.95","","","","","","","fee schedule","27.95","38.92","APC"
"Manual therapy 1/> regions","97140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.77","","","","","","","fee schedule","27.95","38.92","APC"
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","22.45","","","","","","","fee schedule","18.16","22.45",""
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","22.45","","","","","","","fee schedule","18.16","22.45",""
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","22.45","","","","","","","fee schedule","18.16","22.45",""
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.65","","","","","","","fee schedule","18.16","22.45","APC"
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.33","","","","","","","fee schedule","18.16","22.45","APC"
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.16","","","","","","","fee schedule","18.16","22.45","APC"
"Group therapeutic procedures","97150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.69","","","","","","","fee schedule","18.16","22.45","APC"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by tech","97154","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Fam adapt bhv tx gdn phy/qhp","97156","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Mult fam adapt bhv tx gdn","97157","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Grp adapt bhv tx by phy/qhp","97158","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","101.59","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","99.89","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","98.92","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval low complex 20 min","97161","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","101.83","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","101.59","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","99.89","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","98.92","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval mod complex 30 min","97162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","101.83","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","104.03","","","","","","","fee schedule","98.92","104.03",""
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","101.59","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","99.89","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","98.92","","","","","","","fee schedule","98.92","104.03","APC"
"Pt eval high complex 45 min","97163","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","101.83","","","","","","","fee schedule","98.92","104.03","APC"
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","70.66","","","","","","","fee schedule","68.12","70.66",""
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","70.66","","","","","","","fee schedule","68.12","70.66",""
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","70.66","","","","","","","fee schedule","68.12","70.66",""
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","69.95","","","","","","","fee schedule","68.12","70.66","APC"
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","68.78","","","","","","","fee schedule","68.12","70.66","APC"
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","68.12","","","","","","","fee schedule","68.12","70.66","APC"
"Pt re-eval est plan care","97164","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70.12","","","","","","","fee schedule","68.12","70.66","APC"
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.34","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.6","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.6","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval low complex 30 min","97165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.59","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.34","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.6","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.6","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval mod complex 45 min","97166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.59","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","100.84","","","","","","","fee schedule","100.84","104.59",""
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.34","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.6","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.6","","","","","","","fee schedule","100.84","104.59","APC"
"Ot eval high complex 60 min","97167","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.59","","","","","","","fee schedule","100.84","104.59","APC"
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","66.64","","","","","","","fee schedule","66.64","71.15",""
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","66.64","","","","","","","fee schedule","66.64","71.15",""
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","66.64","","","","","","","fee schedule","66.64","71.15",""
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","70.98","","","","","","","fee schedule","66.64","71.15","APC"
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","69.79","","","","","","","fee schedule","66.64","71.15","APC"
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","69.12","","","","","","","fee schedule","66.64","71.15","APC"
"Ot re-eval est plan care","97168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","71.15","","","","","","","fee schedule","66.64","71.15","APC"
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","45.31","","","","","","","fee schedule","35.32","45.31",""
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","45.31","","","","","","","fee schedule","35.32","45.31",""
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","45.31","","","","","","","fee schedule","35.32","45.31",""
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.27","","","","","","","fee schedule","35.32","45.31","APC"
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.67","","","","","","","fee schedule","35.32","45.31","APC"
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.32","","","","","","","fee schedule","35.32","45.31","APC"
"Therapeutic activities","97530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.36","","","","","","","fee schedule","35.32","45.31","APC"
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","38.02","","","","","","","fee schedule","38.02","62.94",""
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","38.02","","","","","","","fee schedule","38.02","62.94",""
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","38.02","","","","","","","fee schedule","38.02","62.94",""
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.79","","","","","","","fee schedule","38.02","62.94","APC"
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.74","","","","","","","fee schedule","38.02","62.94","APC"
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61.14","","","","","","","fee schedule","38.02","62.94","APC"
"Sensory Integration","97533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62.94","","","","","","","fee schedule","38.02","62.94","APC"
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","45.25","","","","","","","fee schedule","32.65","45.25",""
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","45.25","","","","","","","fee schedule","32.65","45.25",""
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","45.25","","","","","","","fee schedule","32.65","45.25",""
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.53","","","","","","","fee schedule","32.65","45.25","APC"
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.97","","","","","","","fee schedule","32.65","45.25","APC"
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.65","","","","","","","fee schedule","32.65","45.25","APC"
"Self care mngment training","97535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.61","","","","","","","fee schedule","32.65","45.25","APC"
"Community/work reintegration","97537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.21","","","","","","","fee schedule","32.33","33.28","APC"
"Community/work reintegration","97537","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.65","","","","","","","fee schedule","32.33","33.28","APC"
"Community/work reintegration","97537","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.33","","","","","","","fee schedule","32.33","33.28","APC"
"Community/work reintegration","97537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.29","","","","","","","fee schedule","32.33","33.28","APC"
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","39.8","","","","","","","fee schedule","31.32","39.8",""
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","39.8","","","","","","","fee schedule","31.32","39.8",""
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","39.8","","","","","","","fee schedule","31.32","39.8",""
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.17","","","","","","","fee schedule","31.32","39.8","APC"
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.63","","","","","","","fee schedule","31.32","39.8","APC"
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.32","","","","","","","fee schedule","31.32","39.8","APC"
"Wheelchair mngment training","97542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.25","","","","","","","fee schedule","31.32","39.8","APC"
"Caregiver traing 1st 30 min","97550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.43","","","","","","","fee schedule","40.34","41.53","APC"
"Caregiver traing 1st 30 min","97550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.74","","","","","","","fee schedule","40.34","41.53","APC"
"Caregiver traing 1st 30 min","97550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.34","","","","","","","fee schedule","40.34","41.53","APC"
"Caregiver traing 1st 30 min","97550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.53","","","","","","","fee schedule","40.34","41.53","APC"
"Caregiver traing ea addl 15","97551","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.99","","","","","","","fee schedule","21.41","22.04","APC"
"Caregiver traing ea addl 15","97551","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.62","","","","","","","fee schedule","21.41","22.04","APC"
"Caregiver traing ea addl 15","97551","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.41","","","","","","","fee schedule","21.41","22.04","APC"
"Caregiver traing ea addl 15","97551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.04","","","","","","","fee schedule","21.41","22.04","APC"
"Group caregiver training","97552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.67","","","","","","","fee schedule","9.41","9.69","APC"
"Group caregiver training","97552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.51","","","","","","","fee schedule","9.41","9.69","APC"
"Group caregiver training","97552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.41","","","","","","","fee schedule","9.41","9.69","APC"
"Group caregiver training","97552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.69","","","","","","","fee schedule","9.41","9.69","APC"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","199.67","2633",""
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","656","","","","","","","fee schedule","199.67","2633",""
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","199.67","2633",""
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","674","","","","","","","fee schedule","199.67","2633",""
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","658","","","","","","","fee schedule","199.67","2633",""
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","2633","APC 277.30"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","2633","APC 296.56"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","2633","APC 308.91"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl devital tis 20 cm/<","97597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","2633","APC"
"Rmvl devital tis addl 20cm/<","97598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Rmvl devital tis addl 20cm/<","97598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","692.67","APC 277.30"
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","692.67","APC 296.56"
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","692.67","APC 308.91"
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","692.67","APC"
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","692.67","APC"
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","692.67","APC"
"Wound(s) care non-selective","97602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","692.67","APC"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","162","","","","","","","fee schedule","162","692.67",""
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","166","","","","","","","fee schedule","162","692.67",""
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","162","","","","","","","fee schedule","162","692.67",""
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","162","692.67","APC 277.30"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","162","692.67","APC 296.56"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","162","692.67","APC 308.91"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","162","692.67","APC"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","162","692.67","APC"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","162","692.67","APC"
"Neg press wound tx <=50 cm","97605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","162","692.67","APC"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wnd tx <=50 sq cm","97607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1259.84","","","","","","","fee schedule","404.56","1403.45","APC 277.30"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1347.34","","","","","","","fee schedule","404.56","1403.45","APC 296.56"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1403.45","","","","","","","fee schedule","404.56","1403.45","APC 308.91"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.47","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.53","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.56","","","","","","","fee schedule","404.56","1403.45","APC"
"Neg press wound tx >50 cm","97608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.46","","","","","","","fee schedule","404.56","1403.45","APC"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","692.67","APC 277.30"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","692.67","APC 296.56"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","692.67","APC 308.91"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","692.67","APC"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","692.67","APC"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","692.67","APC"
"Low frequency non-thermal us","97610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","692.67","APC"
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","42.53","","","","","","","fee schedule","33.99","42.53",""
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","42.53","","","","","","","fee schedule","33.99","42.53",""
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","42.53","","","","","","","fee schedule","33.99","42.53",""
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34.9","","","","","","","fee schedule","33.99","42.53","APC"
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.32","","","","","","","fee schedule","33.99","42.53","APC"
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.99","","","","","","","fee schedule","33.99","42.53","APC"
"Physical performance test","97750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34.99","","","","","","","fee schedule","33.99","42.53","APC"
"Assistive technology assess","97755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.13","","","","","","","fee schedule","38.11","39.23","APC"
"Assistive technology assess","97755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.48","","","","","","","fee schedule","38.11","39.23","APC"
"Assistive technology assess","97755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.11","","","","","","","fee schedule","38.11","39.23","APC"
"Assistive technology assess","97755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.23","","","","","","","fee schedule","38.11","39.23","APC"
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","49.34","","","","","","","fee schedule","46.41","49.34",""
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","49.34","","","","","","","fee schedule","46.41","49.34",""
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","49.34","","","","","","","fee schedule","46.41","49.34",""
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.66","","","","","","","fee schedule","46.41","49.34","APC"
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46.86","","","","","","","fee schedule","46.41","49.34","APC"
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.41","","","","","","","fee schedule","46.41","49.34","APC"
"Orthotic mgmt and training","97760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.78","","","","","","","fee schedule","46.41","49.34","APC"
"Prosthetic training","97761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.82","","","","","","","fee schedule","40.72","41.92","APC"
"Prosthetic training","97761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.12","","","","","","","fee schedule","40.72","41.92","APC"
"Prosthetic training","97761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.72","","","","","","","fee schedule","40.72","41.92","APC"
"Prosthetic training","97761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.92","","","","","","","fee schedule","40.72","41.92","APC"
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","62.83","","","","","","","fee schedule","50.42","62.83",""
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","62.83","","","","","","","fee schedule","50.42","62.83",""
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","62.83","","","","","","","fee schedule","50.42","62.83",""
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.78","","","","","","","fee schedule","50.42","62.83","APC"
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.91","","","","","","","fee schedule","50.42","62.83","APC"
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.42","","","","","","","fee schedule","50.42","62.83","APC"
"Orthc/prostc mgmt sbsq enc","97763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.9","","","","","","","fee schedule","50.42","62.83","APC"
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","265","","","","","","","fee schedule","26.67","271",""
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","271","","","","","","","fee schedule","26.67","271",""
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","266","","","","","","","fee schedule","26.67","271",""
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.39","","","","","","","fee schedule","26.67","271","APC"
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.93","","","","","","","fee schedule","26.67","271","APC"
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.67","","","","","","","fee schedule","26.67","271","APC"
"Medical nutrition indiv in","97802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.46","","","","","","","fee schedule","26.67","271","APC"
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","170","","","","","","","fee schedule","22.27","175",""
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","175","","","","","","","fee schedule","22.27","175",""
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","171","","","","","","","fee schedule","22.27","175",""
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.87","","","","","","","fee schedule","22.27","175","APC"
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.48","","","","","","","fee schedule","22.27","175","APC"
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.27","","","","","","","fee schedule","22.27","175","APC"
"Med nutrition indiv subseq","97803","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.92","","","","","","","fee schedule","22.27","175","APC"
"Medical nutrition group","97804","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.78","","","","","","","fee schedule","12.44","12.81","APC"
"Medical nutrition group","97804","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.57","","","","","","","fee schedule","12.44","12.81","APC"
"Medical nutrition group","97804","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.44","","","","","","","fee schedule","12.44","12.81","APC"
"Medical nutrition group","97804","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.81","","","","","","","fee schedule","12.44","12.81","APC"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","39.79","","","","","","","fee schedule","28.78","99.86",""
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","39.79","","","","","","","fee schedule","28.78","99.86",""
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","39.79","","","","","","","fee schedule","28.78","99.86",""
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/o stimul 15 min","97810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/o stimul addl 15m","97811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","32.95","","","","","","","fee schedule","32.95","32.95",""
"Acupunct w/o stimul addl 15m","97811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","32.95","","","","","","","fee schedule","32.95","32.95",""
"Acupunct w/o stimul addl 15m","97811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","32.95","","","","","","","fee schedule","32.95","32.95",""
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","43","","","","","","","fee schedule","28.78","99.86",""
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","43","","","","","","","fee schedule","28.78","99.86",""
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","43","","","","","","","fee schedule","28.78","99.86",""
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/stimul 15 min","97813","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Acupunct w/stimul addl 15m","97814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","36.17","","","","","","","fee schedule","36.17","36.17",""
"Acupunct w/stimul addl 15m","97814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","36.17","","","","","","","fee schedule","36.17","36.17",""
"Acupunct w/stimul addl 15m","97814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","36.17","","","","","","","fee schedule","36.17","36.17",""
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 1-2 regions","98925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 3-4 regions","98926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 5-6 regions","98927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 7-8 regions","98928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Osteopath manj 9-10 regions","98929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","29.33","","","","","","","fee schedule","21.49","74.55",""
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","29.33","","","","","","","fee schedule","21.49","74.55",""
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","29.33","","","","","","","fee schedule","21.49","74.55",""
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 1-2 regions","98940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","44.99","","","","","","","fee schedule","21.49","74.55",""
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","44.99","","","","","","","fee schedule","21.49","74.55",""
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","44.99","","","","","","","fee schedule","21.49","74.55",""
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj 3-4 regions","98941","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","61.03","","","","","","","fee schedule","21.49","74.55",""
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","61.03","","","","","","","fee schedule","21.49","74.55",""
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","61.03","","","","","","","fee schedule","21.49","74.55",""
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.92","","","","","","","fee schedule","21.49","74.55","APC 277.30"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.56","","","","","","","fee schedule","21.49","74.55","APC 296.56"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.55","","","","","","","fee schedule","21.49","74.55","APC 308.91"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.07","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.49","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropractic manj 5 regions","98942","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.12","","","","","","","fee schedule","21.49","74.55","APC"
"Chiropract manj xtrspinl 1/>","98943","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","30.65","","","","","","","fee schedule","30.65","30.65",""
"Chiropract manj xtrspinl 1/>","98943","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","30.65","","","","","","","fee schedule","30.65","30.65",""
"Chiropract manj xtrspinl 1/>","98943","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","30.65","","","","","","","fee schedule","30.65","30.65",""
"Hc pro phone call 5-10 min","98966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.72","","","","","","","fee schedule","10.43","10.74","APC"
"Hc pro phone call 5-10 min","98966","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.54","","","","","","","fee schedule","10.43","10.74","APC"
"Hc pro phone call 5-10 min","98966","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.43","","","","","","","fee schedule","10.43","10.74","APC"
"Hc pro phone call 5-10 min","98966","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.74","","","","","","","fee schedule","10.43","10.74","APC"
"Hc pro phone call 11-20 min","98967","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.74","","","","","","","fee schedule","20.2","20.79","APC"
"Hc pro phone call 11-20 min","98967","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.39","","","","","","","fee schedule","20.2","20.79","APC"
"Hc pro phone call 11-20 min","98967","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.2","","","","","","","fee schedule","20.2","20.79","APC"
"Hc pro phone call 11-20 min","98967","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.79","","","","","","","fee schedule","20.2","20.79","APC"
"Hc pro phone call 21-30 min","98968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.18","","","","","","","fee schedule","29.39","30.25","APC"
"Hc pro phone call 21-30 min","98968","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.67","","","","","","","fee schedule","29.39","30.25","APC"
"Hc pro phone call 21-30 min","98968","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.39","","","","","","","fee schedule","29.39","30.25","APC"
"Hc pro phone call 21-30 min","98968","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.25","","","","","","","fee schedule","29.39","30.25","APC"
"Qnhp ol dig e/m svc 5-10min","98970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.72","","","","","","","fee schedule","10.43","10.74","APC"
"Qnhp ol dig e/m svc 5-10min","98970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.54","","","","","","","fee schedule","10.43","10.74","APC"
"Qnhp ol dig e/m svc 5-10min","98970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.43","","","","","","","fee schedule","10.43","10.74","APC"
"Qnhp ol dig e/m svc 5-10min","98970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.74","","","","","","","fee schedule","10.43","10.74","APC"
"Qnhp ol dig em svc 11-20min","98971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.67","","","","","","","fee schedule","19.16","19.72","APC"
"Qnhp ol dig em svc 11-20min","98971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.34","","","","","","","fee schedule","19.16","19.72","APC"
"Qnhp ol dig em svc 11-20min","98971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.16","","","","","","","fee schedule","19.16","19.72","APC"
"Qnhp ol dig em svc 11-20min","98971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.72","","","","","","","fee schedule","19.16","19.72","APC"
"Qnhp ol dig e/m svc 21+ min","98972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.04","","","","","","","fee schedule","29.25","30.11","APC"
"Qnhp ol dig e/m svc 21+ min","98972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.54","","","","","","","fee schedule","29.25","30.11","APC"
"Qnhp ol dig e/m svc 21+ min","98972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.25","","","","","","","fee schedule","29.25","30.11","APC"
"Qnhp ol dig e/m svc 21+ min","98972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.11","","","","","","","fee schedule","29.25","30.11","APC"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","24.69","","","","","","","fee schedule","24.69","459.64",""
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","24.69","","","","","","","fee schedule","24.69","459.64",""
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","24.69","","","","","","","fee schedule","24.69","459.64",""
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","24.69","459.64","APC 277.30"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","24.69","459.64","APC 296.56"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","24.69","459.64","APC 308.91"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","24.69","459.64","APC"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","24.69","459.64","APC"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","24.69","459.64","APC"
"Rem ther mntr 1st setup&edu","98975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","24.69","459.64","APC"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","58.8","","","","","","","fee schedule","37.14","128.85",""
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","58.8","","","","","","","fee schedule","37.14","128.85",""
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","58.8","","","","","","","fee schedule","37.14","128.85",""
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply resp","98976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","58.8","","","","","","","fee schedule","37.14","128.85",""
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","58.8","","","","","","","fee schedule","37.14","128.85",""
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","58.8","","","","","","","fee schedule","37.14","128.85",""
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dv sply mscskl","98977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem ther mntr dev sply cbt","98978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm tx mgmt 1st 10 min","98979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.78","","","","","","","fee schedule","11.48","11.81","APC"
"Rtm tx mgmt 1st 10 min","98979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.59","","","","","","","fee schedule","11.48","11.81","APC"
"Rtm tx mgmt 1st 10 min","98979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.48","","","","","","","fee schedule","11.48","11.81","APC"
"Rtm tx mgmt 1st 10 min","98979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.81","","","","","","","fee schedule","11.48","11.81","APC"
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","37.83","","","","","","","fee schedule","25.87","37.83",""
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","37.83","","","","","","","fee schedule","25.87","37.83",""
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","37.83","","","","","","","fee schedule","25.87","37.83",""
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.56","","","","","","","fee schedule","25.87","37.83","APC"
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.12","","","","","","","fee schedule","25.87","37.83","APC"
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.87","","","","","","","fee schedule","25.87","37.83","APC"
"Rem ther mntr 1st 20 min","98980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.63","","","","","","","fee schedule","25.87","37.83","APC"
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","37.4","","","","","","","fee schedule","25.52","37.4",""
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","37.4","","","","","","","fee schedule","25.52","37.4",""
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","37.4","","","","","","","fee schedule","25.52","37.4",""
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.21","","","","","","","fee schedule","25.52","37.4","APC"
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.77","","","","","","","fee schedule","25.52","37.4","APC"
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.52","","","","","","","fee schedule","25.52","37.4","APC"
"Rem ther mntr ea addl 20 min","98981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.27","","","","","","","fee schedule","25.52","37.4","APC"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply resp sys 2-15 d","98984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply mscsk sys 2-15d","98985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rtm dev sply cbt 2-15 d","98986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Specimen handling office-lab","99000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","6.92","","","","","","","fee schedule","6.92","6.92",""
"Specimen handling office-lab","99000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","6.92","","","","","","","fee schedule","6.92","6.92",""
"Specimen handling pt-lab","99001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.23","","","","","","","fee schedule","8.23","8.23",""
"Specimen handling pt-lab","99001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.23","","","","","","","fee schedule","8.23","8.23",""
"Group health education","99078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","44","","","","","","","fee schedule","44","46",""
"Group health education","99078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","46","","","","","","","fee schedule","44","46",""
"Group health education","99078","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","44","","","","","","","fee schedule","44","46",""
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","626.55","","","","","","","fee schedule","201.2","697.97","APC 277.30"
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","670.07","","","","","","","fee schedule","201.2","697.97","APC 296.56"
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","697.97","","","","","","","fee schedule","201.2","697.97","APC 308.91"
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206.62","","","","","","","fee schedule","201.2","697.97","APC"
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.17","","","","","","","fee schedule","201.2","697.97","APC"
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.2","","","","","","","fee schedule","201.2","697.97","APC"
"Anogenital exam child w imag","99170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.12","","","","","","","fee schedule","201.2","697.97","APC"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","174","","","","","","","fee schedule","132.41","459.34",""
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","180","","","","","","","fee schedule","132.41","459.34",""
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","174","","","","","","","fee schedule","132.41","459.34",""
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","459.34","APC 277.30"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","459.34","APC 296.56"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","459.34","APC 308.91"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","459.34","APC"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","459.34","APC"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","459.34","APC"
"Phlebotomy","99195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","459.34","APC"
"Office/outpatient visit new","99202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","65.29","","","","","","","fee schedule","65.29","65.29",""
"Office/outpatient visit new","99202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","65.29","","","","","","","fee schedule","65.29","65.29",""
"Office/outpatient visit new","99202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","65.29","","","","","","","fee schedule","65.29","65.29",""
"Office/outpatient visit new","99203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","98.91","","","","","","","fee schedule","98.91","98.91",""
"Office/outpatient visit new","99203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","98.91","","","","","","","fee schedule","98.91","98.91",""
"Office/outpatient visit new","99203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","98.91","","","","","","","fee schedule","98.91","98.91",""
"Office/outpatient visit new","99204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","167.47","","","","","","","fee schedule","167.47","167.47",""
"Office/outpatient visit new","99204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","167.47","","","","","","","fee schedule","167.47","167.47",""
"Office/outpatient visit new","99204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","167.47","","","","","","","fee schedule","167.47","167.47",""
"Office/outpatient visit est","99212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","32.87","","","","","","","fee schedule","32.87","32.87",""
"Office/outpatient visit est","99212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","32.87","","","","","","","fee schedule","32.87","32.87",""
"Office/outpatient visit est","99212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","32.87","","","","","","","fee schedule","32.87","32.87",""
"Office/outpatient visit est","99213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","65.81","","","","","","","fee schedule","65.81","65.81",""
"Office/outpatient visit est","99213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","65.81","","","","","","","fee schedule","65.81","65.81",""
"Office/outpatient visit est","99213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","65.81","","","","","","","fee schedule","65.81","65.81",""
"Office/outpatient visit est","99214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","101.51","","","","","","","fee schedule","101.51","101.51",""
"Office/outpatient visit est","99214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","101.51","","","","","","","fee schedule","101.51","101.51",""
"Office/outpatient visit est","99214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","101.51","","","","","","","fee schedule","101.51","101.51",""
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","261.33","","","","","","","fee schedule","83.92","291.12","APC 277.30"
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","279.48","","","","","","","fee schedule","83.92","291.12","APC 296.56"
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","291.12","","","","","","","fee schedule","83.92","291.12","APC 308.91"
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","86.18","","","","","","","fee schedule","83.92","291.12","APC"
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","84.74","","","","","","","fee schedule","83.92","291.12","APC"
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","83.92","","","","","","","fee schedule","83.92","291.12","APC"
"Emergency dept visit","99281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","86.39","","","","","","","fee schedule","83.92","291.12","APC"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","475.85","","","","","","","fee schedule","152.81","530.1","APC 277.30"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","508.9","","","","","","","fee schedule","152.81","530.1","APC 296.56"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","530.1","","","","","","","fee schedule","152.81","530.1","APC 308.91"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","156.93","","","","","","","fee schedule","152.81","530.1","APC"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.31","","","","","","","fee schedule","152.81","530.1","APC"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","152.81","","","","","","","fee schedule","152.81","530.1","APC"
"Emergency dept visit","99282","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.3","","","","","","","fee schedule","152.81","530.1","APC"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","845.99","","","","","","","fee schedule","271.67","942.43","APC 277.30"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","904.75","","","","","","","fee schedule","271.67","942.43","APC 296.56"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","942.43","","","","","","","fee schedule","271.67","942.43","APC 308.91"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","278.99","","","","","","","fee schedule","271.67","942.43","APC"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","274.33","","","","","","","fee schedule","271.67","942.43","APC"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","271.67","","","","","","","fee schedule","271.67","942.43","APC"
"Emergency dept visit","99283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","279.66","","","","","","","fee schedule","271.67","942.43","APC"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1293.15","","","","","","","fee schedule","415.26","1440.55","APC 277.30"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1382.96","","","","","","","fee schedule","415.26","1440.55","APC 296.56"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1440.55","","","","","","","fee schedule","415.26","1440.55","APC 308.91"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","426.45","","","","","","","fee schedule","415.26","1440.55","APC"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","419.33","","","","","","","fee schedule","415.26","1440.55","APC"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","415.26","","","","","","","fee schedule","415.26","1440.55","APC"
"Emergency dept visit","99284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","427.47","","","","","","","fee schedule","415.26","1440.55","APC"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1845.62","","","","","","","fee schedule","592.67","2056.01","APC 277.30"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1973.81","","","","","","","fee schedule","592.67","2056.01","APC 296.56"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2056.01","","","","","","","fee schedule","592.67","2056.01","APC 308.91"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","608.65","","","","","","","fee schedule","592.67","2056.01","APC"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","598.48","","","","","","","fee schedule","592.67","2056.01","APC"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","592.67","","","","","","","fee schedule","592.67","2056.01","APC"
"Emergency dept visit","99285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","610.1","","","","","","","fee schedule","592.67","2056.01","APC"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2559.96","","","","","","","fee schedule","822.06","2851.78","APC 277.30"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2737.77","","","","","","","fee schedule","822.06","2851.78","APC 296.56"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2851.78","","","","","","","fee schedule","822.06","2851.78","APC 308.91"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","844.23","","","","","","","fee schedule","822.06","2851.78","APC"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","830.12","","","","","","","fee schedule","822.06","2851.78","APC"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","822.06","","","","","","","fee schedule","822.06","2851.78","APC"
"Critical care first hour","99291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","846.24","","","","","","","fee schedule","822.06","2851.78","APC"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking 3-10 min","99406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Behav chng smoking > 10 min","99407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Ol dig e/m svc 5-10 min","99421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","15.76","","","","","","","fee schedule","15.76","15.76",""
"Ol dig e/m svc 5-10 min","99421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","15.76","","","","","","","fee schedule","15.76","15.76",""
"Ol dig e/m svc 5-10 min","99421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","15.76","","","","","","","fee schedule","15.76","15.76",""
"Ol dig e/m svc 11-20 min","99422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","31.1","","","","","","","fee schedule","31.1","31.1",""
"Ol dig e/m svc 11-20 min","99422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","31.1","","","","","","","fee schedule","31.1","31.1",""
"Ol dig e/m svc 11-20 min","99422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","31.1","","","","","","","fee schedule","31.1","31.1",""
"Ol dig e/m svc 21+ min","99423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","49.8","","","","","","","fee schedule","49.8","49.8",""
"Ol dig e/m svc 21+ min","99423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","49.8","","","","","","","fee schedule","49.8","49.8",""
"Ol dig e/m svc 21+ min","99423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","49.8","","","","","","","fee schedule","49.8","49.8",""
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param 2-15","99445","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr physiol param setup","99453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.66","","","","","","","fee schedule","37.14","128.85","APC 277.30"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.7","","","","","","","fee schedule","37.14","128.85","APC 296.56"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.85","","","","","","","fee schedule","37.14","128.85","APC 308.91"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.51","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.14","","","","","","","fee schedule","37.14","128.85","APC"
"Rem mntr physiol param dev","99454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.23","","","","","","","fee schedule","37.14","128.85","APC"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Init nb em per day hosp","99460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Same day nb discharge","99463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2048.35","","","","","","","fee schedule","657.77","2281.84","APC 277.30"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2190.62","","","","","","","fee schedule","657.77","2281.84","APC 296.56"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2281.84","","","","","","","fee schedule","657.77","2281.84","APC 308.91"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","675.5","","","","","","","fee schedule","657.77","2281.84","APC"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","664.22","","","","","","","fee schedule","657.77","2281.84","APC"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","657.77","","","","","","","fee schedule","657.77","2281.84","APC"
"Nb resuscitation","99465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","677.12","","","","","","","fee schedule","657.77","2281.84","APC"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Self-meas bp pt educaj/train","99473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Care mgmt svc bhvl hlth cond","99484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 14 day disch","99495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Trans care mgmt 7 day disch","99496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Vag inser rectal control sys","A4563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1718.21","","","","","","","fee schedule","1673.11","1722.32","APC"
"Vag inser rectal control sys","A4563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1689.51","","","","","","","fee schedule","1673.11","1722.32","APC"
"Vag inser rectal control sys","A4563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1673.11","","","","","","","fee schedule","1673.11","1722.32","APC"
"Vag inser rectal control sys","A4563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1722.32","","","","","","","fee schedule","1673.11","1722.32","APC"
"Neuromod sti sys adj rehab","A4593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.72","","","","","","","fee schedule","50.36","51.84","APC"
"Neuromod sti sys adj rehab","A4593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.85","","","","","","","fee schedule","50.36","51.84","APC"
"Neuromod sti sys adj rehab","A4593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.36","","","","","","","fee schedule","50.36","51.84","APC"
"Neuromod sti sys adj rehab","A4593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.84","","","","","","","fee schedule","50.36","51.84","APC"
"G com garmnt glove nghttime","A6520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","132.46","","","","","","","fee schedule","128.98","132.77","APC"
"G com garmnt glove nghttime","A6520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","130.24","","","","","","","fee schedule","128.98","132.77","APC"
"G com garmnt glove nghttime","A6520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.98","","","","","","","fee schedule","128.98","132.77","APC"
"G com garmnt glove nghttime","A6520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.77","","","","","","","fee schedule","128.98","132.77","APC"
"G com garmnt glove nght cust","A6521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","525.58","","","","","","","fee schedule","511.78","526.84","APC"
"G com garmnt glove nght cust","A6521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","516.8","","","","","","","fee schedule","511.78","526.84","APC"
"G com garmnt glove nght cust","A6521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","511.78","","","","","","","fee schedule","511.78","526.84","APC"
"G com garmnt glove nght cust","A6521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","526.84","","","","","","","fee schedule","511.78","526.84","APC"
"G com garment arm nighttime","A6522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","321.85","","","","","","","fee schedule","313.41","322.62","APC"
"G com garment arm nighttime","A6522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","316.48","","","","","","","fee schedule","313.41","322.62","APC"
"G com garment arm nighttime","A6522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","313.41","","","","","","","fee schedule","313.41","322.62","APC"
"G com garment arm nighttime","A6522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","322.62","","","","","","","fee schedule","313.41","322.62","APC"
"G com garment arm nght custm","A6523","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","763.65","","","","","","","fee schedule","743.6","765.47","APC"
"G com garment arm nght custm","A6523","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","750.89","","","","","","","fee schedule","743.6","765.47","APC"
"G com garment arm nght custm","A6523","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","743.6","","","","","","","fee schedule","743.6","765.47","APC"
"G com garment arm nght custm","A6523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","765.47","","","","","","","fee schedule","743.6","765.47","APC"
"G com garmnt lwr leg/ft nght","A6524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","401.55","","","","","","","fee schedule","391.01","402.51","APC"
"G com garmnt lwr leg/ft nght","A6524","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","394.84","","","","","","","fee schedule","391.01","402.51","APC"
"G com garmnt lwr leg/ft nght","A6524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","391.01","","","","","","","fee schedule","391.01","402.51","APC"
"G com garmnt lwr leg/ft nght","A6524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","402.51","","","","","","","fee schedule","391.01","402.51","APC"
"G com garm lwrleg/ft ngt cus","A6525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","810.66","","","","","","","fee schedule","789.38","812.6","APC"
"G com garm lwrleg/ft ngt cus","A6525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","797.12","","","","","","","fee schedule","789.38","812.6","APC"
"G com garm lwrleg/ft ngt cus","A6525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","789.38","","","","","","","fee schedule","789.38","812.6","APC"
"G com garm lwrleg/ft ngt cus","A6525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","812.6","","","","","","","fee schedule","789.38","812.6","APC"
"G com garmt full leg/ft nght","A6526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","725.98","","","","","","","fee schedule","706.92","727.71","APC"
"G com garmt full leg/ft nght","A6526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","713.85","","","","","","","fee schedule","706.92","727.71","APC"
"G com garmt full leg/ft nght","A6526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","706.92","","","","","","","fee schedule","706.92","727.71","APC"
"G com garmt full leg/ft nght","A6526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","727.71","","","","","","","fee schedule","706.92","727.71","APC"
"G garmt full leg/ft nght cus","A6527","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1334.99","","","","","","","fee schedule","1299.94","1338.17","APC"
"G garmt full leg/ft nght cus","A6527","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1312.68","","","","","","","fee schedule","1299.94","1338.17","APC"
"G garmt full leg/ft nght cus","A6527","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1299.94","","","","","","","fee schedule","1299.94","1338.17","APC"
"G garmt full leg/ft nght cus","A6527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1338.17","","","","","","","fee schedule","1299.94","1338.17","APC"
"G com garment bra nighttime","A6528","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","698.07","","","","","","","fee schedule","679.75","699.74","APC"
"G com garment bra nighttime","A6528","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","686.41","","","","","","","fee schedule","679.75","699.74","APC"
"G com garment bra nighttime","A6528","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","679.75","","","","","","","fee schedule","679.75","699.74","APC"
"G com garment bra nighttime","A6528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","699.74","","","","","","","fee schedule","679.75","699.74","APC"
"G com garmt bra night custm","A6529","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1103.06","","","","","","","fee schedule","1074.1","1105.69","APC"
"G com garmt bra night custm","A6529","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1084.63","","","","","","","fee schedule","1074.1","1105.69","APC"
"G com garmt bra night custm","A6529","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1074.1","","","","","","","fee schedule","1074.1","1105.69","APC"
"G com garmt bra night custm","A6529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1105.69","","","","","","","fee schedule","1074.1","1105.69","APC"
"Compression stocking bk18-30","A6530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40.93","","","","","","","fee schedule","39.85","41.02","APC"
"Compression stocking bk18-30","A6530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.24","","","","","","","fee schedule","39.85","41.02","APC"
"Compression stocking bk18-30","A6530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39.85","","","","","","","fee schedule","39.85","41.02","APC"
"Compression stocking bk18-30","A6530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.02","","","","","","","fee schedule","39.85","41.02","APC"
"Compression stocking bk30-40","A6531","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.59","","","","","","","fee schedule","62.89","64.74","APC"
"Compression stocking bk30-40","A6531","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.51","","","","","","","fee schedule","62.89","64.74","APC"
"Compression stocking bk30-40","A6531","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.89","","","","","","","fee schedule","62.89","64.74","APC"
"Compression stocking bk30-40","A6531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.74","","","","","","","fee schedule","62.89","64.74","APC"
"Compression stocking bk40-50","A6532","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","91.01","","","","","","","fee schedule","88.62","91.22","APC"
"Compression stocking bk40-50","A6532","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","89.49","","","","","","","fee schedule","88.62","91.22","APC"
"Compression stocking bk40-50","A6532","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","88.62","","","","","","","fee schedule","88.62","91.22","APC"
"Compression stocking bk40-50","A6532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","91.22","","","","","","","fee schedule","88.62","91.22","APC"
"Gc stocking thighlngth 18-30","A6533","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57.47","","","","","","","fee schedule","55.96","57.6","APC"
"Gc stocking thighlngth 18-30","A6533","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","56.51","","","","","","","fee schedule","55.96","57.6","APC"
"Gc stocking thighlngth 18-30","A6533","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","55.96","","","","","","","fee schedule","55.96","57.6","APC"
"Gc stocking thighlngth 18-30","A6533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57.6","","","","","","","fee schedule","55.96","57.6","APC"
"Gc stocking thighlngth 30-40","A6534","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.63","","","","","","","fee schedule","63.9","65.78","APC"
"Gc stocking thighlngth 30-40","A6534","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64.53","","","","","","","fee schedule","63.9","65.78","APC"
"Gc stocking thighlngth 30-40","A6534","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.9","","","","","","","fee schedule","63.9","65.78","APC"
"Gc stocking thighlngth 30-40","A6534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.78","","","","","","","fee schedule","63.9","65.78","APC"
"Gc stocking thighlngth 40-50","A6535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","75.56","","","","","","","fee schedule","73.57","75.74","APC"
"Gc stocking thighlngth 40-50","A6535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","74.29","","","","","","","fee schedule","73.57","75.74","APC"
"Gc stocking thighlngth 40-50","A6535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","73.57","","","","","","","fee schedule","73.57","75.74","APC"
"Gc stocking thighlngth 40-50","A6535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","75.74","","","","","","","fee schedule","73.57","75.74","APC"
"Gc stocking full lngth 18-30","A6536","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","77.46","","","","","","","fee schedule","75.43","77.65","APC"
"Gc stocking full lngth 18-30","A6536","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.17","","","","","","","fee schedule","75.43","77.65","APC"
"Gc stocking full lngth 18-30","A6536","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","75.43","","","","","","","fee schedule","75.43","77.65","APC"
"Gc stocking full lngth 18-30","A6536","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","77.65","","","","","","","fee schedule","75.43","77.65","APC"
"Gc stocking full lngth 30-40","A6537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","91.83","","","","","","","fee schedule","89.42","92.05","APC"
"Gc stocking full lngth 30-40","A6537","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","90.3","","","","","","","fee schedule","89.42","92.05","APC"
"Gc stocking full lngth 30-40","A6537","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","89.42","","","","","","","fee schedule","89.42","92.05","APC"
"Gc stocking full lngth 30-40","A6537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.05","","","","","","","fee schedule","89.42","92.05","APC"
"Gc stocking full lngth 40-50","A6538","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.53","","","","","","","fee schedule","104.7","107.78","APC"
"Gc stocking full lngth 40-50","A6538","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.73","","","","","","","fee schedule","104.7","107.78","APC"
"Gc stocking full lngth 40-50","A6538","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.7","","","","","","","fee schedule","104.7","107.78","APC"
"Gc stocking full lngth 40-50","A6538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.78","","","","","","","fee schedule","104.7","107.78","APC"
"Gc stocking waistlngth 18-30","A6539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","102.51","","","","","","","fee schedule","99.82","102.75","APC"
"Gc stocking waistlngth 18-30","A6539","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","100.8","","","","","","","fee schedule","99.82","102.75","APC"
"Gc stocking waistlngth 18-30","A6539","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","99.82","","","","","","","fee schedule","99.82","102.75","APC"
"Gc stocking waistlngth 18-30","A6539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","102.75","","","","","","","fee schedule","99.82","102.75","APC"
"Gc stocking waistlngth 30-40","A6540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","122.22","","","","","","","fee schedule","119.01","122.51","APC"
"Gc stocking waistlngth 30-40","A6540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","120.18","","","","","","","fee schedule","119.01","122.51","APC"
"Gc stocking waistlngth 30-40","A6540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","119.01","","","","","","","fee schedule","119.01","122.51","APC"
"Gc stocking waistlngth 30-40","A6540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","122.51","","","","","","","fee schedule","119.01","122.51","APC"
"Gc stocking waistlngth 40-50","A6541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","144.77","","","","","","","fee schedule","140.97","145.12","APC"
"Gc stocking waistlngth 40-50","A6541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","142.36","","","","","","","fee schedule","140.97","145.12","APC"
"Gc stocking waistlngth 40-50","A6541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","140.97","","","","","","","fee schedule","140.97","145.12","APC"
"Gc stocking waistlngth 40-50","A6541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","145.12","","","","","","","fee schedule","140.97","145.12","APC"
"Grad comp non-elastic BK","A6545","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","127.18","","","","","","","fee schedule","123.84","127.48","APC"
"Grad comp non-elastic BK","A6545","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","125.05","","","","","","","fee schedule","123.84","127.48","APC"
"Grad comp non-elastic BK","A6545","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","123.84","","","","","","","fee schedule","123.84","127.48","APC"
"Grad comp non-elastic BK","A6545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","127.48","","","","","","","fee schedule","123.84","127.48","APC"
"Grad com stocking bk 30-40","A6552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.72","","","","","","","fee schedule","59.13","60.87","APC"
"Grad com stocking bk 30-40","A6552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.71","","","","","","","fee schedule","59.13","60.87","APC"
"Grad com stocking bk 30-40","A6552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.13","","","","","","","fee schedule","59.13","60.87","APC"
"Grad com stocking bk 30-40","A6552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.87","","","","","","","fee schedule","59.13","60.87","APC"
"G com stcking bk 30-40 custm","A6553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","237.13","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 30-40 custm","A6553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","233.17","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 30-40 custm","A6553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","230.91","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 30-40 custm","A6553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","237.7","","","","","","","fee schedule","230.91","237.7","APC"
"Grad com stocking bk 40+","A6554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","83.51","","","","","","","fee schedule","81.31","83.71","APC"
"Grad com stocking bk 40+","A6554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","82.11","","","","","","","fee schedule","81.31","83.71","APC"
"Grad com stocking bk 40+","A6554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","81.31","","","","","","","fee schedule","81.31","83.71","APC"
"Grad com stocking bk 40+","A6554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.71","","","","","","","fee schedule","81.31","83.71","APC"
"G com stcking bk 40+ custm","A6555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","237.13","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 40+ custm","A6555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","233.17","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 40+ custm","A6555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","230.91","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 40+ custm","A6555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","237.7","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking thgh18-30 cust","A6556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.99","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh18-30 cust","A6556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","319.56","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh18-30 cust","A6556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","316.46","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh18-30 cust","A6556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.76","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh30-40 cust","A6557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.99","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh30-40 cust","A6557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","319.56","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh30-40 cust","A6557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","316.46","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh30-40 cust","A6557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.76","","","","","","","fee schedule","316.46","325.76","APC"
"G com stcking thgh 40+ cust","A6558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","335.38","","","","","","","fee schedule","326.57","336.18","APC"
"G com stcking thgh 40+ cust","A6558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","329.78","","","","","","","fee schedule","326.57","336.18","APC"
"G com stcking thgh 40+ cust","A6558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","326.57","","","","","","","fee schedule","326.57","336.18","APC"
"G com stcking thgh 40+ cust","A6558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","336.18","","","","","","","fee schedule","326.57","336.18","APC"
"G com stckng waist18-30 cust","A6562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1063.6","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist18-30 cust","A6562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1045.83","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist18-30 cust","A6562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1035.68","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist18-30 cust","A6562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1066.14","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist30-40 cust","A6563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1063.6","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist30-40 cust","A6563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1045.83","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist30-40 cust","A6563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1035.68","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist30-40 cust","A6563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1066.14","","","","","","","fee schedule","1035.68","1066.14","APC"
"G com stckng waist 40+ cust","A6564","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1145.73","","","","","","","fee schedule","1115.66","1148.47","APC"
"G com stckng waist 40+ cust","A6564","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1126.59","","","","","","","fee schedule","1115.66","1148.47","APC"
"G com stckng waist 40+ cust","A6564","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1115.66","","","","","","","fee schedule","1115.66","1148.47","APC"
"G com stckng waist 40+ cust","A6564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1148.47","","","","","","","fee schedule","1115.66","1148.47","APC"
"Grad comp gauntlet custom","A6565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.78","","","","","","","fee schedule","178.96","184.22","APC"
"Grad comp gauntlet custom","A6565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.71","","","","","","","fee schedule","178.96","184.22","APC"
"Grad comp gauntlet custom","A6565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.96","","","","","","","fee schedule","178.96","184.22","APC"
"Grad comp gauntlet custom","A6565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.22","","","","","","","fee schedule","178.96","184.22","APC"
"Grad com garment neck/head","A6566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","266.85","","","","","","","fee schedule","259.85","267.49","APC"
"Grad com garment neck/head","A6566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","262.39","","","","","","","fee schedule","259.85","267.49","APC"
"Grad com garment neck/head","A6566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","259.85","","","","","","","fee schedule","259.85","267.49","APC"
"Grad com garment neck/head","A6566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","267.49","","","","","","","fee schedule","259.85","267.49","APC"
"G com garment neck/head cust","A6567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","838.44","","","","","","","fee schedule","816.43","840.44","APC"
"G com garment neck/head cust","A6567","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","824.43","","","","","","","fee schedule","816.43","840.44","APC"
"G com garment neck/head cust","A6567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","816.43","","","","","","","fee schedule","816.43","840.44","APC"
"G com garment neck/head cust","A6567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","840.44","","","","","","","fee schedule","816.43","840.44","APC"
"G com garment torso/shldr","A6568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","174.16","","","","","","","fee schedule","169.59","174.57","APC"
"G com garment torso/shldr","A6568","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","171.25","","","","","","","fee schedule","169.59","174.57","APC"
"G com garment torso/shldr","A6568","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.59","","","","","","","fee schedule","169.59","174.57","APC"
"G com garment torso/shldr","A6568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.57","","","","","","","fee schedule","169.59","174.57","APC"
"G com garmnt torso/shdr cust","A6569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","991.71","","","","","","","fee schedule","965.67","994.08","APC"
"G com garmnt torso/shdr cust","A6569","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","975.14","","","","","","","fee schedule","965.67","994.08","APC"
"G com garmnt torso/shdr cust","A6569","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","965.67","","","","","","","fee schedule","965.67","994.08","APC"
"G com garmnt torso/shdr cust","A6569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","994.08","","","","","","","fee schedule","965.67","994.08","APC"
"Grad com garment genital","A6570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","118.66","","","","","","","fee schedule","115.55","118.94","APC"
"Grad com garment genital","A6570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","116.68","","","","","","","fee schedule","115.55","118.94","APC"
"Grad com garment genital","A6570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","115.55","","","","","","","fee schedule","115.55","118.94","APC"
"Grad com garment genital","A6570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","118.94","","","","","","","fee schedule","115.55","118.94","APC"
"G com garment genital custm","A6571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","713.18","","","","","","","fee schedule","694.46","714.88","APC"
"G com garment genital custm","A6571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","701.27","","","","","","","fee schedule","694.46","714.88","APC"
"G com garment genital custm","A6571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","694.46","","","","","","","fee schedule","694.46","714.88","APC"
"G com garment genital custm","A6571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","714.88","","","","","","","fee schedule","694.46","714.88","APC"
"Grad com garment toe caps","A6572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","110.1","","","","","","","fee schedule","107.21","110.37","APC"
"Grad com garment toe caps","A6572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","108.26","","","","","","","fee schedule","107.21","110.37","APC"
"Grad com garment toe caps","A6572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","107.21","","","","","","","fee schedule","107.21","110.37","APC"
"Grad com garment toe caps","A6572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","110.37","","","","","","","fee schedule","107.21","110.37","APC"
"Grad com garmnt toe cap cust","A6573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","261.28","","","","","","","fee schedule","254.42","261.9","APC"
"Grad com garmnt toe cap cust","A6573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","256.91","","","","","","","fee schedule","254.42","261.9","APC"
"Grad com garmnt toe cap cust","A6573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","254.42","","","","","","","fee schedule","254.42","261.9","APC"
"Grad com garmnt toe cap cust","A6573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","261.9","","","","","","","fee schedule","254.42","261.9","APC"
"Custom gradient sleev/glov","A6574","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","333.09","","","","","","","fee schedule","324.35","333.89","APC"
"Custom gradient sleev/glov","A6574","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","327.53","","","","","","","fee schedule","324.35","333.89","APC"
"Custom gradient sleev/glov","A6574","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","324.35","","","","","","","fee schedule","324.35","333.89","APC"
"Custom gradient sleev/glov","A6574","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","333.89","","","","","","","fee schedule","324.35","333.89","APC"
"Gradient comp sleev/glov","A6575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.94","","","","","","","fee schedule","105.11","108.2","APC"
"Gradient comp sleev/glov","A6575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.14","","","","","","","fee schedule","105.11","108.2","APC"
"Gradient comp sleev/glov","A6575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","105.11","","","","","","","fee schedule","105.11","108.2","APC"
"Gradient comp sleev/glov","A6575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.2","","","","","","","fee schedule","105.11","108.2","APC"
"Custom grad com sleeve med","A6576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","204.43","","","","","","","fee schedule","199.06","204.92","APC"
"Custom grad com sleeve med","A6576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.01","","","","","","","fee schedule","199.06","204.92","APC"
"Custom grad com sleeve med","A6576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.06","","","","","","","fee schedule","199.06","204.92","APC"
"Custom grad com sleeve med","A6576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.92","","","","","","","fee schedule","199.06","204.92","APC"
"Custom grad cm sleeve heavy","A6577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","169.2","","","","","","","fee schedule","164.76","169.61","APC"
"Custom grad cm sleeve heavy","A6577","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","166.38","","","","","","","fee schedule","164.76","169.61","APC"
"Custom grad cm sleeve heavy","A6577","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","164.76","","","","","","","fee schedule","164.76","169.61","APC"
"Custom grad cm sleeve heavy","A6577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","169.61","","","","","","","fee schedule","164.76","169.61","APC"
"Gradient comp sleeve","A6578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","83.33","","","","","","","fee schedule","81.14","83.53","APC"
"Gradient comp sleeve","A6578","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.94","","","","","","","fee schedule","81.14","83.53","APC"
"Gradient comp sleeve","A6578","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","81.14","","","","","","","fee schedule","81.14","83.53","APC"
"Gradient comp sleeve","A6578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.53","","","","","","","fee schedule","81.14","83.53","APC"
"Custom grad com glove med","A6579","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","328.14","","","","","","","fee schedule","319.53","328.92","APC"
"Custom grad com glove med","A6579","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","322.66","","","","","","","fee schedule","319.53","328.92","APC"
"Custom grad com glove med","A6579","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","319.53","","","","","","","fee schedule","319.53","328.92","APC"
"Custom grad com glove med","A6579","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","328.92","","","","","","","fee schedule","319.53","328.92","APC"
"Custom grad com glove heavy","A6580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","325.73","","","","","","","fee schedule","317.18","326.51","APC"
"Custom grad com glove heavy","A6580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","320.29","","","","","","","fee schedule","317.18","326.51","APC"
"Custom grad com glove heavy","A6580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","317.18","","","","","","","fee schedule","317.18","326.51","APC"
"Custom grad com glove heavy","A6580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","326.51","","","","","","","fee schedule","317.18","326.51","APC"
"Gradient comp glove","A6581","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.46","","","","","","","fee schedule","74.45","76.64","APC"
"Gradient comp glove","A6581","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.18","","","","","","","fee schedule","74.45","76.64","APC"
"Gradient comp glove","A6581","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.45","","","","","","","fee schedule","74.45","76.64","APC"
"Gradient comp glove","A6581","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.64","","","","","","","fee schedule","74.45","76.64","APC"
"Gradient comp gauntlet","A6582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50.99","","","","","","","fee schedule","49.65","51.11","APC"
"Gradient comp gauntlet","A6582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.14","","","","","","","fee schedule","49.65","51.11","APC"
"Gradient comp gauntlet","A6582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.65","","","","","","","fee schedule","49.65","51.11","APC"
"Gradient comp gauntlet","A6582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.11","","","","","","","fee schedule","49.65","51.11","APC"
"Grad com wrap w straps bk","A6583","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","167.74","","","","","","","fee schedule","163.33","168.14","APC"
"Grad com wrap w straps bk","A6583","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","164.93","","","","","","","fee schedule","163.33","168.14","APC"
"Grad com wrap w straps bk","A6583","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","163.33","","","","","","","fee schedule","163.33","168.14","APC"
"Grad com wrap w straps bk","A6583","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","168.14","","","","","","","fee schedule","163.33","168.14","APC"
"Grad com wrap w straps ak","A6585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","198.61","","","","","","","fee schedule","193.39","199.08","APC"
"Grad com wrap w straps ak","A6585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","195.29","","","","","","","fee schedule","193.39","199.08","APC"
"Grad com wrap w straps ak","A6585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","193.39","","","","","","","fee schedule","193.39","199.08","APC"
"Grad com wrap w straps ak","A6585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","199.08","","","","","","","fee schedule","193.39","199.08","APC"
"Grad com wrap w straps leg","A6586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","585.12","","","","","","","fee schedule","569.76","586.52","APC"
"Grad com wrap w straps leg","A6586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","575.35","","","","","","","fee schedule","569.76","586.52","APC"
"Grad com wrap w straps leg","A6586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","569.76","","","","","","","fee schedule","569.76","586.52","APC"
"Grad com wrap w straps leg","A6586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","586.52","","","","","","","fee schedule","569.76","586.52","APC"
"Grad com wrap w straps foot","A6587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.65","","","","","","","fee schedule","74.63","76.83","APC"
"Grad com wrap w straps foot","A6587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.37","","","","","","","fee schedule","74.63","76.83","APC"
"Grad com wrap w straps foot","A6587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.63","","","","","","","fee schedule","74.63","76.83","APC"
"Grad com wrap w straps foot","A6587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.83","","","","","","","fee schedule","74.63","76.83","APC"
"Grad com wrap w straps arm","A6588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.45","","","","","","","fee schedule","248.75","256.06","APC"
"Grad com wrap w straps arm","A6588","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.19","","","","","","","fee schedule","248.75","256.06","APC"
"Grad com wrap w straps arm","A6588","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.75","","","","","","","fee schedule","248.75","256.06","APC"
"Grad com wrap w straps arm","A6588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","256.06","","","","","","","fee schedule","248.75","256.06","APC"
"Grad com wrap w straps bra","A6589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.84","","","","","","","fee schedule","98.2","101.08","APC"
"Grad com wrap w straps bra","A6589","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","99.16","","","","","","","fee schedule","98.2","101.08","APC"
"Grad com wrap w straps bra","A6589","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","98.2","","","","","","","fee schedule","98.2","101.08","APC"
"Grad com wrap w straps bra","A6589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","101.08","","","","","","","fee schedule","98.2","101.08","APC"
"G comp bandge liner lwr extr","A6594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.71","","","","","","","fee schedule","35.75","36.8","APC"
"G comp bandge liner lwr extr","A6594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.1","","","","","","","fee schedule","35.75","36.8","APC"
"G comp bandge liner lwr extr","A6594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.75","","","","","","","fee schedule","35.75","36.8","APC"
"G comp bandge liner lwr extr","A6594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.8","","","","","","","fee schedule","35.75","36.8","APC"
"G comp bandge liner upr extr","A6595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.12","","","","","","","fee schedule","35.17","36.2","APC"
"G comp bandge liner upr extr","A6595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.51","","","","","","","fee schedule","35.17","36.2","APC"
"G comp bandge liner upr extr","A6595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.17","","","","","","","fee schedule","35.17","36.2","APC"
"G comp bandge liner upr extr","A6595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.2","","","","","","","fee schedule","35.17","36.2","APC"
"G comp bandge conform gauze","A6596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.19","","","","","","","fee schedule","0.18","0.19","APC"
"G comp bandge conform gauze","A6596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.19","","","","","","","fee schedule","0.18","0.19","APC"
"G comp bandge conform gauze","A6596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.18","","","","","","","fee schedule","0.18","0.19","APC"
"G comp bandge conform gauze","A6596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.19","","","","","","","fee schedule","0.18","0.19","APC"
"G comp bandage long stretch","A6597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.62","","","","","","","fee schedule","1.58","1.63","APC"
"G comp bandage long stretch","A6597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.6","","","","","","","fee schedule","1.58","1.63","APC"
"G comp bandage long stretch","A6597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.58","","","","","","","fee schedule","1.58","1.63","APC"
"G comp bandage long stretch","A6597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.63","","","","","","","fee schedule","1.58","1.63","APC"
"G comp bandage med stretch","A6598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.79","","","","","","","fee schedule","0.76","0.79","APC"
"G comp bandage med stretch","A6598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.77","","","","","","","fee schedule","0.76","0.79","APC"
"G comp bandage med stretch","A6598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.76","","","","","","","fee schedule","0.76","0.79","APC"
"G comp bandage med stretch","A6598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.79","","","","","","","fee schedule","0.76","0.79","APC"
"G comp bandage short stretch","A6599","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.78","","","","","","","fee schedule","1.73","1.78","APC"
"G comp bandage short stretch","A6599","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.75","","","","","","","fee schedule","1.73","1.78","APC"
"G comp bandage short stretch","A6599","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.73","","","","","","","fee schedule","1.73","1.78","APC"
"G comp bandage short stretch","A6599","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.78","","","","","","","fee schedule","1.73","1.78","APC"
"G com bandge hgh dn foam sht","A6600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.22","","","","","","","fee schedule","3.13","3.22","APC"
"G com bandge hgh dn foam sht","A6600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.16","","","","","","","fee schedule","3.13","3.22","APC"
"G com bandge hgh dn foam sht","A6600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.13","","","","","","","fee schedule","3.13","3.22","APC"
"G com bandge hgh dn foam sht","A6600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.22","","","","","","","fee schedule","3.13","3.22","APC"
"G com bandge hgh dn foam pad","A6601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.61","","","","","","","fee schedule","3.52","3.62","APC"
"G com bandge hgh dn foam pad","A6601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.55","","","","","","","fee schedule","3.52","3.62","APC"
"G com bandge hgh dn foam pad","A6601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.52","","","","","","","fee schedule","3.52","3.62","APC"
"G com bandge hgh dn foam pad","A6601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.62","","","","","","","fee schedule","3.52","3.62","APC"
"G com bandge hgh dn foamroll","A6602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.27","","","","","","","fee schedule","5.13","5.28","APC"
"G com bandge hgh dn foamroll","A6602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.18","","","","","","","fee schedule","5.13","5.28","APC"
"G com bandge hgh dn foamroll","A6602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.13","","","","","","","fee schedule","5.13","5.28","APC"
"G com bandge hgh dn foamroll","A6602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.28","","","","","","","fee schedule","5.13","5.28","APC"
"G com bandge low dn foamchnl","A6603","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.47","","","","","","","fee schedule","2.41","2.48","APC"
"G com bandge low dn foamchnl","A6603","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.43","","","","","","","fee schedule","2.41","2.48","APC"
"G com bandge low dn foamchnl","A6603","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.41","","","","","","","fee schedule","2.41","2.48","APC"
"G com bandge low dn foamchnl","A6603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.48","","","","","","","fee schedule","2.41","2.48","APC"
"G com bandge low dn foam flt","A6604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.45","","","","","","","fee schedule","1.41","1.45","APC"
"G com bandge low dn foam flt","A6604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.42","","","","","","","fee schedule","1.41","1.45","APC"
"G com bandge low dn foam flt","A6604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.41","","","","","","","fee schedule","1.41","1.45","APC"
"G com bandge low dn foam flt","A6604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.45","","","","","","","fee schedule","1.41","1.45","APC"
"G com bandage padded foam","A6605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.64","","","","","","","fee schedule","1.6","1.65","APC"
"G com bandage padded foam","A6605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.62","","","","","","","fee schedule","1.6","1.65","APC"
"G com bandage padded foam","A6605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.6","","","","","","","fee schedule","1.6","1.65","APC"
"G com bandage padded foam","A6605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.65","","","","","","","fee schedule","1.6","1.65","APC"
"G com bandage padded textile","A6606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.89","","","","","","","fee schedule","4.76","4.9","APC"
"G com bandage padded textile","A6606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.81","","","","","","","fee schedule","4.76","4.9","APC"
"G com bandage padded textile","A6606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.76","","","","","","","fee schedule","4.76","4.9","APC"
"G com bandage padded textile","A6606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.9","","","","","","","fee schedule","4.76","4.9","APC"
"G com bandage tub protct lyr","A6607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.31","","","","","","","fee schedule","1.27","1.31","APC"
"G com bandage tub protct lyr","A6607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.29","","","","","","","fee schedule","1.27","1.31","APC"
"G com bandage tub protct lyr","A6607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.27","","","","","","","fee schedule","1.27","1.31","APC"
"G com bandage tub protct lyr","A6607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.31","","","","","","","fee schedule","1.27","1.31","APC"
"G com bandage tub protct pad","A6608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.46","","","","","","","fee schedule","5.31","5.47","APC"
"G com bandage tub protct pad","A6608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.37","","","","","","","fee schedule","5.31","5.47","APC"
"G com bandage tub protct pad","A6608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.31","","","","","","","fee schedule","5.31","5.47","APC"
"G com bandage tub protct pad","A6608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.47","","","","","","","fee schedule","5.31","5.47","APC"
"G com stcking bk 18-30 custm","A6610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","237.13","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 18-30 custm","A6610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","233.17","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 18-30 custm","A6610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","230.91","","","","","","","fee schedule","230.91","237.7","APC"
"G com stcking bk 18-30 custm","A6610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","237.7","","","","","","","fee schedule","230.91","237.7","APC"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1044.95","","","","","","","fee schedule","335.17","1163.24",""
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1117.24","","","","","","","fee schedule","335.17","1163.24",""
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1163.24","","","","","","","fee schedule","335.17","1163.24",""
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1043.75","","","","","","","fee schedule","335.17","1163.24","APC 277.30"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1116.24","","","","","","","fee schedule","335.17","1163.24","APC 296.56"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1162.73","","","","","","","fee schedule","335.17","1163.24","APC 308.91"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","344.21","","","","","","","fee schedule","335.17","1163.24","APC"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","338.46","","","","","","","fee schedule","335.17","1163.24","APC"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","335.17","","","","","","","fee schedule","335.17","1163.24","APC"
"Tc-99m graphite crucible","A9506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","345.03","","","","","","","fee schedule","335.17","1163.24","APC"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","994.35","","","","","","","fee schedule","323.33","1121.63",""
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1063.15","","","","","","","fee schedule","323.33","1121.63",""
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1106.92","","","","","","","fee schedule","323.33","1121.63",""
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1006.86","","","","","","","fee schedule","323.33","1121.63","APC 277.30"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1076.79","","","","","","","fee schedule","323.33","1121.63","APC 296.56"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1121.63","","","","","","","fee schedule","323.33","1121.63","APC 308.91"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","332.04","","","","","","","fee schedule","323.33","1121.63","APC"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","326.5","","","","","","","fee schedule","323.33","1121.63","APC"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","323.33","","","","","","","fee schedule","323.33","1121.63","APC"
"Lutetium lu 177 dotatat ther","A9513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","332.84","","","","","","","fee schedule","323.33","1121.63","APC"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6560.15","","","","","","","fee schedule","2566.76","8904.22",""
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7014","","","","","","","fee schedule","2566.76","8904.22",""
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7302.81","","","","","","","fee schedule","2566.76","8904.22",""
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7993.08","","","","","","","fee schedule","2566.76","8904.22","APC 277.30"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8548.24","","","","","","","fee schedule","2566.76","8904.22","APC 296.56"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8904.22","","","","","","","fee schedule","2566.76","8904.22","APC 308.91"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2635.96","","","","","","","fee schedule","2566.76","8904.22","APC"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2591.92","","","","","","","fee schedule","2566.76","8904.22","APC"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2566.76","","","","","","","fee schedule","2566.76","8904.22","APC"
"Choline c-11","A9515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2642.25","","","","","","","fee schedule","2566.76","8904.22","APC"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","73.55","","","","","","","fee schedule","24.55","85.17",""
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","78.64","","","","","","","fee schedule","24.55","85.17",""
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","81.88","","","","","","","fee schedule","24.55","85.17",""
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","76.45","","","","","","","fee schedule","24.55","85.17","APC 277.30"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","81.77","","","","","","","fee schedule","24.55","85.17","APC 296.56"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","85.17","","","","","","","fee schedule","24.55","85.17","APC 308.91"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.21","","","","","","","fee schedule","24.55","85.17","APC"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.79","","","","","","","fee schedule","24.55","85.17","APC"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.55","","","","","","","fee schedule","24.55","85.17","APC"
"I131 iodide cap, rx","A9517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.27","","","","","","","fee schedule","24.55","85.17","APC"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2551.44","","","","","","","fee schedule","946.26","3282.64",""
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2727.96","","","","","","","fee schedule","946.26","3282.64",""
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2840.28","","","","","","","fee schedule","946.26","3282.64",""
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2946.74","","","","","","","fee schedule","946.26","3282.64","APC 277.30"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3151.4","","","","","","","fee schedule","946.26","3282.64","APC 296.56"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3282.64","","","","","","","fee schedule","946.26","3282.64","APC 308.91"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","971.78","","","","","","","fee schedule","946.26","3282.64","APC"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","955.54","","","","","","","fee schedule","946.26","3282.64","APC"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","946.26","","","","","","","fee schedule","946.26","3282.64","APC"
"Tc99m exametazime","A9521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","974.1","","","","","","","fee schedule","946.26","3282.64","APC"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.4","","","","","","","fee schedule","21.19","73.92",""
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.99","","","","","","","fee schedule","21.19","73.92",""
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","73.92","","","","","","","fee schedule","21.19","73.92",""
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","65.97","","","","","","","fee schedule","21.19","73.92","APC 277.30"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","70.56","","","","","","","fee schedule","21.19","73.92","APC 296.56"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","73.49","","","","","","","fee schedule","21.19","73.92","APC 308.91"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.76","","","","","","","fee schedule","21.19","73.92","APC"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.39","","","","","","","fee schedule","21.19","73.92","APC"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.19","","","","","","","fee schedule","21.19","73.92","APC"
"I131 iodide sol, rx","A9530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.81","","","","","","","fee schedule","21.19","73.92","APC"
"In111 ibritumomab, dx","A9542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2537.7","","","","","","","fee schedule","2537.7","2824.99",""
"In111 ibritumomab, dx","A9542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2713.27","","","","","","","fee schedule","2537.7","2824.99",""
"In111 ibritumomab, dx","A9542","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2824.99","","","","","","","fee schedule","2537.7","2824.99",""
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","180702.07","","","","","","","fee schedule","57961.04","201158.91",""
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193203.47","","","","","","","fee schedule","57961.04","201158.91",""
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","201158.91","","","","","","","fee schedule","57961.04","201158.91",""
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","180494.94","","","","","","","fee schedule","57961.04","201158.91","APC 277.30"
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193031.3","","","","","","","fee schedule","57961.04","201158.91","APC 296.56"
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","201069.93","","","","","","","fee schedule","57961.04","201158.91","APC 308.91"
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59523.72","","","","","","","fee schedule","57961.04","201158.91","APC"
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","58529.29","","","","","","","fee schedule","57961.04","201158.91","APC"
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57961.04","","","","","","","fee schedule","57961.04","201158.91","APC"
"Y90 ibritumomab, rx","A9543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59665.78","","","","","","","fee schedule","57961.04","201158.91","APC"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2457","","","","","","","fee schedule","848.09","2942.07",""
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2626.98","","","","","","","fee schedule","848.09","2942.07",""
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2735.15","","","","","","","fee schedule","848.09","2942.07",""
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2641.01","","","","","","","fee schedule","848.09","2942.07","APC 277.30"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2824.44","","","","","","","fee schedule","848.09","2942.07","APC 296.56"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2942.07","","","","","","","fee schedule","848.09","2942.07","APC 308.91"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","870.95","","","","","","","fee schedule","848.09","2942.07","APC"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","856.4","","","","","","","fee schedule","848.09","2942.07","APC"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","848.09","","","","","","","fee schedule","848.09","2942.07","APC"
"In111 oxyquinoline","A9547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","873.03","","","","","","","fee schedule","848.09","2942.07","APC"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2274.62","","","","","","","fee schedule","760.53","2638.33",""
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2431.99","","","","","","","fee schedule","760.53","2638.33",""
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2532.13","","","","","","","fee schedule","760.53","2638.33",""
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2368.35","","","","","","","fee schedule","760.53","2638.33","APC 277.30"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2532.85","","","","","","","fee schedule","760.53","2638.33","APC 296.56"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2638.33","","","","","","","fee schedule","760.53","2638.33","APC 308.91"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","781.04","","","","","","","fee schedule","760.53","2638.33","APC"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","767.99","","","","","","","fee schedule","760.53","2638.33","APC"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","760.53","","","","","","","fee schedule","760.53","2638.33","APC"
"In111 pentetate","A9548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","782.9","","","","","","","fee schedule","760.53","2638.33","APC"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2174.48","","","","","","","fee schedule","791.03","2744.13",""
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2324.92","","","","","","","fee schedule","791.03","2744.13",""
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2420.65","","","","","","","fee schedule","791.03","2744.13",""
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2463.33","","","","","","","fee schedule","791.03","2744.13","APC 277.30"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2634.42","","","","","","","fee schedule","791.03","2744.13","APC 296.56"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2744.13","","","","","","","fee schedule","791.03","2744.13","APC 308.91"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","812.36","","","","","","","fee schedule","791.03","2744.13","APC"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","798.79","","","","","","","fee schedule","791.03","2744.13","APC"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","791.03","","","","","","","fee schedule","791.03","2744.13","APC"
"Tc99m bicisate","A9557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","814.3","","","","","","","fee schedule","791.03","2744.13","APC"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","569.6","","","","","","","fee schedule","283.8","984.53",""
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","609.01","","","","","","","fee schedule","283.8","984.53",""
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","634.08","","","","","","","fee schedule","283.8","984.53",""
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","883.79","","","","","","","fee schedule","283.8","984.53","APC 277.30"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","945.17","","","","","","","fee schedule","283.8","984.53","APC 296.56"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","984.53","","","","","","","fee schedule","283.8","984.53","APC 308.91"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","291.46","","","","","","","fee schedule","283.8","984.53","APC"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","286.59","","","","","","","fee schedule","283.8","984.53","APC"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","283.8","","","","","","","fee schedule","283.8","984.53","APC"
"P32 na phosphate","A9563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","292.15","","","","","","","fee schedule","283.8","984.53","APC"
"Technetium tc99m arcitumomab","A9568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2574.24","","","","","","","fee schedule","2574.24","2865.67",""
"Technetium tc99m arcitumomab","A9568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2752.33","","","","","","","fee schedule","2574.24","2865.67",""
"Technetium tc99m arcitumomab","A9568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2865.67","","","","","","","fee schedule","2574.24","2865.67",""
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3308.22","","","","","","","fee schedule","952.81","3682.73",""
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3537.09","","","","","","","fee schedule","952.81","3682.73",""
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3682.73","","","","","","","fee schedule","952.81","3682.73",""
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2967.13","","","","","","","fee schedule","952.81","3682.73","APC 277.30"
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3173.21","","","","","","","fee schedule","952.81","3682.73","APC 296.56"
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3305.36","","","","","","","fee schedule","952.81","3682.73","APC 308.91"
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","978.5","","","","","","","fee schedule","952.81","3682.73","APC"
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","962.15","","","","","","","fee schedule","952.81","3682.73","APC"
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","952.81","","","","","","","fee schedule","952.81","3682.73","APC"
"Technetium TC-99m auto WBC","A9569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","980.84","","","","","","","fee schedule","952.81","3682.73","APC"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3279.82","","","","","","","fee schedule","1125.25","3903.57",""
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3506.73","","","","","","","fee schedule","1125.25","3903.57",""
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3651.12","","","","","","","fee schedule","1125.25","3903.57",""
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3504.12","","","","","","","fee schedule","1125.25","3903.57","APC 277.30"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3747.5","","","","","","","fee schedule","1125.25","3903.57","APC 296.56"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3903.57","","","","","","","fee schedule","1125.25","3903.57","APC 308.91"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1155.59","","","","","","","fee schedule","1125.25","3903.57","APC"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1136.29","","","","","","","fee schedule","1125.25","3903.57","APC"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1125.25","","","","","","","fee schedule","1125.25","3903.57","APC"
"Indium In-111 auto WBC","A9570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1158.35","","","","","","","fee schedule","1125.25","3903.57","APC"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6088.46","","","","","","","fee schedule","2040.96","7080.19",""
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6509.67","","","","","","","fee schedule","2040.96","7080.19",""
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6777.72","","","","","","","fee schedule","2040.96","7080.19",""
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6355.7","","","","","","","fee schedule","2040.96","7080.19","APC 277.30"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6797.13","","","","","","","fee schedule","2040.96","7080.19","APC 296.56"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7080.19","","","","","","","fee schedule","2040.96","7080.19","APC 308.91"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2095.98","","","","","","","fee schedule","2040.96","7080.19","APC"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2060.97","","","","","","","fee schedule","2040.96","7080.19","APC"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2040.96","","","","","","","fee schedule","2040.96","7080.19","APC"
"Indium In-111 pentetreotide","A9572","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2100.99","","","","","","","fee schedule","2040.96","7080.19","APC"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6597.9","","","","","","","fee schedule","2363.85","8200.32",""
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7054.35","","","","","","","fee schedule","2363.85","8200.32",""
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7344.83","","","","","","","fee schedule","2363.85","8200.32",""
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7361.2","","","","","","","fee schedule","2363.85","8200.32","APC 277.30"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7872.48","","","","","","","fee schedule","2363.85","8200.32","APC 296.56"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8200.32","","","","","","","fee schedule","2363.85","8200.32","APC 308.91"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2427.58","","","","","","","fee schedule","2363.85","8200.32","APC"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2387.02","","","","","","","fee schedule","2363.85","8200.32","APC"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2363.85","","","","","","","fee schedule","2363.85","8200.32","APC"
"Iodine I-123 iobenguane","A9582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2433.38","","","","","","","fee schedule","2363.85","8200.32","APC"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4413.9","","","","","","","fee schedule","1415.49","4913.59",""
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4719.27","","","","","","","fee schedule","1415.49","4913.59",""
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4913.59","","","","","","","fee schedule","1415.49","4913.59",""
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4407.95","","","","","","","fee schedule","1415.49","4913.59","APC 277.30"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4714.11","","","","","","","fee schedule","1415.49","4913.59","APC 296.56"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4910.43","","","","","","","fee schedule","1415.49","4913.59","APC 308.91"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1453.66","","","","","","","fee schedule","1415.49","4913.59","APC"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1429.37","","","","","","","fee schedule","1415.49","4913.59","APC"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1415.49","","","","","","","fee schedule","1415.49","4913.59","APC"
"Iodine i-123 ioflupane","A9584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1457.13","","","","","","","fee schedule","1415.49","4913.59","APC"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6978.89","","","","","","","fee schedule","1862.15","7768.95",""
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7461.71","","","","","","","fee schedule","1862.15","7768.95",""
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7768.95","","","","","","","fee schedule","1862.15","7768.95",""
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5798.88","","","","","","","fee schedule","1862.15","7768.95","APC 277.30"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6201.64","","","","","","","fee schedule","1862.15","7768.95","APC 296.56"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6459.91","","","","","","","fee schedule","1862.15","7768.95","APC 308.91"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1912.36","","","","","","","fee schedule","1862.15","7768.95","APC"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1880.41","","","","","","","fee schedule","1862.15","7768.95","APC"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1862.15","","","","","","","fee schedule","1862.15","7768.95","APC"
"Florbetapir F18","A9586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1916.92","","","","","","","fee schedule","1862.15","7768.95","APC"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","162.47","","","","","","","fee schedule","50.62","180.86",""
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","173.71","","","","","","","fee schedule","50.62","180.86",""
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","180.86","","","","","","","fee schedule","50.62","180.86",""
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","157.64","","","","","","","fee schedule","50.62","180.86","APC 277.30"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","168.59","","","","","","","fee schedule","50.62","180.86","APC 296.56"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","175.61","","","","","","","fee schedule","50.62","180.86","APC 308.91"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.99","","","","","","","fee schedule","50.62","180.86","APC"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.12","","","","","","","fee schedule","50.62","180.86","APC"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.62","","","","","","","fee schedule","50.62","180.86","APC"
"Gallium ga-68","A9587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.11","","","","","","","fee schedule","50.62","180.86","APC"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","853.58","","","","","","","fee schedule","328.72","1140.33",""
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","912.63","","","","","","","fee schedule","328.72","1140.33",""
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","950.21","","","","","","","fee schedule","328.72","1140.33",""
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.64","","","","","","","fee schedule","328.72","1140.33","APC 277.30"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.74","","","","","","","fee schedule","328.72","1140.33","APC 296.56"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.33","","","","","","","fee schedule","328.72","1140.33","APC 308.91"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.33","APC"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.33","APC"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.33","APC"
"Fluciclovine f-18","A9588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.38","","","","","","","fee schedule","328.72","1140.33","APC"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1585.77","","","","","","","fee schedule","469.63","1765.29",""
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1695.48","","","","","","","fee schedule","469.63","1765.29",""
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1765.29","","","","","","","fee schedule","469.63","1765.29",""
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1462.46","","","","","","","fee schedule","469.63","1765.29","APC 277.30"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1564.03","","","","","","","fee schedule","469.63","1765.29","APC 296.56"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1629.17","","","","","","","fee schedule","469.63","1765.29","APC 308.91"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","482.29","","","","","","","fee schedule","469.63","1765.29","APC"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","474.23","","","","","","","fee schedule","469.63","1765.29","APC"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","469.63","","","","","","","fee schedule","469.63","1765.29","APC"
"Fluoroestradiol f 18","A9591","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","483.44","","","","","","","fee schedule","469.63","1765.29","APC"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1892.42","","","","","","","fee schedule","606.17","2106.65",""
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2023.34","","","","","","","fee schedule","606.17","2106.65",""
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2106.65","","","","","","","fee schedule","606.17","2106.65",""
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1887.64","","","","","","","fee schedule","606.17","2106.65","APC 277.30"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2018.75","","","","","","","fee schedule","606.17","2106.65","APC 296.56"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2102.82","","","","","","","fee schedule","606.17","2106.65","APC 308.91"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","622.51","","","","","","","fee schedule","606.17","2106.65","APC"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","612.11","","","","","","","fee schedule","606.17","2106.65","APC"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","606.17","","","","","","","fee schedule","606.17","2106.65","APC"
"Copper cu 64 dotatate diag","A9592","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","623.99","","","","","","","fee schedule","606.17","2106.65","APC"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1701.01","","","","","","","fee schedule","561.13","1946.6",""
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1818.69","","","","","","","fee schedule","561.13","1946.6",""
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1893.58","","","","","","","fee schedule","561.13","1946.6",""
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1747.41","","","","","","","fee schedule","561.13","1946.6","APC 277.30"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1868.78","","","","","","","fee schedule","561.13","1946.6","APC 296.56"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1946.6","","","","","","","fee schedule","561.13","1946.6","APC 308.91"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","576.26","","","","","","","fee schedule","561.13","1946.6","APC"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","566.63","","","","","","","fee schedule","561.13","1946.6","APC"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","561.13","","","","","","","fee schedule","561.13","1946.6","APC"
"Gallium ga-68 psma-11 ucsf","A9593","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","577.64","","","","","","","fee schedule","561.13","1946.6","APC"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1183.5","","","","","","","fee schedule","370.77","1317.48",""
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1265.38","","","","","","","fee schedule","370.77","1317.48",""
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1317.48","","","","","","","fee schedule","370.77","1317.48",""
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1154.61","","","","","","","fee schedule","370.77","1317.48","APC 277.30"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1234.8","","","","","","","fee schedule","370.77","1317.48","APC 296.56"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1286.22","","","","","","","fee schedule","370.77","1317.48","APC 308.91"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","380.77","","","","","","","fee schedule","370.77","1317.48","APC"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","374.4","","","","","","","fee schedule","370.77","1317.48","APC"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","370.77","","","","","","","fee schedule","370.77","1317.48","APC"
"Gallium ga-68 psma-11, ucla","A9594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","381.68","","","","","","","fee schedule","370.77","1317.48","APC"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1057.16","","","","","","","fee schedule","353.42","1226.03",""
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1130.3","","","","","","","fee schedule","353.42","1226.03",""
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1176.84","","","","","","","fee schedule","353.42","1226.03",""
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1100.58","","","","","","","fee schedule","353.42","1226.03","APC 277.30"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1177.02","","","","","","","fee schedule","353.42","1226.03","APC 296.56"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1226.03","","","","","","","fee schedule","353.42","1226.03","APC 308.91"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","362.95","","","","","","","fee schedule","353.42","1226.03","APC"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","356.88","","","","","","","fee schedule","353.42","1226.03","APC"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","353.42","","","","","","","fee schedule","353.42","1226.03","APC"
"Piflu f-18, dia 1 millicurie","A9595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","363.81","","","","","","","fee schedule","353.42","1226.03","APC"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3096.18","","","","","","","fee schedule","488.09","3446.69",""
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3310.38","","","","","","","fee schedule","488.09","3446.69",""
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3446.69","","","","","","","fee schedule","488.09","3446.69",""
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1519.95","","","","","","","fee schedule","488.09","3446.69","APC 277.30"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1625.52","","","","","","","fee schedule","488.09","3446.69","APC 296.56"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1693.21","","","","","","","fee schedule","488.09","3446.69","APC 308.91"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","501.25","","","","","","","fee schedule","488.09","3446.69","APC"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","492.88","","","","","","","fee schedule","488.09","3446.69","APC"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","488.09","","","","","","","fee schedule","488.09","3446.69","APC"
"Gallium illuccix 1 millicure","A9596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","502.45","","","","","","","fee schedule","488.09","3446.69","APC"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13185.36","","","","","","","fee schedule","4229.26","14678.04",""
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14097.56","","","","","","","fee schedule","4229.26","14678.04",""
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14678.04","","","","","","","fee schedule","4229.26","14678.04",""
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13170.23","","","","","","","fee schedule","4229.26","14678.04","APC 277.30"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14084.98","","","","","","","fee schedule","4229.26","14678.04","APC 296.56"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14671.53","","","","","","","fee schedule","4229.26","14678.04","APC 308.91"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4343.29","","","","","","","fee schedule","4229.26","14678.04","APC"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4270.73","","","","","","","fee schedule","4229.26","14678.04","APC"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4229.26","","","","","","","fee schedule","4229.26","14678.04","APC"
"Sr89 strontium","A9600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4353.65","","","","","","","fee schedule","4229.26","14678.04","APC"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11797.8","","","","","","","fee schedule","3784.2","13133.4",""
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12614","","","","","","","fee schedule","3784.2","13133.4",""
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13133.4","","","","","","","fee schedule","3784.2","13133.4",""
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11784.28","","","","","","","fee schedule","3784.2","13133.4","APC 277.30"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12602.76","","","","","","","fee schedule","3784.2","13133.4","APC 296.56"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13127.59","","","","","","","fee schedule","3784.2","13133.4","APC 308.91"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3886.23","","","","","","","fee schedule","3784.2","13133.4","APC"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3821.3","","","","","","","fee schedule","3784.2","13133.4","APC"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3784.2","","","","","","","fee schedule","3784.2","13133.4","APC"
"Flortaucipir inj 1 millicuri","A9601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3895.5","","","","","","","fee schedule","3784.2","13133.4","APC"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1585.61","","","","","","","fee schedule","872.66","3027.31",""
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1695.31","","","","","","","fee schedule","872.66","3027.31",""
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1765.11","","","","","","","fee schedule","872.66","3027.31",""
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2717.53","","","","","","","fee schedule","872.66","3027.31","APC 277.30"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2906.28","","","","","","","fee schedule","872.66","3027.31","APC 296.56"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3027.31","","","","","","","fee schedule","872.66","3027.31","APC 308.91"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","896.19","","","","","","","fee schedule","872.66","3027.31","APC"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","881.22","","","","","","","fee schedule","872.66","3027.31","APC"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","872.66","","","","","","","fee schedule","872.66","3027.31","APC"
"Fluorodopa f-18 diag per mci","A9602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","898.33","","","","","","","fee schedule","872.66","3027.31","APC"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13721.41","","","","","","","fee schedule","3223","15274.78",""
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14670.69","","","","","","","fee schedule","3223","15274.78",""
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15274.78","","","","","","","fee schedule","3223","15274.78",""
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10036.65","","","","","","","fee schedule","3223","15274.78","APC 277.30"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10733.75","","","","","","","fee schedule","3223","15274.78","APC 296.56"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11180.74","","","","","","","fee schedule","3223","15274.78","APC 308.91"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3309.89","","","","","","","fee schedule","3223","15274.78","APC"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3254.59","","","","","","","fee schedule","3223","15274.78","APC"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3223","","","","","","","fee schedule","3223","15274.78","APC"
"Sm 153 lexidronam","A9604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3317.79","","","","","","","fee schedule","3223","15274.78","APC"
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","546.26","","","","","","","fee schedule","175.67","608.1",""
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.05","","","","","","","fee schedule","175.67","608.1",""
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.1","","","","","","","fee schedule","175.67","608.1",""
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","180.4","","","","","","","fee schedule","175.67","608.1","APC"
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","177.39","","","","","","","fee schedule","175.67","608.1","APC"
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","175.67","","","","","","","fee schedule","175.67","608.1","APC"
"Radium ra223 dichloride ther","A9606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","180.83","","","","","","","fee schedule","175.67","608.1","APC"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","805.11","","","","","","","fee schedule","260.96","905.27",""
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","860.81","","","","","","","fee schedule","260.96","905.27",""
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","896.26","","","","","","","fee schedule","260.96","905.27",""
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","812.64","","","","","","","fee schedule","260.96","905.27","APC 277.30"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","869.08","","","","","","","fee schedule","260.96","905.27","APC 296.56"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","905.27","","","","","","","fee schedule","260.96","905.27","APC 308.91"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","267.99","","","","","","","fee schedule","260.96","905.27","APC"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","263.51","","","","","","","fee schedule","260.96","905.27","APC"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","260.96","","","","","","","fee schedule","260.96","905.27","APC"
"Lutetium lu 177 vipivotide","A9607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","268.63","","","","","","","fee schedule","260.96","905.27","APC"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2134.48","","","","","","","fee schedule","684.64","2376.12",""
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2282.15","","","","","","","fee schedule","684.64","2376.12",""
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2376.12","","","","","","","fee schedule","684.64","2376.12",""
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2132.03","","","","","","","fee schedule","684.64","2376.12","APC 277.30"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2280.11","","","","","","","fee schedule","684.64","2376.12","APC 296.56"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2375.06","","","","","","","fee schedule","684.64","2376.12","APC 308.91"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","703.1","","","","","","","fee schedule","684.64","2376.12","APC"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","691.36","","","","","","","fee schedule","684.64","2376.12","APC"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","684.64","","","","","","","fee schedule","684.64","2376.12","APC"
"Flotufolastat f18 diag 1 mci","A9608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","704.78","","","","","","","fee schedule","684.64","2376.12","APC"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1685.4","","","","","","","fee schedule","540.6","1876.2",""
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1802","","","","","","","fee schedule","540.6","1876.2",""
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1876.2","","","","","","","fee schedule","540.6","1876.2",""
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1683.47","","","","","","","fee schedule","540.6","1876.2","APC 277.30"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1800.39","","","","","","","fee schedule","540.6","1876.2","APC 296.56"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1875.37","","","","","","","fee schedule","540.6","1876.2","APC 308.91"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","555.18","","","","","","","fee schedule","540.6","1876.2","APC"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.9","","","","","","","fee schedule","540.6","1876.2","APC"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.6","","","","","","","fee schedule","540.6","1876.2","APC"
"Flurpiridaz f18, diag, 1 mci","A9611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.5","","","","","","","fee schedule","540.6","1876.2","APC"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.91","","","","","","","fee schedule","38.26","132.72",""
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.93","","","","","","","fee schedule","38.26","132.72",""
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.03","","","","","","","fee schedule","38.26","132.72",""
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","119.14","","","","","","","fee schedule","38.26","132.72","APC 277.30"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","127.41","","","","","","","fee schedule","38.26","132.72","APC 296.56"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","132.72","","","","","","","fee schedule","38.26","132.72","APC 308.91"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.29","","","","","","","fee schedule","38.26","132.72","APC"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.63","","","","","","","fee schedule","38.26","132.72","APC"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.26","","","","","","","fee schedule","38.26","132.72","APC"
"Inj, pegulicianine, 1 mg","A9615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.38","","","","","","","fee schedule","38.26","132.72","APC"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36188.11","","","","","","","fee schedule","1279.08","40284.88",""
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38691.69","","","","","","","fee schedule","1279.08","40284.88",""
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40284.88","","","","","","","fee schedule","1279.08","40284.88",""
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3983.15","","","","","","","fee schedule","1279.08","40284.88","APC 277.30"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4259.8","","","","","","","fee schedule","1279.08","40284.88","APC 296.56"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4437.2","","","","","","","fee schedule","1279.08","40284.88","APC 308.91"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1313.56","","","","","","","fee schedule","1279.08","40284.88","APC"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1291.62","","","","","","","fee schedule","1279.08","40284.88","APC"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1279.08","","","","","","","fee schedule","1279.08","40284.88","APC"
"Inj, magtrace per study dose","A9697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1316.7","","","","","","","fee schedule","1279.08","40284.88","APC"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2777.54","","","","","","","fee schedule","369.75","3091.98",""
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2969.7","","","","","","","fee schedule","369.75","3091.98",""
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3091.98","","","","","","","fee schedule","369.75","3091.98",""
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1151.43","","","","","","","fee schedule","369.75","3091.98","APC 277.30"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1231.4","","","","","","","fee schedule","369.75","3091.98","APC 296.56"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1282.68","","","","","","","fee schedule","369.75","3091.98","APC 308.91"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","379.72","","","","","","","fee schedule","369.75","3091.98","APC"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","373.38","","","","","","","fee schedule","369.75","3091.98","APC"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","369.75","","","","","","","fee schedule","369.75","3091.98","APC"
"Gallium locametz 1 millicuri","A9800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","380.62","","","","","","","fee schedule","369.75","3091.98","APC"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1135.52","","","","","","","fee schedule","364.64","1264.95","APC 277.30"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1214.38","","","","","","","fee schedule","364.64","1264.95","APC 296.56"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1264.95","","","","","","","fee schedule","364.64","1264.95","APC 308.91"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","374.47","","","","","","","fee schedule","364.64","1264.95","APC"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","368.21","","","","","","","fee schedule","364.64","1264.95","APC"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","364.64","","","","","","","fee schedule","364.64","1264.95","APC"
"Brachytx, non-str,hdr ir-192","C1717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","375.36","","","","","","","fee schedule","364.64","1264.95","APC"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56447.04","","","","","","","fee schedule","18126.43","62881.55","APC 277.30"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60367.59","","","","","","","fee schedule","18126.43","62881.55","APC 296.56"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62881.55","","","","","","","fee schedule","18126.43","62881.55","APC 308.91"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18615.13","","","","","","","fee schedule","18126.43","62881.55","APC"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18304.14","","","","","","","fee schedule","18126.43","62881.55","APC"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18126.43","","","","","","","fee schedule","18126.43","62881.55","APC"
"Brachytx, non-str,Yttrium-90","C2616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18659.56","","","","","","","fee schedule","18126.43","62881.55","APC"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","204.81","","","","","","","fee schedule","65.77","228.16","APC 277.30"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","219.04","","","","","","","fee schedule","65.77","228.16","APC 296.56"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","228.16","","","","","","","fee schedule","65.77","228.16","APC 308.91"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.54","","","","","","","fee schedule","65.77","228.16","APC"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.41","","","","","","","fee schedule","65.77","228.16","APC"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.77","","","","","","","fee schedule","65.77","228.16","APC"
"Brachytx, non-stranded,P-103","C2641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.7","","","","","","","fee schedule","65.77","228.16","APC"
"Low cost skin substitute app","C5271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Low cost skin substitute app","C5273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Low cost skin substitute app","C5274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Low cost skin substitute app","C5278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Deb bone 20 cm2 w/drug dev","C7500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Deb bone 20 cm2 w/drug dev","C7500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perc bx breast lesions stero","C7501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perc bx breast lesions stero","C7501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perc bx breast lesions mr","C7502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perc bx breast lesions mr","C7502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Open exc cerv node(s) w/ id","C7503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Open exc cerv node(s) w/ id","C7503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq cvt&ls inj vert bodies","C7504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq cvt&ls inj vert bodies","C7504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq ls&cvt inj vert bodies","C7505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq ls&cvt inj vert bodies","C7505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Fusion of finger joints","C7506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Fusion of finger joints","C7506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq thor&lumb vert aug","C7507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq thor&lumb vert aug","C7507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Perq lumb&thor vert aug","C7508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Perq lumb&thor vert aug","C7508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Dx bronch w/ navigation","C7509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Dx bronch w/ navigation","C7509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bronch/lavag w/ navigation","C7510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Bronch/lavag w/ navigation","C7510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bronch/bpsy(s) w/ navigation","C7511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Bronch/bpsy(s) w/ navigation","C7511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bronch/bpsy(s) w/ ebus","C7512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Bronch/bpsy(s) w/ ebus","C7512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cath/angio dialcir w/aplasty","C7513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cath/angio dialcir w/aplasty","C7513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cath/angio dial cir w/stents","C7514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cath/angio dial cir w/stents","C7514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cath/angio dial cir w/embol","C7515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cath/angio dial cir w/embol","C7515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cor angio w/ ivus or oct","C7516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cor angio w/ ivus or oct","C7516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cor angio w/ilic/fem angio","C7517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cor angio w/ilic/fem angio","C7517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cor/gft angio w/ ivus or oct","C7518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cor/gft angio w/ ivus or oct","C7518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cor/gft angio w/ flow resrv","C7519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cor/gft angio w/ flow resrv","C7519","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cor/gft angio w/ilic/fem ang","C7520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cor/gft angio w/ilic/fem ang","C7520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R hrt angio w/ ivus or oct","C7521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R hrt angio w/ ivus or oct","C7521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R hrt angio w/flow resrv","C7522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R hrt angio w/flow resrv","C7522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"L hrt angio w/ ivus or oct","C7523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"L hrt angio w/ ivus or oct","C7523","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"L hrt angio w/flow resrv","C7524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"L hrt angio w/flow resrv","C7524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"L hrt gft ang w/ ivus or oct","C7525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"L hrt gft ang w/ ivus or oct","C7525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"L hrt gft ang w/flow resrv","C7526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"L hrt gft ang w/flow resrv","C7526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R&l hrt angio w/ ivus or oct","C7527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R&l hrt angio w/ ivus or oct","C7527","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R&l hrt angio w/flow resrv","C7528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R&l hrt angio w/flow resrv","C7528","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R&l hrt gft ang w/flow resrv","C7529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R&l hrt gft ang w/flow resrv","C7529","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cath/aplasty dial cir w/stnt","C7530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cath/aplasty dial cir w/stnt","C7530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Angio fem/pop w/ us","C7531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Angio fem/pop w/ us","C7531","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Angio w/ us non-coronary","C7532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Angio w/ us non-coronary","C7532","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ptca w/ plcmt brachytx dev","C7533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ptca w/ plcmt brachytx dev","C7533","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Fem/pop revasc w/arthr & us","C7534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Fem/pop revasc w/arthr & us","C7534","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Fem/pop revasc w/stent & us","C7535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Fem/pop revasc w/stent & us","C7535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Insrt atril pm w/l vent lead","C7537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Insrt atril pm w/l vent lead","C7537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Insrt vent pm w/l vent lead","C7538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Insrt vent pm w/l vent lead","C7538","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Insrt a & v pm w/l vent lead","C7539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Insrt a & v pm w/l vent lead","C7539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmv&rplc pm dul w/l vnt lead","C7540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rmv&rplc pm dul w/l vnt lead","C7540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ercp w/ pancreatoscopy","C7541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ercp w/ pancreatoscopy","C7541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ercp w/bx & pancreatoscopy","C7542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ercp w/bx & pancreatoscopy","C7542","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ercp w/otomy, pancreatoscopy","C7543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ercp w/otomy, pancreatoscopy","C7543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ercp rmv calc pancreatoscopy","C7544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ercp rmv calc pancreatoscopy","C7544","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Exch bil cath w/ rmv calculi","C7545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Exch bil cath w/ rmv calculi","C7545","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rep nph/urt cath w/dil stric","C7546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rep nph/urt cath w/dil stric","C7546","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cnvrt neph cath w/ dil stric","C7547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cnvrt neph cath w/ dil stric","C7547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Exch neph cath w/ dil stric","C7548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Exch neph cath w/ dil stric","C7548","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Chge urtr stent w/ dil stric","C7549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Chge urtr stent w/ dil stric","C7549","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cysto w/ bx(s) w/ blue light","C7550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cysto w/ bx(s) w/ blue light","C7550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Exc neuroma w/ implnt nv end","C7551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Exc neuroma w/ implnt nv end","C7551","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R hrt art/grft ang hrt flow","C7552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R hrt art/grft ang hrt flow","C7552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R&l hrt art/vent ang drg ad","C7553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R&l hrt art/vent ang drg ad","C7553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cystureth blu li cyst fl img","C7554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cystureth blu li cyst fl img","C7554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rmvl thyrd w/autotran parath","C7555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rmvl thyrd w/autotran parath","C7555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Cor angio/vent w/ffr","C7557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Cor angio/vent w/ffr","C7557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Ercp remove forgn body&endo","C7560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Ercp remove forgn body&endo","C7560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"R&l hrt angio w/ffr & 3d map","C7562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"R&l hrt angio w/ffr & 3d map","C7562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Trluml ballo angiop all art","C7563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Trluml ballo angiop all art","C7563","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Vein mech throm w/intrvas us","C7564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Vein mech throm w/intrvas us","C7564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rpr aa hrn < 3 rdc w/ rmvl","C7565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rpr aa hrn < 3 rdc w/ rmvl","C7565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, 15-29 min","C7900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hopd mntl hlt, grp","C7903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"3d anat seg imaging preop","C8001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","17449.63","60533.69",""
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","17449.63","60533.69",""
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54339.42","","","","","","","fee schedule","17449.63","60533.69","APC 277.30"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58113.59","","","","","","","fee schedule","17449.63","60533.69","APC 296.56"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60533.69","","","","","","","fee schedule","17449.63","60533.69","APC 308.91"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17920.08","","","","","","","fee schedule","17449.63","60533.69","APC"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17620.7","","","","","","","fee schedule","17449.63","60533.69","APC"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17449.63","","","","","","","fee schedule","17449.63","60533.69","APC"
"Imp extar knee shck absrb","C8003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17962.85","","","","","","","fee schedule","17449.63","60533.69","APC"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Sim ang w/prs cath rad emb","C8004","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20063.15","","","","","","","fee schedule","6442.74","22350.2","APC 277.30"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21456.65","","","","","","","fee schedule","6442.74","22350.2","APC 296.56"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22350.2","","","","","","","fee schedule","6442.74","22350.2","APC 308.91"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6616.44","","","","","","","fee schedule","6442.74","22350.2","APC"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6505.9","","","","","","","fee schedule","6442.74","22350.2","APC"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6442.74","","","","","","","fee schedule","6442.74","22350.2","APC"
"Inst pleu-perit shnt w pump","C8006","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6632.23","","","","","","","fee schedule","6442.74","22350.2","APC"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1565","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1610","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1572","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/cont, abd","C8900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1565","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1610","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1572","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o cont, abd","C8901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1565","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1610","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1572","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, abd","C8902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1081","","","","","","","fee schedule","174.56","7211.2",""
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1113","","","","","","","fee schedule","174.56","7211.2",""
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1085","","","","","","","fee schedule","174.56","7211.2",""
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","174.56","7211.2",""
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","543.59","","","","","","","fee schedule","174.56","7211.2","APC 277.30"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","581.34","","","","","","","fee schedule","174.56","7211.2","APC 296.56"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","605.55","","","","","","","fee schedule","174.56","7211.2","APC 308.91"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.26","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.27","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.56","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri w/cont, breast,  uni","C8903","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.69","","","","","","","fee schedule","174.56","7211.2","APC"
"Mri w/o cont, breast, uni","C8904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1081","","","","","","","fee schedule","1081","5369.86",""
"Mri w/o cont, breast, uni","C8904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1113","","","","","","","fee schedule","1081","5369.86",""
"Mri w/o cont, breast, uni","C8904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1085","","","","","","","fee schedule","1081","5369.86",""
"Mri w/o cont, breast, uni","C8904","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","1081","5369.86",""
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1081","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1113","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1085","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/o fol w/cont, brst, un","C8905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1353","","","","","","","fee schedule","347.2","7211.2",""
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1391","","","","","","","fee schedule","347.2","7211.2",""
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1358","","","","","","","fee schedule","347.2","7211.2",""
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri w/cont, breast,  bi","C8906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mri w/o cont, breast, bi","C8907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1353","","","","","","","fee schedule","1353","5369.86",""
"Mri w/o cont, breast, bi","C8907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1391","","","","","","","fee schedule","1353","5369.86",""
"Mri w/o cont, breast, bi","C8907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1358","","","","","","","fee schedule","1353","5369.86",""
"Mri w/o cont, breast, bi","C8907","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","1353","5369.86",""
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1353","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1391","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1358","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mri w/o fol w/cont, breast,","C8908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1196","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1231","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1202","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/cont, chest","C8909","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1196","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1231","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1202","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o cont, chest","C8910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1196","","","","","","","fee schedule","347.2","8716.76",""
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1231","","","","","","","fee schedule","347.2","8716.76",""
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1202","","","","","","","fee schedule","347.2","8716.76",""
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA w/o fol w/cont, chest","C8911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1786","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1838","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1794","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/cont, lwr ext","C8912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1786","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1838","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1794","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o cont, lwr ext","C8913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1786","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1838","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1794","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, lwr ext","C8914","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1552","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1597","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1559","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/cont, pelvis","C8918","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1552","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1597","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1559","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA w/o cont, pelvis","C8919","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1552","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1597","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1559","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"Mra w/o fol w/cont, pelvis","C8920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, com","C8921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/cont, f/u","C8922","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tte w or w/o fol w/con,co","C8923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"2d tte w or w/o fol w/con,fu","C8924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"2d tee w or w/o fol w/con,in","C8925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Tee w or w/o fol w/cont,cong","C8926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"TEE w or w/o fol w/cont, mon","C8927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1382","","","","","","","fee schedule","780.16","2706.41",""
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1422","","","","","","","fee schedule","780.16","2706.41",""
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1389","","","","","","","fee schedule","780.16","2706.41",""
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"Tte w or w/o fol w/con,stres","C8928","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1196","","","","","","","fee schedule","780.16","2706.41",""
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1231","","","","","","","fee schedule","780.16","2706.41",""
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1202","","","","","","","fee schedule","780.16","2706.41",""
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or wo fol wcon,Doppler","C8929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2429.47","","","","","","","fee schedule","780.16","2706.41","APC 277.30"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2598.2","","","","","","","fee schedule","780.16","2706.41","APC 296.56"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2706.41","","","","","","","fee schedule","780.16","2706.41","APC 308.91"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","801.19","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","787.81","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.16","","","","","","","fee schedule","780.16","2706.41","APC"
"TTE w or w/o contr, cont ECG","C8930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.1","","","","","","","fee schedule","780.16","2706.41","APC"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1648","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1696","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1655","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/dye, spinal canal","C8931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1648","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1696","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1655","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o dye, spinal canal","C8932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1648","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1696","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1655","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/o&w/dye, spinal canal","C8933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2605","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2681","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2616","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","7211.2","","","","","","","fee schedule","347.2","7211.2",""
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","7211.2","APC 277.30"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","7211.2","APC 296.56"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","7211.2","APC 308.91"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/dye, upper extremity","C8934","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","7211.2","APC"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2605","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2681","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2616","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5369.86","","","","","","","fee schedule","237.46","5369.86",""
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","5369.86","APC 277.30"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","5369.86","APC 296.56"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","5369.86","APC 308.91"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o dye, upper extr","C8935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","5369.86","APC"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","2605","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","2681","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","2616","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","8716.76","","","","","","","fee schedule","347.2","8716.76",""
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","8716.76","APC 277.30"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","8716.76","APC 296.56"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","8716.76","APC 308.91"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","8716.76","APC"
"MRA, w/o&w/dye, upper extr","C8936","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","8716.76","APC"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","659.19","","","","","","","fee schedule","211.68","734.33","APC 277.30"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","704.98","","","","","","","fee schedule","211.68","734.33","APC 296.56"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","734.33","","","","","","","fee schedule","211.68","734.33","APC 308.91"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.39","","","","","","","fee schedule","211.68","734.33","APC"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.76","","","","","","","fee schedule","211.68","734.33","APC"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.68","","","","","","","fee schedule","211.68","734.33","APC"
"Prolonged iv inf, req pump","C8957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.91","","","","","","","fee schedule","211.68","734.33","APC"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.88","","","","","","","fee schedule","3.68","14.34",""
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.77","","","","","","","fee schedule","3.68","14.34",""
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.34","","","","","","","fee schedule","3.68","14.34",""
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.47","","","","","","","fee schedule","3.68","14.34","APC 277.30"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.26","","","","","","","fee schedule","3.68","14.34","APC 296.56"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.77","","","","","","","fee schedule","3.68","14.34","APC 308.91"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.78","","","","","","","fee schedule","3.68","14.34","APC"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.72","","","","","","","fee schedule","3.68","14.34","APC"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.68","","","","","","","fee schedule","3.68","14.34","APC"
"Gallium ga-68 dotatoc","C9067","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.79","","","","","","","fee schedule","3.68","14.34","APC"
"Instill, bupivac and meloxic","C9088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.58","","","","","","","fee schedule","2.58","2.87",""
"Instill, bupivac and meloxic","C9088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.75","","","","","","","fee schedule","2.58","2.87",""
"Instill, bupivac and meloxic","C9088","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.87","","","","","","","fee schedule","2.58","2.87",""
"Bupivacaine implant, 1 mg","C9089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.4","","","","","","","fee schedule","8.4","9.35",""
"Bupivacaine implant, 1 mg","C9089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.98","","","","","","","fee schedule","8.4","9.35",""
"Bupivacaine implant, 1 mg","C9089","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.35","","","","","","","fee schedule","8.4","9.35",""
"Inj, oliceridine 0.1 mg","C9101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.13","","","","","","","fee schedule","4.13","4.6",""
"Inj, oliceridine 0.1 mg","C9101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.42","","","","","","","fee schedule","4.13","4.6",""
"Inj, oliceridine 0.1 mg","C9101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.6","","","","","","","fee schedule","4.13","4.6",""
"Inj, bupivacaine (posimir)","C9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.62","","","","","","","fee schedule","1.62","1.81",""
"Inj, bupivacaine (posimir)","C9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.73","","","","","","","fee schedule","1.62","1.81",""
"Inj, bupivacaine (posimir)","C9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.81","","","","","","","fee schedule","1.62","1.81",""
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.11","","","","","","","fee schedule","1.95","6.8",""
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.53","","","","","","","fee schedule","1.95","6.8",""
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.8","","","","","","","fee schedule","1.95","6.8",""
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.07","","","","","","","fee schedule","1.95","6.8","APC 277.30"
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.49","","","","","","","fee schedule","1.95","6.8","APC 296.56"
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.76","","","","","","","fee schedule","1.95","6.8","APC 308.91"
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2","","","","","","","fee schedule","1.95","6.8","APC"
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.97","","","","","","","fee schedule","1.95","6.8","APC"
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.95","","","","","","","fee schedule","1.95","6.8","APC"
"Inj, aponvie, 1 mg","C9145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.01","","","","","","","fee schedule","1.95","6.8","APC"
"Datopotamab deruxtecan, 1 mg","C9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","160.21","","","","","","","fee schedule","160.21","178.35",""
"Datopotamab deruxtecan, 1 mg","C9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","171.29","","","","","","","fee schedule","160.21","178.35",""
"Datopotamab deruxtecan, 1 mg","C9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","178.35","","","","","","","fee schedule","160.21","178.35",""
"Inj, treosulfan, 50 mg","C9175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","99.92","","","","","","","fee schedule","99.92","111.23",""
"Inj, treosulfan, 50 mg","C9175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","106.83","","","","","","","fee schedule","99.92","111.23",""
"Inj, treosulfan, 50 mg","C9175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","111.23","","","","","","","fee schedule","99.92","111.23",""
"Inj, clevidipine butyrate","C9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.16","","","","","","","fee schedule","9.16","10.2",""
"Inj, clevidipine butyrate","C9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.79","","","","","","","fee schedule","9.16","10.2",""
"Inj, clevidipine butyrate","C9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.2","","","","","","","fee schedule","9.16","10.2",""
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","451.78","","","","","","","fee schedule","144.73","502.93",""
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","483.04","","","","","","","fee schedule","144.73","502.93",""
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","502.93","","","","","","","fee schedule","144.73","502.93",""
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","450.7","","","","","","","fee schedule","144.73","502.93","APC 277.30"
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","482.01","","","","","","","fee schedule","144.73","502.93","APC 296.56"
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","502.08","","","","","","","fee schedule","144.73","502.93","APC 308.91"
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","148.63","","","","","","","fee schedule","144.73","502.93","APC"
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","146.15","","","","","","","fee schedule","144.73","502.93","APC"
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","144.73","","","","","","","fee schedule","144.73","502.93","APC"
"Artiss fibrin sealant","C9250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","148.99","","","","","","","fee schedule","144.73","502.93","APC"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.82","","","","","","","fee schedule","1.87","6.48",""
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.22","","","","","","","fee schedule","1.87","6.48",""
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.48","","","","","","","fee schedule","1.87","6.48",""
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.81","","","","","","","fee schedule","1.87","6.48","APC 277.30"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.22","","","","","","","fee schedule","1.87","6.48","APC 296.56"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.48","","","","","","","fee schedule","1.87","6.48","APC 308.91"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.92","","","","","","","fee schedule","1.87","6.48","APC"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.88","","","","","","","fee schedule","1.87","6.48","APC"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.87","","","","","","","fee schedule","1.87","6.48","APC"
"Bevacizumab injection","C9257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.92","","","","","","","fee schedule","1.87","6.48","APC"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","63","","","","","","","fee schedule","20.38","70.7",""
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.35","","","","","","","fee schedule","20.38","70.7",""
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.13","","","","","","","fee schedule","20.38","70.7",""
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","63.47","","","","","","","fee schedule","20.38","70.7","APC 277.30"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.87","","","","","","","fee schedule","20.38","70.7","APC 296.56"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.7","","","","","","","fee schedule","20.38","70.7","APC 308.91"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.93","","","","","","","fee schedule","20.38","70.7","APC"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.58","","","","","","","fee schedule","20.38","70.7","APC"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.38","","","","","","","fee schedule","20.38","70.7","APC"
"Injection, cangrelor","C9460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.98","","","","","","","fee schedule","20.38","70.7","APC"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79.66","","","","","","","fee schedule","25.55","88.68",""
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.17","","","","","","","fee schedule","25.55","88.68",""
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","88.68","","","","","","","fee schedule","25.55","88.68",""
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79.56","","","","","","","fee schedule","25.55","88.68","APC 277.30"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.09","","","","","","","fee schedule","25.55","88.68","APC 296.56"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","88.63","","","","","","","fee schedule","25.55","88.68","APC 308.91"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.24","","","","","","","fee schedule","25.55","88.68","APC"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.8","","","","","","","fee schedule","25.55","88.68","APC"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.55","","","","","","","fee schedule","25.55","88.68","APC"
"Sotalol hydrochloride IV","C9482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.3","","","","","","","fee schedule","25.55","88.68","APC"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39642","","","","","","","fee schedule","5220","39855.12",""
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36037","","","","","","","fee schedule","5220","39855.12",""
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Perc drug-el cor stent sing","C9600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Perc drug-el cor stent bran","C9601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perc drug-el cor stent bran","C9601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perc drug-el cor stent bran","C9601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor stent ather s","C9602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor stent ather br","C9603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor stent ather br","C9603","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor stent ather br","C9603","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","39855.12",""
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","39855.12",""
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Perc d-e cor revasc t cabg s","C9604","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Perc d-e cor revasc t cabg b","C9605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor revasc t cabg b","C9605","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor revasc t cabg b","C9605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Perc d-e cor revasc w AMI s","C9606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Perc d-e cor revasc w AMI s","C9606","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Perc d-e cor revasc w AMI s","C9606","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor revasc chro sin","C9607","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Perc d-e cor revasc chro add","C9608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39642","","","","","","","fee schedule","5220","39642",""
"Perc d-e cor revasc chro add","C9608","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39642",""
"Perc d-e cor revasc chro add","C9608","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36037","","","","","","","fee schedule","5220","39642",""
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","5220",""
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5220",""
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","5220",""
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5220","APC 277.30"
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5220","APC 296.56"
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5220","APC 308.91"
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5220","APC"
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5220","APC"
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5220","APC"
"Place endorectal app","C9725","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5220","APC"
"Rxt breast appl place/remov","C9726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Rxt breast appl place/remov","C9726","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Rxt breast appl place/remov","C9726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","1544.13","5790",""
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5790",""
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","1544.13","5790",""
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5790","APC 277.30"
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5790","APC 296.56"
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5790","APC 308.91"
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5790","APC"
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5790","APC"
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5790","APC"
"Insert palate implants","C9727","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5790","APC"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1377.48","5220",""
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4289.59","","","","","","","fee schedule","1377.48","5220","APC 277.30"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4587.52","","","","","","","fee schedule","1377.48","5220","APC 296.56"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4778.57","","","","","","","fee schedule","1377.48","5220","APC 308.91"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1414.62","","","","","","","fee schedule","1377.48","5220","APC"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1390.99","","","","","","","fee schedule","1377.48","5220","APC"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1377.48","","","","","","","fee schedule","1377.48","5220","APC"
"Place device/marker, non pro","C9728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1418","","","","","","","fee schedule","1377.48","5220","APC"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1081.2","","","","","","","fee schedule","347.2","1204.45","APC 277.30"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1156.3","","","","","","","fee schedule","347.2","1204.45","APC 296.56"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1204.45","","","","","","","fee schedule","347.2","1204.45","APC 308.91"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.56","","","","","","","fee schedule","347.2","1204.45","APC"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.6","","","","","","","fee schedule","347.2","1204.45","APC"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.2","","","","","","","fee schedule","347.2","1204.45","APC"
"Non-ophthalmic FVA","C9733","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.41","","","","","","","fee schedule","347.2","1204.45","APC"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"U/s trtmt, not leiomyomata","C9734","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Blue light cysto imag agent","C9738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Blue light cysto imag agent","C9738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","5336.05","18511.05",""
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","5336.05","18511.05",""
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16616.86","","","","","","","fee schedule","5336.05","18511.05","APC 277.30"
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17770.99","","","","","","","fee schedule","5336.05","18511.05","APC 296.56"
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18511.05","","","","","","","fee schedule","5336.05","18511.05","APC 308.91"
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5479.92","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5388.37","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5336.05","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cystoscopy prostatic imp 1-3","C9739","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5492.99","","","","","","","fee schedule","5336.05","18511.05","APC"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","9421.01","32681.98",""
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","9421.01","32681.98",""
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto impl 4 or more","C9740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Trans imp balloon cont","C9746","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Microwave bronch, 3d, ebus","C9751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","5220","19040",""
"Microwave bronch, 3d, ebus","C9751","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","19040",""
"Microwave bronch, 3d, ebus","C9751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","5220","19040",""
"Intraosseous destruct add'l","C9753","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fluorescence lymph map w/ICG","C9756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Fluorescence lymph map w/ICG","C9756","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","44324.22",""
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","44324.22",""
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","44324.22",""
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","5220","44324.22","APC 277.30"
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","5220","44324.22","APC 296.56"
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","5220","44324.22","APC 308.91"
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","5220","44324.22","APC"
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","5220","44324.22","APC"
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","5220","44324.22","APC"
"Spine/lumbar disk surgery","C9757","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","5220","44324.22","APC"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","17047.24","59137.77",""
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","17047.24","59137.77",""
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","53086.35","","","","","","","fee schedule","17047.24","59137.77","APC 277.30"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","56773.49","","","","","","","fee schedule","17047.24","59137.77","APC 296.56"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","59137.77","","","","","","","fee schedule","17047.24","59137.77","APC 308.91"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17506.84","","","","","","","fee schedule","17047.24","59137.77","APC"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17214.37","","","","","","","fee schedule","17047.24","59137.77","APC"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17047.24","","","","","","","fee schedule","17047.24","59137.77","APC"
"Interatrial shunt IDE","C9758","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17548.63","","","","","","","fee schedule","17047.24","59137.77","APC"
"Transcath intraop microinf","C9759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Transcath intraop microinf","C9759","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","60970","","","","","","","fee schedule","5220","92929.82",""
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","92929.82",""
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","55036","","","","","","","fee schedule","5220","92929.82",""
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","83420.54","","","","","","","fee schedule","5220","92929.82","APC 277.30"
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89214.55","","","","","","","fee schedule","5220","92929.82","APC 296.56"
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","92929.82","","","","","","","fee schedule","5220","92929.82","APC 308.91"
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27510.47","","","","","","","fee schedule","5220","92929.82","APC"
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27050.87","","","","","","","fee schedule","5220","92929.82","APC"
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26788.24","","","","","","","fee schedule","5220","92929.82","APC"
"Non-blind interatrial shunt","C9760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27576.13","","","","","","","fee schedule","5220","92929.82","APC"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","9421.01","32681.98",""
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","9421.01","32681.98",""
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29337.71","","","","","","","fee schedule","9421.01","32681.98","APC 277.30"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31375.38","","","","","","","fee schedule","9421.01","32681.98","APC 296.56"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32681.98","","","","","","","fee schedule","9421.01","32681.98","APC 308.91"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9675.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9513.37","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9421.01","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cysto, litho, vacuum kidney","C9761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9698.1","","","","","","","fee schedule","9421.01","32681.98","APC"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys strain","C9762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.41","","","","","","","fee schedule","543.79","1886.44","APC 277.30"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1811.02","","","","","","","fee schedule","543.79","1886.44","APC 296.56"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1886.44","","","","","","","fee schedule","543.79","1886.44","APC 308.91"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.45","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.12","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Cardiac MRI seg dys stress","C9763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.79","","","","","","","fee schedule","543.79","1886.44","APC"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","39855.12",""
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","39855.12",""
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","39855.12",""
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","5220","39855.12","APC 277.30"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","5220","39855.12","APC 296.56"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","5220","39855.12","APC 308.91"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","5220","39855.12","APC"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","5220","39855.12","APC"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","5220","39855.12","APC"
"Revasc intravasc lithotripsy","C9764","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","5220","39855.12","APC"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-stent","C9765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc intra lithotrip-ather","C9766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","5220","63288.08",""
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","63288.08",""
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","5220","63288.08",""
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","5220","63288.08","APC 277.30"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","5220","63288.08","APC 296.56"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","5220","63288.08","APC 308.91"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc lithotrip-stent-ather","C9767","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","5220","63288.08","APC"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revasc lithotrip tibi/perone","C9772","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-stent tib/per","C9773","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lithotr-ather tib/per","C9774","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Revasc lith-sten-ath tib/per","C9775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"Esophag mucosal integ add-on","C9777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","4978.43","17270.44",""
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","4978.43","17270.44",""
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15503.2","","","","","","","fee schedule","4978.43","17270.44","APC 277.30"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16579.98","","","","","","","fee schedule","4978.43","17270.44","APC 296.56"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17270.44","","","","","","","fee schedule","4978.43","17270.44","APC 308.91"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5112.65","","","","","","","fee schedule","4978.43","17270.44","APC"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5027.24","","","","","","","fee schedule","4978.43","17270.44","APC"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4978.43","","","","","","","fee schedule","4978.43","17270.44","APC"
"Colpopexy, min/inv, ex-perit","C9778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5124.85","","","","","","","fee schedule","4978.43","17270.44","APC"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","3836.96","14111",""
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","3836.96","14111",""
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11948.58","","","","","","","fee schedule","3836.96","14111","APC 277.30"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12778.47","","","","","","","fee schedule","3836.96","14111","APC 296.56"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13310.62","","","","","","","fee schedule","3836.96","14111","APC 308.91"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3940.41","","","","","","","fee schedule","3836.96","14111","APC"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3874.58","","","","","","","fee schedule","3836.96","14111","APC"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3836.96","","","","","","","fee schedule","3836.96","14111","APC"
"ESD endoscopy or colonoscopy","C9779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3949.81","","","","","","","fee schedule","3836.96","14111","APC"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","8036.81","35289",""
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","8036.81","35289",""
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25027.22","","","","","","","fee schedule","8036.81","35289","APC 277.30"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26765.5","","","","","","","fee schedule","8036.81","35289","APC 296.56"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27880.13","","","","","","","fee schedule","8036.81","35289","APC 308.91"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8253.49","","","","","","","fee schedule","8036.81","35289","APC"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8115.6","","","","","","","fee schedule","8036.81","35289","APC"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8036.81","","","","","","","fee schedule","8036.81","35289","APC"
"Insert cv cath inf & sup app","C9780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8273.19","","","","","","","fee schedule","8036.81","35289","APC"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","12777.04","44324.22",""
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","12777.04","44324.22",""
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39788.63","","","","","","","fee schedule","12777.04","44324.22","APC 277.30"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42552.17","","","","","","","fee schedule","12777.04","44324.22","APC 296.56"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44324.22","","","","","","","fee schedule","12777.04","44324.22","APC 308.91"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13121.51","","","","","","","fee schedule","12777.04","44324.22","APC"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12902.3","","","","","","","fee schedule","12777.04","44324.22","APC"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12777.04","","","","","","","fee schedule","12777.04","44324.22","APC"
"Arthro/shoul surg; w/spacer","C9781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13152.83","","","","","","","fee schedule","12777.04","44324.22","APC"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","50815","","","","","","","fee schedule","17047.24","59137.77",""
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45861","","","","","","","fee schedule","17047.24","59137.77",""
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","53086.35","","","","","","","fee schedule","17047.24","59137.77","APC 277.30"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","56773.49","","","","","","","fee schedule","17047.24","59137.77","APC 296.56"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","59137.77","","","","","","","fee schedule","17047.24","59137.77","APC 308.91"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17506.84","","","","","","","fee schedule","17047.24","59137.77","APC"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17214.37","","","","","","","fee schedule","17047.24","59137.77","APC"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17047.24","","","","","","","fee schedule","17047.24","59137.77","APC"
"Blind myocar trpl bon marrow","C9782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17548.63","","","","","","","fee schedule","17047.24","59137.77","APC"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","11488.76","39855.12",""
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","11488.76","39855.12",""
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35776.84","","","","","","","fee schedule","11488.76","39855.12","APC 277.30"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38261.74","","","","","","","fee schedule","11488.76","39855.12","APC 296.56"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39855.12","","","","","","","fee schedule","11488.76","39855.12","APC 308.91"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11798.51","","","","","","","fee schedule","11488.76","39855.12","APC"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11601.39","","","","","","","fee schedule","11488.76","39855.12","APC"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11488.76","","","","","","","fee schedule","11488.76","39855.12","APC"
"Blind cor sinus reducer impl","C9783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11826.66","","","","","","","fee schedule","11488.76","39855.12","APC"
"Endo sleeve gastro w/tube","C9784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","26537","29398",""
"Endo sleeve gastro w/tube","C9784","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","26537","29398",""
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Endo outlet restrict w/tube","C9785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","1218.11","14111",""
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","1218.11","14111",""
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3793.29","","","","","","","fee schedule","1218.11","14111","APC 277.30"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4056.76","","","","","","","fee schedule","1218.11","14111","APC 296.56"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4225.7","","","","","","","fee schedule","1218.11","14111","APC 308.91"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1250.95","","","","","","","fee schedule","1218.11","14111","APC"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1230.05","","","","","","","fee schedule","1218.11","14111","APC"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1218.11","","","","","","","fee schedule","1218.11","14111","APC"
"Instill pharm renal pelvis","C9789","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1253.94","","","","","","","fee schedule","1218.11","14111","APC"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","9497.96","35289",""
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","9497.96","35289",""
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29577.35","","","","","","","fee schedule","9497.96","35289","APC 277.30"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31631.66","","","","","","","fee schedule","9497.96","35289","APC 296.56"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32948.94","","","","","","","fee schedule","9497.96","35289","APC 308.91"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9754.03","","","","","","","fee schedule","9497.96","35289","APC"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9591.08","","","","","","","fee schedule","9497.96","35289","APC"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9497.96","","","","","","","fee schedule","9497.96","35289","APC"
"Blind/nonblind trans atrial","C9792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9777.31","","","","","","","fee schedule","9497.96","35289","APC"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Pre-plan 3d model w/ccta","C9793","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","14111","","","","","","","fee schedule","2762.33","14111",""
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12739","","","","","","","fee schedule","2762.33","14111",""
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8602.11","","","","","","","fee schedule","2762.33","14111","APC 277.30"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9199.57","","","","","","","fee schedule","2762.33","14111","APC 296.56"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9582.68","","","","","","","fee schedule","2762.33","14111","APC 308.91"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2836.81","","","","","","","fee schedule","2762.33","14111","APC"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2789.41","","","","","","","fee schedule","2762.33","14111","APC"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2762.33","","","","","","","fee schedule","2762.33","14111","APC"
"Rpr intst excl anrect fist","C9796","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2843.58","","","","","","","fee schedule","2762.33","14111","APC"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","35289","","","","","","","fee schedule","18243.62","63288.08",""
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31849","","","","","","","fee schedule","18243.62","63288.08",""
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56811.96","","","","","","","fee schedule","18243.62","63288.08","APC 277.30"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60757.87","","","","","","","fee schedule","18243.62","63288.08","APC 296.56"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63288.08","","","","","","","fee schedule","18243.62","63288.08","APC 308.91"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18735.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18422.48","","","","","","","fee schedule","18243.62","63288.08","APC"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18243.62","","","","","","","fee schedule","18243.62","63288.08","APC"
"Vasc emb/occ w/prs cath","C9797","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.19","","","","","","","fee schedule","18243.62","63288.08","APC"
"Dermal filler inj px/suppl","C9800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","10578.79","36698.4",""
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","10578.79","36698.4",""
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32943.14","","","","","","","fee schedule","10578.79","36698.4","APC 277.30"
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35231.22","","","","","","","fee schedule","10578.79","36698.4","APC 296.56"
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36698.4","","","","","","","fee schedule","10578.79","36698.4","APC 308.91"
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10864.01","","","","","","","fee schedule","10578.79","36698.4","APC"
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10682.51","","","","","","","fee schedule","10578.79","36698.4","APC"
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10578.79","","","","","","","fee schedule","10578.79","36698.4","APC"
"Endo defect closure GI tract","C9901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10889.94","","","","","","","fee schedule","10578.79","36698.4","APC"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Periodic oral evaluation","D0120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Limit oral eval problm focus","D0140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Comprehensve oral evaluation","D0150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Extensv oral eval prob focus","D0160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval,est pt,problem focus","D0170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Re-eval post-op visit","D0171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Comp periodontal evaluation","D0180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Assessment of a patient","D0191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Intraor complete film series","D0210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periapical first","D0220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlusal film","D0240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral 2d project image","D0250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Extraoral posterior image","D0251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewing single image","D0270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Dental bitewings two images","D0272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings - three images","D0273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Bitewings four images","D0274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Vert bitewings 7 to 8 images","D0277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Dental saliography","D0310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Dental tmj arthrogram incl i","D0320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Other tmj images by report","D0321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Dental tomographic survey","D0322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","739.46","","","","","","","fee schedule","237.46","823.75","APC 277.30"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","790.82","","","","","","","fee schedule","237.46","823.75","APC 296.56"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","823.75","","","","","","","fee schedule","237.46","823.75","APC 308.91"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.86","","","","","","","fee schedule","237.46","823.75","APC"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.78","","","","","","","fee schedule","237.46","823.75","APC"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.46","","","","","","","fee schedule","237.46","823.75","APC"
"Panoramic image","D0330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.44","","","","","","","fee schedule","237.46","823.75","APC"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"2d cephalometric image","D0340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Oral/facial photo images","D0350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt & interp","D0364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete man","D0365","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete max","D0366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interp both jaw","D0367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct interprete TMJ","D0368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI capture & interprete","D0369","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound capt & interp","D0370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Sialoendoscopy capt & interp","D0371","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture limited","D0380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt mandible","D0381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capt maxilla","D0382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct both jaws","D0383","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Cone beam ct capture TMJ","D0384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Max MRI image capture","D0385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Max ultrasound image capture","D0386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Trtmnt simulation 3d image","D0393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Digital sub 2 or more images","D0394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Fusion 2 or more 3d images","D0395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=61.50","D0701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=52.50 and M <61.50","D0702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Fracture of lower extremity M >=41.50 and M <52.50","D0703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Extra oral post radio image","D0705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral occlus radio image","D0706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral periap radio image","D0707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral bite radio image","D0708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Intraoral cmplt radio images","D0709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Dental prophylaxis adult","D1110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Indirect rest remov","D2956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Indirect rest remov","D2956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Excavate tooth non-restorabl","D2989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Excavate tooth non-restorabl","D2989","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Apicoectomy - anterior","D3410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery bicuspid","D3421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery molar","D3425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Root surgery ea add root","D3426","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Bone graft peri per tooth","D3428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Bone graft peri each addl","D3429","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Guided tissue regeneration","D3432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Root amputation","D3450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res anterior","D3471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res premolar","D3472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"Surg rep root res molar","D3473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf anterior","D3501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf premolar","D3502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"Surg exp root surf molar","D3503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Isolation- tooth w rubb dam","D3910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Tooth splitting","D3920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","643.38","5790",""
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","643.38","5790",""
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5790","APC 277.30"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5790","APC 296.56"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5790","APC 308.91"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5790","APC"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5790","APC"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5790","APC"
"D?cor or submerg erupt tooth","D3921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5790","APC"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Endodontic procedure","D3999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 4 or mor","D4210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty 1 to 3","D4211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingivectomy/plasty rest","D4212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Ana crown exp 4 or> per quad","D4230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Ana crown exp 1-3 per quad","D4231","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gingival flap proc w/ planin","D4240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Gngvl flap w rootplan 1-3 th","D4241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Apically positioned flap","D4245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Crown lengthen hard tissue","D4249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Osseous surgery 4 or more","D4260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Osseous surg 1 to 3 teeth","D4261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Bone replce graft first site","D4263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Bone replce graft each add","D4264","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen resorble","D4266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Guided tiss regen nonresorb","D4267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Surgical revision procedure","D4268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Pedicle soft tissue graft pr","D4270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Auto tissue graft 1st tooth","D4273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Mesial/distal wedge proc","D4274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Non-auto graft 1st tooth","D4275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Con tissue w dble ped graft","D4276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Soft tissue graft firsttooth","D4277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Soft tissue graft addl tooth","D4278","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Remove non-resorb barrier","D4286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Remove non-resorb barrier","D4286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Gingival irrigation per quad","D4921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","734.03","","","","","","","fee schedule","235.71","817.7","APC 277.30"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","785.01","","","","","","","fee schedule","235.71","817.7","APC 296.56"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","817.7","","","","","","","fee schedule","235.71","817.7","APC 308.91"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242.07","","","","","","","fee schedule","235.71","817.7","APC"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","238.02","","","","","","","fee schedule","235.71","817.7","APC"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235.71","","","","","","","fee schedule","235.71","817.7","APC"
"Unspecified periodontal proc","D4999","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242.65","","","","","","","fee schedule","235.71","817.7","APC"
"Peri medicament w/seal, max","D5995","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Peri medicament w/seal, max","D5995","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Peri medicament w/seal, mand","D5996","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Peri medicament w/seal, mand","D5996","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Odontics endosteal implant","D6010","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Second stage implant surgery","D6011","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Endosteal implant","D6012","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Surgical place mini implant","D6013","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Odontics eposteal implant","D6040","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Odontics transosteal implnt","D6050","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Interim abutment","D6051","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Access/retorq implant screw","D6089","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Access/retorq implant screw","D6089","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Bone graft repair perimplant","D6103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone graft time of implant","D6104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Remove implant body","D6105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Remove implant body","D6105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tissue regen resorbable","D6106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tissue regen resorbable","D6106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tissue regen non-resorbable","D6107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tissue regen non-resorbable","D6107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Semi precision abutment","D6191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Semi precision abutment","D6191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Semi precision attachment","D6192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Semi precision attachment","D6192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Replace implnt screw","D6193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Replace implnt screw","D6193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Replace material prosthesis","D6197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Replace material prosthesis","D6197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Remove interim implant","D6198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Remove interim implant","D6198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Extraction coronal remnants","D7111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Extraction erupted tooth/exr","D7140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Rem imp tooth w mucoper flp","D7210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov soft tiss","D7220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov part bony","D7230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth remov comp bony","D7240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Impact tooth rem bony w/comp","D7241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Tooth root removal","D7250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Coronectomy","D7251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Part extract for implant","D7252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Part extract for implant","D7252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Nerve dissection","D7259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Nerve dissection","D7259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Oral antral fistula closure","D7260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Primary closure sinus perf","D7261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Tooth reimplantation","D7270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Tooth transplantation","D7272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Exposure of unerupted tooth","D7280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Mobilize erupted/malpos toot","D7282","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Place device impacted tooth","D7283","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Exc biopsy of saliv glands","D7284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Exc biopsy of saliv glands","D7284","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Biopsy of oral tissue hard","D7285","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Biopsy of oral tissue soft","D7286","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Exfoliative cytolog collect","D7287","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Brush biopsy","D7288","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repositioning of teeth","D7290","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Transseptal fiberotomy","D7291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Screw retained plate","D7292","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Temp anchorage dev w flap","D7293","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Temp anchorage dev w/o flap","D7294","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone harvest,auto graft proc","D7295","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Remove screw retained plate","D7298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Remove screw retained plate","D7298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rem anchorage device w/flap","D7299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rem anchorage device w/flap","D7299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Rem anchorage dev w/o flap","D7300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Rem anchorage dev w/o flap","D7300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/ extraction","D7310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty w/extract 1-3","D7311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoplasty w/o extraction","D7320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Alveoloplasty not w/extracts","D7321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty ridge extens","D7340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Vestibuloplasty exten graft","D7350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Rad exc lesion up to 1.25 cm","D7410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion>1.25c","D7411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision benign lesion compl","D7412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion<=1.25c","D7413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig lesion>1.25cm","D7414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","1544.13","5356.68",""
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4808.55","","","","","","","fee schedule","1544.13","5356.68","APC 277.30"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5142.53","","","","","","","fee schedule","1544.13","5356.68","APC 296.56"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5356.68","","","","","","","fee schedule","1544.13","5356.68","APC 308.91"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1585.76","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.27","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.13","","","","","","","fee schedule","1544.13","5356.68","APC"
"Excision malig les complicat","D7415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.55","","","","","","","fee schedule","1544.13","5356.68","APC"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor exc to 1.25 cm","D7440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Malig tumor > 1.25 cm","D7441","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst to 1.25cm","D7450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem odontogen cyst > 1.25 cm","D7451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst to 1.25cm","D7460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Rem nonodonto cyst > 1.25 cm","D7461","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Lesion destruction","D7465","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3299.54","11446.28",""
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Rem exostosis any site","D7471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Removal of torus palatinus","D7472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Remove torus mandibularis","D7473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Surg reduct osseoustuberosit","D7485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Maxilla or mandible resectio","D7490","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Marsupialization odon cyst","D7509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Marsupialization odon cyst","D7509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"I&d absc intraoral soft tiss","D7510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess intra","D7511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"I&d abscess extraoral","D7520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","704.73","5220",""
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2194.59","","","","","","","fee schedule","704.73","5220","APC 277.30"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2347.01","","","","","","","fee schedule","704.73","5220","APC 296.56"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2444.75","","","","","","","fee schedule","704.73","5220","APC 308.91"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","723.73","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","711.64","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","704.73","","","","","","","fee schedule","704.73","5220","APC"
"Incision/drain abscess extra","D7521","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","725.46","","","","","","","fee schedule","704.73","5220","APC"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Removal fb skin/areolar tiss","D7530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Removal of fb reaction","D7540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Removal of sloughed off bone","D7550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Maxillary sinusotomy","D7560","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Maxilla open reduct simple","D7610","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Open red simpl mandible fx","D7630","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Open red simp malar/zygom fx","D7650","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Closd rductn splint alveolus","D7670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Alveolus open reduction","D7671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Reduct simple facial bone fx","D7680","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Maxilla open reduct compound","D7710","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Open reduct compd mandble fx","D7730","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Open red comp malar/zygma fx","D7750","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Open reduc compd alveolus fx","D7770","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Alveolus clsd reduc stblz te","D7771","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Reduct compnd facial bone fx","D7780","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj open reduct-dislocation","D7810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj manipulation under anest","D7830","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Removal of tmj condyle","D7840","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj meniscectomy","D7850","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj repair of joint disc","D7852","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj excisn of joint membrane","D7854","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj cutting of a muscle","D7856","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj reconstruction","D7858","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj cutting into joint","D7860","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj reshaping components","D7865","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj aspiration joint fluid","D7870","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Lysis + lavage w catheters","D7871","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj diagnostic arthroscopy","D7872","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj arthroscopy lysis adhesn","D7873","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","11296.24",""
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","11296.24","APC 277.30"
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","11296.24","APC 296.56"
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","11296.24","APC 308.91"
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tmj arthroscopy disc reposit","D7874","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","11296.24","APC"
"Tmj arthroscopy synovectomy","D7875","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj arthroscopy discectomy","D7876","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tmj arthroscopy debridement","D7877","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Dent sutur recent wnd to 5cm","D7910","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Dental suture wound to 5 cm","D7911","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Suture complicate wnd > 5 cm","D7912","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Dental skin graft","D7920","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Collect & appl blood product","D7921","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Indexing for osteotomy","D7939","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Indexing for osteotomy","D7939","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","643.38","5220",""
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2003.54","","","","","","","fee schedule","643.38","5220","APC 277.30"
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2142.7","","","","","","","fee schedule","643.38","5220","APC 296.56"
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2231.93","","","","","","","fee schedule","643.38","5220","APC 308.91"
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","660.73","","","","","","","fee schedule","643.38","5220","APC"
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","649.69","","","","","","","fee schedule","643.38","5220","APC"
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","643.38","","","","","","","fee schedule","643.38","5220","APC"
"Reshaping bone orthognathic","D7940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","662.31","","","","","","","fee schedule","643.38","5220","APC"
"Bone cutting ramus closed","D7941","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cutting ramus open w/graft","D7943","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone cutting segmented","D7944","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone cutting body mandible","D7945","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Reconstruction maxilla total","D7946","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Reconstruct maxilla segment","D7947","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Reconstruct midface no graft","D7948","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Reconstruct midface w/graft","D7949","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","20437.6",""
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18346.27","","","","","","","fee schedule","5220","20437.6","APC 277.30"
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19620.52","","","","","","","fee schedule","5220","20437.6","APC 296.56"
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20437.6","","","","","","","fee schedule","5220","20437.6","APC 308.91"
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6050.24","","","","","","","fee schedule","5220","20437.6","APC"
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5949.16","","","","","","","fee schedule","5220","20437.6","APC"
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5891.41","","","","","","","fee schedule","5220","20437.6","APC"
"Mandible graft","D7950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6064.68","","","","","","","fee schedule","5220","20437.6","APC"
"Sinus aug w bone or bone sub","D7951","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Sinus augmentation vertical","D7952","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone replacement graft","D7953","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair maxillofacial defects","D7955","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Tiss regen edent resorb","D7956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tiss regen edent resorb","D7956","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Tiss regen edent nonresorb","D7957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Tiss regen edent nonresorb","D7957","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Buccal/labial frenectomy","D7961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Buccal/labial frenectomy","D7961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Lingual frenectomy","D7962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Lingual frenectomy","D7962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Frenuloplasty","D7963","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Excision hyperplastic tissue","D7970","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Excision pericoronal gingiva","D7971","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Surg redct fibrous tuberosit","D7972","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Sialolithotomy","D7980","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Excision of salivary gland","D7981","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Sialodochoplasty","D7982","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Closure of salivary fistula","D7983","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Emergency tracheotomy","D7990","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Dental coronoidectomy","D7991","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Surg place craniofacial impl","D7993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Surg place craniofacial impl","D7993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Surg place zygomatic impl","D7994","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Surg place zygomatic impl","D7994","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Synthetic graft facial bones","D7995","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Implant mandible for augment","D7996","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Appliance removal","D7997","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Intraoral place of fix dev","D7998","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Oral surgery procedure","D7999","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Repair sleep apnea appliance","D9949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5226","5790",""
"Repair sleep apnea appliance","D9949","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5226","5790",""
"Penile contractur devic manu","E0201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","153.48","","","","","","","fee schedule","149.45","153.85","APC"
"Penile contractur devic manu","E0201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","150.92","","","","","","","fee schedule","149.45","153.85","APC"
"Penile contractur devic manu","E0201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","149.45","","","","","","","fee schedule","149.45","153.85","APC"
"Penile contractur devic manu","E0201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","153.85","","","","","","","fee schedule","149.45","153.85","APC"
"Transcut tibial nerv stimula","E0736","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.87","","","","","","","fee schedule","53.43","55","APC"
"Transcut tibial nerv stimula","E0736","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.95","","","","","","","fee schedule","53.43","55","APC"
"Transcut tibial nerv stimula","E0736","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","53.43","","","","","","","fee schedule","53.43","55","APC"
"Transcut tibial nerv stimula","E0736","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55","","","","","","","fee schedule","53.43","55","APC"
"Upper extremity rehab","E0738","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2136.52","","","","","","","fee schedule","2080.43","2141.62","APC"
"Upper extremity rehab","E0738","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2100.83","","","","","","","fee schedule","2080.43","2141.62","APC"
"Upper extremity rehab","E0738","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2080.43","","","","","","","fee schedule","2080.43","2141.62","APC"
"Upper extremity rehab","E0738","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2141.62","","","","","","","fee schedule","2080.43","2141.62","APC"
"Rehab sys active assist rt","E0739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1673.55","","","","","","","fee schedule","1629.61","1677.54","APC"
"Rehab sys active assist rt","E0739","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1645.59","","","","","","","fee schedule","1629.61","1677.54","APC"
"Rehab sys active assist rt","E0739","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1629.61","","","","","","","fee schedule","1629.61","1677.54","APC"
"Rehab sys active assist rt","E0739","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1677.54","","","","","","","fee schedule","1629.61","1677.54","APC"
"Vr cbt therapy","E1905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","706.82","","","","","","","fee schedule","688.27","708.51","APC"
"Vr cbt therapy","E1905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","695.01","","","","","","","fee schedule","688.27","708.51","APC"
"Vr cbt therapy","E1905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","688.27","","","","","","","fee schedule","688.27","708.51","APC"
"Vr cbt therapy","E1905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","708.51","","","","","","","fee schedule","688.27","708.51","APC"
"Glucose monitor w cartridge","E2104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57.11","","","","","","","fee schedule","55.61","57.25","APC"
"Glucose monitor w cartridge","E2104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","56.16","","","","","","","fee schedule","55.61","57.25","APC"
"Glucose monitor w cartridge","E2104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","55.61","","","","","","","fee schedule","55.61","57.25","APC"
"Glucose monitor w cartridge","E2104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57.25","","","","","","","fee schedule","55.61","57.25","APC"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Admin influenza virus vac","G0008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Admin pneumococcal vaccine","G0009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","145.12","","","","","","","fee schedule","46.6","161.66","APC 277.30"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","155.2","","","","","","","fee schedule","46.6","161.66","APC 296.56"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161.66","","","","","","","fee schedule","46.6","161.66","APC 308.91"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.86","","","","","","","fee schedule","46.6","161.66","APC"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.06","","","","","","","fee schedule","46.6","161.66","APC"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.6","","","","","","","fee schedule","46.6","161.66","APC"
"Admin hepatitis b vaccine","G0010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.97","","","","","","","fee schedule","46.6","161.66","APC"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","223.14","","","","","","","fee schedule","71.65","248.57","APC 277.30"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","238.64","","","","","","","fee schedule","71.65","248.57","APC 296.56"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","248.57","","","","","","","fee schedule","71.65","248.57","APC 308.91"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.59","","","","","","","fee schedule","71.65","248.57","APC"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.36","","","","","","","fee schedule","71.65","248.57","APC"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.65","","","","","","","fee schedule","71.65","248.57","APC"
"Injection of hiv prep drug","G0012","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.76","","","","","","","fee schedule","71.65","248.57","APC"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Hiv prep counsel, clin staff","G0013","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.18","","","","","","","fee schedule","6.5","11.18",""
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.5","","","","","","","fee schedule","6.5","11.18",""
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.5","","","","","","","fee schedule","6.5","11.18",""
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.5","","","","","","","fee schedule","6.5","11.18",""
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.18","","","","","","","fee schedule","6.5","11.18",""
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.81","","","","","","","fee schedule","6.5","11.18","APC"
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.7","","","","","","","fee schedule","6.5","11.18","APC"
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.63","","","","","","","fee schedule","6.5","11.18","APC"
"Semen analysis","G0027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.82","","","","","","","fee schedule","6.5","11.18","APC"
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","31.61","","","","","","","fee schedule","19.31","31.61",""
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.31","","","","","","","fee schedule","19.31","31.61",""
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.31","","","","","","","fee schedule","19.31","31.61",""
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.31","","","","","","","fee schedule","19.31","31.61",""
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","31.61","","","","","","","fee schedule","19.31","31.61",""
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.23","","","","","","","fee schedule","19.31","31.61","APC"
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.89","","","","","","","fee schedule","19.31","31.61","APC"
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.7","","","","","","","fee schedule","19.31","31.61","APC"
"PSA Screening","G0103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.28","","","","","","","fee schedule","19.31","31.61","APC"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","5220",""
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","925.49","5220",""
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","5220",""
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","5220","APC 277.30"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","5220","APC 296.56"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","5220","APC 308.91"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","5220","APC"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","5220","APC"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","5220","APC"
"CA screen;flexi sigmoidscope","G0104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","5220","APC"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","4564",""
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","925.49","4564",""
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","4564",""
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","4564","APC 277.30"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","4564","APC 296.56"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","4564","APC 308.91"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","4564","APC"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","4564","APC"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","4564","APC"
"Colorectal scrn; hi risk ind","G0105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","4564","APC"
"Colon CA screen;barium enema","G0106","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Diab manage trn  per indiv","G0108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57.58","","","","","","","fee schedule","56.07","57.72","APC"
"Diab manage trn  per indiv","G0108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","56.62","","","","","","","fee schedule","56.07","57.72","APC"
"Diab manage trn  per indiv","G0108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.07","","","","","","","fee schedule","56.07","57.72","APC"
"Diab manage trn  per indiv","G0108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57.72","","","","","","","fee schedule","56.07","57.72","APC"
"Diab manage trn ind/group","G0109","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.56","","","","","","","fee schedule","16.13","16.6","APC"
"Diab manage trn ind/group","G0109","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.28","","","","","","","fee schedule","16.13","16.6","APC"
"Diab manage trn ind/group","G0109","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.13","","","","","","","fee schedule","16.13","16.6","APC"
"Diab manage trn ind/group","G0109","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.6","","","","","","","fee schedule","16.13","16.6","APC"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Glaucoma scrn hgh risk direc","G0117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Glaucoma scrn hgh risk direc","G0118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Colon ca scrn; barium enema","G0120","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","925.49","4564",""
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","4564","","","","","","","fee schedule","925.49","4564",""
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","925.49","4564",""
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","4564","APC 277.30"
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","4564","APC 296.56"
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","4564","APC 308.91"
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","4564","APC"
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","4564","APC"
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","4564","APC"
"Colon ca scrn not hi rsk ind","G0121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","4564","APC"
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.82","","","","","","","fee schedule","20.26","34.82",""
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.26","","","","","","","fee schedule","20.26","34.82",""
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.26","","","","","","","fee schedule","20.26","34.82",""
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.26","","","","","","","fee schedule","20.26","34.82",""
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.82","","","","","","","fee schedule","20.26","34.82",""
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.22","","","","","","","fee schedule","20.26","34.82","APC"
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.87","","","","","","","fee schedule","20.26","34.82","APC"
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.67","","","","","","","fee schedule","20.26","34.82","APC"
"Screen cerv/vag thin layer","G0123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.27","","","","","","","fee schedule","20.26","34.82","APC"
"Screen c/v thin layer by MD","G0124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.78","","","","","","","fee schedule","33.78","33.78",""
"Screen c/v thin layer by MD","G0124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.78","","","","","","","fee schedule","33.78","33.78",""
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","58.71","5220",""
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","58.71","5220",""
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","58.71","5220",""
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","58.71","5220","APC 277.30"
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","58.71","5220","APC 296.56"
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","58.71","5220","APC 308.91"
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","58.71","5220","APC"
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","58.71","5220","APC"
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","58.71","5220","APC"
"Trim nail(s)","G0127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","58.71","5220","APC"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","324","","","","","","","fee schedule","104.04","360.93","APC 277.30"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","346.5","","","","","","","fee schedule","104.04","360.93","APC 296.56"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","360.93","","","","","","","fee schedule","104.04","360.93","APC 308.91"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.85","","","","","","","fee schedule","104.04","360.93","APC"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.06","","","","","","","fee schedule","104.04","360.93","APC"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.04","","","","","","","fee schedule","104.04","360.93","APC"
"Single energy x-ray study","G0130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.1","","","","","","","fee schedule","104.04","360.93","APC"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Adm of soc dtr assess 5-15 m","G0136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Scr c/v cyto,autosys and md","G0141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.78","","","","","","","fee schedule","33.78","33.78",""
"Scr c/v cyto,autosys and md","G0141","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.78","","","","","","","fee schedule","33.78","33.78",""
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","34.82","","","","","","","fee schedule","27.05","34.82",""
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.05","","","","","","","fee schedule","27.05","34.82",""
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.05","","","","","","","fee schedule","27.05","34.82",""
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.05","","","","","","","fee schedule","27.05","34.82",""
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","34.82","","","","","","","fee schedule","27.05","34.82",""
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.33","","","","","","","fee schedule","27.05","34.82","APC"
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.86","","","","","","","fee schedule","27.05","34.82","APC"
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.59","","","","","","","fee schedule","27.05","34.82","APC"
"Scr c/v cyto,thinlayer,rescr","G0143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.4","","","","","","","fee schedule","27.05","34.82","APC"
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","36.72","","","","","","","fee schedule","36.72","46.17",""
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","43.97","","","","","","","fee schedule","36.72","46.17",""
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","43.97","","","","","","","fee schedule","36.72","46.17",""
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.97","","","","","","","fee schedule","36.72","46.17",""
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","36.72","","","","","","","fee schedule","36.72","46.17",""
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.06","","","","","","","fee schedule","36.72","46.17","APC"
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.29","","","","","","","fee schedule","36.72","46.17","APC"
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.85","","","","","","","fee schedule","36.72","46.17","APC"
"Scr c/v cyto,thinlayer,rescr","G0144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.17","","","","","","","fee schedule","36.72","46.17","APC"
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","45.53","","","","","","","fee schedule","26.49","45.53",""
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","26.49","","","","","","","fee schedule","26.49","45.53",""
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.49","","","","","","","fee schedule","26.49","45.53",""
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.49","","","","","","","fee schedule","26.49","45.53",""
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","45.53","","","","","","","fee schedule","26.49","45.53",""
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.75","","","","","","","fee schedule","26.49","45.53","APC"
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.28","","","","","","","fee schedule","26.49","45.53","APC"
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.02","","","","","","","fee schedule","26.49","45.53","APC"
"Scr c/v cyto,thinlayer,rescr","G0145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.81","","","","","","","fee schedule","26.49","45.53","APC"
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","19.56","","","","","","","fee schedule","18.19","19.56",""
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.19","19.56",""
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.19","19.56",""
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.19","19.56",""
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19.56","","","","","","","fee schedule","18.19","19.56",""
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.19","19.56","APC"
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.19","19.56","APC"
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.19","19.56","APC"
"Scr c/v cyto, automated sys","G0147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.19","19.56","APC"
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26.12","","","","","","","fee schedule","26.12","33.54",""
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.94","","","","","","","fee schedule","26.12","33.54",""
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.94","","","","","","","fee schedule","26.12","33.54",""
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","31.94","","","","","","","fee schedule","26.12","33.54",""
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","26.12","","","","","","","fee schedule","26.12","33.54",""
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.46","","","","","","","fee schedule","26.12","33.54","APC"
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.9","","","","","","","fee schedule","26.12","33.54","APC"
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.58","","","","","","","fee schedule","26.12","33.54","APC"
"Scr c/v cyto, autosys, rescr","G0148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.54","","","","","","","fee schedule","26.12","33.54","APC"
"HHCP-serv of pt,ea 15 min","G0151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","42.28","","","","","","","fee schedule","42.28","42.28",""
"HHCP-serv of pt,ea 15 min","G0151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","42.28","","","","","","","fee schedule","42.28","42.28",""
"HHCP-serv of pt,ea 15 min","G0151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","42.28","","","","","","","fee schedule","42.28","42.28",""
"HHCP-serv of ot,ea 15 min","G0152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","42.28","","","","","","","fee schedule","42.28","42.28",""
"HHCP-serv of ot,ea 15 min","G0152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","42.28","","","","","","","fee schedule","42.28","42.28",""
"HHCP-serv of ot,ea 15 min","G0152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","42.28","","","","","","","fee schedule","42.28","42.28",""
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","132.41","3408",""
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.33","","","","","","","fee schedule","132.41","3408","APC 277.30"
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.97","","","","","","","fee schedule","132.41","3408","APC 296.56"
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.34","","","","","","","fee schedule","132.41","3408","APC 308.91"
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.98","","","","","","","fee schedule","132.41","3408","APC"
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.71","","","","","","","fee schedule","132.41","3408","APC"
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.41","","","","","","","fee schedule","132.41","3408","APC"
"Extrnl counterpulse, per tx","G0166","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.3","","","","","","","fee schedule","132.41","3408","APC"
"Wound closure by adhesive","G0168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Wound closure by adhesive","G0168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1293.15","","","","","","","fee schedule","415.26","1440.55","APC 277.30"
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1382.96","","","","","","","fee schedule","415.26","1440.55","APC 296.56"
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1440.55","","","","","","","fee schedule","415.26","1440.55","APC 308.91"
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","426.45","","","","","","","fee schedule","415.26","1440.55","APC"
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","419.33","","","","","","","fee schedule","415.26","1440.55","APC"
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","415.26","","","","","","","fee schedule","415.26","1440.55","APC"
"Opps service,sched team conf","G0175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","427.47","","","","","","","fee schedule","415.26","1440.55","APC"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","269.7","","","","","","","fee schedule","86.61","300.45","APC 277.30"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","288.43","","","","","","","fee schedule","86.61","300.45","APC 296.56"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","300.45","","","","","","","fee schedule","86.61","300.45","APC 308.91"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.94","","","","","","","fee schedule","86.61","300.45","APC"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.46","","","","","","","fee schedule","86.61","300.45","APC"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.61","","","","","","","fee schedule","86.61","300.45","APC"
"Software meas of cardiac vol","G0183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.15","","","","","","","fee schedule","86.61","300.45","APC"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","547.36","3880",""
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","547.36","3880",""
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","547.36","3880",""
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1704.51","","","","","","","fee schedule","547.36","3880","APC 277.30"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1822.9","","","","","","","fee schedule","547.36","3880","APC 296.56"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1898.81","","","","","","","fee schedule","547.36","3880","APC 308.91"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","562.11","","","","","","","fee schedule","547.36","3880","APC"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","552.72","","","","","","","fee schedule","547.36","3880","APC"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","547.36","","","","","","","fee schedule","547.36","3880","APC"
"Dstry eye lesn,fdr vssl tech","G0186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","563.46","","","","","","","fee schedule","547.36","3880","APC"
"Scr mammo bi incl cad","G0202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","252","","","","","","","fee schedule","252","260",""
"Scr mammo bi incl cad","G0202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","260","","","","","","","fee schedule","252","260",""
"Scr mammo bi incl cad","G0202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","253","","","","","","","fee schedule","252","260",""
"Dx mammo incl cad bi","G0204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","494","","","","","","","fee schedule","494","508",""
"Dx mammo incl cad bi","G0204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","508","","","","","","","fee schedule","494","508",""
"Dx mammo incl cad bi","G0204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","496","","","","","","","fee schedule","494","508",""
"Dx mammo incl cad uni","G0206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","397","","","","","","","fee schedule","397","408",""
"Dx mammo incl cad uni","G0206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","408","","","","","","","fee schedule","397","408",""
"Dx mammo incl cad uni","G0206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","398","","","","","","","fee schedule","397","408",""
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1238.94","","","","","","","fee schedule","397.85","1380.17","APC 277.30"
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1324.99","","","","","","","fee schedule","397.85","1380.17","APC 296.56"
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1380.17","","","","","","","fee schedule","397.85","1380.17","APC 308.91"
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","408.58","","","","","","","fee schedule","397.85","1380.17","APC"
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","401.75","","","","","","","fee schedule","397.85","1380.17","APC"
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","397.85","","","","","","","fee schedule","397.85","1380.17","APC"
"PET not otherwise specified","G0235","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","409.55","","","","","","","fee schedule","397.85","1380.17","APC"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","105","","","","","","","fee schedule","28.78","108",""
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","108","","","","","","","fee schedule","28.78","108",""
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","105","","","","","","","fee schedule","28.78","108",""
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","108","APC 277.30"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","108","APC 296.56"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","108","APC 308.91"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","108","APC"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","108","APC"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","108","APC"
"Therapeutic procd strg endur","G0237","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","108","APC"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Oth resp proc, indiv","G0238","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Oth resp proc, group","G0239","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Initial foot exam pt lops","G0245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Followup eval of foot pt lop","G0246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","199.67","5220",""
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","621.79","","","","","","","fee schedule","199.67","5220","APC 277.30"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","664.98","","","","","","","fee schedule","199.67","5220","APC 296.56"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","692.67","","","","","","","fee schedule","199.67","5220","APC 308.91"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.05","","","","","","","fee schedule","199.67","5220","APC"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.63","","","","","","","fee schedule","199.67","5220","APC"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.67","","","","","","","fee schedule","199.67","5220","APC"
"Routine footcare pt w lops","G0247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.54","","","","","","","fee schedule","199.67","5220","APC"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Demonstrate use home inr mon","G0248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Provide INR test mater/equip","G0249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2126.97","","","","","","","fee schedule","683.02","2369.43","APC 277.30"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2274.7","","","","","","","fee schedule","683.02","2369.43","APC 296.56"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2369.43","","","","","","","fee schedule","683.02","2369.43","APC 308.91"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","701.43","","","","","","","fee schedule","683.02","2369.43","APC"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","689.72","","","","","","","fee schedule","683.02","2369.43","APC"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","683.02","","","","","","","fee schedule","683.02","2369.43","APC"
"Unsched dialysis ESRD pt hos","G0257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","703.11","","","","","","","fee schedule","683.02","2369.43","APC"
"Inject for sacroiliac joint","G0259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Inject for sacroiliac joint","G0259","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Inject for sacroiliac joint","G0259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3880","","","","","","","fee schedule","702.49","3880",""
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","702.49","3880",""
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3499","","","","","","","fee schedule","702.49","3880",""
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2187.61","","","","","","","fee schedule","702.49","3880","APC 277.30"
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2339.55","","","","","","","fee schedule","702.49","3880","APC 296.56"
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2436.98","","","","","","","fee schedule","702.49","3880","APC 308.91"
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","721.43","","","","","","","fee schedule","702.49","3880","APC"
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","709.38","","","","","","","fee schedule","702.49","3880","APC"
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","702.49","","","","","","","fee schedule","702.49","3880","APC"
"Inj for sacroiliac jt anesth","G0260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","723.15","","","","","","","fee schedule","702.49","3880","APC"
"Removal of impacted wax md","G0268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Removal of impacted wax md","G0268","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Removal of impacted wax md","G0268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Occlusive device in vein art","G0269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Occlusive device in vein art","G0269","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Occlusive device in vein art","G0269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"MNT subs tx for change dx","G0270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.87","","","","","","","fee schedule","22.27","22.92","APC"
"MNT subs tx for change dx","G0270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.48","","","","","","","fee schedule","22.27","22.92","APC"
"MNT subs tx for change dx","G0270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.27","","","","","","","fee schedule","22.27","22.92","APC"
"MNT subs tx for change dx","G0270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.92","","","","","","","fee schedule","22.27","22.92","APC"
"Group MNT 2 or more 30 mins","G0271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.78","","","","","","","fee schedule","12.44","12.81","APC"
"Group MNT 2 or more 30 mins","G0271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.57","","","","","","","fee schedule","12.44","12.81","APC"
"Group MNT 2 or more 30 mins","G0271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.44","","","","","","","fee schedule","12.44","12.81","APC"
"Group MNT 2 or more 30 mins","G0271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.81","","","","","","","fee schedule","12.44","12.81","APC"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Pild/placebo control clin tr","G0276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","1138","","","","","","","fee schedule","136.95","1170",""
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","1170","","","","","","","fee schedule","136.95","1170",""
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","1142","","","","","","","fee schedule","136.95","1170",""
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","426.47","","","","","","","fee schedule","136.95","1170","APC 277.30"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","456.09","","","","","","","fee schedule","136.95","1170","APC 296.56"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","475.08","","","","","","","fee schedule","136.95","1170","APC 308.91"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","140.64","","","","","","","fee schedule","136.95","1170","APC"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","138.29","","","","","","","fee schedule","136.95","1170","APC"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","136.95","","","","","","","fee schedule","136.95","1170","APC"
"Hbot, full body chamber, 30m","G0277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","140.98","","","","","","","fee schedule","136.95","1170","APC"
"Tomosynthesis, mammo","G0279","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.07","","","","","","","fee schedule","12.73","13.1","APC"
"Tomosynthesis, mammo","G0279","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.85","","","","","","","fee schedule","12.73","13.1","APC"
"Tomosynthesis, mammo","G0279","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.73","","","","","","","fee schedule","12.73","13.1","APC"
"Tomosynthesis, mammo","G0279","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.1","","","","","","","fee schedule","12.73","13.1","APC"
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","17.83","","","","","","","fee schedule","11.73","17.83",""
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","17.83","","","","","","","fee schedule","11.73","17.83",""
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","17.83","","","","","","","fee schedule","11.73","17.83",""
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.05","","","","","","","fee schedule","11.73","17.83","APC"
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.84","","","","","","","fee schedule","11.73","17.83","APC"
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.73","","","","","","","fee schedule","11.73","17.83","APC"
"Elec stim unattend for press","G0281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.08","","","","","","","fee schedule","11.73","17.83","APC"
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","17.83","","","","","","","fee schedule","12.74","17.83",""
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","17.83","","","","","","","fee schedule","12.74","17.83",""
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","17.83","","","","","","","fee schedule","12.74","17.83",""
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.08","","","","","","","fee schedule","12.74","17.83","APC"
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.86","","","","","","","fee schedule","12.74","17.83","APC"
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.74","","","","","","","fee schedule","12.74","17.83","APC"
"Elec stim other than wound","G0283","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.11","","","","","","","fee schedule","12.74","17.83","APC"
"Arthro, loose body + chondro","G0289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","5220",""
"Arthro, loose body + chondro","G0289","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2375","5220",""
"Arthro, loose body + chondro","G0289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","5220",""
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov surg proc,clin trial","G0293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Non-cov proc, clinical trial","G0294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Ldct for lung ca screen","G0297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","395","","","","","","","fee schedule","395","3172.42",""
"Ldct for lung ca screen","G0297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","406","","","","","","","fee schedule","395","3172.42",""
"Ldct for lung ca screen","G0297","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","396","","","","","","","fee schedule","395","3172.42",""
"Ldct for lung ca screen","G0297","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3172.42","","","","","","","fee schedule","395","3172.42",""
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS complete","G0302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Pre-op service LVRS 10-15dos","G0303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Pre-op service LVRS 1-9 dos","G0304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Post op service LVRS min 6","G0305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","13.37","","","","","","","fee schedule","7.77","13.37",""
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.77","","","","","","","fee schedule","7.77","13.37",""
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.77","","","","","","","fee schedule","7.77","13.37",""
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.77","","","","","","","fee schedule","7.77","13.37",""
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","13.37","","","","","","","fee schedule","7.77","13.37",""
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.14","","","","","","","fee schedule","7.77","13.37","APC"
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8","","","","","","","fee schedule","7.77","13.37","APC"
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.93","","","","","","","fee schedule","7.77","13.37","APC"
"CBC/diffwbc w/o platelet","G0306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.16","","","","","","","fee schedule","7.77","13.37","APC"
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","11.12","","","","","","","fee schedule","6.47","11.12",""
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.47","","","","","","","fee schedule","6.47","11.12",""
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.47","","","","","","","fee schedule","6.47","11.12",""
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.47","","","","","","","fee schedule","6.47","11.12",""
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","11.12","","","","","","","fee schedule","6.47","11.12",""
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.78","","","","","","","fee schedule","6.47","11.12","APC"
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.66","","","","","","","fee schedule","6.47","11.12","APC"
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.47","11.12","APC"
"CBC without platelet","G0307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.79","","","","","","","fee schedule","6.47","11.12","APC"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Care manage beh svs 20mins","G0323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","27.34","","","","","","","fee schedule","18.05","27.34",""
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.05","","","","","","","fee schedule","18.05","27.34",""
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.05","","","","","","","fee schedule","18.05","27.34",""
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.05","","","","","","","fee schedule","18.05","27.34",""
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","27.34","","","","","","","fee schedule","18.05","27.34",""
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.05","27.34","APC"
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.59","","","","","","","fee schedule","18.05","27.34","APC"
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.41","","","","","","","fee schedule","18.05","27.34","APC"
"Fecal blood scrn immunoassay","G0328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.95","","","","","","","fee schedule","18.05","27.34","APC"
"Electromagntic tx for ulcers","G0329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.95","","","","","","","fee schedule","10.66","10.97","APC"
"Electromagntic tx for ulcers","G0329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.76","","","","","","","fee schedule","10.66","10.97","APC"
"Electromagntic tx for ulcers","G0329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.66","","","","","","","fee schedule","10.66","10.97","APC"
"Electromagntic tx for ulcers","G0329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.97","","","","","","","fee schedule","10.66","10.97","APC"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","3299.54","11446.28",""
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","3299.54","11446.28",""
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10275.01","","","","","","","fee schedule","3299.54","11446.28","APC 277.30"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10988.66","","","","","","","fee schedule","3299.54","11446.28","APC 296.56"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11446.28","","","","","","","fee schedule","3299.54","11446.28","APC 308.91"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3388.5","","","","","","","fee schedule","3299.54","11446.28","APC"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3331.89","","","","","","","fee schedule","3299.54","11446.28","APC"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3299.54","","","","","","","fee schedule","3299.54","11446.28","APC"
"Facility svs dental rehab","G0330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3396.58","","","","","","","fee schedule","3299.54","11446.28","APC"
"Robot lin-radsurg com, first","G0339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23971","","","","","","","fee schedule","21639","23971",""
"Robot lin-radsurg com, first","G0339","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","21639","","","","","","","fee schedule","21639","23971",""
"Robt lin-radsurg fractx 2-5","G0340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Robt lin-radsurg fractx 2-5","G0340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Percutaneous islet celltrans","G0341","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Laparoscopy islet cell trans","G0342","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Laparotomy islet cell transp","G0343","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Bone marrow aspirate &biopsy","G0364","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","3408","","","","","","","fee schedule","3408","3408",""
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1845.62","","","","","","","fee schedule","592.67","2056.01","APC 277.30"
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1973.81","","","","","","","fee schedule","592.67","2056.01","APC 296.56"
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2056.01","","","","","","","fee schedule","592.67","2056.01","APC 308.91"
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","608.65","","","","","","","fee schedule","592.67","2056.01","APC"
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","598.48","","","","","","","fee schedule","592.67","2056.01","APC"
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","592.67","","","","","","","fee schedule","592.67","2056.01","APC"
"Direct refer hospital observ","G0379","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","610.1","","","","","","","fee schedule","592.67","2056.01","APC"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4130.85","","","","","","","fee schedule","1326.51","4601.73","APC 277.30"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4417.76","","","","","","","fee schedule","1326.51","4601.73","APC 296.56"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4601.73","","","","","","","fee schedule","1326.51","4601.73","APC 308.91"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1362.27","","","","","","","fee schedule","1326.51","4601.73","APC"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1339.51","","","","","","","fee schedule","1326.51","4601.73","APC"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1326.51","","","","","","","fee schedule","1326.51","4601.73","APC"
"Trauma Respons w/hosp criti","G0390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1365.52","","","","","","","fee schedule","1326.51","4601.73","APC"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Alcohol/subs interv 15-30mn","G0396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 2 porta","G0398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 3 porta","G0399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","669.17","","","","","","","fee schedule","214.89","745.45","APC 277.30"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","715.65","","","","","","","fee schedule","214.89","745.45","APC 296.56"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","745.45","","","","","","","fee schedule","214.89","745.45","APC 308.91"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","220.68","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.99","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.89","","","","","","","fee schedule","214.89","745.45","APC"
"Home sleep test/type 4 porta","G0400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","221.21","","","","","","","fee schedule","214.89","745.45","APC"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Initial preventive exam","G0402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"EKG tracing for initial prev","G0404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Open tx iliac spine uni/bil","G0412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","13700","","","","","","","fee schedule","7221.37","25051.33",""
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","7221.37","25051.33",""
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","7221.37","25051.33",""
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","7221.37","25051.33","APC 277.30"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","7221.37","25051.33","APC 296.56"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","7221.37","25051.33","APC 308.91"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","7221.37","25051.33","APC"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","7221.37","25051.33","APC"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","7221.37","25051.33","APC"
"Pelvic ring fracture uni/bil","G0413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","7221.37","25051.33","APC"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","29398",""
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","5220","29398",""
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","5220","29398",""
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22487.89","","","","","","","fee schedule","5220","29398","APC 277.30"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24049.79","","","","","","","fee schedule","5220","29398","APC 296.56"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25051.33","","","","","","","fee schedule","5220","29398","APC 308.91"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7416.07","","","","","","","fee schedule","5220","29398","APC"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7292.17","","","","","","","fee schedule","5220","29398","APC"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7221.37","","","","","","","fee schedule","5220","29398","APC"
"Pelvic ring fx treat int fix","G0414","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7433.77","","","","","","","fee schedule","5220","29398","APC"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","3256.29","29398",""
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","29398","","","","","","","fee schedule","3256.29","29398",""
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","26537","","","","","","","fee schedule","3256.29","29398",""
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10140.33","","","","","","","fee schedule","3256.29","29398","APC 277.30"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10844.63","","","","","","","fee schedule","3256.29","29398","APC 296.56"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11296.24","","","","","","","fee schedule","3256.29","29398","APC 308.91"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3344.08","","","","","","","fee schedule","3256.29","29398","APC"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3288.21","","","","","","","fee schedule","3256.29","29398","APC"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3256.29","","","","","","","fee schedule","3256.29","29398","APC"
"Open tx post pelvic fxcture","G0415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3352.06","","","","","","","fee schedule","3256.29","29398","APC"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","420","","","","","","","fee schedule","356.73","1237.5",""
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","420","","","","","","","fee schedule","356.73","1237.5",""
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1110.87","","","","","","","fee schedule","356.73","1237.5","APC 277.30"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1188.02","","","","","","","fee schedule","356.73","1237.5","APC 296.56"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1237.5","","","","","","","fee schedule","356.73","1237.5","APC 308.91"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","366.34","","","","","","","fee schedule","356.73","1237.5","APC"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","360.22","","","","","","","fee schedule","356.73","1237.5","APC"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.73","","","","","","","fee schedule","356.73","1237.5","APC"
"Prostate biopsy, any mthd","G0416","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","367.22","","","","","","","fee schedule","356.73","1237.5","APC"
"Ed svc CKD ind per session","G0420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","116.93","","","","","","","fee schedule","113.86","117.21","APC"
"Ed svc CKD ind per session","G0420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","114.98","","","","","","","fee schedule","113.86","117.21","APC"
"Ed svc CKD ind per session","G0420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","113.86","","","","","","","fee schedule","113.86","117.21","APC"
"Ed svc CKD ind per session","G0420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","117.21","","","","","","","fee schedule","113.86","117.21","APC"
"Ed svc CKD grp per session","G0421","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.21","","","","","","","fee schedule","27.47","28.28","APC"
"Ed svc CKD grp per session","G0421","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.74","","","","","","","fee schedule","27.47","28.28","APC"
"Ed svc CKD grp per session","G0421","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.47","","","","","","","fee schedule","27.47","28.28","APC"
"Ed svc CKD grp per session","G0421","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.28","","","","","","","fee schedule","27.47","28.28","APC"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","399.5","","","","","","","fee schedule","128.29","445.04","APC 277.30"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","427.25","","","","","","","fee schedule","128.29","445.04","APC 296.56"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","445.04","","","","","","","fee schedule","128.29","445.04","APC 308.91"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.75","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.55","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.29","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab w/exerc","G0422","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.06","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","399.5","","","","","","","fee schedule","128.29","445.04","APC 277.30"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","427.25","","","","","","","fee schedule","128.29","445.04","APC 296.56"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","445.04","","","","","","","fee schedule","128.29","445.04","APC 308.91"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.75","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.55","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.29","","","","","","","fee schedule","128.29","445.04","APC"
"Intens cardiac rehab no exer","G0423","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.06","","","","","","","fee schedule","128.29","445.04","APC"
"Pulmonary rehab w exer","G0424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","133","","","","","","","fee schedule","133","137",""
"Pulmonary rehab w exer","G0424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","137","","","","","","","fee schedule","133","137",""
"Pulmonary rehab w exer","G0424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","133","","","","","","","fee schedule","133","137",""
"Collagen Meniscus Implant","G0428","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Collagen Meniscus Implant","G0428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Collagen Meniscus Implant","G0428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","2053.37","7123.26",""
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Dermal filler injection(s)","G0429","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.16","","","","","","","fee schedule","19.57","23.16",""
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.57","","","","","","","fee schedule","19.57","23.16",""
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.57","","","","","","","fee schedule","19.57","23.16",""
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.57","","","","","","","fee schedule","19.57","23.16",""
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.16","","","","","","","fee schedule","19.57","23.16",""
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.5","","","","","","","fee schedule","19.57","23.16","APC"
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.16","","","","","","","fee schedule","19.57","23.16","APC"
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.96","","","","","","","fee schedule","19.57","23.16","APC"
"EIA HIV-1/HIV-2 screen","G0432","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.55","","","","","","","fee schedule","19.57","23.16","APC"
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.16","","","","","","","fee schedule","18.29","23.16",""
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.29","","","","","","","fee schedule","18.29","23.16",""
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.29","","","","","","","fee schedule","18.29","23.16",""
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.29","","","","","","","fee schedule","18.29","23.16",""
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.16","","","","","","","fee schedule","18.29","23.16",""
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.16","","","","","","","fee schedule","18.29","23.16","APC"
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.84","","","","","","","fee schedule","18.29","23.16","APC"
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.66","","","","","","","fee schedule","18.29","23.16","APC"
"ELISA HIV-1/HIV-2 screen","G0433","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.2","","","","","","","fee schedule","18.29","23.16","APC"
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","20.26","","","","","","","fee schedule","11.98","20.26",""
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.98","","","","","","","fee schedule","11.98","20.26",""
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.98","","","","","","","fee schedule","11.98","20.26",""
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.98","","","","","","","fee schedule","11.98","20.26",""
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","20.26","","","","","","","fee schedule","11.98","20.26",""
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.55","","","","","","","fee schedule","11.98","20.26","APC"
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.34","","","","","","","fee schedule","11.98","20.26","APC"
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.22","","","","","","","fee schedule","11.98","20.26","APC"
"Oral hiv-1/hiv-2 screen","G0435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.58","","","","","","","fee schedule","11.98","20.26","APC"
"PPPS, initial visit","G0438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.43","","","","","","","fee schedule","174.72","179.85","APC"
"PPPS, initial visit","G0438","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.43","","","","","","","fee schedule","174.72","179.85","APC"
"PPPS, initial visit","G0438","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.72","","","","","","","fee schedule","174.72","179.85","APC"
"PPPS, initial visit","G0438","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.85","","","","","","","fee schedule","174.72","179.85","APC"
"PPPS, subseq visit","G0439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","141.58","","","","","","","fee schedule","137.86","141.92","APC"
"PPPS, subseq visit","G0439","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","139.21","","","","","","","fee schedule","137.86","141.92","APC"
"PPPS, subseq visit","G0439","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","137.86","","","","","","","fee schedule","137.86","141.92","APC"
"PPPS, subseq visit","G0439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","141.92","","","","","","","fee schedule","137.86","141.92","APC"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Annual alcohol screen 15 min","G0442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Depression Screen annual","G0444","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Intens behave ther cardio dx","G0446","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Place perm pacing cardiovert","G0448","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5790",""
"Place perm pacing cardiovert","G0448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","5790","","","","","","","fee schedule","5220","5790",""
"Place perm pacing cardiovert","G0448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","5226","","","","","","","fee schedule","5220","5790",""
"Molecular pathology interpr","G0452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","22.45","","","","","","","fee schedule","22.45","22.45",""
"Molecular pathology interpr","G0452","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","22.45","","","","","","","fee schedule","22.45","22.45",""
"Cont intraop neuro monitor","G0453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Cont intraop neuro monitor","G0453","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2882.05","","","","","","","fee schedule","925.49","3210.58","APC 277.30"
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3082.23","","","","","","","fee schedule","925.49","3210.58","APC 296.56"
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3210.58","","","","","","","fee schedule","925.49","3210.58","APC 308.91"
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","950.44","","","","","","","fee schedule","925.49","3210.58","APC"
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","934.57","","","","","","","fee schedule","925.49","3210.58","APC"
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","925.49","","","","","","","fee schedule","925.49","3210.58","APC"
"Fecal microbiota prep instil","G0455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","952.71","","","","","","","fee schedule","925.49","3210.58","APC"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6394.36","","","","","","","fee schedule","2053.37","7123.26","APC 277.30"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6838.48","","","","","","","fee schedule","2053.37","7123.26","APC 296.56"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7123.26","","","","","","","fee schedule","2053.37","7123.26","APC 308.91"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2108.73","","","","","","","fee schedule","2053.37","7123.26","APC"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2073.5","","","","","","","fee schedule","2053.37","7123.26","APC"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2053.37","","","","","","","fee schedule","2053.37","7123.26","APC"
"Autologous PRP for ulcers","G0460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2113.77","","","","","","","fee schedule","2053.37","7123.26","APC"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","204","","","","","","","fee schedule","132.5","459.64",""
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","210","","","","","","","fee schedule","132.5","459.64",""
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","205","","","","","","","fee schedule","132.5","459.64",""
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Hospital outpt clinic visit","G0463","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.09","","","","","","","fee schedule","11.09","11.91",""
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.09","","","","","","","fee schedule","11.09","11.91",""
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.09","","","","","","","fee schedule","11.09","11.91",""
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.09","11.91","APC"
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.68","","","","","","","fee schedule","11.09","11.91","APC"
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.57","","","","","","","fee schedule","11.09","11.91","APC"
"Ven blood coll snf/hha","G0471","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.91","","","","","","","fee schedule","11.09","11.91","APC"
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","23.33","","","","","","","fee schedule","23.33","48.67",""
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.35","","","","","","","fee schedule","23.33","48.67",""
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","46.35","","","","","","","fee schedule","23.33","48.67",""
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.35","","","","","","","fee schedule","23.33","48.67",""
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","23.33","","","","","","","fee schedule","23.33","48.67",""
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48.55","","","","","","","fee schedule","23.33","48.67","APC"
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.74","","","","","","","fee schedule","23.33","48.67","APC"
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.28","","","","","","","fee schedule","23.33","48.67","APC"
"Hep c screen high risk/other","G0472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.67","","","","","","","fee schedule","23.33","48.67","APC"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Group behave couns 2-10","G0473","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","39.64","","","","","","","fee schedule","24.08","39.64",""
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.08","","","","","","","fee schedule","24.08","39.64",""
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.08","","","","","","","fee schedule","24.08","39.64",""
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.08","","","","","","","fee schedule","24.08","39.64",""
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","39.64","","","","","","","fee schedule","24.08","39.64",""
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.22","","","","","","","fee schedule","24.08","39.64","APC"
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.8","","","","","","","fee schedule","24.08","39.64","APC"
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.56","","","","","","","fee schedule","24.08","39.64","APC"
"Hiv combination assay","G0475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.28","","","","","","","fee schedule","24.08","39.64","APC"
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","57.77","","","","","","","fee schedule","35.09","57.77",""
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.09","","","","","","","fee schedule","35.09","57.77",""
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.09","","","","","","","fee schedule","35.09","57.77",""
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.09","","","","","","","fee schedule","35.09","57.77",""
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","57.77","","","","","","","fee schedule","35.09","57.77",""
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.09","57.77","APC"
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.09","57.77","APC"
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.09","57.77","APC"
"Hpv combo assay ca screen","G0476","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.09","57.77","APC"
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","95.93","","","","","","","fee schedule","95.93","120.15",""
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","114.43","","","","","","","fee schedule","95.93","120.15",""
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.43","","","","","","","fee schedule","95.93","120.15",""
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.43","","","","","","","fee schedule","95.93","120.15",""
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","95.93","","","","","","","fee schedule","95.93","120.15",""
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.87","","","","","","","fee schedule","95.93","120.15","APC"
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.86","","","","","","","fee schedule","95.93","120.15","APC"
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.72","","","","","","","fee schedule","95.93","120.15","APC"
"Drug test def 1-7 classes","G0480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.15","","","","","","","fee schedule","95.93","120.15","APC"
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","147.59","","","","","","","fee schedule","147.59","164.42",""
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","156.59","","","","","","","fee schedule","147.59","164.42",""
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","156.59","","","","","","","fee schedule","147.59","164.42",""
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","156.59","","","","","","","fee schedule","147.59","164.42",""
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","147.59","","","","","","","fee schedule","147.59","164.42",""
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","164.03","","","","","","","fee schedule","147.59","164.42","APC"
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","161.29","","","","","","","fee schedule","147.59","164.42","APC"
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.72","","","","","","","fee schedule","147.59","164.42","APC"
"Drug test def 8-14 classes","G0481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","164.42","","","","","","","fee schedule","147.59","164.42","APC"
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","199.24","","","","","","","fee schedule","198.74","208.68",""
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","198.74","","","","","","","fee schedule","198.74","208.68",""
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.74","","","","","","","fee schedule","198.74","208.68",""
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.74","","","","","","","fee schedule","198.74","208.68",""
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","199.24","","","","","","","fee schedule","198.74","208.68",""
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","208.18","","","","","","","fee schedule","198.74","208.68","APC"
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","204.7","","","","","","","fee schedule","198.74","208.68","APC"
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","202.71","","","","","","","fee schedule","198.74","208.68","APC"
"Drug test def 15-21 classes","G0482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","208.68","","","","","","","fee schedule","198.74","208.68","APC"
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","258.28","","","","","","","fee schedule","246.92","259.27",""
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.92","","","","","","","fee schedule","246.92","259.27",""
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.92","","","","","","","fee schedule","246.92","259.27",""
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","258.28","","","","","","","fee schedule","246.92","259.27",""
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","258.65","","","","","","","fee schedule","246.92","259.27","APC"
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","254.33","","","","","","","fee schedule","246.92","259.27","APC"
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","251.86","","","","","","","fee schedule","246.92","259.27","APC"
"Drug test def 22+ classes","G0483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","259.27","","","","","","","fee schedule","246.92","259.27","APC"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1023.66","","","","","","","fee schedule","328.72","1140.35","APC 277.30"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1094.76","","","","","","","fee schedule","328.72","1140.35","APC 296.56"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1140.35","","","","","","","fee schedule","328.72","1140.35","APC 308.91"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","337.58","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","331.94","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","328.72","","","","","","","fee schedule","328.72","1140.35","APC"
"Chemo extend iv infus w/pump","G0498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","338.39","","","","","","","fee schedule","328.72","1140.35","APC"
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","41.88","","","","","","","fee schedule","28.27","41.88",""
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.27","","","","","","","fee schedule","28.27","41.88",""
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","28.27","","","","","","","fee schedule","28.27","41.88",""
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28.27","","","","","","","fee schedule","28.27","41.88",""
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","41.88","","","","","","","fee schedule","28.27","41.88",""
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.61","","","","","","","fee schedule","28.27","41.88","APC"
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.12","","","","","","","fee schedule","28.27","41.88","APC"
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.84","","","","","","","fee schedule","28.27","41.88","APC"
"Hepb screen high risk indiv","G0499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.68","","","","","","","fee schedule","28.27","41.88","APC"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Insert drug del implant, >4","G0516","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Remove drug implant","G0517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","444.58","5220",""
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","444.58","5220",""
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","444.58","5220",""
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1384.45","","","","","","","fee schedule","444.58","5220","APC 277.30"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1480.61","","","","","","","fee schedule","444.58","5220","APC 296.56"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1542.27","","","","","","","fee schedule","444.58","5220","APC 308.91"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","456.57","","","","","","","fee schedule","444.58","5220","APC"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","448.94","","","","","","","fee schedule","444.58","5220","APC"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","444.58","","","","","","","fee schedule","444.58","5220","APC"
"Remove w insert drug implant","G0518","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","457.66","","","","","","","fee schedule","444.58","5220","APC"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Risk ascvd tst once pr 12 mo","G0537","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Initial care training 30 m","G0539","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.43","","","","","","","fee schedule","40.34","41.53","APC"
"Initial care training 30 m","G0539","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.74","","","","","","","fee schedule","40.34","41.53","APC"
"Initial care training 30 m","G0539","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.34","","","","","","","fee schedule","40.34","41.53","APC"
"Initial care training 30 m","G0539","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.53","","","","","","","fee schedule","40.34","41.53","APC"
"Train for caregiver add 15","G0540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.99","","","","","","","fee schedule","21.41","22.04","APC"
"Train for caregiver add 15","G0540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.62","","","","","","","fee schedule","21.41","22.04","APC"
"Train for caregiver add 15","G0540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.41","","","","","","","fee schedule","21.41","22.04","APC"
"Train for caregiver add 15","G0540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.04","","","","","","","fee schedule","21.41","22.04","APC"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"No pt prsnt train initial 30","G0541","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Group train w/o patient","G0543","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Supply of digital device","G0552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.61","","","","","","","fee schedule","132.5","459.64","APC 277.30"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","441.26","","","","","","","fee schedule","132.5","459.64","APC 296.56"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","459.64","","","","","","","fee schedule","132.5","459.64","APC 308.91"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.07","","","","","","","fee schedule","132.5","459.64","APC"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.8","","","","","","","fee schedule","132.5","459.64","APC"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","132.5","459.64","APC"
"Monthly tx for dmht 20mins","G0553","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.39","","","","","","","fee schedule","132.5","459.64","APC"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2661.34","","","","","","","fee schedule","854.62","2964.71","APC 277.30"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2846.18","","","","","","","fee schedule","854.62","2964.71","APC 296.56"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2964.71","","","","","","","fee schedule","854.62","2964.71","APC 308.91"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.66","","","","","","","fee schedule","854.62","2964.71","APC"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863","","","","","","","fee schedule","854.62","2964.71","APC"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.62","","","","","","","fee schedule","854.62","2964.71","APC"
"Replacment pt electronic sys","G0555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.75","","","","","","","fee schedule","854.62","2964.71","APC"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 1","G0556","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Adv prim care mgmt lvl 2","G0557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Safety plan interven","G0560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.14","","","","","","","fee schedule","40.06","41.23","APC"
"Safety plan interven","G0560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.45","","","","","","","fee schedule","40.06","41.23","APC"
"Safety plan interven","G0560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.06","","","","","","","fee schedule","40.06","41.23","APC"
"Safety plan interven","G0560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.23","","","","","","","fee schedule","40.06","41.23","APC"
"Temp tube delivery, unil","G0561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","2633","","","","","","","fee schedule","2375","2633",""
"Temp tube delivery, unil","G0561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","2375","","","","","","","fee schedule","2375","2633",""
"365 d implant glucose sensor","G0564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"365 d implant glucose sensor","G0564","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"Rem/ins glu snsr 365 dif sit","G0565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","19040","","","","","","","fee schedule","17187","19040",""
"Rem/ins glu snsr 365 dif sit","G0565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17187","","","","","","","fee schedule","17187","19040",""
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","398.77","","","","","","","fee schedule","128.06","444.23","APC 277.30"
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","426.47","","","","","","","fee schedule","128.06","444.23","APC 296.56"
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","444.23","","","","","","","fee schedule","128.06","444.23","APC 308.91"
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.51","","","","","","","fee schedule","128.06","444.23","APC"
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.31","","","","","","","fee schedule","128.06","444.23","APC"
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.06","","","","","","","fee schedule","128.06","444.23","APC"
"3d bn img algor drvd fr mri","G0566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","131.82","","","","","","","fee schedule","128.06","444.23","APC"
"Screening Hep C detect","G0567","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.79","36.84","APC"
"Screening Hep C detect","G0567","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.79","36.84","APC"
"Screening Hep C detect","G0567","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.79","36.84","APC"
"Screening Hep C detect","G0567","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.79","36.84","APC"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.12","","","","","","","fee schedule","37.29","129.36","APC 277.30"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.18","","","","","","","fee schedule","37.29","129.36","APC 296.56"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.36","","","","","","","fee schedule","37.29","129.36","APC 308.91"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.29","","","","","","","fee schedule","37.29","129.36","APC"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.65","","","","","","","fee schedule","37.29","129.36","APC"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.29","","","","","","","fee schedule","37.29","129.36","APC"
"Care manage serv, pr cal mo","G0570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.39","","","","","","","fee schedule","37.29","129.36","APC"
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","95.77","","","","","","","fee schedule","62.14","95.77",""
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.14","","","","","","","fee schedule","62.14","95.77",""
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.14","","","","","","","fee schedule","62.14","95.77",""
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62.14","","","","","","","fee schedule","62.14","95.77",""
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","95.77","","","","","","","fee schedule","62.14","95.77",""
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.09","","","","","","","fee schedule","62.14","95.77","APC"
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64","","","","","","","fee schedule","62.14","95.77","APC"
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.38","","","","","","","fee schedule","62.14","95.77","APC"
"Drug test def simple all cl","G0659","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.25","","","","","","","fee schedule","62.14","95.77","APC"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1156.46","","","","","","","fee schedule","371.37","1288.29","APC 277.30"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1236.78","","","","","","","fee schedule","371.37","1288.29","APC 296.56"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1288.29","","","","","","","fee schedule","371.37","1288.29","APC 308.91"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.38","","","","","","","fee schedule","371.37","1288.29","APC"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","375.01","","","","","","","fee schedule","371.37","1288.29","APC"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.37","","","","","","","fee schedule","371.37","1288.29","APC"
"Blinded conv. Tx MDD clin tr","G2000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.29","","","","","","","fee schedule","371.37","1288.29","APC"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","28.78","99.86","APC 277.30"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","28.78","99.86","APC 296.56"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","28.78","99.86","APC 308.91"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","99.86","APC"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","99.86","APC"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","99.86","APC"
"Alcohol/sub abuse assess","G2011","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","99.86","APC"
"Qual nonMD est pt 5-10m","G2061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","15.76","","","","","","","fee schedule","15.76","15.76",""
"Qual nonMD est pt 5-10m","G2061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","15.76","","","","","","","fee schedule","15.76","15.76",""
"Qual nonMD est pt 5-10m","G2061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","15.76","","","","","","","fee schedule","15.76","15.76",""
"Qual nonMD est pt 11-20m","G2062","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","31.1","","","","","","","fee schedule","31.1","31.1",""
"Qual nonMD est pt 11-20m","G2062","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","31.1","","","","","","","fee schedule","31.1","31.1",""
"Qual nonMD est pt 11-20m","G2062","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","31.1","","","","","","","fee schedule","31.1","31.1",""
"Qual nonMD est pt 21>min","G2063","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","49.8","","","","","","","fee schedule","49.8","49.8",""
"Qual nonMD est pt 21>min","G2063","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","49.8","","","","","","","fee schedule","49.8","49.8",""
"Qual nonMD est pt 21>min","G2063","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","49.8","","","","","","","fee schedule","49.8","49.8",""
"Avf by tissue w thermal e","G2170","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Avf use magnetic/art/ven","G2171","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Remot img sub by pt, non e/m","G2250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.26","","","","","","","fee schedule","8.05","8.28","APC"
"Remot img sub by pt, non e/m","G2250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.13","","","","","","","fee schedule","8.05","8.28","APC"
"Remot img sub by pt, non e/m","G2250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.05","","","","","","","fee schedule","8.05","8.28","APC"
"Remot img sub by pt, non e/m","G2250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.28","","","","","","","fee schedule","8.05","8.28","APC"
"Brief chkin, 5-10, non-e/m","G2251","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.77","11.09","APC"
"Brief chkin, 5-10, non-e/m","G2251","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.88","","","","","","","fee schedule","10.77","11.09","APC"
"Brief chkin, 5-10, non-e/m","G2251","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.77","","","","","","","fee schedule","10.77","11.09","APC"
"Brief chkin, 5-10, non-e/m","G2251","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.09","","","","","","","fee schedule","10.77","11.09","APC"
"Brief chkin by md/qhp, 11-20","G2252","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.95","","","","","","","fee schedule","22.35","23.01","APC"
"Brief chkin by md/qhp, 11-20","G2252","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.57","","","","","","","fee schedule","22.35","23.01","APC"
"Brief chkin by md/qhp, 11-20","G2252","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.35","","","","","","","fee schedule","22.35","23.01","APC"
"Brief chkin by md/qhp, 11-20","G2252","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.01","","","","","","","fee schedule","22.35","23.01","APC"
"Warfarin respon genetic test","G9143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","203.84","","","","","","","fee schedule","120.72","203.84",""
"Warfarin respon genetic test","G9143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","120.72","","","","","","","fee schedule","120.72","203.84",""
"Warfarin respon genetic test","G9143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","120.72","","","","","","","fee schedule","120.72","203.84",""
"Warfarin respon genetic test","G9143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","120.72","","","","","","","fee schedule","120.72","203.84",""
"Warfarin respon genetic test","G9143","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","203.84","","","","","","","fee schedule","120.72","203.84",""
"Adtl spine proc on same date","G9942","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Adtl spine proc on same date","G9948","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.75","","","","","","","fee schedule","4.1","14.2",""
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.63","","","","","","","fee schedule","4.1","14.2",""
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.2","","","","","","","fee schedule","4.1","14.2",""
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.21","","","","","","","fee schedule","4.1","14.2","APC"
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.14","","","","","","","fee schedule","4.1","14.2","APC"
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.1","","","","","","","fee schedule","4.1","14.2","APC"
"Inj., omadacycline, 1 mg","J0121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.22","","","","","","","fee schedule","4.1","14.2","APC"
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","141.48","","","","","","","fee schedule","44.99","157.49",""
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","151.27","","","","","","","fee schedule","44.99","157.49",""
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","157.49","","","","","","","fee schedule","44.99","157.49",""
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.2","","","","","","","fee schedule","44.99","157.49","APC"
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.43","","","","","","","fee schedule","44.99","157.49","APC"
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.99","","","","","","","fee schedule","44.99","157.49","APC"
"Abatacept injection","J0129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.31","","","","","","","fee schedule","44.99","157.49","APC"
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.7","","","","","","","fee schedule","0.04","0.78",""
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.75","","","","","","","fee schedule","0.04","0.78",""
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.78","","","","","","","fee schedule","0.04","0.78",""
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.78","APC"
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.78","APC"
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.78","APC"
"Injection, acetaminoph 10 mg","J0138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.78","APC"
"Inj, adalimumab, 1 mg","J0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","291.7","","","","","","","fee schedule","291.7","324.72",""
"Inj, adalimumab, 1 mg","J0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","311.88","","","","","","","fee schedule","291.7","324.72",""
"Inj, adalimumab, 1 mg","J0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","324.72","","","","","","","fee schedule","291.7","324.72",""
"Inj, aducanumab-avwa, 2 mg","J0172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.02","","","","","","","fee schedule","19.02","21.17",""
"Inj, aducanumab-avwa, 2 mg","J0172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.33","","","","","","","fee schedule","19.02","21.17",""
"Inj, aducanumab-avwa, 2 mg","J0172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.17","","","","","","","fee schedule","19.02","21.17",""
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.23","","","","","","","fee schedule","1.35","4.71",""
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.52","","","","","","","fee schedule","1.35","4.71",""
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.71","","","","","","","fee schedule","1.35","4.71",""
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.39","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.36","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.35","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, lecanemab-irmb","J0174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.39","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.17","","","","","","","fee schedule","4.22","14.66",""
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.08","","","","","","","fee schedule","4.22","14.66",""
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.66","","","","","","","fee schedule","4.22","14.66",""
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.33","","","","","","","fee schedule","4.22","14.66","APC"
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.26","","","","","","","fee schedule","4.22","14.66","APC"
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.22","","","","","","","fee schedule","4.22","14.66","APC"
"Inj, donanemab-azbt, 2 mg","J0175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.34","","","","","","","fee schedule","4.22","14.66","APC"
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1016.77","","","","","","","fee schedule","317.61","1131.88",""
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1087.12","","","","","","","fee schedule","317.61","1131.88",""
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1131.88","","","","","","","fee schedule","317.61","1131.88",""
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","326.17","","","","","","","fee schedule","317.61","1131.88","APC"
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","320.72","","","","","","","fee schedule","317.61","1131.88","APC"
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","317.61","","","","","","","fee schedule","317.61","1131.88","APC"
"Inj, aflibercept hd, 1 mg","J0177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","326.95","","","","","","","fee schedule","317.61","1131.88","APC"
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2512.33","","","","","","","fee schedule","786.99","2796.74",""
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2686.14","","","","","","","fee schedule","786.99","2796.74",""
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2796.74","","","","","","","fee schedule","786.99","2796.74",""
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","808.21","","","","","","","fee schedule","786.99","2796.74","APC"
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","794.7","","","","","","","fee schedule","786.99","2796.74","APC"
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","786.99","","","","","","","fee schedule","786.99","2796.74","APC"
"Aflibercept injection","J0178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","810.14","","","","","","","fee schedule","786.99","2796.74","APC"
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1100.88","","","","","","","fee schedule","353.03","1225.51",""
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1177.05","","","","","","","fee schedule","353.03","1225.51",""
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1225.51","","","","","","","fee schedule","353.03","1225.51",""
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","362.55","","","","","","","fee schedule","353.03","1225.51","APC"
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","356.49","","","","","","","fee schedule","353.03","1225.51","APC"
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","353.03","","","","","","","fee schedule","353.03","1225.51","APC"
"Inj, brolucizumab-dbll, 1 mg","J0179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","363.41","","","","","","","fee schedule","353.03","1225.51","APC"
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","732.23","","","","","","","fee schedule","234.76","815.12",""
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","782.88","","","","","","","fee schedule","234.76","815.12",""
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","815.12","","","","","","","fee schedule","234.76","815.12",""
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","241.09","","","","","","","fee schedule","234.76","815.12","APC"
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","237.06","","","","","","","fee schedule","234.76","815.12","APC"
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","234.76","","","","","","","fee schedule","234.76","815.12","APC"
"Agalsidase beta injection","J0180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","241.66","","","","","","","fee schedule","234.76","815.12","APC"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.72","","","","","","","fee schedule","9.81","34.2",""
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","32.84","","","","","","","fee schedule","9.81","34.2",""
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.2","","","","","","","fee schedule","9.81","34.2",""
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.53","","","","","","","fee schedule","9.81","34.2","APC 277.30"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","32.66","","","","","","","fee schedule","9.81","34.2","APC 296.56"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.01","","","","","","","fee schedule","9.81","34.2","APC 308.91"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.07","","","","","","","fee schedule","9.81","34.2","APC"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.9","","","","","","","fee schedule","9.81","34.2","APC"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.81","","","","","","","fee schedule","9.81","34.2","APC"
"Inj, amisulpride, 1 mg","J0184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.09","","","","","","","fee schedule","9.81","34.2","APC"
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.63","","","","","","","fee schedule","1.67","6.27",""
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.02","","","","","","","fee schedule","1.67","6.27",""
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.27","","","","","","","fee schedule","1.67","6.27",""
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.72","","","","","","","fee schedule","1.67","6.27","APC"
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.69","","","","","","","fee schedule","1.67","6.27","APC"
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.67","","","","","","","fee schedule","1.67","6.27","APC"
"Inj., aprepitant, 1 mg","J0185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.72","","","","","","","fee schedule","1.67","6.27","APC"
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7761.43","","","","","","","fee schedule","2478.49","8640.08",""
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8298.38","","","","","","","fee schedule","2478.49","8640.08",""
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8640.08","","","","","","","fee schedule","2478.49","8640.08",""
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2545.31","","","","","","","fee schedule","2478.49","8640.08","APC"
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2502.79","","","","","","","fee schedule","2478.49","8640.08","APC"
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2478.49","","","","","","","fee schedule","2478.49","8640.08","APC"
"Injection, alemtuzumab","J0202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2551.39","","","","","","","fee schedule","2478.49","8640.08","APC"
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.44","","","","","","","fee schedule","4.82","16.07",""
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.44","","","","","","","fee schedule","4.82","16.07",""
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.07","","","","","","","fee schedule","4.82","16.07",""
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.95","","","","","","","fee schedule","4.82","16.07","APC"
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.86","","","","","","","fee schedule","4.82","16.07","APC"
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.82","","","","","","","fee schedule","4.82","16.07","APC"
"Inj allopurinol sodium 1 mg","J0206","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.96","","","","","","","fee schedule","4.82","16.07","APC"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","302.55","","","","","","","fee schedule","97.01","336.8",""
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","323.48","","","","","","","fee schedule","97.01","336.8",""
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","336.8","","","","","","","fee schedule","97.01","336.8",""
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","302.11","","","","","","","fee schedule","97.01","336.8","APC 277.30"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","323.09","","","","","","","fee schedule","97.01","336.8","APC 296.56"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","336.54","","","","","","","fee schedule","97.01","336.8","APC 308.91"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","99.63","","","","","","","fee schedule","97.01","336.8","APC"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","97.96","","","","","","","fee schedule","97.01","336.8","APC"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","97.01","","","","","","","fee schedule","97.01","336.8","APC"
"Inj sodium thiosulfate 100mg","J0208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99.87","","","","","","","fee schedule","97.01","336.8","APC"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.9","","","","","","","fee schedule","2.28","7.9",""
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.38","","","","","","","fee schedule","2.28","7.9",""
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.68","","","","","","","fee schedule","2.28","7.9",""
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.09","","","","","","","fee schedule","2.28","7.9","APC 277.30"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.59","","","","","","","fee schedule","2.28","7.9","APC 296.56"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.9","","","","","","","fee schedule","2.28","7.9","APC 308.91"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.34","","","","","","","fee schedule","2.28","7.9","APC"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.3","","","","","","","fee schedule","2.28","7.9","APC"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.28","","","","","","","fee schedule","2.28","7.9","APC"
"Inj, nithiodote, 3mg / 125mg","J0211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.34","","","","","","","fee schedule","2.28","7.9","APC"
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1478.86","","","","","","","fee schedule","474.54","1646.28",""
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1581.17","","","","","","","fee schedule","474.54","1646.28",""
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1646.28","","","","","","","fee schedule","474.54","1646.28",""
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","487.33","","","","","","","fee schedule","474.54","1646.28","APC"
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","479.19","","","","","","","fee schedule","474.54","1646.28","APC"
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","474.54","","","","","","","fee schedule","474.54","1646.28","APC"
"Inj velmanase alfa-tycv 1 mg","J0217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","488.5","","","","","","","fee schedule","474.54","1646.28","APC"
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1252.35","","","","","","","fee schedule","401.53","1394.12",""
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1338.99","","","","","","","fee schedule","401.53","1394.12",""
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1394.12","","","","","","","fee schedule","401.53","1394.12",""
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","412.36","","","","","","","fee schedule","401.53","1394.12","APC"
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","405.47","","","","","","","fee schedule","401.53","1394.12","APC"
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","401.53","","","","","","","fee schedule","401.53","1394.12","APC"
"Inj olipudase alfa-rpcp 1mg","J0218","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","413.34","","","","","","","fee schedule","401.53","1394.12","APC"
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","256.79","","","","","","","fee schedule","82.53","285.86",""
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","274.55","","","","","","","fee schedule","82.53","285.86",""
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","285.86","","","","","","","fee schedule","82.53","285.86",""
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","84.75","","","","","","","fee schedule","82.53","285.86","APC"
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","83.34","","","","","","","fee schedule","82.53","285.86","APC"
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","82.53","","","","","","","fee schedule","82.53","285.86","APC"
"Inj aval alfa-nqpt 4mg","J0219","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","84.96","","","","","","","fee schedule","82.53","285.86","APC"
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","657.05","","","","","","","fee schedule","210.72","731.43",""
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","702.51","","","","","","","fee schedule","210.72","731.43",""
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","731.43","","","","","","","fee schedule","210.72","731.43",""
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","216.4","","","","","","","fee schedule","210.72","731.43","APC"
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","212.79","","","","","","","fee schedule","210.72","731.43","APC"
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","210.72","","","","","","","fee schedule","210.72","731.43","APC"
"Lumizyme injection","J0221","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","216.92","","","","","","","fee schedule","210.72","731.43","APC"
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","317.43","","","","","","","fee schedule","101.97","353.36",""
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","339.39","","","","","","","fee schedule","101.97","353.36",""
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","353.36","","","","","","","fee schedule","101.97","353.36",""
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.72","","","","","","","fee schedule","101.97","353.36","APC"
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.97","","","","","","","fee schedule","101.97","353.36","APC"
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.97","","","","","","","fee schedule","101.97","353.36","APC"
"Inj., patisiran, 0.1 mg","J0222","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.97","","","","","","","fee schedule","101.97","353.36","APC"
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","372.66","","","","","","","fee schedule","119.71","414.85",""
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","398.45","","","","","","","fee schedule","119.71","414.85",""
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","414.85","","","","","","","fee schedule","119.71","414.85",""
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","122.93","","","","","","","fee schedule","119.71","414.85","APC"
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","120.88","","","","","","","fee schedule","119.71","414.85","APC"
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","119.71","","","","","","","fee schedule","119.71","414.85","APC"
"Inj givosiran 0.5 mg","J0223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","123.23","","","","","","","fee schedule","119.71","414.85","APC"
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1046.54","","","","","","","fee schedule","335.63","1165.01",""
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1118.94","","","","","","","fee schedule","335.63","1165.01",""
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1165.01","","","","","","","fee schedule","335.63","1165.01",""
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","344.68","","","","","","","fee schedule","335.63","1165.01","APC"
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","338.92","","","","","","","fee schedule","335.63","1165.01","APC"
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","335.63","","","","","","","fee schedule","335.63","1165.01","APC"
"Inj. lumasiran, 0.5 mg","J0224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","345.5","","","","","","","fee schedule","335.63","1165.01","APC"
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15848.67","","","","","","","fee schedule","5103.71","17642.86",""
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16945.12","","","","","","","fee schedule","5103.71","17642.86",""
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17642.86","","","","","","","fee schedule","5103.71","17642.86",""
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5241.31","","","","","","","fee schedule","5103.71","17642.86","APC"
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5153.75","","","","","","","fee schedule","5103.71","17642.86","APC"
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5103.71","","","","","","","fee schedule","5103.71","17642.86","APC"
"Inj, vutrisiran, 1 mg","J0225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5253.82","","","","","","","fee schedule","5103.71","17642.86","APC"
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.4","","","","","","","fee schedule","6.86","23.82",""
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.88","","","","","","","fee schedule","6.86","23.82",""
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.82","","","","","","","fee schedule","6.86","23.82",""
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.05","","","","","","","fee schedule","6.86","23.82","APC"
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.93","","","","","","","fee schedule","6.86","23.82","APC"
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.86","","","","","","","fee schedule","6.86","23.82","APC"
"Inj, remdesivir, 1 mg?","J0248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.07","","","","","","","fee schedule","6.86","23.82","APC"
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.5","","","","","","","fee schedule","5.57","18.37",""
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.65","","","","","","","fee schedule","5.57","18.37",""
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.37","","","","","","","fee schedule","5.57","18.37",""
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.72","","","","","","","fee schedule","5.57","18.37","APC"
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.62","","","","","","","fee schedule","5.57","18.37","APC"
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.57","","","","","","","fee schedule","5.57","18.37","APC"
"Alpha 1 proteinase inhibitor","J0256","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.73","","","","","","","fee schedule","5.57","18.37","APC"
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.16","","","","","","","fee schedule","5.75","20.21",""
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.41","","","","","","","fee schedule","5.75","20.21",""
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.21","","","","","","","fee schedule","5.75","20.21",""
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.91","","","","","","","fee schedule","5.75","20.21","APC"
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.81","","","","","","","fee schedule","5.75","20.21","APC"
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.75","","","","","","","fee schedule","5.75","20.21","APC"
"Glassia injection","J0257","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.92","","","","","","","fee schedule","5.75","20.21","APC"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.75","","","","","","","fee schedule","10.5","36.46",""
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.02","","","","","","","fee schedule","10.5","36.46",""
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.46","","","","","","","fee schedule","10.5","36.46",""
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.71","","","","","","","fee schedule","10.5","36.46","APC 277.30"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.99","","","","","","","fee schedule","10.5","36.46","APC 296.56"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.44","","","","","","","fee schedule","10.5","36.46","APC 308.91"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.79","","","","","","","fee schedule","10.5","36.46","APC"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.61","","","","","","","fee schedule","10.5","36.46","APC"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.5","","","","","","","fee schedule","10.5","36.46","APC"
"Amphotericin b lipid complex","J0287","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.81","","","","","","","fee schedule","10.5","36.46","APC"
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","71.93","","","","","","","fee schedule","21.91","80.07",""
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","76.91","","","","","","","fee schedule","21.91","80.07",""
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","80.07","","","","","","","fee schedule","21.91","80.07",""
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.5","","","","","","","fee schedule","21.91","80.07","APC"
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.13","","","","","","","fee schedule","21.91","80.07","APC"
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.91","","","","","","","fee schedule","21.91","80.07","APC"
"Amphotericin b liposome inj","J0289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.56","","","","","","","fee schedule","21.91","80.07","APC"
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.35","","","","","","","fee schedule","3.57","12.64",""
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.14","","","","","","","fee schedule","3.57","12.64",""
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.64","","","","","","","fee schedule","3.57","12.64",""
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.67","","","","","","","fee schedule","3.57","12.64","APC"
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.61","","","","","","","fee schedule","3.57","12.64","APC"
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.57","","","","","","","fee schedule","3.57","12.64","APC"
"Inj., plazomicin, 5 mg","J0291","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.68","","","","","","","fee schedule","3.57","12.64","APC"
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.77","","","","","","","fee schedule","10.84","37.59",""
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.11","","","","","","","fee schedule","10.84","37.59",""
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.59","","","","","","","fee schedule","10.84","37.59",""
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.13","","","","","","","fee schedule","10.84","37.59","APC"
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.94","","","","","","","fee schedule","10.84","37.59","APC"
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.84","","","","","","","fee schedule","10.84","37.59","APC"
"Inj, rezafungin, 1 mg","J0349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.16","","","","","","","fee schedule","10.84","37.59","APC"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","164.82","","","","","","","fee schedule","52.87","183.48",""
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","176.22","","","","","","","fee schedule","52.87","183.48",""
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","183.48","","","","","","","fee schedule","52.87","183.48",""
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","164.63","","","","","","","fee schedule","52.87","183.48","APC 277.30"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","176.06","","","","","","","fee schedule","52.87","183.48","APC 296.56"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","183.39","","","","","","","fee schedule","52.87","183.48","APC 308.91"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.29","","","","","","","fee schedule","52.87","183.48","APC"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.38","","","","","","","fee schedule","52.87","183.48","APC"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.87","","","","","","","fee schedule","52.87","183.48","APC"
"Inj, artesunate, 1mg","J0391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.42","","","","","","","fee schedule","52.87","183.48","APC"
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.02","","","","","","","fee schedule","7.42","25.63",""
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.62","","","","","","","fee schedule","7.42","25.63",""
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.63","","","","","","","fee schedule","7.42","25.63",""
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.62","","","","","","","fee schedule","7.42","25.63","APC"
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.49","","","","","","","fee schedule","7.42","25.63","APC"
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.42","","","","","","","fee schedule","7.42","25.63","APC"
"Inj aripiprazole ext rel 1mg","J0401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.64","","","","","","","fee schedule","7.42","25.63","APC"
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.18","","","","","","","fee schedule","6.15","21.35",""
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.5","","","","","","","fee schedule","6.15","21.35",""
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.35","","","","","","","fee schedule","6.15","21.35",""
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.31","","","","","","","fee schedule","6.15","21.35","APC"
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.21","","","","","","","fee schedule","6.15","21.35","APC"
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.15","","","","","","","fee schedule","6.15","21.35","APC"
"Inj, abilify asimtufii, 1 mg","J0402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.33","","","","","","","fee schedule","6.15","21.35","APC"
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","559.11","","","","","","","fee schedule","184.85","622.4",""
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","597.79","","","","","","","fee schedule","184.85","622.4",""
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","622.4","","","","","","","fee schedule","184.85","622.4",""
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","189.83","","","","","","","fee schedule","184.85","622.4","APC"
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","186.66","","","","","","","fee schedule","184.85","622.4","APC"
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","184.85","","","","","","","fee schedule","184.85","622.4","APC"
"Baclofen 10 mg injection","J0475","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","190.28","","","","","","","fee schedule","184.85","622.4","APC"
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14858.45","","","","","","","fee schedule","4780.59","16540.54",""
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15886.4","","","","","","","fee schedule","4780.59","16540.54",""
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16540.54","","","","","","","fee schedule","4780.59","16540.54",""
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4909.48","","","","","","","fee schedule","4780.59","16540.54","APC"
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4827.46","","","","","","","fee schedule","4780.59","16540.54","APC"
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4780.59","","","","","","","fee schedule","4780.59","16540.54","APC"
"Basiliximab","J0480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4921.2","","","","","","","fee schedule","4780.59","16540.54","APC"
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.37","","","","","","","fee schedule","3.96","13.77",""
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.23","","","","","","","fee schedule","3.96","13.77",""
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.77","","","","","","","fee schedule","3.96","13.77",""
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.07","","","","","","","fee schedule","3.96","13.77","APC"
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4","","","","","","","fee schedule","3.96","13.77","APC"
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.96","","","","","","","fee schedule","3.96","13.77","APC"
"Belatacept injection","J0485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.08","","","","","","","fee schedule","3.96","13.77","APC"
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","178.11","","","","","","","fee schedule","57.19","198.28",""
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","190.43","","","","","","","fee schedule","57.19","198.28",""
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.28","","","","","","","fee schedule","57.19","198.28",""
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.73","","","","","","","fee schedule","57.19","198.28","APC"
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.75","","","","","","","fee schedule","57.19","198.28","APC"
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.19","","","","","","","fee schedule","57.19","198.28","APC"
"Belimumab injection","J0490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.87","","","","","","","fee schedule","57.19","198.28","APC"
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","57.56","","","","","","","fee schedule","18.44","64.07",""
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.54","","","","","","","fee schedule","18.44","64.07",""
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.07","","","","","","","fee schedule","18.44","64.07",""
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.94","","","","","","","fee schedule","18.44","64.07","APC"
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.62","","","","","","","fee schedule","18.44","64.07","APC"
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.44","","","","","","","fee schedule","18.44","64.07","APC"
"Inj anifrolumab-fnia 1mg","J0491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.98","","","","","","","fee schedule","18.44","64.07","APC"
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","534.65","","","","","","","fee schedule","167.88","595.18",""
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","571.64","","","","","","","fee schedule","167.88","595.18",""
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","595.18","","","","","","","fee schedule","167.88","595.18",""
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","172.41","","","","","","","fee schedule","167.88","595.18","APC"
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","169.53","","","","","","","fee schedule","167.88","595.18","APC"
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","167.88","","","","","","","fee schedule","167.88","595.18","APC"
"Inj., benralizumab, 1 mg","J0517","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","172.82","","","","","","","fee schedule","167.88","595.18","APC"
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.24","","","","","","","fee schedule","19.91","61.49",""
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59.06","","","","","","","fee schedule","19.91","61.49",""
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.49","","","","","","","fee schedule","19.91","61.49",""
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.45","","","","","","","fee schedule","19.91","61.49","APC"
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.11","","","","","","","fee schedule","19.91","61.49","APC"
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.91","","","","","","","fee schedule","19.91","61.49","APC"
"PenG benzathine/procaine inj","J0558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.5","","","","","","","fee schedule","19.91","61.49","APC"
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","93.17","","","","","","","fee schedule","30.61","103.72",""
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","99.62","","","","","","","fee schedule","30.61","103.72",""
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","103.72","","","","","","","fee schedule","30.61","103.72",""
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.44","","","","","","","fee schedule","30.61","103.72","APC"
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.91","","","","","","","fee schedule","30.61","103.72","APC"
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.61","","","","","","","fee schedule","30.61","103.72","APC"
"Penicillin g benzathine inj","J0561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.51","","","","","","","fee schedule","30.61","103.72","APC"
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","126.66","","","","","","","fee schedule","40.62","141",""
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","135.42","","","","","","","fee schedule","40.62","141",""
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","141","","","","","","","fee schedule","40.62","141",""
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.72","","","","","","","fee schedule","40.62","141","APC"
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.02","","","","","","","fee schedule","40.62","141","APC"
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.62","","","","","","","fee schedule","40.62","141","APC"
"Inj, bezlotoxumab, 10 mg","J0565","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.82","","","","","","","fee schedule","40.62","141","APC"
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1344.6","","","","","","","fee schedule","429.05","1496.82",""
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1437.62","","","","","","","fee schedule","429.05","1496.82",""
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1496.82","","","","","","","fee schedule","429.05","1496.82",""
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","440.62","","","","","","","fee schedule","429.05","1496.82","APC"
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","433.26","","","","","","","fee schedule","429.05","1496.82","APC"
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","429.05","","","","","","","fee schedule","429.05","1496.82","APC"
"Inj, brixadi, 7 days or less","J0577","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","441.67","","","","","","","fee schedule","429.05","1496.82","APC"
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5378.37","","","","","","","fee schedule","1716.2","5987.24",""
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5750.45","","","","","","","fee schedule","1716.2","5987.24",""
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5987.24","","","","","","","fee schedule","1716.2","5987.24",""
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1762.47","","","","","","","fee schedule","1716.2","5987.24","APC"
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1733.02","","","","","","","fee schedule","1716.2","5987.24","APC"
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1716.2","","","","","","","fee schedule","1716.2","5987.24","APC"
"Inj brixadi, more than 7 day","J0578","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1766.67","","","","","","","fee schedule","1716.2","5987.24","APC"
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1531.39","","","","","","","fee schedule","493.82","1704.76",""
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1637.34","","","","","","","fee schedule","493.82","1704.76",""
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1704.76","","","","","","","fee schedule","493.82","1704.76",""
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","507.13","","","","","","","fee schedule","493.82","1704.76","APC"
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","498.66","","","","","","","fee schedule","493.82","1704.76","APC"
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","493.82","","","","","","","fee schedule","493.82","1704.76","APC"
"Injection, burosumab-twza 1m","J0584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","508.34","","","","","","","fee schedule","493.82","1704.76","APC"
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.67","","","","","","","fee schedule","6.63","23.01",""
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.1","","","","","","","fee schedule","6.63","23.01",""
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.01","","","","","","","fee schedule","6.63","23.01",""
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.81","","","","","","","fee schedule","6.63","23.01","APC"
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.69","","","","","","","fee schedule","6.63","23.01","APC"
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.63","","","","","","","fee schedule","6.63","23.01","APC"
"Injection,onabotulinumtoxina","J0585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.82","","","","","","","fee schedule","6.63","23.01","APC"
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.16","","","","","","","fee schedule","8.93","32.46",""
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.18","","","","","","","fee schedule","8.93","32.46",""
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.46","","","","","","","fee schedule","8.93","32.46",""
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.17","","","","","","","fee schedule","8.93","32.46","APC"
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.01","","","","","","","fee schedule","8.93","32.46","APC"
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.93","","","","","","","fee schedule","8.93","32.46","APC"
"Abobotulinumtoxina","J0586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.19","","","","","","","fee schedule","8.93","32.46","APC"
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.42","","","","","","","fee schedule","13.55","47.22",""
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","45.36","","","","","","","fee schedule","13.55","47.22",""
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.22","","","","","","","fee schedule","13.55","47.22",""
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.92","","","","","","","fee schedule","13.55","47.22","APC"
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.69","","","","","","","fee schedule","13.55","47.22","APC"
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.55","","","","","","","fee schedule","13.55","47.22","APC"
"Inj, rimabotulinumtoxinb","J0587","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.95","","","","","","","fee schedule","13.55","47.22","APC"
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.89","","","","","","","fee schedule","5.68","18.8",""
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.05","","","","","","","fee schedule","5.68","18.8",""
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.8","","","","","","","fee schedule","5.68","18.8",""
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.83","","","","","","","fee schedule","5.68","18.8","APC"
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.74","","","","","","","fee schedule","5.68","18.8","APC"
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.68","","","","","","","fee schedule","5.68","18.8","APC"
"Incobotulinumtoxin a","J0588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.85","","","","","","","fee schedule","5.68","18.8","APC"
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.89","","","","","","","fee schedule","3.21","11.01",""
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.57","","","","","","","fee schedule","3.21","11.01",""
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.01","","","","","","","fee schedule","3.21","11.01",""
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.3","","","","","","","fee schedule","3.21","11.01","APC"
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.24","","","","","","","fee schedule","3.21","11.01","APC"
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.21","","","","","","","fee schedule","3.21","11.01","APC"
"Inj daxibotulinumtoxina-lanm","J0589","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.31","","","","","","","fee schedule","3.21","11.01","APC"
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.85","","","","","","","fee schedule","0.9","6.51",""
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.26","","","","","","","fee schedule","0.9","6.51",""
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.51","","","","","","","fee schedule","0.9","6.51",""
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.92","","","","","","","fee schedule","0.9","6.51","APC"
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.91","","","","","","","fee schedule","0.9","6.51","APC"
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.9","","","","","","","fee schedule","0.9","6.51","APC"
"Busulfan injection","J0594","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.92","","","","","","","fee schedule","0.9","6.51","APC"
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.83","","","","","","","fee schedule","37.5","130.06",""
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.92","","","","","","","fee schedule","37.5","130.06",""
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","130.06","","","","","","","fee schedule","37.5","130.06",""
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.51","","","","","","","fee schedule","37.5","130.06","APC"
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.87","","","","","","","fee schedule","37.5","130.06","APC"
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.5","","","","","","","fee schedule","37.5","130.06","APC"
"Injection, ruconest","J0596","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.6","","","","","","","fee schedule","37.5","130.06","APC"
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","241.23","","","","","","","fee schedule","77.38","268.54",""
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","257.92","","","","","","","fee schedule","77.38","268.54",""
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","268.54","","","","","","","fee schedule","77.38","268.54",""
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.46","","","","","","","fee schedule","77.38","268.54","APC"
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.13","","","","","","","fee schedule","77.38","268.54","APC"
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.38","","","","","","","fee schedule","77.38","268.54","APC"
"C-1 esterase, berinert","J0597","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.65","","","","","","","fee schedule","77.38","268.54","APC"
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","209.02","","","","","","","fee schedule","66.94","232.68",""
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","223.48","","","","","","","fee schedule","66.94","232.68",""
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","232.68","","","","","","","fee schedule","66.94","232.68",""
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.74","","","","","","","fee schedule","66.94","232.68","APC"
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.59","","","","","","","fee schedule","66.94","232.68","APC"
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.94","","","","","","","fee schedule","66.94","232.68","APC"
"C-1 esterase, cinryze","J0598","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.91","","","","","","","fee schedule","66.94","232.68","APC"
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20525.53","","","","","","","fee schedule","6536.54","22849.18",""
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21945.54","","","","","","","fee schedule","6536.54","22849.18",""
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22849.18","","","","","","","fee schedule","6536.54","22849.18",""
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6712.77","","","","","","","fee schedule","6536.54","22849.18","APC"
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6600.63","","","","","","","fee schedule","6536.54","22849.18","APC"
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6536.54","","","","","","","fee schedule","6536.54","22849.18","APC"
"Edetate calcium disodium inj","J0600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6728.79","","","","","","","fee schedule","6536.54","22849.18","APC"
"Calcitonin salmon injection","J0630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2657.84","","","","","","","fee schedule","2657.84","2958.73",""
"Calcitonin salmon injection","J0630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2841.72","","","","","","","fee schedule","2657.84","2958.73",""
"Calcitonin salmon injection","J0630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2958.73","","","","","","","fee schedule","2657.84","2958.73",""
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","448.38","","","","","","","fee schedule","144.44","499.14",""
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","479.4","","","","","","","fee schedule","144.44","499.14",""
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","499.14","","","","","","","fee schedule","144.44","499.14",""
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","148.33","","","","","","","fee schedule","144.44","499.14","APC"
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","145.85","","","","","","","fee schedule","144.44","499.14","APC"
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","144.44","","","","","","","fee schedule","144.44","499.14","APC"
"Canakinumab injection","J0638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","148.68","","","","","","","fee schedule","144.44","499.14","APC"
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.58","","","","","","","fee schedule","6.97","25.13",""
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24.14","","","","","","","fee schedule","6.97","25.13",""
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25.13","","","","","","","fee schedule","6.97","25.13",""
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.15","","","","","","","fee schedule","6.97","25.13","APC"
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.03","","","","","","","fee schedule","6.97","25.13","APC"
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.97","","","","","","","fee schedule","6.97","25.13","APC"
"Inj, levothyroxine, freskabi","J0651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.17","","","","","","","fee schedule","6.97","25.13","APC"
"Inj, levothyroxine, hikma","J0652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.35","","","","","","","fee schedule","16.35","18.2",""
"Inj, levothyroxine, hikma","J0652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.48","","","","","","","fee schedule","16.35","18.2",""
"Inj, levothyroxine, hikma","J0652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.2","","","","","","","fee schedule","16.35","18.2",""
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.74","","","","","","","fee schedule","1.5","5.27",""
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.07","","","","","","","fee schedule","1.5","5.27",""
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.27","","","","","","","fee schedule","1.5","5.27",""
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.54","","","","","","","fee schedule","1.5","5.27","APC"
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.51","","","","","","","fee schedule","1.5","5.27","APC"
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.5","","","","","","","fee schedule","1.5","5.27","APC"
"Inj, bupivacaine liposome","J0666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.54","","","","","","","fee schedule","1.5","5.27","APC"
"Inj cefazolin (wg crit care)","J0687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.18","","","","","","","fee schedule","3.18","3.54",""
"Inj cefazolin (wg crit care)","J0687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.4","","","","","","","fee schedule","3.18","3.54",""
"Inj cefazolin (wg crit care)","J0687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.54","","","","","","","fee schedule","3.18","3.54",""
"Inj cefazolin sodium, hikma","J0688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.89","","","","","","","fee schedule","2.89","3.22",""
"Inj cefazolin sodium, hikma","J0688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.09","","","","","","","fee schedule","2.89","3.22",""
"Inj cefazolin sodium, hikma","J0688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.22","","","","","","","fee schedule","2.89","3.22",""
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","29.03","","","","","","","fee schedule","9.25","32.32",""
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","31.04","","","","","","","fee schedule","9.25","32.32",""
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.32","","","","","","","fee schedule","9.25","32.32",""
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.5","","","","","","","fee schedule","9.25","32.32","APC"
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.34","","","","","","","fee schedule","9.25","32.32","APC"
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.25","","","","","","","fee schedule","9.25","32.32","APC"
"Inj ceftolozane tazobactam","J0695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.52","","","","","","","fee schedule","9.25","32.32","APC"
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.63","","","","","","","fee schedule","2.47","8.5",""
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.16","","","","","","","fee schedule","2.47","8.5",""
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.5","","","","","","","fee schedule","2.47","8.5",""
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.53","","","","","","","fee schedule","2.47","8.5","APC"
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.49","","","","","","","fee schedule","2.47","8.5","APC"
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.47","","","","","","","fee schedule","2.47","8.5","APC"
"Inj, cefiderocol, 10 mg","J0699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.54","","","","","","","fee schedule","2.47","8.5","APC"
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.48","","","","","","","fee schedule","4.31","15.01",""
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.42","","","","","","","fee schedule","4.31","15.01",""
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.01","","","","","","","fee schedule","4.31","15.01",""
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.43","","","","","","","fee schedule","4.31","15.01","APC"
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.35","","","","","","","fee schedule","4.31","15.01","APC"
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.31","","","","","","","fee schedule","4.31","15.01","APC"
"Ceftaroline fosamil inj","J0712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.31","15.01","APC"
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","333.74","","","","","","","fee schedule","106.82","371.52",""
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","356.83","","","","","","","fee schedule","106.82","371.52",""
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","371.52","","","","","","","fee schedule","106.82","371.52",""
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","109.7","","","","","","","fee schedule","106.82","371.52","APC"
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","107.87","","","","","","","fee schedule","106.82","371.52","APC"
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","106.82","","","","","","","fee schedule","106.82","371.52","APC"
"Ceftazidime and avibactam","J0714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","109.97","","","","","","","fee schedule","106.82","371.52","APC"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15451.65","","","","","","","fee schedule","4969.38","17239.04",""
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16520.63","","","","","","","fee schedule","4969.38","17239.04",""
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17200.9","","","","","","","fee schedule","4969.38","17239.04",""
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15475.01","","","","","","","fee schedule","4969.38","17239.04","APC 277.30"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16549.84","","","","","","","fee schedule","4969.38","17239.04","APC 296.56"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17239.04","","","","","","","fee schedule","4969.38","17239.04","APC 308.91"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5103.36","","","","","","","fee schedule","4969.38","17239.04","APC"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5018.1","","","","","","","fee schedule","4969.38","17239.04","APC"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4969.38","","","","","","","fee schedule","4969.38","17239.04","APC"
"Centruroides immune f(ab)","J0716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5115.54","","","","","","","fee schedule","4969.38","17239.04","APC"
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.28","","","","","","","fee schedule","3.99","15.89",""
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.27","","","","","","","fee schedule","3.99","15.89",""
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.89","","","","","","","fee schedule","3.99","15.89",""
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.1","","","","","","","fee schedule","3.99","15.89","APC"
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.03","","","","","","","fee schedule","3.99","15.89","APC"
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.99","","","","","","","fee schedule","3.99","15.89","APC"
"Certolizumab pegol inj 1mg","J0717","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.11","","","","","","","fee schedule","3.99","15.89","APC"
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.36","","","","","","","fee schedule","7.16","24.89",""
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.9","","","","","","","fee schedule","7.16","24.89",""
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.89","","","","","","","fee schedule","7.16","24.89",""
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.35","","","","","","","fee schedule","7.16","24.89","APC"
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.23","","","","","","","fee schedule","7.16","24.89","APC"
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.16","","","","","","","fee schedule","7.16","24.89","APC"
"Injection, cabotegravir 1 mg","J0739","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.37","","","","","","","fee schedule","7.16","24.89","APC"
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1683.43","","","","","","","fee schedule","557.22","1874.01",""
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1799.89","","","","","","","fee schedule","557.22","1874.01",""
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1874.01","","","","","","","fee schedule","557.22","1874.01",""
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","572.24","","","","","","","fee schedule","557.22","1874.01","APC"
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","562.68","","","","","","","fee schedule","557.22","1874.01","APC"
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","557.22","","","","","","","fee schedule","557.22","1874.01","APC"
"Cidofovir injection","J0740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","573.61","","","","","","","fee schedule","557.22","1874.01","APC"
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","75.14","","","","","","","fee schedule","24.12","83.65",""
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","80.34","","","","","","","fee schedule","24.12","83.65",""
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","83.65","","","","","","","fee schedule","24.12","83.65",""
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.77","","","","","","","fee schedule","24.12","83.65","APC"
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.36","","","","","","","fee schedule","24.12","83.65","APC"
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.12","","","","","","","fee schedule","24.12","83.65","APC"
"Inj, cabote rilpivir 2mg 3mg","J0741","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.83","","","","","","","fee schedule","24.12","83.65","APC"
"Inj imip 4 cilas 4 releb 2mg","J0742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.3","","","","","","","fee schedule","8.3","9.24",""
"Inj imip 4 cilas 4 releb 2mg","J0742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.87","","","","","","","fee schedule","8.3","9.24",""
"Inj imip 4 cilas 4 releb 2mg","J0742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.24","","","","","","","fee schedule","8.3","9.24",""
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.53","","","","","","","fee schedule","1.77","6.16",""
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.92","","","","","","","fee schedule","1.77","6.16",""
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.16","","","","","","","fee schedule","1.77","6.16",""
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.82","","","","","","","fee schedule","1.77","6.16","APC"
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.79","","","","","","","fee schedule","1.77","6.16","APC"
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.77","","","","","","","fee schedule","1.77","6.16","APC"
"Hiv prep, ftc/tdf 200/300mg","J0750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.82","","","","","","","fee schedule","1.77","6.16","APC"
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","226.64","","","","","","","fee schedule","72.75","252.3",""
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","242.32","","","","","","","fee schedule","72.75","252.3",""
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","252.3","","","","","","","fee schedule","72.75","252.3",""
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","74.71","","","","","","","fee schedule","72.75","252.3","APC"
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","73.46","","","","","","","fee schedule","72.75","252.3","APC"
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","72.75","","","","","","","fee schedule","72.75","252.3","APC"
"Hiv prep, ftc/taf 200/25mg","J0751","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","74.89","","","","","","","fee schedule","72.75","252.3","APC"
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","232.65","","","","","","","fee schedule","77.42","258.99",""
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","248.74","","","","","","","fee schedule","77.42","258.99",""
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","258.99","","","","","","","fee schedule","77.42","258.99",""
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.51","","","","","","","fee schedule","77.42","258.99","APC"
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.18","","","","","","","fee schedule","77.42","258.99","APC"
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.42","","","","","","","fee schedule","77.42","258.99","APC"
"Collagenase, clost hist inj","J0775","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.7","","","","","","","fee schedule","77.42","258.99","APC"
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","412.06","","","","","","","fee schedule","132.07","458.71",""
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","440.57","","","","","","","fee schedule","132.07","458.71",""
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","458.71","","","","","","","fee schedule","132.07","458.71",""
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.63","","","","","","","fee schedule","132.07","458.71","APC"
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","133.36","","","","","","","fee schedule","132.07","458.71","APC"
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.07","","","","","","","fee schedule","132.07","458.71","APC"
"Inj crizanlizumab-tmca 5mg","J0791","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.95","","","","","","","fee schedule","132.07","458.71","APC"
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5918.39","","","","","","","fee schedule","1865.29","6588.4",""
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6327.84","","","","","","","fee schedule","1865.29","6588.4",""
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6588.4","","","","","","","fee schedule","1865.29","6588.4",""
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1915.58","","","","","","","fee schedule","1865.29","6588.4","APC"
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1883.58","","","","","","","fee schedule","1865.29","6588.4","APC"
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1865.29","","","","","","","fee schedule","1865.29","6588.4","APC"
"Crotalidae poly immune fab","J0840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1920.15","","","","","","","fee schedule","1865.29","6588.4","APC"
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3320.37","","","","","","","fee schedule","1066.05","3696.26",""
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3550.08","","","","","","","fee schedule","1066.05","3696.26",""
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3696.26","","","","","","","fee schedule","1066.05","3696.26",""
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1094.79","","","","","","","fee schedule","1066.05","3696.26","APC"
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1076.5","","","","","","","fee schedule","1066.05","3696.26","APC"
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1066.05","","","","","","","fee schedule","1066.05","3696.26","APC"
"Inj crotalidae im f(ab')2 eq","J0841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1097.41","","","","","","","fee schedule","1066.05","3696.26","APC"
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5754.02","","","","","","","fee schedule","1844.82","6405.42",""
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6152.1","","","","","","","fee schedule","1844.82","6405.42",""
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6405.42","","","","","","","fee schedule","1844.82","6405.42",""
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1894.56","","","","","","","fee schedule","1844.82","6405.42","APC"
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1862.9","","","","","","","fee schedule","1844.82","6405.42","APC"
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1844.82","","","","","","","fee schedule","1844.82","6405.42","APC"
"Cytomegalovirus imm IV /vial","J0850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1899.08","","","","","","","fee schedule","1844.82","6405.42","APC"
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","181.32","","","","","","","fee schedule","58.17","201.85",""
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","193.87","","","","","","","fee schedule","58.17","201.85",""
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","201.85","","","","","","","fee schedule","58.17","201.85",""
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59.74","","","","","","","fee schedule","58.17","201.85","APC"
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","58.74","","","","","","","fee schedule","58.17","201.85","APC"
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.17","","","","","","","fee schedule","58.17","201.85","APC"
"Injection, imetelstat, 1 mg","J0870","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59.88","","","","","","","fee schedule","58.17","201.85","APC"
"Daptomycin (xellia) unrefrig","J0872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.16","","","","","","","fee schedule","0.16","0.18",""
"Daptomycin (xellia) unrefrig","J0872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.17","","","","","","","fee schedule","0.16","0.18",""
"Daptomycin (xellia) unrefrig","J0872","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.18","","","","","","","fee schedule","0.16","0.18",""
"Inj, daptomycin (xellia)","J0873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.13","","","","","","","fee schedule","0.13","0.14",""
"Inj, daptomycin (xellia)","J0873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.14","","","","","","","fee schedule","0.13","0.14",""
"Inj, daptomycin (xellia)","J0873","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.14","","","","","","","fee schedule","0.13","0.14",""
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","49.45","","","","","","","fee schedule","15.93","55.05",""
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","52.87","","","","","","","fee schedule","15.93","55.05",""
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","55.05","","","","","","","fee schedule","15.93","55.05",""
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.35","","","","","","","fee schedule","15.93","55.05","APC"
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.08","","","","","","","fee schedule","15.93","55.05","APC"
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.93","","","","","","","fee schedule","15.93","55.05","APC"
"Injection, dalbavancin","J0875","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.39","","","","","","","fee schedule","15.93","55.05","APC"
"Difelikefalin, esrd on dialy","J0879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.25","","","","","","","fee schedule","0.25","0.28",""
"Difelikefalin, esrd on dialy","J0879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.27","","","","","","","fee schedule","0.25","0.28",""
"Difelikefalin, esrd on dialy","J0879","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.28","","","","","","","fee schedule","0.25","0.28",""
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.54","","","","","","","fee schedule","2.98","10.62",""
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.2","","","","","","","fee schedule","2.98","10.62",""
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.62","","","","","","","fee schedule","2.98","10.62",""
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.06","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.01","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.98","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, non-esrd","J0881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.07","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.54","","","","","","","fee schedule","2.98","10.62",""
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.2","","","","","","","fee schedule","2.98","10.62",""
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.62","","","","","","","fee schedule","2.98","10.62",""
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.06","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.01","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.98","","","","","","","fee schedule","2.98","10.62","APC"
"Darbepoetin alfa, esrd use","J0882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.07","","","","","","","fee schedule","2.98","10.62","APC"
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.35","","","","","","","fee schedule","0.81","2.62",""
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.52","","","","","","","fee schedule","0.81","2.62",""
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.62","","","","","","","fee schedule","0.81","2.62",""
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.83","","","","","","","fee schedule","0.81","2.62","APC"
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.82","","","","","","","fee schedule","0.81","2.62","APC"
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.81","","","","","","","fee schedule","0.81","2.62","APC"
"Argatroban nonesrd use 1mg","J0883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.84","","","","","","","fee schedule","0.81","2.62","APC"
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.42","","","","","","","fee schedule","8.71","27.19",""
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.11","","","","","","","fee schedule","8.71","27.19",""
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.19","","","","","","","fee schedule","8.71","27.19",""
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.95","","","","","","","fee schedule","8.71","27.19","APC"
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.8","","","","","","","fee schedule","8.71","27.19","APC"
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.71","","","","","","","fee schedule","8.71","27.19","APC"
"Epoetin alfa, non-esrd","J0885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.97","","","","","","","fee schedule","8.71","27.19","APC"
"Epoetin beta non esrd","J0888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.48","","","","","","","fee schedule","4.48","4.99",""
"Epoetin beta non esrd","J0888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.79","","","","","","","fee schedule","4.48","4.99",""
"Epoetin beta non esrd","J0888","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.99","","","","","","","fee schedule","4.48","4.99",""
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.79","","","","","","","fee schedule","1.85","6.44",""
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.19","","","","","","","fee schedule","1.85","6.44",""
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.44","","","","","","","fee schedule","1.85","6.44",""
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.77","","","","","","","fee schedule","1.85","6.44","APC 277.30"
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.17","","","","","","","fee schedule","1.85","6.44","APC 296.56"
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.42","","","","","","","fee schedule","1.85","6.44","APC 308.91"
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.9","","","","","","","fee schedule","1.85","6.44","APC"
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.87","","","","","","","fee schedule","1.85","6.44","APC"
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.85","","","","","","","fee schedule","1.85","6.44","APC"
"Argatroban nonesrd (accord)","J0891","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.91","","","","","","","fee schedule","1.85","6.44","APC"
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","133.43","","","","","","","fee schedule","42.82","148.54",""
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.66","","","","","","","fee schedule","42.82","148.54",""
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","148.54","","","","","","","fee schedule","42.82","148.54",""
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.98","","","","","","","fee schedule","42.82","148.54","APC"
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.24","","","","","","","fee schedule","42.82","148.54","APC"
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.82","","","","","","","fee schedule","42.82","148.54","APC"
"Inj luspatercept-aamt 0.25mg","J0896","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.08","","","","","","","fee schedule","42.82","148.54","APC"
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","92.98","","","","","","","fee schedule","29.97","103.51",""
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","99.42","","","","","","","fee schedule","29.97","103.51",""
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","103.51","","","","","","","fee schedule","29.97","103.51",""
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.78","","","","","","","fee schedule","29.97","103.51","APC"
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.26","","","","","","","fee schedule","29.97","103.51","APC"
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.97","","","","","","","fee schedule","29.97","103.51","APC"
"Denosumab injection","J0897","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.85","","","","","","","fee schedule","29.97","103.51","APC"
"Argatroban nonesrd (auromed)","J0898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.61","","","","","","","fee schedule","4.61","5.13",""
"Argatroban nonesrd (auromed)","J0898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.93","","","","","","","fee schedule","4.61","5.13",""
"Argatroban nonesrd (auromed)","J0898","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.13","","","","","","","fee schedule","4.61","5.13",""
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.42","","","","","","","fee schedule","6.54","27.19",""
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.11","","","","","","","fee schedule","6.54","27.19",""
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.19","","","","","","","fee schedule","6.54","27.19",""
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","20.35","","","","","","","fee schedule","6.54","27.19","APC 277.30"
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.77","","","","","","","fee schedule","6.54","27.19","APC 296.56"
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.67","","","","","","","fee schedule","6.54","27.19","APC 308.91"
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.71","","","","","","","fee schedule","6.54","27.19","APC"
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.6","","","","","","","fee schedule","6.54","27.19","APC"
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.54","","","","","","","fee schedule","6.54","27.19","APC"
"Inst tauro 1.35mg/hep 100u","J0911","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.73","","","","","","","fee schedule","6.54","27.19","APC"
"Inj, methylpred acetate 1 mg","J1010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.38","","","","","","","fee schedule","0.38","0.42",""
"Inj, methylpred acetate 1 mg","J1010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.41","","","","","","","fee schedule","0.38","0.42",""
"Inj, methylpred acetate 1 mg","J1010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.42","","","","","","","fee schedule","0.38","0.42",""
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.23","","","","","","","fee schedule","1.35","4.71",""
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.52","","","","","","","fee schedule","1.35","4.71",""
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.71","","","","","","","fee schedule","1.35","4.71",""
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.39","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.36","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.35","","","","","","","fee schedule","1.35","4.71","APC"
"Inj, testosterone, azmiro","J1072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.39","","","","","","","fee schedule","1.35","4.71","APC"
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","322.74","","","","","","","fee schedule","104.99","359.27",""
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","345.07","","","","","","","fee schedule","104.99","359.27",""
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","359.27","","","","","","","fee schedule","104.99","359.27",""
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.82","","","","","","","fee schedule","104.99","359.27","APC"
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.02","","","","","","","fee schedule","104.99","359.27","APC"
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.99","","","","","","","fee schedule","104.99","359.27","APC"
"Dexametha opth insert 0.1 mg","J1096","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.08","","","","","","","fee schedule","104.99","359.27","APC"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","309.8","","","","","","","fee schedule","98.85","344.87",""
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","331.23","","","","","","","fee schedule","98.85","344.87",""
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","344.87","","","","","","","fee schedule","98.85","344.87",""
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","307.82","","","","","","","fee schedule","98.85","344.87","APC 277.30"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","329.2","","","","","","","fee schedule","98.85","344.87","APC 296.56"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","342.91","","","","","","","fee schedule","98.85","344.87","APC 308.91"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","101.51","","","","","","","fee schedule","98.85","344.87","APC"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","99.82","","","","","","","fee schedule","98.85","344.87","APC"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","98.85","","","","","","","fee schedule","98.85","344.87","APC"
"Phenylep ketorolac opth soln","J1097","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","101.76","","","","","","","fee schedule","98.85","344.87","APC"
"Dexmedetomidine film, 1 mcg","J1105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.04","","","","","","","fee schedule","2.04","2.27",""
"Dexmedetomidine film, 1 mcg","J1105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.18","","","","","","","fee schedule","2.04","2.27",""
"Dexmedetomidine film, 1 mcg","J1105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.27","","","","","","","fee schedule","2.04","2.27",""
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15800.08","","","","","","","fee schedule","5271.59","17588.77",""
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16893.17","","","","","","","fee schedule","5271.59","17588.77",""
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17588.77","","","","","","","fee schedule","5271.59","17588.77",""
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5413.72","","","","","","","fee schedule","5271.59","17588.77","APC"
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5323.28","","","","","","","fee schedule","5271.59","17588.77","APC"
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5271.59","","","","","","","fee schedule","5271.59","17588.77","APC"
"Digoxin immune fab (ovine)","J1162","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5426.64","","","","","","","fee schedule","5271.59","17588.77","APC"
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","102.05","","","","","","","fee schedule","64.32","113.6",""
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","109.11","","","","","","","fee schedule","64.32","113.6",""
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","113.6","","","","","","","fee schedule","64.32","113.6",""
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66.06","","","","","","","fee schedule","64.32","113.6","APC"
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64.95","","","","","","","fee schedule","64.32","113.6","APC"
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","64.32","","","","","","","fee schedule","64.32","113.6","APC"
"Dexrazoxane hcl injection","J1190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","66.21","","","","","","","fee schedule","64.32","113.6","APC"
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","52.15","","","","","","","fee schedule","16.85","58.06",""
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","55.76","","","","","","","fee schedule","16.85","58.06",""
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","58.06","","","","","","","fee schedule","16.85","58.06",""
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.3","","","","","","","fee schedule","16.85","58.06","APC"
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.01","","","","","","","fee schedule","16.85","58.06","APC"
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16.85","","","","","","","fee schedule","16.85","58.06","APC"
"Inj. cetirizine hcl 0.5mg","J1201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.34","","","","","","","fee schedule","16.85","58.06","APC"
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","285.56","","","","","","","fee schedule","93.04","317.89",""
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","305.32","","","","","","","fee schedule","93.04","317.89",""
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","317.89","","","","","","","fee schedule","93.04","317.89",""
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.55","","","","","","","fee schedule","93.04","317.89","APC"
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","93.95","","","","","","","fee schedule","93.04","317.89","APC"
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.04","","","","","","","fee schedule","93.04","317.89","APC"
"Inj, cipaglucosidase, 5 mg","J1203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","95.77","","","","","","","fee schedule","93.04","317.89","APC"
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2362.42","","","","","","","fee schedule","763.82","2629.87",""
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2525.86","","","","","","","fee schedule","763.82","2629.87",""
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2629.87","","","","","","","fee schedule","763.82","2629.87",""
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","784.42","","","","","","","fee schedule","763.82","2629.87","APC"
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","771.31","","","","","","","fee schedule","763.82","2629.87","APC"
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","763.82","","","","","","","fee schedule","763.82","2629.87","APC"
"Dimethyl sulfoxide 50% 50 ML","J1212","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","786.29","","","","","","","fee schedule","763.82","2629.87","APC"
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1844.37","","","","","","","fee schedule","591.56","2053.16",""
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1971.97","","","","","","","fee schedule","591.56","2053.16",""
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2053.16","","","","","","","fee schedule","591.56","2053.16",""
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","607.51","","","","","","","fee schedule","591.56","2053.16","APC"
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","597.36","","","","","","","fee schedule","591.56","2053.16","APC"
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","591.56","","","","","","","fee schedule","591.56","2053.16","APC"
"Ecallantide injection","J1290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","608.96","","","","","","","fee schedule","591.56","2053.16","APC"
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","142.37","","","","","","","fee schedule","45.72","158.49",""
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","152.22","","","","","","","fee schedule","45.72","158.49",""
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","158.49","","","","","","","fee schedule","45.72","158.49",""
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.95","","","","","","","fee schedule","45.72","158.49","APC"
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46.17","","","","","","","fee schedule","45.72","158.49","APC"
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45.72","","","","","","","fee schedule","45.72","158.49","APC"
"Inj, eculizumab, 2 mg","J1299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.06","","","","","","","fee schedule","45.72","158.49","APC"
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","59.91","","","","","","","fee schedule","21.41","66.69",""
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.06","","","","","","","fee schedule","21.41","66.69",""
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","66.69","","","","","","","fee schedule","21.41","66.69",""
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.99","","","","","","","fee schedule","21.41","66.69","APC"
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.62","","","","","","","fee schedule","21.41","66.69","APC"
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.41","","","","","","","fee schedule","21.41","66.69","APC"
"Injection, edaravone, 1 mg","J1301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.04","","","","","","","fee schedule","21.41","66.69","APC"
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","57.59","","","","","","","fee schedule","19.24","64.11",""
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.57","","","","","","","fee schedule","19.24","64.11",""
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.11","","","","","","","fee schedule","19.24","64.11",""
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.76","","","","","","","fee schedule","19.24","64.11","APC"
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.43","","","","","","","fee schedule","19.24","64.11","APC"
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.24","","","","","","","fee schedule","19.24","64.11","APC"
"Inj, sutimlimab-jome, 10 mg","J1302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.8","","","","","","","fee schedule","19.24","64.11","APC"
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","716.1","","","","","","","fee schedule","229.61","797.17",""
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","765.65","","","","","","","fee schedule","229.61","797.17",""
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","797.17","","","","","","","fee schedule","229.61","797.17",""
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","235.8","","","","","","","fee schedule","229.61","797.17","APC"
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","231.86","","","","","","","fee schedule","229.61","797.17","APC"
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","229.61","","","","","","","fee schedule","229.61","797.17","APC"
"Inj., ravulizumab-cwvz 10 mg","J1303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","236.36","","","","","","","fee schedule","229.61","797.17","APC"
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","493.98","","","","","","","fee schedule","162.59","549.9",""
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","528.16","","","","","","","fee schedule","162.59","549.9",""
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","549.9","","","","","","","fee schedule","162.59","549.9",""
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.97","","","","","","","fee schedule","162.59","549.9","APC"
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","164.18","","","","","","","fee schedule","162.59","549.9","APC"
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","162.59","","","","","","","fee schedule","162.59","549.9","APC"
"Inj tofersen intrathec 1 mg","J1304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","167.37","","","","","","","fee schedule","162.59","549.9","APC"
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","603.41","","","","","","","fee schedule","197.63","671.72",""
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","645.15","","","","","","","fee schedule","197.63","671.72",""
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","671.72","","","","","","","fee schedule","197.63","671.72",""
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.96","","","","","","","fee schedule","197.63","671.72","APC"
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.57","","","","","","","fee schedule","197.63","671.72","APC"
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.63","","","","","","","fee schedule","197.63","671.72","APC"
"Inj, evinacumab-dgnb, 5mg","J1305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","203.45","","","","","","","fee schedule","197.63","671.72","APC"
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39.27","","","","","","","fee schedule","12.56","43.72",""
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.99","","","","","","","fee schedule","12.56","43.72",""
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.72","","","","","","","fee schedule","12.56","43.72",""
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.9","","","","","","","fee schedule","12.56","43.72","APC"
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.69","","","","","","","fee schedule","12.56","43.72","APC"
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.56","","","","","","","fee schedule","12.56","43.72","APC"
"Injection, inclisiran, 1 mg","J1306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.93","","","","","","","fee schedule","12.56","43.72","APC"
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1753.8","","","","","","","fee schedule","562.54","1952.35",""
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1875.13","","","","","","","fee schedule","562.54","1952.35",""
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1952.35","","","","","","","fee schedule","562.54","1952.35",""
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","577.71","","","","","","","fee schedule","562.54","1952.35","APC"
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","568.06","","","","","","","fee schedule","562.54","1952.35","APC"
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","562.54","","","","","","","fee schedule","562.54","1952.35","APC"
"Inj, crovalimab-akkz, 10 mg","J1307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","579.09","","","","","","","fee schedule","562.54","1952.35","APC"
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","975.62","","","","","","","fee schedule","314.86","1086.07",""
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1043.12","","","","","","","fee schedule","314.86","1086.07",""
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1086.07","","","","","","","fee schedule","314.86","1086.07",""
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","323.35","","","","","","","fee schedule","314.86","1086.07","APC"
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","317.94","","","","","","","fee schedule","314.86","1086.07","APC"
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","314.86","","","","","","","fee schedule","314.86","1086.07","APC"
"Elosulfase alfa, injection","J1322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","324.12","","","","","","","fee schedule","314.86","1086.07","APC"
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","589.29","","","","","","","fee schedule","187.75","656",""
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","630.05","","","","","","","fee schedule","187.75","656",""
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","656","","","","","","","fee schedule","187.75","656",""
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","192.82","","","","","","","fee schedule","187.75","656","APC"
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","189.59","","","","","","","fee schedule","187.75","656","APC"
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","187.75","","","","","","","fee schedule","187.75","656","APC"
"Inj, elranatamab-bcmm, 1 mg","J1323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","193.28","","","","","","","fee schedule","187.75","656","APC"
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","106.72","","","","","","","fee schedule","34.38","118.8",""
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.1","","","","","","","fee schedule","34.38","118.8",""
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","118.8","","","","","","","fee schedule","34.38","118.8",""
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.31","","","","","","","fee schedule","34.38","118.8","APC"
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.72","","","","","","","fee schedule","34.38","118.8","APC"
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.38","","","","","","","fee schedule","34.38","118.8","APC"
"Inj, zolbetuximab-clzb, 2 mg","J1326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.39","","","","","","","fee schedule","34.38","118.8","APC"
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1242.55","","","","","","","fee schedule","399.9","1383.22",""
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1328.52","","","","","","","fee schedule","399.9","1383.22",""
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1383.22","","","","","","","fee schedule","399.9","1383.22",""
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","410.69","","","","","","","fee schedule","399.9","1383.22","APC"
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","403.82","","","","","","","fee schedule","399.9","1383.22","APC"
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","399.9","","","","","","","fee schedule","399.9","1383.22","APC"
"Inj estrogen conjugate 25 MG","J1410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","411.67","","","","","","","fee schedule","399.9","1383.22","APC"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","13040073.86",""
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","13040073.86",""
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","13040073.86",""
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11705715.2","","","","","","","fee schedule","0.03","13040073.86","APC 277.30"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12518741.07","","","","","","","fee schedule","0.03","13040073.86","APC 296.56"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13040073.86","","","","","","","fee schedule","0.03","13040073.86","APC 308.91"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3860316.83","","","","","","","fee schedule","0.03","13040073.86","APC"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3795824.67","","","","","","","fee schedule","0.03","13040073.86","APC"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3758972","","","","","","","fee schedule","0.03","13040073.86","APC"
"Inj, hemgenix, per tx dose","J1411","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3869530","","","","","","","fee schedule","0.03","13040073.86","APC"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","44420.49",""
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","44420.49",""
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","44420.49",""
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","39875.05","","","","","","","fee schedule","0.03","44420.49","APC 277.30"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","42644.59","","","","","","","fee schedule","0.03","44420.49","APC 296.56"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","44420.49","","","","","","","fee schedule","0.03","44420.49","APC 308.91"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13150.01","","","","","","","fee schedule","0.03","44420.49","APC"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12930.32","","","","","","","fee schedule","0.03","44420.49","APC"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12804.79","","","","","","","fee schedule","0.03","44420.49","APC"
"Inj roctavian ml 2x10^13vc g","J1412","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13181.4","","","","","","","fee schedule","0.03","44420.49","APC"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","11735084.87",""
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","11735084.87",""
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","11735084.87",""
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10534262.52","","","","","","","fee schedule","0.03","11735084.87","APC 277.30"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11265924.6","","","","","","","fee schedule","0.03","11735084.87","APC 296.56"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11735084.87","","","","","","","fee schedule","0.03","11735084.87","APC 308.91"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3473994.56","","","","","","","fee schedule","0.03","11735084.87","APC"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3415956.47","","","","","","","fee schedule","0.03","11735084.87","APC"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3382791.84","","","","","","","fee schedule","0.03","11735084.87","APC"
"Inj delandistrogene mox rokl","J1413","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3482285.72","","","","","","","fee schedule","0.03","11735084.87","APC"
"Inj, beqvez, per tx dose","J1414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","0.04",""
"Inj, beqvez, per tx dose","J1414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","0.04",""
"Inj, beqvez, per tx dose","J1414","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","0.04",""
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1652.07","","","","","","","fee schedule","519.14","1839.1",""
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1766.37","","","","","","","fee schedule","519.14","1839.1",""
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1839.1","","","","","","","fee schedule","519.14","1839.1",""
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","533.14","","","","","","","fee schedule","519.14","1839.1","APC"
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","524.23","","","","","","","fee schedule","519.14","1839.1","APC"
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","519.14","","","","","","","fee schedule","519.14","1839.1","APC"
"Ethanolamine oleate 100 mg","J1430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","534.41","","","","","","","fee schedule","519.14","1839.1","APC"
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.13","","","","","","","fee schedule","2.9","10.16",""
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.76","","","","","","","fee schedule","2.9","10.16",""
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.16","","","","","","","fee schedule","2.9","10.16",""
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.97","","","","","","","fee schedule","2.9","10.16","APC"
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.92","","","","","","","fee schedule","2.9","10.16","APC"
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.9","","","","","","","fee schedule","2.9","10.16","APC"
"Inj, focinvez, 1mg","J1434","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.98","","","","","","","fee schedule","2.9","10.16","APC"
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","60.26","","","","","","","fee schedule","22.46","67.08",""
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","64.43","","","","","","","fee schedule","22.46","67.08",""
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","67.08","","","","","","","fee schedule","22.46","67.08",""
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.06","","","","","","","fee schedule","22.46","67.08","APC"
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.68","","","","","","","fee schedule","22.46","67.08","APC"
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.46","","","","","","","fee schedule","22.46","67.08","APC"
"Inj. fe derisomaltose 10 mg","J1437","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.12","","","","","","","fee schedule","22.46","67.08","APC"
"Etanercept injection","J1438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3437.2","","","","","","","fee schedule","3437.2","3826.32",""
"Etanercept injection","J1438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3674.99","","","","","","","fee schedule","3437.2","3826.32",""
"Etanercept injection","J1438","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3826.32","","","","","","","fee schedule","3437.2","3826.32",""
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.63","","","","","","","fee schedule","1.13","4.04",""
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.88","","","","","","","fee schedule","1.13","4.04",""
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.04","","","","","","","fee schedule","1.13","4.04",""
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.16","","","","","","","fee schedule","1.13","4.04","APC"
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.14","","","","","","","fee schedule","1.13","4.04","APC"
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.13","","","","","","","fee schedule","1.13","4.04","APC"
"Inj ferric carboxymaltos 1mg","J1439","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.16","","","","","","","fee schedule","1.13","4.04","APC"
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","203.62","","","","","","","fee schedule","65.12","226.67",""
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","217.7","","","","","","","fee schedule","65.12","226.67",""
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","226.67","","","","","","","fee schedule","65.12","226.67",""
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66.87","","","","","","","fee schedule","65.12","226.67","APC"
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65.75","","","","","","","fee schedule","65.12","226.67","APC"
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.12","","","","","","","fee schedule","65.12","226.67","APC"
"Fecal?microbiota jslm 1 ml","J1440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.03","","","","","","","fee schedule","65.12","226.67","APC"
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.15","","","","","","","fee schedule","1.02","3.5",""
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.37","","","","","","","fee schedule","1.02","3.5",""
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.5","","","","","","","fee schedule","1.02","3.5",""
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.04","","","","","","","fee schedule","1.02","3.5","APC"
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.03","","","","","","","fee schedule","1.02","3.5","APC"
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.02","","","","","","","fee schedule","1.02","3.5","APC"
"Inj filgrastim excl biosimil","J1442","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.05","","","","","","","fee schedule","1.02","3.5","APC"
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.95","","","","","","","fee schedule","0.29","1.06",""
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.02","","","","","","","fee schedule","0.29","1.06",""
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.06","","","","","","","fee schedule","0.29","1.06",""
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.29","","","","","","","fee schedule","0.29","1.06","APC"
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.29","","","","","","","fee schedule","0.29","1.06","APC"
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.29","","","","","","","fee schedule","0.29","1.06","APC"
"Inj tbo filgrastim 1 microg","J1447","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.29","","","","","","","fee schedule","0.29","1.06","APC"
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.14","","","","","","","fee schedule","5.57","19.08",""
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.33","","","","","","","fee schedule","5.57","19.08",""
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.08","","","","","","","fee schedule","5.57","19.08",""
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.72","","","","","","","fee schedule","5.57","19.08","APC"
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.63","","","","","","","fee schedule","5.57","19.08","APC"
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.57","","","","","","","fee schedule","5.57","19.08","APC"
"Injection, trilaciclib, 1mg","J1448","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.74","","","","","","","fee schedule","5.57","19.08","APC"
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","67.16","","","","","","","fee schedule","21.29","74.76",""
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.81","","","","","","","fee schedule","21.29","74.76",""
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","74.76","","","","","","","fee schedule","21.29","74.76",""
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.87","","","","","","","fee schedule","21.29","74.76","APC"
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.5","","","","","","","fee schedule","21.29","74.76","APC"
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.29","","","","","","","fee schedule","21.29","74.76","APC"
"Inj eflapegrastim-xnst 0.1mg","J1449","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.92","","","","","","","fee schedule","21.29","74.76","APC"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.18","","","","","","","fee schedule","6.4","22.21",""
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.5","","","","","","","fee schedule","6.4","22.21",""
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.35","","","","","","","fee schedule","6.4","22.21",""
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.94","","","","","","","fee schedule","6.4","22.21","APC 277.30"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","21.32","","","","","","","fee schedule","6.4","22.21","APC 296.56"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","22.21","","","","","","","fee schedule","6.4","22.21","APC 308.91"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.58","","","","","","","fee schedule","6.4","22.21","APC"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.47","","","","","","","fee schedule","6.4","22.21","APC"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.4","","","","","","","fee schedule","6.4","22.21","APC"
"Fomepizole, 15 mg","J1451","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.59","","","","","","","fee schedule","6.4","22.21","APC"
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1928.19","","","","","","","fee schedule","587.01","2146.48",""
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2061.59","","","","","","","fee schedule","587.01","2146.48",""
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2146.48","","","","","","","fee schedule","587.01","2146.48",""
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","602.84","","","","","","","fee schedule","587.01","2146.48","APC"
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","592.77","","","","","","","fee schedule","587.01","2146.48","APC"
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","587.01","","","","","","","fee schedule","587.01","2146.48","APC"
"Inj fosnetupitant, palonoset","J1454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","604.28","","","","","","","fee schedule","587.01","2146.48","APC"
"Foscarnet sodium injection","J1455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","49.54","","","","","","","fee schedule","49.54","55.15",""
"Foscarnet sodium injection","J1455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","52.97","","","","","","","fee schedule","49.54","55.15",""
"Foscarnet sodium injection","J1455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","55.15","","","","","","","fee schedule","49.54","55.15",""
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.59","","","","","","","fee schedule","1.05","4",""
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.84","","","","","","","fee schedule","1.05","4",""
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4","","","","","","","fee schedule","1.05","4",""
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.08","","","","","","","fee schedule","1.05","4","APC"
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.06","","","","","","","fee schedule","1.05","4","APC"
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.05","","","","","","","fee schedule","1.05","4","APC"
"Inj, fosaprepitant (teva)","J1456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.08","","","","","","","fee schedule","1.05","4","APC"
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","160.37","","","","","","","fee schedule","51.75","178.52",""
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","171.46","","","","","","","fee schedule","51.75","178.52",""
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","178.52","","","","","","","fee schedule","51.75","178.52",""
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.15","","","","","","","fee schedule","51.75","178.52","APC"
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.26","","","","","","","fee schedule","51.75","178.52","APC"
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.75","","","","","","","fee schedule","51.75","178.52","APC"
"Inj IVIG privigen 500 mg","J1459","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.27","","","","","","","fee schedule","51.75","178.52","APC"
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","153.98","","","","","","","fee schedule","50.01","171.41",""
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","164.63","","","","","","","fee schedule","50.01","171.41",""
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","171.41","","","","","","","fee schedule","50.01","171.41",""
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.36","","","","","","","fee schedule","50.01","171.41","APC"
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.5","","","","","","","fee schedule","50.01","171.41","APC"
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.01","","","","","","","fee schedule","50.01","171.41","APC"
"Gamma globulin 1 CC inj","J1460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.48","","","","","","","fee schedule","50.01","171.41","APC"
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","416.96","","","","","","","fee schedule","132.84","464.16",""
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","445.81","","","","","","","fee schedule","132.84","464.16",""
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.16","","","","","","","fee schedule","132.84","464.16",""
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","136.42","","","","","","","fee schedule","132.84","464.16","APC"
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","134.14","","","","","","","fee schedule","132.84","464.16","APC"
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","132.84","","","","","","","fee schedule","132.84","464.16","APC"
"Inj, alyglo, 500 mg","J1552","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","136.75","","","","","","","fee schedule","132.84","464.16","APC"
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1578.9","","","","","","","fee schedule","506.67","1757.65",""
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1688.13","","","","","","","fee schedule","506.67","1757.65",""
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1757.65","","","","","","","fee schedule","506.67","1757.65",""
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","520.33","","","","","","","fee schedule","506.67","1757.65","APC"
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","511.64","","","","","","","fee schedule","506.67","1757.65","APC"
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","506.67","","","","","","","fee schedule","506.67","1757.65","APC"
"Inj. asceniv","J1554","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","521.58","","","","","","","fee schedule","506.67","1757.65","APC"
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.94","","","","","","","fee schedule","17.18","62.27",""
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59.81","","","","","","","fee schedule","17.18","62.27",""
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","62.27","","","","","","","fee schedule","17.18","62.27",""
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.64","","","","","","","fee schedule","17.18","62.27","APC"
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.35","","","","","","","fee schedule","17.18","62.27","APC"
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.18","","","","","","","fee schedule","17.18","62.27","APC"
"Inj cuvitru, 100 mg","J1555","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.68","","","","","","","fee schedule","17.18","62.27","APC"
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","198.65","","","","","","","fee schedule","64.96","221.14",""
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","212.4","","","","","","","fee schedule","64.96","221.14",""
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","221.14","","","","","","","fee schedule","64.96","221.14",""
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66.71","","","","","","","fee schedule","64.96","221.14","APC"
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65.59","","","","","","","fee schedule","64.96","221.14","APC"
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","64.96","","","","","","","fee schedule","64.96","221.14","APC"
"Gammaplex injection","J1557","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","66.87","","","","","","","fee schedule","64.96","221.14","APC"
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.41","","","","","","","fee schedule","15.14","52.78",""
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.69","","","","","","","fee schedule","15.14","52.78",""
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","52.78","","","","","","","fee schedule","15.14","52.78",""
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.55","","","","","","","fee schedule","15.14","52.78","APC"
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.29","","","","","","","fee schedule","15.14","52.78","APC"
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.14","","","","","","","fee schedule","15.14","52.78","APC"
"Inj. xembify, 100 mg","J1558","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.59","","","","","","","fee schedule","15.14","52.78","APC"
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44.9","","","","","","","fee schedule","14.62","49.98",""
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","48.01","","","","","","","fee schedule","14.62","49.98",""
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","49.98","","","","","","","fee schedule","14.62","49.98",""
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.02","","","","","","","fee schedule","14.62","49.98","APC"
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.77","","","","","","","fee schedule","14.62","49.98","APC"
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.62","","","","","","","fee schedule","14.62","49.98","APC"
"Hizentra injection","J1559","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.05","","","","","","","fee schedule","14.62","49.98","APC"
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","531.25","","","","","","","fee schedule","173.89","591.39",""
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","568","","","","","","","fee schedule","173.89","591.39",""
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","591.39","","","","","","","fee schedule","173.89","591.39",""
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","178.57","","","","","","","fee schedule","173.89","591.39","APC"
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","175.59","","","","","","","fee schedule","173.89","591.39","APC"
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","173.89","","","","","","","fee schedule","173.89","591.39","APC"
"Gamma globulin > 10 CC inj","J1560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179","","","","","","","fee schedule","173.89","591.39","APC"
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","152.74","","","","","","","fee schedule","49.94","170.03",""
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","163.3","","","","","","","fee schedule","49.94","170.03",""
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","170.03","","","","","","","fee schedule","49.94","170.03",""
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.29","","","","","","","fee schedule","49.94","170.03","APC"
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.43","","","","","","","fee schedule","49.94","170.03","APC"
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.94","","","","","","","fee schedule","49.94","170.03","APC"
"Gamunex-c/gammaked","J1561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.41","","","","","","","fee schedule","49.94","170.03","APC"
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","259.81","","","","","","","fee schedule","80.37","289.22",""
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","277.78","","","","","","","fee schedule","80.37","289.22",""
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","289.22","","","","","","","fee schedule","80.37","289.22",""
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.54","","","","","","","fee schedule","80.37","289.22","APC"
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.16","","","","","","","fee schedule","80.37","289.22","APC"
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.37","","","","","","","fee schedule","80.37","289.22","APC"
"Immune globulin, powder","J1566","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.73","","","","","","","fee schedule","80.37","289.22","APC"
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","153.85","","","","","","","fee schedule","48.48","171.27",""
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","164.49","","","","","","","fee schedule","48.48","171.27",""
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","171.27","","","","","","","fee schedule","48.48","171.27",""
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.78","","","","","","","fee schedule","48.48","171.27","APC"
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.95","","","","","","","fee schedule","48.48","171.27","APC"
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.48","","","","","","","fee schedule","48.48","171.27","APC"
"Octagam injection","J1568","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.9","","","","","","","fee schedule","48.48","171.27","APC"
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","152","","","","","","","fee schedule","46.22","169.21",""
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","162.52","","","","","","","fee schedule","46.22","169.21",""
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","169.21","","","","","","","fee schedule","46.22","169.21",""
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.47","","","","","","","fee schedule","46.22","169.21","APC"
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46.67","","","","","","","fee schedule","46.22","169.21","APC"
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.22","","","","","","","fee schedule","46.22","169.21","APC"
"Gammagard liquid injection","J1569","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47.58","","","","","","","fee schedule","46.22","169.21","APC"
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","227.88","","","","","","","fee schedule","67.97","253.68",""
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","243.64","","","","","","","fee schedule","67.97","253.68",""
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","253.68","","","","","","","fee schedule","67.97","253.68",""
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","69.81","","","","","","","fee schedule","67.97","253.68","APC"
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","68.64","","","","","","","fee schedule","67.97","253.68","APC"
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","67.97","","","","","","","fee schedule","67.97","253.68","APC"
"HepaGam B IM injection","J1571","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","69.97","","","","","","","fee schedule","67.97","253.68","APC"
"Flebogamma injection","J1572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","177.32","","","","","","","fee schedule","177.32","197.39",""
"Flebogamma injection","J1572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","189.58","","","","","","","fee schedule","177.32","197.39",""
"Flebogamma injection","J1572","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","197.39","","","","","","","fee schedule","177.32","197.39",""
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","227.88","","","","","","","fee schedule","67.97","253.68",""
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","243.64","","","","","","","fee schedule","67.97","253.68",""
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","253.68","","","","","","","fee schedule","67.97","253.68",""
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","69.81","","","","","","","fee schedule","67.97","253.68","APC"
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","68.64","","","","","","","fee schedule","67.97","253.68","APC"
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","67.97","","","","","","","fee schedule","67.97","253.68","APC"
"Hepagam B intravenous, inj","J1573","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","69.97","","","","","","","fee schedule","67.97","253.68","APC"
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.48","","","","","","","fee schedule","18.51","65.1",""
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.53","","","","","","","fee schedule","18.51","65.1",""
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","65.1","","","","","","","fee schedule","18.51","65.1",""
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.51","65.1","APC"
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.7","","","","","","","fee schedule","18.51","65.1","APC"
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.51","","","","","","","fee schedule","18.51","65.1","APC"
"Hyqvia 100mg immuneglobulin","J1575","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.06","","","","","","","fee schedule","18.51","65.1","APC"
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","236.78","","","","","","","fee schedule","74.46","263.59",""
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","253.16","","","","","","","fee schedule","74.46","263.59",""
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","263.59","","","","","","","fee schedule","74.46","263.59",""
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.46","","","","","","","fee schedule","74.46","263.59","APC"
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.19","","","","","","","fee schedule","74.46","263.59","APC"
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.46","","","","","","","fee schedule","74.46","263.59","APC"
"Inj, panzyga, 500 mg","J1576","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.65","","","","","","","fee schedule","74.46","263.59","APC"
"Injection glatiramer acetate","J1595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","510.04","","","","","","","fee schedule","510.04","567.78",""
"Injection glatiramer acetate","J1595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","545.33","","","","","","","fee schedule","510.04","567.78",""
"Injection glatiramer acetate","J1595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","567.78","","","","","","","fee schedule","510.04","567.78",""
"Inj, glycopyrrolate, 0.1 mg","J1596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.37","","","","","","","fee schedule","1.37","1.52",""
"Inj, glycopyrrolate, 0.1 mg","J1596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.46","","","","","","","fee schedule","1.37","1.52",""
"Inj, glycopyrrolate, 0.1 mg","J1596","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.52","","","","","","","fee schedule","1.37","1.52",""
"Inj glycopyrrolate fres kabi","J1598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.88","","","","","","","fee schedule","5.88","6.55",""
"Inj glycopyrrolate fres kabi","J1598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.29","","","","","","","fee schedule","5.88","6.55",""
"Inj glycopyrrolate fres kabi","J1598","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.55","","","","","","","fee schedule","5.88","6.55",""
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.08","","","","","","","fee schedule","11.26","39.05",""
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.5","","","","","","","fee schedule","11.26","39.05",""
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","39.05","","","","","","","fee schedule","11.26","39.05",""
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.56","","","","","","","fee schedule","11.26","39.05","APC"
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.37","","","","","","","fee schedule","11.26","39.05","APC"
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.26","","","","","","","fee schedule","11.26","39.05","APC"
"Golimumab for iv use 1mg","J1602","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.59","","","","","","","fee schedule","11.26","39.05","APC"
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","622.61","","","","","","","fee schedule","186.1","693.1",""
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","665.69","","","","","","","fee schedule","186.1","693.1",""
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","693.1","","","","","","","fee schedule","186.1","693.1",""
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","191.11","","","","","","","fee schedule","186.1","693.1","APC"
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","187.92","","","","","","","fee schedule","186.1","693.1","APC"
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","186.1","","","","","","","fee schedule","186.1","693.1","APC"
"Glucagon hydrochloride/1 mg","J1610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","191.57","","","","","","","fee schedule","186.1","693.1","APC"
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","460.72","","","","","","","fee schedule","151.97","512.88",""
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","492.59","","","","","","","fee schedule","151.97","512.88",""
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","512.88","","","","","","","fee schedule","151.97","512.88",""
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","156.07","","","","","","","fee schedule","151.97","512.88","APC"
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","153.46","","","","","","","fee schedule","151.97","512.88","APC"
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","151.97","","","","","","","fee schedule","151.97","512.88","APC"
"Inj glucagon hcl, fresenius","J1611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","156.44","","","","","","","fee schedule","151.97","512.88","APC"
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.77","","","","","","","fee schedule","4.37","17.56",""
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.86","","","","","","","fee schedule","4.37","17.56",""
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.56","","","","","","","fee schedule","4.37","17.56",""
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.49","","","","","","","fee schedule","4.37","17.56","APC"
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.42","","","","","","","fee schedule","4.37","17.56","APC"
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.37","","","","","","","fee schedule","4.37","17.56","APC"
"Inj, granisetron, xr, 0.1 mg","J1627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.5","","","","","","","fee schedule","4.37","17.56","APC"
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","238.05","","","","","","","fee schedule","77.49","265",""
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","254.52","","","","","","","fee schedule","77.49","265",""
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","265","","","","","","","fee schedule","77.49","265",""
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.58","","","","","","","fee schedule","77.49","265","APC"
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.25","","","","","","","fee schedule","77.49","265","APC"
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.49","","","","","","","fee schedule","77.49","265","APC"
"Inj., guselkumab, 1 mg","J1628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.77","","","","","","","fee schedule","77.49","265","APC"
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","108.66","","","","","","","fee schedule","34.86","120.96",""
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","116.18","","","","","","","fee schedule","34.86","120.96",""
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","120.96","","","","","","","fee schedule","34.86","120.96",""
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.8","","","","","","","fee schedule","34.86","120.96","APC"
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.21","","","","","","","fee schedule","34.86","120.96","APC"
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.86","","","","","","","fee schedule","34.86","120.96","APC"
"Hemin, 1 mg","J1640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.89","","","","","","","fee schedule","34.86","120.96","APC"
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1835.02","","","","","","","fee schedule","604.86","2042.76",""
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1961.97","","","","","","","fee schedule","604.86","2042.76",""
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2042.76","","","","","","","fee schedule","604.86","2042.76",""
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","621.17","","","","","","","fee schedule","604.86","2042.76","APC"
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","610.79","","","","","","","fee schedule","604.86","2042.76","APC"
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","604.86","","","","","","","fee schedule","604.86","2042.76","APC"
"Tetanus immune globulin inj","J1670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","622.65","","","","","","","fee schedule","604.86","2042.76","APC"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","696.61","","","","","","","fee schedule","175.75","775.47",""
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","744.8","","","","","","","fee schedule","175.75","775.47",""
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","775.47","","","","","","","fee schedule","175.75","775.47",""
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","547.31","","","","","","","fee schedule","175.75","775.47","APC 277.30"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","585.32","","","","","","","fee schedule","175.75","775.47","APC 296.56"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","609.7","","","","","","","fee schedule","175.75","775.47","APC 308.91"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","180.49","","","","","","","fee schedule","175.75","775.47","APC"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","177.48","","","","","","","fee schedule","175.75","775.47","APC"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","175.75","","","","","","","fee schedule","175.75","775.47","APC"
"Ibutilide fumarate injection","J1742","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","180.92","","","","","","","fee schedule","175.75","775.47","APC"
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1776.22","","","","","","","fee schedule","569.63","1977.3",""
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1899.1","","","","","","","fee schedule","569.63","1977.3",""
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1977.3","","","","","","","fee schedule","569.63","1977.3",""
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","584.98","","","","","","","fee schedule","569.63","1977.3","APC"
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","575.21","","","","","","","fee schedule","569.63","1977.3","APC"
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","569.63","","","","","","","fee schedule","569.63","1977.3","APC"
"Idursulfase injection","J1743","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","586.38","","","","","","","fee schedule","569.63","1977.3","APC"
"Icatibant injection","J1744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","370.18","","","","","","","fee schedule","370.18","412.09",""
"Icatibant injection","J1744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","395.79","","","","","","","fee schedule","370.18","412.09",""
"Icatibant injection","J1744","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","412.09","","","","","","","fee schedule","370.18","412.09",""
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","99.15","","","","","","","fee schedule","31.71","110.38",""
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","106.01","","","","","","","fee schedule","31.71","110.38",""
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","110.38","","","","","","","fee schedule","31.71","110.38",""
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.57","","","","","","","fee schedule","31.71","110.38","APC"
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.02","","","","","","","fee schedule","31.71","110.38","APC"
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.71","","","","","","","fee schedule","31.71","110.38","APC"
"Infliximab not biosimil 10mg","J1745","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.64","","","","","","","fee schedule","31.71","110.38","APC"
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","252.46","","","","","","","fee schedule","80.84","281.04",""
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","269.93","","","","","","","fee schedule","80.84","281.04",""
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","281.04","","","","","","","fee schedule","80.84","281.04",""
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","83.02","","","","","","","fee schedule","80.84","281.04","APC"
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.64","","","","","","","fee schedule","80.84","281.04","APC"
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.84","","","","","","","fee schedule","80.84","281.04","APC"
"Inj., ibalizumab-uiyk, 10 mg","J1746","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.22","","","","","","","fee schedule","80.84","281.04","APC"
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","209.02","","","","","","","fee schedule","67.04","232.68",""
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","223.48","","","","","","","fee schedule","67.04","232.68",""
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","232.68","","","","","","","fee schedule","67.04","232.68",""
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.85","","","","","","","fee schedule","67.04","232.68","APC"
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.7","","","","","","","fee schedule","67.04","232.68","APC"
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","67.04","","","","","","","fee schedule","67.04","232.68","APC"
"Inj, spesolimab-sbzo, 1 mg","J1747","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","69.01","","","","","","","fee schedule","67.04","232.68","APC"
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","57.34","","","","","","","fee schedule","18.47","63.83",""
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.3","","","","","","","fee schedule","18.47","63.83",""
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63.83","","","","","","","fee schedule","18.47","63.83",""
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.97","","","","","","","fee schedule","18.47","63.83","APC"
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.65","","","","","","","fee schedule","18.47","63.83","APC"
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.47","","","","","","","fee schedule","18.47","63.83","APC"
"Inj iron dextran","J1750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.01","","","","","","","fee schedule","18.47","63.83","APC"
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137.66","","","","","","","fee schedule","44.05","153.25",""
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","147.19","","","","","","","fee schedule","44.05","153.25",""
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","153.25","","","","","","","fee schedule","44.05","153.25",""
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45.24","","","","","","","fee schedule","44.05","153.25","APC"
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.49","","","","","","","fee schedule","44.05","153.25","APC"
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44.05","","","","","","","fee schedule","44.05","153.25","APC"
"Imuglucerase injection","J1786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45.35","","","","","","","fee schedule","44.05","153.25","APC"
"Fiasp for insulin pump use","J1811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.68","","","","","","","fee schedule","24.68","27.47",""
"Fiasp for insulin pump use","J1811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.38","","","","","","","fee schedule","24.68","27.47",""
"Fiasp for insulin pump use","J1811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.47","","","","","","","fee schedule","24.68","27.47",""
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1572.29","","","","","","","fee schedule","505.46","1750.28",""
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1681.06","","","","","","","fee schedule","505.46","1750.28",""
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1750.28","","","","","","","fee schedule","505.46","1750.28",""
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","519.08","","","","","","","fee schedule","505.46","1750.28","APC"
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","510.41","","","","","","","fee schedule","505.46","1750.28","APC"
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","505.46","","","","","","","fee schedule","505.46","1750.28","APC"
"Inj. inebilizumab-cdon, 1 mg","J1823","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","520.32","","","","","","","fee schedule","505.46","1750.28","APC"
"Interferon Beta-1A inj","J1826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7005.99","","","","","","","fee schedule","7005.99","7799.12",""
"Interferon Beta-1A inj","J1826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7490.68","","","","","","","fee schedule","7005.99","7799.12",""
"Interferon Beta-1A inj","J1826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7799.12","","","","","","","fee schedule","7005.99","7799.12",""
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.21","","","","","","","fee schedule","1.03","3.58",""
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.43","","","","","","","fee schedule","1.03","3.58",""
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.58","","","","","","","fee schedule","1.03","3.58",""
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.19","","","","","","","fee schedule","1.03","3.58","APC 277.30"
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.41","","","","","","","fee schedule","1.03","3.58","APC 296.56"
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.56","","","","","","","fee schedule","1.03","3.58","APC 308.91"
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.05","","","","","","","fee schedule","1.03","3.58","APC"
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.04","","","","","","","fee schedule","1.03","3.58","APC"
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.03","","","","","","","fee schedule","1.03","3.58","APC"
"Injection, isavuconazonium","J1833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.06","","","","","","","fee schedule","1.03","3.58","APC"
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.11","","","","","","","fee schedule","0.31","1.24",""
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.19","","","","","","","fee schedule","0.31","1.24",""
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.24","","","","","","","fee schedule","0.31","1.24",""
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.32","","","","","","","fee schedule","0.31","1.24","APC"
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.31","","","","","","","fee schedule","0.31","1.24","APC"
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.31","","","","","","","fee schedule","0.31","1.24","APC"
"Ketorolac tromethamine inj","J1885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.32","","","","","","","fee schedule","0.31","1.24","APC"
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.58","","","","","","","fee schedule","34.73","129.78",""
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.64","","","","","","","fee schedule","34.73","129.78",""
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.78","","","","","","","fee schedule","34.73","129.78",""
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.66","","","","","","","fee schedule","34.73","129.78","APC"
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","35.07","","","","","","","fee schedule","34.73","129.78","APC"
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.73","","","","","","","fee schedule","34.73","129.78","APC"
"Lanreotide injection","J1930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.75","","","","","","","fee schedule","34.73","129.78","APC"
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","126.82","","","","","","","fee schedule","40.67","141.18",""
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","135.59","","","","","","","fee schedule","40.67","141.18",""
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","141.18","","","","","","","fee schedule","40.67","141.18",""
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.76","","","","","","","fee schedule","40.67","141.18","APC"
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.07","","","","","","","fee schedule","40.67","141.18","APC"
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.67","","","","","","","fee schedule","40.67","141.18","APC"
"Laronidase injection","J1931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.86","","","","","","","fee schedule","40.67","141.18","APC"
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","77.75","","","","","","","fee schedule","30.44","86.55",""
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","83.13","","","","","","","fee schedule","30.44","86.55",""
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","86.55","","","","","","","fee schedule","30.44","86.55",""
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.26","","","","","","","fee schedule","30.44","86.55","APC"
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.74","","","","","","","fee schedule","30.44","86.55","APC"
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.44","","","","","","","fee schedule","30.44","86.55","APC"
"Inj, lanreotide, (cipla) 1mg","J1932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.34","","","","","","","fee schedule","30.44","86.55","APC"
"Inj, bumetanide, 0.5 mg","J1939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.94","","","","","","","fee schedule","1.94","2.16",""
"Inj, bumetanide, 0.5 mg","J1939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.07","","","","","","","fee schedule","1.94","2.16",""
"Inj, bumetanide, 0.5 mg","J1939","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.16","","","","","","","fee schedule","1.94","2.16",""
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.37","","","","","","","fee schedule","3.31","11.54",""
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.08","","","","","","","fee schedule","3.31","11.54",""
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.54","","","","","","","fee schedule","3.31","11.54",""
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.4","","","","","","","fee schedule","3.31","11.54","APC"
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.34","","","","","","","fee schedule","3.31","11.54","APC"
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.31","","","","","","","fee schedule","3.31","11.54","APC"
"Inj., aristada initio, 1 mg","J1943","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.41","","","","","","","fee schedule","3.31","11.54","APC"
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.59","","","","","","","fee schedule","3.41","11.79",""
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.32","","","","","","","fee schedule","3.41","11.79",""
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.79","","","","","","","fee schedule","3.41","11.79",""
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.5","","","","","","","fee schedule","3.41","11.79","APC"
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.45","","","","","","","fee schedule","3.41","11.79","APC"
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.41","","","","","","","fee schedule","3.41","11.79","APC"
"Aripirazole lauroxil 1 mg","J1944","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.51","","","","","","","fee schedule","3.41","11.79","APC"
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5523.98","","","","","","","fee schedule","1764.93","6149.33",""
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5906.14","","","","","","","fee schedule","1764.93","6149.33",""
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6149.33","","","","","","","fee schedule","1764.93","6149.33",""
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1812.51","","","","","","","fee schedule","1764.93","6149.33","APC"
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1782.23","","","","","","","fee schedule","1764.93","6149.33","APC"
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1764.93","","","","","","","fee schedule","1764.93","6149.33","APC"
"Leuprolide acetate /3.75 mg","J1950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1816.84","","","","","","","fee schedule","1764.93","6149.33","APC"
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","446.57","","","","","","","fee schedule","143.81","497.12",""
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","477.46","","","","","","","fee schedule","143.81","497.12",""
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","497.12","","","","","","","fee schedule","143.81","497.12",""
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","147.69","","","","","","","fee schedule","143.81","497.12","APC"
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","145.22","","","","","","","fee schedule","143.81","497.12","APC"
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","143.81","","","","","","","fee schedule","143.81","497.12","APC"
"Inj fensolvi 0.25 mg","J1951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","148.04","","","","","","","fee schedule","143.81","497.12","APC"
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","163.48","","","","","","","fee schedule","80.49","181.99",""
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","174.79","","","","","","","fee schedule","80.49","181.99",""
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","181.99","","","","","","","fee schedule","80.49","181.99",""
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.66","","","","","","","fee schedule","80.49","181.99","APC"
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.28","","","","","","","fee schedule","80.49","181.99","APC"
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.49","","","","","","","fee schedule","80.49","181.99","APC"
"Leuprolide inj, camcevi, 1mg","J1952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.86","","","","","","","fee schedule","80.49","181.99","APC"
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","701.95","","","","","","","fee schedule","701.95","781.42",""
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","750.52","","","","","","","fee schedule","701.95","781.42",""
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","781.42","","","","","","","fee schedule","701.95","781.42",""
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","740.23","","","","","","","fee schedule","701.95","781.42","APC"
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.87","","","","","","","fee schedule","701.95","781.42","APC"
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.8","","","","","","","fee schedule","701.95","781.42","APC"
"Leuprolide depot cipla 7.5mg","J1954","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","742","","","","","","","fee schedule","701.95","781.42","APC"
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.02","","","","","","","fee schedule","22.6","77.95",""
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","74.87","","","","","","","fee schedule","22.6","77.95",""
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","77.95","","","","","","","fee schedule","22.6","77.95",""
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.21","","","","","","","fee schedule","22.6","77.95","APC"
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22.82","","","","","","","fee schedule","22.6","77.95","APC"
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.6","","","","","","","fee schedule","22.6","77.95","APC"
"Inj, lenacapavir, 1 mg","J1961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.26","","","","","","","fee schedule","22.6","77.95","APC"
"Inj, lidocaine in d5w, 1 mg","J2002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","0.04",""
"Inj, lidocaine in d5w, 1 mg","J2002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","0.04",""
"Inj, lidocaine in d5w, 1 mg","J2002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","0.04",""
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","99.63","","","","","","","fee schedule","31.9","110.91",""
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","106.52","","","","","","","fee schedule","31.9","110.91",""
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","110.91","","","","","","","fee schedule","31.9","110.91",""
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.76","","","","","","","fee schedule","31.9","110.91","APC"
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.21","","","","","","","fee schedule","31.9","110.91","APC"
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.9","","","","","","","fee schedule","31.9","110.91","APC"
"Injection, mepolizumab, 1mg","J2182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.83","","","","","","","fee schedule","31.9","110.91","APC"
"Inj meropenem (wg crit care)","J2183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.15","","","","","","","fee schedule","5.15","5.73",""
"Inj meropenem (wg crit care)","J2183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.51","","","","","","","fee schedule","5.15","5.73",""
"Inj meropenem (wg crit care)","J2183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.73","","","","","","","fee schedule","5.15","5.73",""
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.93","","","","","","","fee schedule","2.23","7.72",""
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.41","","","","","","","fee schedule","2.23","7.72",""
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.72","","","","","","","fee schedule","2.23","7.72",""
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.93","","","","","","","fee schedule","2.23","7.72","APC 277.30"
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.42","","","","","","","fee schedule","2.23","7.72","APC 296.56"
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.72","","","","","","","fee schedule","2.23","7.72","APC 308.91"
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.29","","","","","","","fee schedule","2.23","7.72","APC"
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.25","","","","","","","fee schedule","2.23","7.72","APC"
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.23","","","","","","","fee schedule","2.23","7.72","APC"
"Inj., meropenem, vaborbactam","J2186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.29","","","","","","","fee schedule","2.23","7.72","APC"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.49","","","","","","","fee schedule","2.72","9.45",""
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.08","","","","","","","fee schedule","2.72","9.45",""
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.45","","","","","","","fee schedule","2.72","9.45",""
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.48","","","","","","","fee schedule","2.72","9.45","APC 277.30"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.07","","","","","","","fee schedule","2.72","9.45","APC 296.56"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.45","","","","","","","fee schedule","2.72","9.45","APC 308.91"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.8","","","","","","","fee schedule","2.72","9.45","APC"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.75","","","","","","","fee schedule","2.72","9.45","APC"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.72","","","","","","","fee schedule","2.72","9.45","APC"
"Minocycline hydrochloride","J2265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.8","","","","","","","fee schedule","2.72","9.45","APC"
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","153.5","","","","","","","fee schedule","43.91","170.88",""
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","164.12","","","","","","","fee schedule","43.91","170.88",""
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","170.88","","","","","","","fee schedule","43.91","170.88",""
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","45.09","","","","","","","fee schedule","43.91","170.88","APC"
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.34","","","","","","","fee schedule","43.91","170.88","APC"
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.91","","","","","","","fee schedule","43.91","170.88","APC"
"Inj, mirikizumab-mrkz, 1 mg","J2267","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45.2","","","","","","","fee schedule","43.91","170.88","APC"
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","80.2","","","","","","","fee schedule","25.72","89.28",""
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.75","","","","","","","fee schedule","25.72","89.28",""
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","89.28","","","","","","","fee schedule","25.72","89.28",""
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.42","","","","","","","fee schedule","25.72","89.28","APC"
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.97","","","","","","","fee schedule","25.72","89.28","APC"
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.72","","","","","","","fee schedule","25.72","89.28","APC"
"Inj, motixafortide, 0.25 mg","J2277","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.48","","","","","","","fee schedule","25.72","89.28","APC"
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.21","","","","","","","fee schedule","10.34","35.86",""
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.44","","","","","","","fee schedule","10.34","35.86",""
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.86","","","","","","","fee schedule","10.34","35.86",""
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.62","","","","","","","fee schedule","10.34","35.86","APC"
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.44","","","","","","","fee schedule","10.34","35.86","APC"
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.34","","","","","","","fee schedule","10.34","35.86","APC"
"Ziconotide injection","J2278","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.65","","","","","","","fee schedule","10.34","35.86","APC"
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.48","","","","","","","fee schedule","4.32","15.01",""
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.42","","","","","","","fee schedule","4.32","15.01",""
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.01","","","","","","","fee schedule","4.32","15.01",""
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.32","15.01","APC"
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.37","","","","","","","fee schedule","4.32","15.01","APC"
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.32","","","","","","","fee schedule","4.32","15.01","APC"
"Naltrexone, depot form","J2315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.45","","","","","","","fee schedule","4.32","15.01","APC"
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","76.73","","","","","","","fee schedule","24.48","85.42",""
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","82.04","","","","","","","fee schedule","24.48","85.42",""
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","85.42","","","","","","","fee schedule","24.48","85.42",""
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.14","","","","","","","fee schedule","24.48","85.42","APC"
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.72","","","","","","","fee schedule","24.48","85.42","APC"
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.48","","","","","","","fee schedule","24.48","85.42","APC"
"Natalizumab injection","J2323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.2","","","","","","","fee schedule","24.48","85.42","APC"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3965.27","","","","","","","fee schedule","1305.86","4530.08",""
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4239.6","","","","","","","fee schedule","1305.86","4530.08",""
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4414.17","","","","","","","fee schedule","1305.86","4530.08",""
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4066.53","","","","","","","fee schedule","1305.86","4530.08","APC 277.30"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4348.97","","","","","","","fee schedule","1305.86","4530.08","APC 296.56"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4530.08","","","","","","","fee schedule","1305.86","4530.08","APC 308.91"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1341.06","","","","","","","fee schedule","1305.86","4530.08","APC"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1318.66","","","","","","","fee schedule","1305.86","4530.08","APC"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1305.86","","","","","","","fee schedule","1305.86","4530.08","APC"
"Inj, nusinersen, 0.1mg","J2326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1344.26","","","","","","","fee schedule","1305.86","4530.08","APC"
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.19","","","","","","","fee schedule","15.24","52.53",""
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.46","","","","","","","fee schedule","15.24","52.53",""
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","52.53","","","","","","","fee schedule","15.24","52.53",""
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.65","","","","","","","fee schedule","15.24","52.53","APC"
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.39","","","","","","","fee schedule","15.24","52.53","APC"
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.24","","","","","","","fee schedule","15.24","52.53","APC"
"Inj risankizumab-rzaa 1 mg","J2327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.69","","","","","","","fee schedule","15.24","52.53","APC"
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","228.64","","","","","","","fee schedule","72.17","254.53",""
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","244.46","","","","","","","fee schedule","72.17","254.53",""
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","254.53","","","","","","","fee schedule","72.17","254.53",""
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","74.11","","","","","","","fee schedule","72.17","254.53","APC"
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.88","","","","","","","fee schedule","72.17","254.53","APC"
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","72.17","","","","","","","fee schedule","72.17","254.53","APC"
"Inj ublituximab-xiiy, 1 mg","J2329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","74.29","","","","","","","fee schedule","72.17","254.53","APC"
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","189.85","","","","","","","fee schedule","60.6","211.34",""
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","202.98","","","","","","","fee schedule","60.6","211.34",""
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","211.34","","","","","","","fee schedule","60.6","211.34",""
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.24","","","","","","","fee schedule","60.6","211.34","APC"
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.2","","","","","","","fee schedule","60.6","211.34","APC"
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","60.6","","","","","","","fee schedule","60.6","211.34","APC"
"Injection, ocrelizumab, 1 mg","J2350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62.38","","","","","","","fee schedule","60.6","211.34","APC"
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150.22","","","","","","","fee schedule","48.18","167.23",""
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","160.62","","","","","","","fee schedule","48.18","167.23",""
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","167.23","","","","","","","fee schedule","48.18","167.23",""
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.48","","","","","","","fee schedule","48.18","167.23","APC"
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.65","","","","","","","fee schedule","48.18","167.23","APC"
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.18","","","","","","","fee schedule","48.18","167.23","APC"
"Inj ocrelizumab 1mg hya-ocsq","J2351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.59","","","","","","","fee schedule","48.18","167.23","APC"
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","674.8","","","","","","","fee schedule","207.65","751.19",""
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","721.48","","","","","","","fee schedule","207.65","751.19",""
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","751.19","","","","","","","fee schedule","207.65","751.19",""
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","213.25","","","","","","","fee schedule","207.65","751.19","APC"
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","209.69","","","","","","","fee schedule","207.65","751.19","APC"
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","207.65","","","","","","","fee schedule","207.65","751.19","APC"
"Octreotide injection, depot","J2353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","213.76","","","","","","","fee schedule","207.65","751.19","APC"
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.19","","","","","","","fee schedule","18.37","64.78",""
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.22","","","","","","","fee schedule","18.37","64.78",""
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.78","","","","","","","fee schedule","18.37","64.78",""
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.86","","","","","","","fee schedule","18.37","64.78","APC"
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.55","","","","","","","fee schedule","18.37","64.78","APC"
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.37","","","","","","","fee schedule","18.37","64.78","APC"
"Inj tezepelumab-ekko, 1mg","J2356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.37","64.78","APC"
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","128.98","","","","","","","fee schedule","45.49","143.58",""
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137.9","","","","","","","fee schedule","45.49","143.58",""
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","143.58","","","","","","","fee schedule","45.49","143.58",""
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.71","","","","","","","fee schedule","45.49","143.58","APC"
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","45.93","","","","","","","fee schedule","45.49","143.58","APC"
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45.49","","","","","","","fee schedule","45.49","143.58","APC"
"Omalizumab injection","J2357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.83","","","","","","","fee schedule","45.49","143.58","APC"
"Olanzapine long-acting inj","J2358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.29","","","","","","","fee schedule","9.29","10.34",""
"Olanzapine long-acting inj","J2358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.93","","","","","","","fee schedule","9.29","10.34",""
"Olanzapine long-acting inj","J2358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.34","","","","","","","fee schedule","9.29","10.34",""
"Inj, immphentiv, 20 mcg","J2373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.41","","","","","","","fee schedule","0.41","0.46",""
"Inj, immphentiv, 20 mcg","J2373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.44","","","","","","","fee schedule","0.41","0.46",""
"Inj, immphentiv, 20 mcg","J2373","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.46","","","","","","","fee schedule","0.41","0.46",""
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.91","","","","","","","fee schedule","0.59","2.12",""
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.04","","","","","","","fee schedule","0.59","2.12",""
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.12","","","","","","","fee schedule","0.59","2.12",""
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.61","","","","","","","fee schedule","0.59","2.12","APC"
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.6","","","","","","","fee schedule","0.59","2.12","APC"
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.59","","","","","","","fee schedule","0.59","2.12","APC"
"Chloroprocaine opht gel, 1mg","J2403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.61","","","","","","","fee schedule","0.59","2.12","APC"
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","131.65","","","","","","","fee schedule","43.33","146.56",""
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","140.76","","","","","","","fee schedule","43.33","146.56",""
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","146.56","","","","","","","fee schedule","43.33","146.56",""
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.5","","","","","","","fee schedule","43.33","146.56","APC"
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.75","","","","","","","fee schedule","43.33","146.56","APC"
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.33","","","","","","","fee schedule","43.33","146.56","APC"
"Injection, oritavancin 10 mg","J2406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.6","","","","","","","fee schedule","43.33","146.56","APC"
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","90.69","","","","","","","fee schedule","29.25","100.96",""
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","96.97","","","","","","","fee schedule","29.25","100.96",""
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","100.96","","","","","","","fee schedule","29.25","100.96",""
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.04","","","","","","","fee schedule","29.25","100.96","APC"
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.54","","","","","","","fee schedule","29.25","100.96","APC"
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.25","","","","","","","fee schedule","29.25","100.96","APC"
"Injection, oritavancin","J2407","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.11","","","","","","","fee schedule","29.25","100.96","APC"
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","114.19","","","","","","","fee schedule","36.26","127.12",""
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","122.09","","","","","","","fee schedule","36.26","127.12",""
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","127.12","","","","","","","fee schedule","36.26","127.12",""
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37.24","","","","","","","fee schedule","36.26","127.12","APC"
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.62","","","","","","","fee schedule","36.26","127.12","APC"
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36.26","","","","","","","fee schedule","36.26","127.12","APC"
"Palifermin injection","J2425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.33","","","","","","","fee schedule","36.26","127.12","APC"
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","47.95","","","","","","","fee schedule","15.41","53.38",""
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.27","","","","","","","fee schedule","15.41","53.38",""
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","53.38","","","","","","","fee schedule","15.41","53.38",""
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.83","","","","","","","fee schedule","15.41","53.38","APC"
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.56","","","","","","","fee schedule","15.41","53.38","APC"
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.41","","","","","","","fee schedule","15.41","53.38","APC"
"Paliperidone palmitate inj","J2426","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.87","","","","","","","fee schedule","15.41","53.38","APC"
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.21","","","","","","","fee schedule","13.26","45.88",""
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.06","","","","","","","fee schedule","13.26","45.88",""
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","45.88","","","","","","","fee schedule","13.26","45.88",""
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.61","","","","","","","fee schedule","13.26","45.88","APC"
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.39","","","","","","","fee schedule","13.26","45.88","APC"
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.26","","","","","","","fee schedule","13.26","45.88","APC"
"Inj, invega hafyera/trinza","J2427","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.26","45.88","APC"
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","54.54","","","","","","","fee schedule","17.1","60.71",""
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","58.31","","","","","","","fee schedule","17.1","60.71",""
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","60.71","","","","","","","fee schedule","17.1","60.71",""
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.56","","","","","","","fee schedule","17.1","60.71","APC"
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.27","","","","","","","fee schedule","17.1","60.71","APC"
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.1","","","","","","","fee schedule","17.1","60.71","APC"
"Inj, erzofri, 1 mg","J2428","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.6","","","","","","","fee schedule","17.1","60.71","APC"
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","187.11","","","","","","","fee schedule","59.4","208.29",""
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","200.06","","","","","","","fee schedule","59.4","208.29",""
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","208.29","","","","","","","fee schedule","59.4","208.29",""
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","61","","","","","","","fee schedule","59.4","208.29","APC"
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.98","","","","","","","fee schedule","59.4","208.29","APC"
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.4","","","","","","","fee schedule","59.4","208.29","APC"
"Inj, palonosetron (avyxa)","J2468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","61.15","","","","","","","fee schedule","59.4","208.29","APC"
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1792.85","","","","","","","fee schedule","584.42","1995.82",""
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1916.89","","","","","","","fee schedule","584.42","1995.82",""
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1995.82","","","","","","","fee schedule","584.42","1995.82",""
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","600.18","","","","","","","fee schedule","584.42","1995.82","APC"
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","590.15","","","","","","","fee schedule","584.42","1995.82","APC"
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","584.42","","","","","","","fee schedule","584.42","1995.82","APC"
"Inj, pasireotide long acting","J2502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","601.61","","","","","","","fee schedule","584.42","1995.82","APC"
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.71","","","","","","","fee schedule","91.13","206.74",""
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.56","","","","","","","fee schedule","91.13","206.74",""
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","206.74","","","","","","","fee schedule","91.13","206.74",""
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","93.59","","","","","","","fee schedule","91.13","206.74","APC"
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","92.02","","","","","","","fee schedule","91.13","206.74","APC"
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","91.13","","","","","","","fee schedule","91.13","206.74","APC"
"Inj pegfilgrast ex bio 0.5mg","J2506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","93.81","","","","","","","fee schedule","91.13","206.74","APC"
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11571.57","","","","","","","fee schedule","3734.05","12881.56",""
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12372.12","","","","","","","fee schedule","3734.05","12881.56",""
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12881.56","","","","","","","fee schedule","3734.05","12881.56",""
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3834.72","","","","","","","fee schedule","3734.05","12881.56","APC"
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3770.66","","","","","","","fee schedule","3734.05","12881.56","APC"
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3734.05","","","","","","","fee schedule","3734.05","12881.56","APC"
"Pegloticase injection","J2507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3843.88","","","","","","","fee schedule","3734.05","12881.56","APC"
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","732.29","","","","","","","fee schedule","232.72","815.19",""
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","782.95","","","","","","","fee schedule","232.72","815.19",""
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","815.19","","","","","","","fee schedule","232.72","815.19",""
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.99","","","","","","","fee schedule","232.72","815.19","APC"
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","235","","","","","","","fee schedule","232.72","815.19","APC"
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.72","","","","","","","fee schedule","232.72","815.19","APC"
"Pegunigalsidase alfa-iwxj","J2508","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.56","","","","","","","fee schedule","232.72","815.19","APC"
"Penicillin g procaine inj","J2510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","150.06","","","","","","","fee schedule","150.06","167.05",""
"Penicillin g procaine inj","J2510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","160.45","","","","","","","fee schedule","150.06","167.05",""
"Penicillin g procaine inj","J2510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","167.05","","","","","","","fee schedule","150.06","167.05",""
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.34","","","","","","","fee schedule","1.71","5.95",""
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.71","","","","","","","fee schedule","1.71","5.95",""
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.95","","","","","","","fee schedule","1.71","5.95",""
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.33","","","","","","","fee schedule","1.71","5.95","APC 277.30"
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.7","","","","","","","fee schedule","1.71","5.95","APC 296.56"
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.94","","","","","","","fee schedule","1.71","5.95","APC 308.91"
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.76","","","","","","","fee schedule","1.71","5.95","APC"
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.73","","","","","","","fee schedule","1.71","5.95","APC"
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.71","","","","","","","fee schedule","1.71","5.95","APC"
"Injection, peramivir","J2547","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.76","","","","","","","fee schedule","1.71","5.95","APC"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.66","","","","","","","fee schedule","1.22","4.22",""
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.91","","","","","","","fee schedule","1.22","4.22",""
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.07","","","","","","","fee schedule","1.22","4.22",""
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.79","","","","","","","fee schedule","1.22","4.22","APC 277.30"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.06","","","","","","","fee schedule","1.22","4.22","APC 296.56"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.22","","","","","","","fee schedule","1.22","4.22","APC 308.91"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.25","","","","","","","fee schedule","1.22","4.22","APC"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.23","","","","","","","fee schedule","1.22","4.22","APC"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.22","","","","","","","fee schedule","1.22","4.22","APC"
"Inj, sezaby, 1 mg","J2561","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.25","","","","","","","fee schedule","1.22","4.22","APC"
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","379.91","","","","","","","fee schedule","25.84","422.92",""
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","406.2","","","","","","","fee schedule","25.84","422.92",""
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","422.92","","","","","","","fee schedule","25.84","422.92",""
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.53","","","","","","","fee schedule","25.84","422.92","APC"
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.09","","","","","","","fee schedule","25.84","422.92","APC"
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.84","","","","","","","fee schedule","25.84","422.92","APC"
"Plerixafor injection","J2562","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.6","","","","","","","fee schedule","25.84","422.92","APC"
"Inj desmopressin acetate","J2597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.37","","","","","","","fee schedule","12.37","13.77",""
"Inj desmopressin acetate","J2597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.23","","","","","","","fee schedule","12.37","13.77",""
"Inj desmopressin acetate","J2597","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.77","","","","","","","fee schedule","12.37","13.77",""
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.35","","","","","","","fee schedule","2.05","10.41",""
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10","","","","","","","fee schedule","2.05","10.41",""
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10.41","","","","","","","fee schedule","2.05","10.41",""
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.1","","","","","","","fee schedule","2.05","10.41","APC"
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.07","","","","","","","fee schedule","2.05","10.41","APC"
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.05","","","","","","","fee schedule","2.05","10.41","APC"
"Inj, vasopressin (baxter)","J2601","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.11","","","","","","","fee schedule","2.05","10.41","APC"
"Inj fluphenazine hcl 1.25 mg","J2679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.63","","","","","","","fee schedule","23.63","26.3",""
"Inj fluphenazine hcl 1.25 mg","J2679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.26","","","","","","","fee schedule","23.63","26.3",""
"Inj fluphenazine hcl 1.25 mg","J2679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.3","","","","","","","fee schedule","23.63","26.3",""
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","617.94","","","","","","","fee schedule","300.58","687.89",""
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","660.69","","","","","","","fee schedule","300.58","687.89",""
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","687.89","","","","","","","fee schedule","300.58","687.89",""
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","308.69","","","","","","","fee schedule","300.58","687.89","APC"
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","303.53","","","","","","","fee schedule","300.58","687.89","APC"
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","300.58","","","","","","","fee schedule","300.58","687.89","APC"
"Procainamide hcl injection","J2690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","309.43","","","","","","","fee schedule","300.58","687.89","APC"
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.77","","","","","","","fee schedule","4.77","15.79",""
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.1","","","","","","","fee schedule","4.77","15.79",""
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.31","","","","","","","fee schedule","4.77","15.79",""
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15.76","","","","","","","fee schedule","4.77","15.79","APC"
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15.49","","","","","","","fee schedule","4.77","15.79","APC"
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.34","","","","","","","fee schedule","4.77","15.79","APC"
"Protein C concentrate","J2724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.79","","","","","","","fee schedule","4.77","15.79","APC"
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1388.1","","","","","","","fee schedule","440.66","1545.25",""
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1484.13","","","","","","","fee schedule","440.66","1545.25",""
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1545.25","","","","","","","fee schedule","440.66","1545.25",""
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","452.54","","","","","","","fee schedule","440.66","1545.25","APC"
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","444.98","","","","","","","fee schedule","440.66","1545.25","APC"
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","440.66","","","","","","","fee schedule","440.66","1545.25","APC"
"Phentolaine mesylate inj","J2760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","453.62","","","","","","","fee schedule","440.66","1545.25","APC"
"Quinupristin/dalfopristin","J2770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.55","","","","","","","fee schedule","13.55","15.08",""
"Quinupristin/dalfopristin","J2770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.48","","","","","","","fee schedule","13.55","15.08",""
"Quinupristin/dalfopristin","J2770","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.08","","","","","","","fee schedule","13.55","15.08",""
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","109.65","","","","","","","fee schedule","34.55","122.06",""
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","117.23","","","","","","","fee schedule","34.55","122.06",""
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","122.06","","","","","","","fee schedule","34.55","122.06",""
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.49","","","","","","","fee schedule","34.55","122.06","APC"
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.89","","","","","","","fee schedule","34.55","122.06","APC"
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.55","","","","","","","fee schedule","34.55","122.06","APC"
"Inj, faricimab-svoa, 0.1mg","J2777","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.57","","","","","","","fee schedule","34.55","122.06","APC"
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","289.73","","","","","","","fee schedule","88.11","322.53",""
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","309.77","","","","","","","fee schedule","88.11","322.53",""
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","322.53","","","","","","","fee schedule","88.11","322.53",""
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","90.49","","","","","","","fee schedule","88.11","322.53","APC"
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","88.98","","","","","","","fee schedule","88.11","322.53","APC"
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","88.11","","","","","","","fee schedule","88.11","322.53","APC"
"Ranibizumab injection","J2778","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","90.7","","","","","","","fee schedule","88.11","322.53","APC"
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","249.41","","","","","","","fee schedule","80.51","277.64",""
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","266.66","","","","","","","fee schedule","80.51","277.64",""
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","277.64","","","","","","","fee schedule","80.51","277.64",""
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.68","","","","","","","fee schedule","80.51","277.64","APC"
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.3","","","","","","","fee schedule","80.51","277.64","APC"
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.51","","","","","","","fee schedule","80.51","277.64","APC"
"Inj, susvimo 0.1 mg","J2779","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.88","","","","","","","fee schedule","80.51","277.64","APC"
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","451.27","","","","","","","fee schedule","141.96","502.36",""
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","482.49","","","","","","","fee schedule","141.96","502.36",""
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","502.36","","","","","","","fee schedule","141.96","502.36",""
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","145.79","","","","","","","fee schedule","141.96","502.36","APC"
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","143.36","","","","","","","fee schedule","141.96","502.36","APC"
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","141.96","","","","","","","fee schedule","141.96","502.36","APC"
"Inj, pegcetacoplan, 1mg","J2781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","146.14","","","","","","","fee schedule","141.96","502.36","APC"
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","336.76","","","","","","","fee schedule","107.23","374.89",""
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","360.06","","","","","","","fee schedule","107.23","374.89",""
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","374.89","","","","","","","fee schedule","107.23","374.89",""
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","110.12","","","","","","","fee schedule","107.23","374.89","APC"
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","108.28","","","","","","","fee schedule","107.23","374.89","APC"
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","107.23","","","","","","","fee schedule","107.23","374.89","APC"
"Inj avacincaptad pegol 0.1mg","J2782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","110.38","","","","","","","fee schedule","107.23","374.89","APC"
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1197.21","","","","","","","fee schedule","385.07","1332.74",""
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1280.03","","","","","","","fee schedule","385.07","1332.74",""
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1332.74","","","","","","","fee schedule","385.07","1332.74",""
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","395.45","","","","","","","fee schedule","385.07","1332.74","APC"
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","388.85","","","","","","","fee schedule","385.07","1332.74","APC"
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","385.07","","","","","","","fee schedule","385.07","1332.74","APC"
"Rasburicase","J2783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","396.4","","","","","","","fee schedule","385.07","1332.74","APC"
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.64","","","","","","","fee schedule","11.17","37.45",""
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.97","","","","","","","fee schedule","11.17","37.45",""
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.45","","","","","","","fee schedule","11.17","37.45",""
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.47","","","","","","","fee schedule","11.17","37.45","APC"
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.28","","","","","","","fee schedule","11.17","37.45","APC"
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.17","","","","","","","fee schedule","11.17","37.45","APC"
"Injection, reslizumab, 1mg","J2786","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.5","","","","","","","fee schedule","11.17","37.45","APC"
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","97.85","","","","","","","fee schedule","25.97","108.93",""
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","104.62","","","","","","","fee schedule","25.97","108.93",""
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","108.93","","","","","","","fee schedule","25.97","108.93",""
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.67","","","","","","","fee schedule","25.97","108.93","APC"
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.22","","","","","","","fee schedule","25.97","108.93","APC"
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.97","","","","","","","fee schedule","25.97","108.93","APC"
"Rho(D) immune globulin h, sd","J2792","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.73","","","","","","","fee schedule","25.97","108.93","APC"
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.79","","","","","","","fee schedule","11.2","38.73",""
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.2","","","","","","","fee schedule","11.2","38.73",""
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.73","","","","","","","fee schedule","11.2","38.73",""
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.5","","","","","","","fee schedule","11.2","38.73","APC"
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.31","","","","","","","fee schedule","11.2","38.73","APC"
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.2","","","","","","","fee schedule","11.2","38.73","APC"
"Risperidone, long acting","J2794","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.53","","","","","","","fee schedule","11.2","38.73","APC"
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.61","","","","","","","fee schedule","12.38","42.98",""
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.28","","","","","","","fee schedule","12.38","42.98",""
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.98","","","","","","","fee schedule","12.38","42.98",""
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.72","","","","","","","fee schedule","12.38","42.98","APC"
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.51","","","","","","","fee schedule","12.38","42.98","APC"
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.38","","","","","","","fee schedule","12.38","42.98","APC"
"Inj., perseris, 0.5 mg","J2798","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.75","","","","","","","fee schedule","12.38","42.98","APC"
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79.75","","","","","","","fee schedule","25.54","88.78",""
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.27","","","","","","","fee schedule","25.54","88.78",""
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","88.78","","","","","","","fee schedule","25.54","88.78",""
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.23","","","","","","","fee schedule","25.54","88.78","APC"
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.79","","","","","","","fee schedule","25.54","88.78","APC"
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.54","","","","","","","fee schedule","25.54","88.78","APC"
"Inj, uzedy, 1 mg","J2799","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.29","","","","","","","fee schedule","25.54","88.78","APC"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.44","","","","","","","fee schedule","13.29","46.13",""
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.3","","","","","","","fee schedule","13.29","46.13",""
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.13","","","","","","","fee schedule","13.29","46.13",""
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.39","","","","","","","fee schedule","13.29","46.13","APC 277.30"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.26","","","","","","","fee schedule","13.29","46.13","APC 296.56"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.11","","","","","","","fee schedule","13.29","46.13","APC 308.91"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.65","","","","","","","fee schedule","13.29","46.13","APC"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.42","","","","","","","fee schedule","13.29","46.13","APC"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.29","","","","","","","fee schedule","13.29","46.13","APC"
"Inj, rykindo, 0.5 mg","J2801","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.68","","","","","","","fee schedule","13.29","46.13","APC"
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.98","","","","","","","fee schedule","11.23","38.94",""
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","37.4","","","","","","","fee schedule","11.23","38.94",""
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.94","","","","","","","fee schedule","11.23","38.94",""
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.54","","","","","","","fee schedule","11.23","38.94","APC"
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.34","","","","","","","fee schedule","11.23","38.94","APC"
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.23","","","","","","","fee schedule","11.23","38.94","APC"
"Inj, romiplostim 1 microgram","J2802","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.56","","","","","","","fee schedule","11.23","38.94","APC"
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","178.37","","","","","","","fee schedule","51.37","198.56",""
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","190.71","","","","","","","fee schedule","51.37","198.56",""
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.56","","","","","","","fee schedule","51.37","198.56",""
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52.76","","","","","","","fee schedule","51.37","198.56","APC"
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.88","","","","","","","fee schedule","51.37","198.56","APC"
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.37","","","","","","","fee schedule","51.37","198.56","APC"
"Sargramostim injection","J2820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.88","","","","","","","fee schedule","51.37","198.56","APC"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1716.21","","","","","","","fee schedule","550.71","1910.5",""
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1834.95","","","","","","","fee schedule","550.71","1910.5",""
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1910.5","","","","","","","fee schedule","550.71","1910.5",""
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1714.96","","","","","","","fee schedule","550.71","1910.5","APC 277.30"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1834.07","","","","","","","fee schedule","550.71","1910.5","APC 296.56"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1910.45","","","","","","","fee schedule","550.71","1910.5","APC 308.91"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","565.56","","","","","","","fee schedule","550.71","1910.5","APC"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","556.11","","","","","","","fee schedule","550.71","1910.5","APC"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","550.71","","","","","","","fee schedule","550.71","1910.5","APC"
"Inj sebelipase alfa 1 mg","J2840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","566.91","","","","","","","fee schedule","550.71","1910.5","APC"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","139.25","","","","","","","fee schedule","41.33","155.02",""
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","148.89","","","","","","","fee schedule","41.33","155.02",""
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","155.02","","","","","","","fee schedule","41.33","155.02",""
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","128.71","","","","","","","fee schedule","41.33","155.02","APC 277.30"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","137.65","","","","","","","fee schedule","41.33","155.02","APC 296.56"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","143.38","","","","","","","fee schedule","41.33","155.02","APC 308.91"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.45","","","","","","","fee schedule","41.33","155.02","APC"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.74","","","","","","","fee schedule","41.33","155.02","APC"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.33","","","","","","","fee schedule","41.33","155.02","APC"
"Inj secretin synthetic human","J2850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.55","","","","","","","fee schedule","41.33","155.02","APC"
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","515.03","","","","","","","fee schedule","169.15","573.34",""
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","550.66","","","","","","","fee schedule","169.15","573.34",""
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","573.34","","","","","","","fee schedule","169.15","573.34",""
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","173.71","","","","","","","fee schedule","169.15","573.34","APC"
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","170.81","","","","","","","fee schedule","169.15","573.34","APC"
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","169.15","","","","","","","fee schedule","169.15","573.34","APC"
"Injection, siltuximab","J2860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","174.12","","","","","","","fee schedule","169.15","573.34","APC"
"Inj, methylpred sod succ 5mg","J2919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.83","","","","","","","fee schedule","0.83","0.92",""
"Inj, methylpred sod succ 5mg","J2919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.88","","","","","","","fee schedule","0.83","0.92",""
"Inj, methylpred sod succ 5mg","J2919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.92","","","","","","","fee schedule","0.83","0.92",""
"Somatropin injection","J2941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","155.57","","","","","","","fee schedule","155.57","173.18",""
"Somatropin injection","J2941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","166.33","","","","","","","fee schedule","155.57","173.18",""
"Somatropin injection","J2941","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.18","","","","","","","fee schedule","155.57","173.18",""
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9236.56","","","","","","","fee schedule","2962.67","10282.21",""
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9875.57","","","","","","","fee schedule","2962.67","10282.21",""
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10282.21","","","","","","","fee schedule","2962.67","10282.21",""
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9225.96","","","","","","","fee schedule","2962.67","10282.21","APC 277.30"
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9866.75","","","","","","","fee schedule","2962.67","10282.21","APC 296.56"
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10277.65","","","","","","","fee schedule","2962.67","10282.21","APC 308.91"
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3042.54","","","","","","","fee schedule","2962.67","10282.21","APC"
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2991.71","","","","","","","fee schedule","2962.67","10282.21","APC"
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2962.67","","","","","","","fee schedule","2962.67","10282.21","APC"
"Reteplase injection","J2993","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3049.8","","","","","","","fee schedule","2962.67","10282.21","APC"
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","299.4","","","","","","","fee schedule","96.34","333.29",""
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","320.11","","","","","","","fee schedule","96.34","333.29",""
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","333.29","","","","","","","fee schedule","96.34","333.29",""
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","98.93","","","","","","","fee schedule","96.34","333.29","APC"
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","97.28","","","","","","","fee schedule","96.34","333.29","APC"
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96.34","","","","","","","fee schedule","96.34","333.29","APC"
"Alteplase recombinant","J2997","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99.17","","","","","","","fee schedule","96.34","333.29","APC"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","102.75","","","","","","","fee schedule","33.42","115.94",""
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","109.85","","","","","","","fee schedule","33.42","115.94",""
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.38","","","","","","","fee schedule","33.42","115.94",""
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","104.08","","","","","","","fee schedule","33.42","115.94","APC 277.30"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","111.31","","","","","","","fee schedule","33.42","115.94","APC 296.56"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","115.94","","","","","","","fee schedule","33.42","115.94","APC 308.91"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34.32","","","","","","","fee schedule","33.42","115.94","APC"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.75","","","","","","","fee schedule","33.42","115.94","APC"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.42","","","","","","","fee schedule","33.42","115.94","APC"
"Inj plasminogen tvmh 1mg","J2998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34.41","","","","","","","fee schedule","33.42","115.94","APC"
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","63.12","","","","","","","fee schedule","20.37","70.27",""
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.49","","","","","","","fee schedule","20.37","70.27",""
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","70.27","","","","","","","fee schedule","20.37","70.27",""
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.92","","","","","","","fee schedule","20.37","70.27","APC"
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.57","","","","","","","fee schedule","20.37","70.27","APC"
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.37","","","","","","","fee schedule","20.37","70.27","APC"
"Inj. eptinezumab-jjmr 1 mg","J3032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.97","","","","","","","fee schedule","20.37","70.27","APC"
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","230.23","","","","","","","fee schedule","74.07","256.3",""
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","246.16","","","","","","","fee schedule","74.07","256.3",""
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","256.3","","","","","","","fee schedule","74.07","256.3",""
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.07","","","","","","","fee schedule","74.07","256.3","APC"
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","74.8","","","","","","","fee schedule","74.07","256.3","APC"
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.07","","","","","","","fee schedule","74.07","256.3","APC"
"Inj talquetamab-tgvs 0.25 mg","J3055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.25","","","","","","","fee schedule","74.07","256.3","APC"
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","130.57","","","","","","","fee schedule","41.93","145.35",""
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","139.6","","","","","","","fee schedule","41.93","145.35",""
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","145.35","","","","","","","fee schedule","41.93","145.35",""
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.06","","","","","","","fee schedule","41.93","145.35","APC"
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.34","","","","","","","fee schedule","41.93","145.35","APC"
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.93","","","","","","","fee schedule","41.93","145.35","APC"
"Inj, taliglucerace alfa 10 u","J3060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.17","","","","","","","fee schedule","41.93","145.35","APC"
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.07","","","","","","","fee schedule","2","6.76",""
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.49","","","","","","","fee schedule","2","6.76",""
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.76","","","","","","","fee schedule","2","6.76",""
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.06","","","","","","","fee schedule","2","6.76","APC"
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.02","","","","","","","fee schedule","2","6.76","APC"
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2","","","","","","","fee schedule","2","6.76","APC"
"Inj tedizolid phosphate","J3090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.06","","","","","","","fee schedule","2","6.76","APC"
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23.75","","","","","","","fee schedule","7.26","26.44",""
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.4","","","","","","","fee schedule","7.26","26.44",""
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.44","","","","","","","fee schedule","7.26","26.44",""
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.45","","","","","","","fee schedule","7.26","26.44","APC"
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.33","","","","","","","fee schedule","7.26","26.44","APC"
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.26","","","","","","","fee schedule","7.26","26.44","APC"
"Telavancin injection","J3095","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.47","","","","","","","fee schedule","7.26","26.44","APC"
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","546.77","","","","","","","fee schedule","175.67","608.67",""
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","584.6","","","","","","","fee schedule","175.67","608.67",""
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","608.67","","","","","","","fee schedule","175.67","608.67",""
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","180.4","","","","","","","fee schedule","175.67","608.67","APC"
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","177.39","","","","","","","fee schedule","175.67","608.67","APC"
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","175.67","","","","","","","fee schedule","175.67","608.67","APC"
"Tenecteplase injection","J3101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","180.83","","","","","","","fee schedule","175.67","608.67","APC"
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.16","","","","","","","fee schedule","12.31","42.48",""
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","40.8","","","","","","","fee schedule","12.31","42.48",""
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.48","","","","","","","fee schedule","12.31","42.48",""
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.64","","","","","","","fee schedule","12.31","42.48","APC"
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.43","","","","","","","fee schedule","12.31","42.48","APC"
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.31","","","","","","","fee schedule","12.31","42.48","APC"
"Inj. romosozumab-aqqg 1 mg","J3111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.67","","","","","","","fee schedule","12.31","42.48","APC"
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.33","","","","","","","fee schedule","2.11","7.04",""
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.77","","","","","","","fee schedule","2.11","7.04",""
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.04","","","","","","","fee schedule","2.11","7.04",""
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.17","","","","","","","fee schedule","2.11","7.04","APC"
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.13","","","","","","","fee schedule","2.11","7.04","APC"
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.11","","","","","","","fee schedule","2.11","7.04","APC"
"Testosterone undecanoate 1mg","J3145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.17","","","","","","","fee schedule","2.11","7.04","APC"
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6720.1","","","","","","","fee schedule","2158.65","7480.87",""
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7185.02","","","","","","","fee schedule","2158.65","7480.87",""
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7480.87","","","","","","","fee schedule","2158.65","7480.87",""
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2216.85","","","","","","","fee schedule","2158.65","7480.87","APC"
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2179.81","","","","","","","fee schedule","2158.65","7480.87","APC"
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2158.65","","","","","","","fee schedule","2158.65","7480.87","APC"
"Thyrotropin injection","J3240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2222.14","","","","","","","fee schedule","2158.65","7480.87","APC"
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1141.91","","","","","","","fee schedule","366.38","1271.18",""
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1220.91","","","","","","","fee schedule","366.38","1271.18",""
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1271.18","","","","","","","fee schedule","366.38","1271.18",""
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","376.25","","","","","","","fee schedule","366.38","1271.18","APC"
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","369.97","","","","","","","fee schedule","366.38","1271.18","APC"
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","366.38","","","","","","","fee schedule","366.38","1271.18","APC"
"Inj. teprotumumab-trbw 10 mg","J3241","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","377.15","","","","","","","fee schedule","366.38","1271.18","APC"
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","401.44","","","","","","","fee schedule","130","446.89",""
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","429.22","","","","","","","fee schedule","130","446.89",""
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","446.89","","","","","","","fee schedule","130","446.89",""
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","133.51","","","","","","","fee schedule","130","446.89","APC"
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","131.28","","","","","","","fee schedule","130","446.89","APC"
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","130","","","","","","","fee schedule","130","446.89","APC"
"Inj., tildrakizumab, 1 mg","J3245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","133.83","","","","","","","fee schedule","130","446.89","APC"
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","56.73","","","","","","","fee schedule","18.2","63.15",""
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","60.66","","","","","","","fee schedule","18.2","63.15",""
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","63.15","","","","","","","fee schedule","18.2","63.15",""
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.69","","","","","","","fee schedule","18.2","63.15","APC"
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.38","","","","","","","fee schedule","18.2","63.15","APC"
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.2","","","","","","","fee schedule","18.2","63.15","APC"
"Inj secukinumab intrav 1mg","J3247","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.74","","","","","","","fee schedule","18.2","63.15","APC"
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.41","","","","","","","fee schedule","5.82","20.5",""
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.69","","","","","","","fee schedule","5.82","20.5",""
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.5","","","","","","","fee schedule","5.82","20.5",""
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.98","","","","","","","fee schedule","5.82","20.5","APC"
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.88","","","","","","","fee schedule","5.82","20.5","APC"
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.82","","","","","","","fee schedule","5.82","20.5","APC"
"Tocilizumab injection","J3262","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.99","","","","","","","fee schedule","5.82","20.5","APC"
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","125.61","","","","","","","fee schedule","40.2","139.83",""
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","134.3","","","","","","","fee schedule","40.2","139.83",""
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","139.83","","","","","","","fee schedule","40.2","139.83",""
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.28","","","","","","","fee schedule","40.2","139.83","APC"
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","40.59","","","","","","","fee schedule","40.2","139.83","APC"
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.2","","","","","","","fee schedule","40.2","139.83","APC"
"Inj, toripalimab-tpzi, 1 mg","J3263","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.38","","","","","","","fee schedule","40.2","139.83","APC"
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","176.43","","","","","","","fee schedule","55.8","196.4",""
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","188.63","","","","","","","fee schedule","55.8","196.4",""
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","196.4","","","","","","","fee schedule","55.8","196.4",""
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57.31","","","","","","","fee schedule","55.8","196.4","APC"
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","56.35","","","","","","","fee schedule","55.8","196.4","APC"
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","55.8","","","","","","","fee schedule","55.8","196.4","APC"
"Treprostinil injection","J3285","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57.44","","","","","","","fee schedule","55.8","196.4","APC"
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","152.64","","","","","","","fee schedule","48.93","169.92",""
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","163.2","","","","","","","fee schedule","48.93","169.92",""
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","169.92","","","","","","","fee schedule","48.93","169.92",""
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50.25","","","","","","","fee schedule","48.93","169.92","APC"
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49.41","","","","","","","fee schedule","48.93","169.92","APC"
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.93","","","","","","","fee schedule","48.93","169.92","APC"
"Inj xipere 1 mg","J3299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50.37","","","","","","","fee schedule","48.93","169.92","APC"
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","77.94","","","","","","","fee schedule","24.99","86.77",""
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","83.33","","","","","","","fee schedule","24.99","86.77",""
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","86.77","","","","","","","fee schedule","24.99","86.77",""
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.66","","","","","","","fee schedule","24.99","86.77","APC"
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.23","","","","","","","fee schedule","24.99","86.77","APC"
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.99","","","","","","","fee schedule","24.99","86.77","APC"
"Triamcinolone A inj PRS-free","J3300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.72","","","","","","","fee schedule","24.99","86.77","APC"
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","57.91","","","","","","","fee schedule","18.66","64.46",""
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","61.91","","","","","","","fee schedule","18.66","64.46",""
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.46","","","","","","","fee schedule","18.66","64.46",""
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.17","","","","","","","fee schedule","18.66","64.46","APC"
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.85","","","","","","","fee schedule","18.66","64.46","APC"
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.66","","","","","","","fee schedule","18.66","64.46","APC"
"Inj triamcinolone ace xr 1mg","J3304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.21","","","","","","","fee schedule","18.66","64.46","APC"
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1564.24","","","","","","","fee schedule","484.33","1741.33",""
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1672.46","","","","","","","fee schedule","484.33","1741.33",""
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1741.33","","","","","","","fee schedule","484.33","1741.33",""
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","497.39","","","","","","","fee schedule","484.33","1741.33","APC"
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","489.08","","","","","","","fee schedule","484.33","1741.33","APC"
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","484.33","","","","","","","fee schedule","484.33","1741.33","APC"
"Triptorelin pamoate","J3315","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","498.58","","","","","","","fee schedule","484.33","1741.33","APC"
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11997.66","","","","","","","fee schedule","3893.62","13355.89",""
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12827.69","","","","","","","fee schedule","3893.62","13355.89",""
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13355.89","","","","","","","fee schedule","3893.62","13355.89",""
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3998.6","","","","","","","fee schedule","3893.62","13355.89","APC"
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3931.8","","","","","","","fee schedule","3893.62","13355.89","APC"
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3893.62","","","","","","","fee schedule","3893.62","13355.89","APC"
"Inj., triptorelin xr 3.75 mg","J3316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4008.14","","","","","","","fee schedule","3893.62","13355.89","APC"
"Ustekinumab sub cu inj, 1 mg","J3357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","501.42","","","","","","","fee schedule","501.42","558.19",""
"Ustekinumab sub cu inj, 1 mg","J3357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","536.11","","","","","","","fee schedule","501.42","558.19",""
"Ustekinumab sub cu inj, 1 mg","J3357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","558.19","","","","","","","fee schedule","501.42","558.19",""
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","42.26","","","","","","","fee schedule","13.25","47.05",""
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","45.19","","","","","","","fee schedule","13.25","47.05",""
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","47.05","","","","","","","fee schedule","13.25","47.05",""
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13.61","","","","","","","fee schedule","13.25","47.05","APC"
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.38","","","","","","","fee schedule","13.25","47.05","APC"
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.25","","","","","","","fee schedule","13.25","47.05","APC"
"Ustekinumab, iv inject, 1 mg","J3358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13.64","","","","","","","fee schedule","13.25","47.05","APC"
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.15","","","","","","","fee schedule","21.74","78.09",""
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","75","","","","","","","fee schedule","21.74","78.09",""
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","78.09","","","","","","","fee schedule","21.74","78.09",""
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.32","","","","","","","fee schedule","21.74","78.09","APC"
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.95","","","","","","","fee schedule","21.74","78.09","APC"
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.74","","","","","","","fee schedule","21.74","78.09","APC"
"Injection, vedolizumab","J3380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.38","","","","","","","fee schedule","21.74","78.09","APC"
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1208.97","","","","","","","fee schedule","388.99","1345.84",""
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1292.61","","","","","","","fee schedule","388.99","1345.84",""
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1345.84","","","","","","","fee schedule","388.99","1345.84",""
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","399.47","","","","","","","fee schedule","388.99","1345.84","APC"
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","392.8","","","","","","","fee schedule","388.99","1345.84","APC"
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","388.99","","","","","","","fee schedule","388.99","1345.84","APC"
"Velaglucerase alfa","J3385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","400.43","","","","","","","fee schedule","388.99","1345.84","APC"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","15940646.38",""
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","15940646.38",""
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","15940646.38",""
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14309479.27","","","","","","","fee schedule","0.03","15940646.38","APC 277.30"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15303350.78","","","","","","","fee schedule","0.03","15940646.38","APC 296.56"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15940646.38","","","","","","","fee schedule","0.03","15940646.38","APC 308.91"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4718987.5","","","","","","","fee schedule","0.03","15940646.38","APC"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4640150","","","","","","","fee schedule","0.03","15940646.38","APC"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4595100","","","","","","","fee schedule","0.03","15940646.38","APC"
"Inj, atidarsagene autotemcel","J3391","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4730250","","","","","","","fee schedule","0.03","15940646.38","APC"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","8251628.71",""
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","8251628.71",""
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","8251628.71",""
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7407259.86","","","","","","","fee schedule","0.03","8251628.71","APC 277.30"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7921734.52","","","","","","","fee schedule","0.03","8251628.71","APC 296.56"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8251628.71","","","","","","","fee schedule","0.03","8251628.71","APC 308.91"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2442770","","","","","","","fee schedule","0.03","8251628.71","APC"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2401960","","","","","","","fee schedule","0.03","8251628.71","APC"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2378640","","","","","","","fee schedule","0.03","8251628.71","APC"
"Inj, exagamglogene autotem","J3392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2448600","","","","","","","fee schedule","0.03","8251628.71","APC"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","10423307.36",""
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","10423307.36",""
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","10423307.36",""
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9356715.97","","","","","","","fee schedule","0.03","10423307.36","APC 277.30"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10006591.02","","","","","","","fee schedule","0.03","10423307.36","APC 296.56"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10423307.36","","","","","","","fee schedule","0.03","10423307.36","APC 308.91"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3085662.65","","","","","","","fee schedule","0.03","10423307.36","APC"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3034112.2","","","","","","","fee schedule","0.03","10423307.36","APC"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3004654.8","","","","","","","fee schedule","0.03","10423307.36","APC"
"Inj, betibeglogene autotemce","J3393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3093027","","","","","","","fee schedule","0.03","10423307.36","APC"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","11494411.63",""
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","11494411.63",""
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","11494411.63",""
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10318216.78","","","","","","","fee schedule","0.03","11494411.63","APC 277.30"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11034873.31","","","","","","","fee schedule","0.03","11494411.63","APC 296.56"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11494411.63","","","","","","","fee schedule","0.03","11494411.63","APC 308.91"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3402746.89","","","","","","","fee schedule","0.03","11494411.63","APC"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3345899.09","","","","","","","fee schedule","0.03","11494411.63","APC"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3313414.63","","","","","","","fee schedule","0.03","11494411.63","APC"
"Inj, lovotibeglogene autotem","J3394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3410868","","","","","","","fee schedule","0.03","11494411.63","APC"
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.73","","","","","","","fee schedule","11.77","40.89",""
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","39.27","","","","","","","fee schedule","11.77","40.89",""
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40.89","","","","","","","fee schedule","11.77","40.89",""
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.09","","","","","","","fee schedule","11.77","40.89","APC"
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.77","40.89","APC"
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.77","","","","","","","fee schedule","11.77","40.89","APC"
"Verteporfin injection","J3396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.11","","","","","","","fee schedule","11.77","40.89","APC"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","10624.44",""
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","10624.44",""
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","10624.44",""
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9537.27","","","","","","","fee schedule","0.03","10624.44","APC 277.30"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10199.68","","","","","","","fee schedule","0.03","10624.44","APC 296.56"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10624.44","","","","","","","fee schedule","0.03","10624.44","APC 308.91"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3145.21","","","","","","","fee schedule","0.03","10624.44","APC"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3092.66","","","","","","","fee schedule","0.03","10624.44","APC"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3062.63","","","","","","","fee schedule","0.03","10624.44","APC"
"Inj luxturna 1 billion vec g","J3398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3152.71","","","","","","","fee schedule","0.03","10624.44","APC"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","8687247.5",""
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","8687247.5",""
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","8687247.5",""
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7798302.84","","","","","","","fee schedule","0.03","8687247.5","APC 277.30"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8339937.58","","","","","","","fee schedule","0.03","8687247.5","APC 296.56"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8687247.5","","","","","","","fee schedule","0.03","8687247.5","APC 308.91"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2571728.36","","","","","","","fee schedule","0.03","8687247.5","APC"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2528763.92","","","","","","","fee schedule","0.03","8687247.5","APC"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2504212.82","","","","","","","fee schedule","0.03","8687247.5","APC"
"Inj onase abepar-xioi treat","J3399","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2577866.14","","","","","","","fee schedule","0.03","8687247.5","APC"
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3298.04","","","","","","","fee schedule","1045.94","3671.4",""
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3526.21","","","","","","","fee schedule","1045.94","3671.4",""
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3671.4","","","","","","","fee schedule","1045.94","3671.4",""
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1074.14","","","","","","","fee schedule","1045.94","3671.4","APC"
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1056.2","","","","","","","fee schedule","1045.94","3671.4","APC"
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1045.94","","","","","","","fee schedule","1045.94","3671.4","APC"
"Vyjuvek 5x10^9pfu/ml, 0.1 ml","J3401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1076.71","","","","","","","fee schedule","1045.94","3671.4","APC"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.47","","","","","","","fee schedule","5.29","18.35",""
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.61","","","","","","","fee schedule","5.29","18.35",""
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.34","","","","","","","fee schedule","5.29","18.35",""
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.47","","","","","","","fee schedule","5.29","18.35","APC 277.30"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17.61","","","","","","","fee schedule","5.29","18.35","APC 296.56"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.35","","","","","","","fee schedule","5.29","18.35","APC 308.91"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.29","18.35","APC"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.34","","","","","","","fee schedule","5.29","18.35","APC"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.29","","","","","","","fee schedule","5.29","18.35","APC"
"Inj hydroxocobalamin iv 25mg","J3424","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.44","","","","","","","fee schedule","5.29","18.35","APC"
"Inj, hydroxocobalamin","J3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","0.04",""
"Inj, hydroxocobalamin","J3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","0.04",""
"Inj, hydroxocobalamin","J3425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","0.04",""
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.01","","","","","","","fee schedule","1.58","5.47",""
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.28","","","","","","","fee schedule","1.58","5.47",""
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.46","","","","","","","fee schedule","1.58","5.47",""
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.91","","","","","","","fee schedule","1.58","5.47","APC 277.30"
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.25","","","","","","","fee schedule","1.58","5.47","APC 296.56"
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.47","","","","","","","fee schedule","1.58","5.47","APC 308.91"
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.62","","","","","","","fee schedule","1.58","5.47","APC"
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.59","","","","","","","fee schedule","1.58","5.47","APC"
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.58","","","","","","","fee schedule","1.58","5.47","APC"
"Inj, human-lans, per i.u","J7165","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.62","","","","","","","fee schedule","1.58","5.47","APC"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.81","","","","","","","fee schedule","2.18","7.58",""
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.28","","","","","","","fee schedule","2.18","7.58",""
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.58","","","","","","","fee schedule","2.18","7.58",""
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.79","","","","","","","fee schedule","2.18","7.58","APC 277.30"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.27","","","","","","","fee schedule","2.18","7.58","APC 296.56"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.57","","","","","","","fee schedule","2.18","7.58","APC 308.91"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.24","","","","","","","fee schedule","2.18","7.58","APC"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.2","","","","","","","fee schedule","2.18","7.58","APC"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.18","","","","","","","fee schedule","2.18","7.58","APC"
"Prothrombin complex kcentra","J7168","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.25","","","","","","","fee schedule","2.18","7.58","APC"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","418.36","","","","","","","fee schedule","134","465.72",""
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","447.3","","","","","","","fee schedule","134","465.72",""
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","465.72","","","","","","","fee schedule","134","465.72",""
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","417.29","","","","","","","fee schedule","134","465.72","APC 277.30"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","446.28","","","","","","","fee schedule","134","465.72","APC 296.56"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","464.86","","","","","","","fee schedule","134","465.72","APC 308.91"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.62","","","","","","","fee schedule","134","465.72","APC"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.32","","","","","","","fee schedule","134","465.72","APC"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","134","","","","","","","fee schedule","134","465.72","APC"
"Inj andexxa, 10 mg","J7169","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.94","","","","","","","fee schedule","134","465.72","APC"
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.63","","","","","","","fee schedule","57.22","203.3",""
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.26","","","","","","","fee schedule","57.22","203.3",""
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.3","","","","","","","fee schedule","57.22","203.3",""
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.77","","","","","","","fee schedule","57.22","203.3","APC"
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.78","","","","","","","fee schedule","57.22","203.3","APC"
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.22","","","","","","","fee schedule","57.22","203.3","APC"
"Inj., emicizumab-kxwh 0.5 mg","J7170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.91","","","","","","","fee schedule","57.22","203.3","APC"
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","113.18","","","","","","","fee schedule","36.3","125.99",""
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","121.01","","","","","","","fee schedule","36.3","125.99",""
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","125.99","","","","","","","fee schedule","36.3","125.99",""
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37.28","","","","","","","fee schedule","36.3","125.99","APC"
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.65","","","","","","","fee schedule","36.3","125.99","APC"
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36.3","","","","","","","fee schedule","36.3","125.99","APC"
"Inj, adzynma, 10 iu","J7171","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.37","","","","","","","fee schedule","36.3","125.99","APC"
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","161.26","","","","","","","fee schedule","52.12","179.51",""
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","172.41","","","","","","","fee schedule","52.12","179.51",""
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","179.51","","","","","","","fee schedule","52.12","179.51",""
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.52","","","","","","","fee schedule","52.12","179.51","APC"
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.63","","","","","","","fee schedule","52.12","179.51","APC"
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.12","","","","","","","fee schedule","52.12","179.51","APC"
"Inj marstacim-hncq, 0.5 mg","J7172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.65","","","","","","","fee schedule","52.12","179.51","APC"
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.51","","","","","","","fee schedule","9.97","35.08",""
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.69","","","","","","","fee schedule","9.97","35.08",""
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.08","","","","","","","fee schedule","9.97","35.08",""
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.24","","","","","","","fee schedule","9.97","35.08","APC"
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.07","","","","","","","fee schedule","9.97","35.08","APC"
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.97","","","","","","","fee schedule","9.97","35.08","APC"
"Inj, factor x, (human), 1iu","J7175","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.26","","","","","","","fee schedule","9.97","35.08","APC"
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.85","","","","","","","fee schedule","1.25","4.28",""
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.11","","","","","","","fee schedule","1.25","4.28",""
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.28","","","","","","","fee schedule","1.25","4.28",""
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.28","","","","","","","fee schedule","1.25","4.28","APC"
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.26","","","","","","","fee schedule","1.25","4.28","APC"
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.25","","","","","","","fee schedule","1.25","4.28","APC"
"Inj., fibryga, 1 mg","J7177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.29","","","","","","","fee schedule","1.25","4.28","APC"
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.83","","","","","","","fee schedule","1.55","5.38",""
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.17","","","","","","","fee schedule","1.55","5.38",""
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.38","","","","","","","fee schedule","1.55","5.38",""
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.59","","","","","","","fee schedule","1.55","5.38","APC"
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.56","","","","","","","fee schedule","1.55","5.38","APC"
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.55","","","","","","","fee schedule","1.55","5.38","APC"
"Human fibrinogen conc inj","J7178","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.59","","","","","","","fee schedule","1.55","5.38","APC"
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.88","","","","","","","fee schedule","1.89","6.55",""
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.29","","","","","","","fee schedule","1.89","6.55",""
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.55","","","","","","","fee schedule","1.89","6.55",""
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.94","","","","","","","fee schedule","1.89","6.55","APC"
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.91","","","","","","","fee schedule","1.89","6.55","APC"
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.89","","","","","","","fee schedule","1.89","6.55","APC"
"Vonvendi inj 1 iu vwf:rco","J7179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.94","","","","","","","fee schedule","1.89","6.55","APC"
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","34.28","","","","","","","fee schedule","10.97","38.16",""
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.65","","","","","","","fee schedule","10.97","38.16",""
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","38.16","","","","","","","fee schedule","10.97","38.16",""
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.27","","","","","","","fee schedule","10.97","38.16","APC"
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.08","","","","","","","fee schedule","10.97","38.16","APC"
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.97","","","","","","","fee schedule","10.97","38.16","APC"
"Factor XIII anti-hem factor","J7180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.29","","","","","","","fee schedule","10.97","38.16","APC"
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.16","","","","","","","fee schedule","18.52","64.75",""
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","62.19","","","","","","","fee schedule","18.52","64.75",""
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","64.75","","","","","","","fee schedule","18.52","64.75",""
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.02","","","","","","","fee schedule","18.52","64.75","APC"
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.7","","","","","","","fee schedule","18.52","64.75","APC"
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.52","","","","","","","fee schedule","18.52","64.75","APC"
"Factor xiii recomb a-subunit","J7181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.06","","","","","","","fee schedule","18.52","64.75","APC"
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.83","","","","","","","fee schedule","1.57","5.38",""
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.17","","","","","","","fee schedule","1.57","5.38",""
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.38","","","","","","","fee schedule","1.57","5.38",""
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.61","","","","","","","fee schedule","1.57","5.38","APC"
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.59","","","","","","","fee schedule","1.57","5.38","APC"
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.57","","","","","","","fee schedule","1.57","5.38","APC"
"Factor viii recomb novoeight","J7182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.62","","","","","","","fee schedule","1.57","5.38","APC"
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.04","","","","","","","fee schedule","1.31","4.5",""
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.32","","","","","","","fee schedule","1.31","4.5",""
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.5","","","","","","","fee schedule","1.31","4.5",""
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.35","","","","","","","fee schedule","1.31","4.5","APC"
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.33","","","","","","","fee schedule","1.31","4.5","APC"
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.31","","","","","","","fee schedule","1.31","4.5","APC"
"Wilate injection","J7183","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.35","","","","","","","fee schedule","1.31","4.5","APC"
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.9","","","","","","","fee schedule","1.71","5.45",""
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.24","","","","","","","fee schedule","1.71","5.45",""
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.45","","","","","","","fee schedule","1.71","5.45",""
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.75","","","","","","","fee schedule","1.71","5.45","APC"
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.72","","","","","","","fee schedule","1.71","5.45","APC"
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.71","","","","","","","fee schedule","1.71","5.45","APC"
"Xyntha inj","J7185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.76","","","","","","","fee schedule","1.71","5.45","APC"
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.91","","","","","","","fee schedule","1.27","4.35",""
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.18","","","","","","","fee schedule","1.27","4.35",""
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.35","","","","","","","fee schedule","1.27","4.35",""
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.3","","","","","","","fee schedule","1.27","4.35","APC"
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.28","","","","","","","fee schedule","1.27","4.35","APC"
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.27","","","","","","","fee schedule","1.27","4.35","APC"
"Antihemophilic viii/vwf comp","J7186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.31","","","","","","","fee schedule","1.27","4.35","APC"
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.74","","","","","","","fee schedule","1.52","5.27",""
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.07","","","","","","","fee schedule","1.52","5.27",""
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.27","","","","","","","fee schedule","1.52","5.27",""
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.56","","","","","","","fee schedule","1.52","5.27","APC"
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.54","","","","","","","fee schedule","1.52","5.27","APC"
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.52","","","","","","","fee schedule","1.52","5.27","APC"
"Humate-P, inj","J7187","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.57","","","","","","","fee schedule","1.52","5.27","APC"
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.27","","","","","","","fee schedule","3.29","11.43",""
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.98","","","","","","","fee schedule","3.29","11.43",""
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.43","","","","","","","fee schedule","3.29","11.43",""
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.38","","","","","","","fee schedule","3.29","11.43","APC"
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.32","","","","","","","fee schedule","3.29","11.43","APC"
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.29","","","","","","","fee schedule","3.29","11.43","APC"
"Factor viii recomb obizur","J7188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.39","","","","","","","fee schedule","3.29","11.43","APC"
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.43","","","","","","","fee schedule","2.71","9.38",""
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.01","","","","","","","fee schedule","2.71","9.38",""
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.38","","","","","","","fee schedule","2.71","9.38",""
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.78","","","","","","","fee schedule","2.71","9.38","APC"
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.73","","","","","","","fee schedule","2.71","9.38","APC"
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.71","","","","","","","fee schedule","2.71","9.38","APC"
"Factor viia","J7189","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.79","","","","","","","fee schedule","2.71","9.38","APC"
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.59","","","","","","","fee schedule","1.11","4",""
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.84","","","","","","","fee schedule","1.11","4",""
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4","","","","","","","fee schedule","1.11","4",""
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.14","","","","","","","fee schedule","1.11","4","APC"
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.12","","","","","","","fee schedule","1.11","4","APC"
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.11","","","","","","","fee schedule","1.11","4","APC"
"Factor viii","J7190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.14","","","","","","","fee schedule","1.11","4","APC"
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.9","","","","","","","fee schedule","1.65","5.45",""
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.24","","","","","","","fee schedule","1.65","5.45",""
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.45","","","","","","","fee schedule","1.65","5.45",""
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.69","","","","","","","fee schedule","1.65","5.45","APC"
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.66","","","","","","","fee schedule","1.65","5.45","APC"
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.65","","","","","","","fee schedule","1.65","5.45","APC"
"Factor viii recombinant nos","J7192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.69","","","","","","","fee schedule","1.65","5.45","APC"
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.26","","","","","","","fee schedule","1.42","4.74",""
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.56","","","","","","","fee schedule","1.42","4.74",""
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.74","","","","","","","fee schedule","1.42","4.74",""
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.46","","","","","","","fee schedule","1.42","4.74","APC"
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.44","","","","","","","fee schedule","1.42","4.74","APC"
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.42","","","","","","","fee schedule","1.42","4.74","APC"
"Factor ix non-recombinant","J7193","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.47","","","","","","","fee schedule","1.42","4.74","APC"
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.41","","","","","","","fee schedule","1.73","6.02",""
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.78","","","","","","","fee schedule","1.73","6.02",""
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.02","","","","","","","fee schedule","1.73","6.02",""
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.78","","","","","","","fee schedule","1.73","6.02","APC"
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.75","","","","","","","fee schedule","1.73","6.02","APC"
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.73","","","","","","","fee schedule","1.73","6.02","APC"
"Factor ix complex","J7194","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.78","","","","","","","fee schedule","1.73","6.02","APC"
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.98","","","","","","","fee schedule","1.89","6.66",""
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.39","","","","","","","fee schedule","1.89","6.66",""
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.66","","","","","","","fee schedule","1.89","6.66",""
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.94","","","","","","","fee schedule","1.89","6.66","APC"
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.9","","","","","","","fee schedule","1.89","6.66","APC"
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.89","","","","","","","fee schedule","1.89","6.66","APC"
"Factor ix recombinant nos","J7195","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.94","","","","","","","fee schedule","1.89","6.66","APC"
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.01","","","","","","","fee schedule","4.19","14.48",""
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","13.91","","","","","","","fee schedule","4.19","14.48",""
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.48","","","","","","","fee schedule","4.19","14.48",""
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.3","","","","","","","fee schedule","4.19","14.48","APC"
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.23","","","","","","","fee schedule","4.19","14.48","APC"
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.19","","","","","","","fee schedule","4.19","14.48","APC"
"Antithrombin iii injection","J7197","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.31","","","","","","","fee schedule","4.19","14.48","APC"
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.79","","","","","","","fee schedule","2.46","8.67",""
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.33","","","","","","","fee schedule","2.46","8.67",""
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.67","","","","","","","fee schedule","2.46","8.67",""
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.53","","","","","","","fee schedule","2.46","8.67","APC"
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.49","","","","","","","fee schedule","2.46","8.67","APC"
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.46","","","","","","","fee schedule","2.46","8.67","APC"
"Anti-inhibitor","J7198","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.53","","","","","","","fee schedule","2.46","8.67","APC"
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.54","","","","","","","fee schedule","3.67","12.85",""
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.34","","","","","","","fee schedule","3.67","12.85",""
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.85","","","","","","","fee schedule","3.67","12.85",""
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.76","","","","","","","fee schedule","3.67","12.85","APC"
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.7","","","","","","","fee schedule","3.67","12.85","APC"
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.67","","","","","","","fee schedule","3.67","12.85","APC"
"Factor ix alprolix recomb","J7201","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.77","","","","","","","fee schedule","3.67","12.85","APC"
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16.98","","","","","","","fee schedule","5.43","18.9",""
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.16","","","","","","","fee schedule","5.43","18.9",""
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.9","","","","","","","fee schedule","5.43","18.9",""
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.57","","","","","","","fee schedule","5.43","18.9","APC"
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.48","","","","","","","fee schedule","5.43","18.9","APC"
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.43","","","","","","","fee schedule","5.43","18.9","APC"
"Factor ix idelvion inj","J7202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.59","","","","","","","fee schedule","5.43","18.9","APC"
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.56","","","","","","","fee schedule","4.55","16.21",""
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.57","","","","","","","fee schedule","4.55","16.21",""
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.21","","","","","","","fee schedule","4.55","16.21",""
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.67","","","","","","","fee schedule","4.55","16.21","APC"
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.6","","","","","","","fee schedule","4.55","16.21","APC"
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.55","","","","","","","fee schedule","4.55","16.21","APC"
"Factor ix recomb gly rebinyn","J7203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.69","","","","","","","fee schedule","4.55","16.21","APC"
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.19","","","","","","","fee schedule","2.27","8",""
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.68","","","","","","","fee schedule","2.27","8",""
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8","","","","","","","fee schedule","2.27","8",""
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.33","","","","","","","fee schedule","2.27","8","APC"
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.29","","","","","","","fee schedule","2.27","8","APC"
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.27","","","","","","","fee schedule","2.27","8","APC"
"Inj recombin esperoct per iu","J7204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.33","","","","","","","fee schedule","2.27","8","APC"
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.7","","","","","","","fee schedule","2.47","8.57",""
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.23","","","","","","","fee schedule","2.47","8.57",""
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.57","","","","","","","fee schedule","2.47","8.57",""
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.54","","","","","","","fee schedule","2.47","8.57","APC"
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.5","","","","","","","fee schedule","2.47","8.57","APC"
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.47","","","","","","","fee schedule","2.47","8.57","APC"
"Factor viii fc fusion recomb","J7205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.55","","","","","","","fee schedule","2.47","8.57","APC"
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.84","","","","","","","fee schedule","2.14","7.61",""
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.31","","","","","","","fee schedule","2.14","7.61",""
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.61","","","","","","","fee schedule","2.14","7.61",""
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.2","","","","","","","fee schedule","2.14","7.61","APC"
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.16","","","","","","","fee schedule","2.14","7.61","APC"
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.14","","","","","","","fee schedule","2.14","7.61","APC"
"Factor viii pegylated recomb","J7207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.2","","","","","","","fee schedule","2.14","7.61","APC"
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8.43","","","","","","","fee schedule","2.7","9.38",""
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.01","","","","","","","fee schedule","2.7","9.38",""
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.38","","","","","","","fee schedule","2.7","9.38",""
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.77","","","","","","","fee schedule","2.7","9.38","APC"
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.73","","","","","","","fee schedule","2.7","9.38","APC"
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.7","","","","","","","fee schedule","2.7","9.38","APC"
"Inj. jivi 1 iu","J7208","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.78","","","","","","","fee schedule","2.7","9.38","APC"
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.75","","","","","","","fee schedule","1.14","4.18",""
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.01","","","","","","","fee schedule","1.14","4.18",""
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.18","","","","","","","fee schedule","1.14","4.18",""
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.17","","","","","","","fee schedule","1.14","4.18","APC"
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.15","","","","","","","fee schedule","1.14","4.18","APC"
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.14","","","","","","","fee schedule","1.14","4.18","APC"
"Factor viii nuwiq recomb 1iu","J7209","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.17","","","","","","","fee schedule","1.14","4.18","APC"
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.02","","","","","","","fee schedule","1.6","5.59",""
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.37","","","","","","","fee schedule","1.6","5.59",""
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.59","","","","","","","fee schedule","1.6","5.59",""
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.65","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.62","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.6","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, afstyla, 1 i.u.","J7210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.65","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.02","","","","","","","fee schedule","1.6","5.59",""
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.37","","","","","","","fee schedule","1.6","5.59",""
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.59","","","","","","","fee schedule","1.6","5.59",""
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.64","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.61","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.6","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, kovaltry, 1 i.u.","J7211","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.64","","","","","","","fee schedule","1.6","5.59","APC"
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.07","","","","","","","fee schedule","1.95","6.76",""
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.49","","","","","","","fee schedule","1.95","6.76",""
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.76","","","","","","","fee schedule","1.95","6.76",""
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2","","","","","","","fee schedule","1.95","6.76","APC"
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.97","","","","","","","fee schedule","1.95","6.76","APC"
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.95","","","","","","","fee schedule","1.95","6.76","APC"
"Inj, ixinity, 1 i.u.","J7213","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.01","","","","","","","fee schedule","1.95","6.76","APC"
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.85","","","","","","","fee schedule","4.76","16.53",""
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.88","","","","","","","fee schedule","4.76","16.53",""
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.53","","","","","","","fee schedule","4.76","16.53",""
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.88","","","","","","","fee schedule","4.76","16.53","APC"
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.8","","","","","","","fee schedule","4.76","16.53","APC"
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.76","","","","","","","fee schedule","4.76","16.53","APC"
"Altuviiio per factor viii iu","J7214","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.9","","","","","","","fee schedule","4.76","16.53","APC"
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1252.51","","","","","","","fee schedule","399.93","1394.3",""
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1339.16","","","","","","","fee schedule","399.93","1394.3",""
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1394.3","","","","","","","fee schedule","399.93","1394.3",""
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","410.71","","","","","","","fee schedule","399.93","1394.3","APC"
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","403.85","","","","","","","fee schedule","399.93","1394.3","APC"
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","399.93","","","","","","","fee schedule","399.93","1394.3","APC"
"Aminolevulinic acid hcl top","J7308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","411.69","","","","","","","fee schedule","399.93","1394.3","APC"
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1080.44","","","","","","","fee schedule","347.12","1202.75",""
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1155.18","","","","","","","fee schedule","347.12","1202.75",""
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1202.75","","","","","","","fee schedule","347.12","1202.75",""
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.48","","","","","","","fee schedule","347.12","1202.75","APC"
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.52","","","","","","","fee schedule","347.12","1202.75","APC"
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.12","","","","","","","fee schedule","347.12","1202.75","APC"
"Fluocinolone acetonide implt","J7311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.33","","","","","","","fee schedule","347.12","1202.75","APC"
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","652.79","","","","","","","fee schedule","208.7","726.69",""
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","697.95","","","","","","","fee schedule","208.7","726.69",""
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","726.69","","","","","","","fee schedule","208.7","726.69",""
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","214.33","","","","","","","fee schedule","208.7","726.69","APC"
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","210.75","","","","","","","fee schedule","208.7","726.69","APC"
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","208.7","","","","","","","fee schedule","208.7","726.69","APC"
"Dexamethasone intra implant","J7312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","214.84","","","","","","","fee schedule","208.7","726.69","APC"
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1583","","","","","","","fee schedule","508.1","1762.21",""
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1692.52","","","","","","","fee schedule","508.1","1762.21",""
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1762.21","","","","","","","fee schedule","508.1","1762.21",""
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","521.8","","","","","","","fee schedule","508.1","1762.21","APC"
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","513.08","","","","","","","fee schedule","508.1","1762.21","APC"
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","508.1","","","","","","","fee schedule","508.1","1762.21","APC"
"Fluocinol acet intravit imp","J7313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","523.04","","","","","","","fee schedule","508.1","1762.21","APC"
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1693.6","","","","","","","fee schedule","540.49","1885.33",""
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1810.77","","","","","","","fee schedule","540.49","1885.33",""
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1885.33","","","","","","","fee schedule","540.49","1885.33",""
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","555.06","","","","","","","fee schedule","540.49","1885.33","APC"
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.79","","","","","","","fee schedule","540.49","1885.33","APC"
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","540.49","","","","","","","fee schedule","540.49","1885.33","APC"
"Inj., yutiq, 0.01 mg","J7314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","556.38","","","","","","","fee schedule","540.49","1885.33","APC"
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","21.24","","","","","","","fee schedule","6.91","23.65",""
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","22.71","","","","","","","fee schedule","6.91","23.65",""
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","23.65","","","","","","","fee schedule","6.91","23.65",""
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.09","","","","","","","fee schedule","6.91","23.65","APC"
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.98","","","","","","","fee schedule","6.91","23.65","APC"
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.91","","","","","","","fee schedule","6.91","23.65","APC"
"Inj, durolane 1 mg","J7318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.11","","","","","","","fee schedule","6.91","23.65","APC"
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","19.14","","","","","","","fee schedule","5.89","21.31",""
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","20.47","","","","","","","fee schedule","5.89","21.31",""
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","21.31","","","","","","","fee schedule","5.89","21.31",""
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.05","","","","","","","fee schedule","5.89","21.31","APC"
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.95","","","","","","","fee schedule","5.89","21.31","APC"
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.89","","","","","","","fee schedule","5.89","21.31","APC"
"Genvisc 850, inj, 1mg","J7320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.06","","","","","","","fee schedule","5.89","21.31","APC"
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.46","","","","","","","fee schedule","17.97","61.74",""
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59.3","","","","","","","fee schedule","17.97","61.74",""
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.74","","","","","","","fee schedule","17.97","61.74",""
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18.45","","","","","","","fee schedule","17.97","61.74","APC"
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18.15","","","","","","","fee schedule","17.97","61.74","APC"
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.97","","","","","","","fee schedule","17.97","61.74","APC"
"Hymovis injection 1 mg","J7322","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18.5","","","","","","","fee schedule","17.97","61.74","APC"
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","364.05","","","","","","","fee schedule","114.7","405.26",""
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","389.23","","","","","","","fee schedule","114.7","405.26",""
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","405.26","","","","","","","fee schedule","114.7","405.26",""
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","117.8","","","","","","","fee schedule","114.7","405.26","APC"
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","115.83","","","","","","","fee schedule","114.7","405.26","APC"
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","114.7","","","","","","","fee schedule","114.7","405.26","APC"
"Euflexxa inj per dose","J7323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","118.08","","","","","","","fee schedule","114.7","405.26","APC"
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","310.69","","","","","","","fee schedule","116.83","345.86",""
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","332.18","","","","","","","fee schedule","116.83","345.86",""
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","345.86","","","","","","","fee schedule","116.83","345.86",""
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.98","","","","","","","fee schedule","116.83","345.86","APC"
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.97","","","","","","","fee schedule","116.83","345.86","APC"
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.83","","","","","","","fee schedule","116.83","345.86","APC"
"Orthovisc inj per dose","J7324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.26","","","","","","","fee schedule","116.83","345.86","APC"
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.91","","","","","","","fee schedule","8.11","32.18",""
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.91","","","","","","","fee schedule","8.11","32.18",""
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","32.18","","","","","","","fee schedule","8.11","32.18",""
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.33","","","","","","","fee schedule","8.11","32.18","APC"
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.19","","","","","","","fee schedule","8.11","32.18","APC"
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.11","","","","","","","fee schedule","8.11","32.18","APC"
"Synvisc or Synvisc-One","J7325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.35","","","","","","","fee schedule","8.11","32.18","APC"
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1666.38","","","","","","","fee schedule","539.84","1855.03",""
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1781.67","","","","","","","fee schedule","539.84","1855.03",""
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1855.03","","","","","","","fee schedule","539.84","1855.03",""
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","554.4","","","","","","","fee schedule","539.84","1855.03","APC"
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","545.14","","","","","","","fee schedule","539.84","1855.03","APC"
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","539.84","","","","","","","fee schedule","539.84","1855.03","APC"
"Gel-one","J7326","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","555.72","","","","","","","fee schedule","539.84","1855.03","APC"
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1680.88","","","","","","","fee schedule","649.32","1871.17",""
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1797.17","","","","","","","fee schedule","649.32","1871.17",""
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1871.17","","","","","","","fee schedule","649.32","1871.17",""
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","666.83","","","","","","","fee schedule","649.32","1871.17","APC"
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","655.69","","","","","","","fee schedule","649.32","1871.17","APC"
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","649.32","","","","","","","fee schedule","649.32","1871.17","APC"
"Monovisc inj per dose","J7327","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","668.42","","","","","","","fee schedule","649.32","1871.17","APC"
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","17.33","","","","","","","fee schedule","4.78","19.29",""
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.53","","","","","","","fee schedule","4.78","19.29",""
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","19.29","","","","","","","fee schedule","4.78","19.29",""
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.91","","","","","","","fee schedule","4.78","19.29","APC"
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.83","","","","","","","fee schedule","4.78","19.29","APC"
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.78","","","","","","","fee schedule","4.78","19.29","APC"
"Inj, trivisc 1 mg","J7329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.93","","","","","","","fee schedule","4.78","19.29","APC"
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.31","","","","","","","fee schedule","10.47","35.97",""
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.54","","","","","","","fee schedule","10.47","35.97",""
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.97","","","","","","","fee schedule","10.47","35.97",""
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.76","","","","","","","fee schedule","10.47","35.97","APC"
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.58","","","","","","","fee schedule","10.47","35.97","APC"
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.47","","","","","","","fee schedule","10.47","35.97","APC"
"Inj., triluron, 1 mg","J7332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.78","","","","","","","fee schedule","10.47","35.97","APC"
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.75","","","","","","","fee schedule","3.49","11.97",""
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.49","","","","","","","fee schedule","3.49","11.97",""
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.97","","","","","","","fee schedule","3.49","11.97",""
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.58","","","","","","","fee schedule","3.49","11.97","APC"
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.52","","","","","","","fee schedule","3.49","11.97","APC"
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.49","","","","","","","fee schedule","3.49","11.97","APC"
"Capsaicin 8% patch","J7336","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.59","","","","","","","fee schedule","3.49","11.97","APC"
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","773.22","","","","","","","fee schedule","248.48","860.75",""
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","826.71","","","","","","","fee schedule","248.48","860.75",""
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","860.75","","","","","","","fee schedule","248.48","860.75",""
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.18","","","","","","","fee schedule","248.48","860.75","APC"
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","250.92","","","","","","","fee schedule","248.48","860.75","APC"
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.48","","","","","","","fee schedule","248.48","860.75","APC"
"Carbidopa levodopa ent 100ml","J7340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.79","","","","","","","fee schedule","248.48","860.75","APC"
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.76","","","","","","","fee schedule","1.83","6.41",""
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.15","","","","","","","fee schedule","1.83","6.41",""
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.41","","","","","","","fee schedule","1.83","6.41",""
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.88","","","","","","","fee schedule","1.83","6.41","APC"
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.85","","","","","","","fee schedule","1.83","6.41","APC"
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.83","","","","","","","fee schedule","1.83","6.41","APC"
"Aminolevulinic acid, 10% gel","J7345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.88","","","","","","","fee schedule","1.83","6.41","APC"
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","675.3","","","","","","","fee schedule","218.12","751.75",""
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","722.02","","","","","","","fee schedule","218.12","751.75",""
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","751.75","","","","","","","fee schedule","218.12","751.75",""
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","224","","","","","","","fee schedule","218.12","751.75","APC"
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.26","","","","","","","fee schedule","218.12","751.75","APC"
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","218.12","","","","","","","fee schedule","218.12","751.75","APC"
"Inj bimatoprost itc imp 1mcg","J7351","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.53","","","","","","","fee schedule","218.12","751.75","APC"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9360.08","","","","","","","fee schedule","3002.29","10419.71",""
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10007.63","","","","","","","fee schedule","3002.29","10419.71",""
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10419.71","","","","","","","fee schedule","3002.29","10419.71",""
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9349.35","","","","","","","fee schedule","3002.29","10419.71","APC 277.30"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9998.71","","","","","","","fee schedule","3002.29","10419.71","APC 296.56"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","10415.1","","","","","","","fee schedule","3002.29","10419.71","APC 308.91"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3083.23","","","","","","","fee schedule","3002.29","10419.71","APC"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3031.72","","","","","","","fee schedule","3002.29","10419.71","APC"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3002.29","","","","","","","fee schedule","3002.29","10419.71","APC"
"Afamelanotide implant, 1 mg","J7352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3090.59","","","","","","","fee schedule","3002.29","10419.71","APC"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.46","","","","","","","fee schedule","59.47","206.45",""
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.29","","","","","","","fee schedule","59.47","206.45",""
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","206.45","","","","","","","fee schedule","59.47","206.45",""
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","185.21","","","","","","","fee schedule","59.47","206.45","APC 277.30"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","198.07","","","","","","","fee schedule","59.47","206.45","APC 296.56"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","206.32","","","","","","","fee schedule","59.47","206.45","APC 308.91"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","61.08","","","","","","","fee schedule","59.47","206.45","APC"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","60.06","","","","","","","fee schedule","59.47","206.45","APC"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59.47","","","","","","","fee schedule","59.47","206.45","APC"
"Anacaulase-bcdb 8.8% gel 1 g","J7353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","61.22","","","","","","","fee schedule","59.47","206.45","APC"
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2129.3","","","","","","","fee schedule","667.85","2370.35",""
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2276.61","","","","","","","fee schedule","667.85","2370.35",""
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2370.35","","","","","","","fee schedule","667.85","2370.35",""
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","685.86","","","","","","","fee schedule","667.85","2370.35","APC"
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","674.4","","","","","","","fee schedule","667.85","2370.35","APC"
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","667.85","","","","","","","fee schedule","667.85","2370.35","APC"
"Cantharidin top, applicator","J7354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","687.49","","","","","","","fee schedule","667.85","2370.35","APC"
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","620.9","","","","","","","fee schedule","199.64","691.19",""
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","663.85","","","","","","","fee schedule","199.64","691.19",""
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","691.19","","","","","","","fee schedule","199.64","691.19",""
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","205.02","","","","","","","fee schedule","199.64","691.19","APC"
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","201.59","","","","","","","fee schedule","199.64","691.19","APC"
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","199.64","","","","","","","fee schedule","199.64","691.19","APC"
"Inj travoprost intra impl","J7355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","205.51","","","","","","","fee schedule","199.64","691.19","APC"
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","36.09","","","","","","","fee schedule","11.57","40.18",""
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","38.59","","","","","","","fee schedule","11.57","40.18",""
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","40.18","","","","","","","fee schedule","11.57","40.18",""
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.88","","","","","","","fee schedule","11.57","40.18","APC"
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.69","","","","","","","fee schedule","11.57","40.18","APC"
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.57","","","","","","","fee schedule","11.57","40.18","APC"
"Mometasone sinus sinuva","J7402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.91","","","","","","","fee schedule","11.57","40.18","APC"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","715.4","","","","","","","fee schedule","259.15","899",""
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","764.9","","","","","","","fee schedule","259.15","899",""
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","796.39","","","","","","","fee schedule","259.15","899",""
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","807","","","","","","","fee schedule","259.15","899","APC 277.30"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","863.05","","","","","","","fee schedule","259.15","899","APC 296.56"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","899","","","","","","","fee schedule","259.15","899","APC 308.91"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","266.13","","","","","","","fee schedule","259.15","899","APC"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","261.69","","","","","","","fee schedule","259.15","899","APC"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","259.15","","","","","","","fee schedule","259.15","899","APC"
"Azathioprine parenteral","J7501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","266.77","","","","","","","fee schedule","259.15","899","APC"
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15941.69","","","","","","","fee schedule","5237.79","17746.41",""
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","17044.57","","","","","","","fee schedule","5237.79","17746.41",""
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17746.41","","","","","","","fee schedule","5237.79","17746.41",""
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5379.01","","","","","","","fee schedule","5237.79","17746.41","APC"
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5289.14","","","","","","","fee schedule","5237.79","17746.41","APC"
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5237.79","","","","","","","fee schedule","5237.79","17746.41","APC"
"Lymphocyte immune globulin","J7504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5391.84","","","","","","","fee schedule","5237.79","17746.41","APC"
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3168.52","","","","","","","fee schedule","1019.35","3527.22",""
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3387.73","","","","","","","fee schedule","1019.35","3527.22",""
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3527.22","","","","","","","fee schedule","1019.35","3527.22",""
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1046.84","","","","","","","fee schedule","1019.35","3527.22","APC"
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1029.35","","","","","","","fee schedule","1019.35","3527.22","APC"
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1019.35","","","","","","","fee schedule","1019.35","3527.22","APC"
"Antithymocyte globuln rabbit","J7511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1049.34","","","","","","","fee schedule","1019.35","3527.22","APC"
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","833.89","","","","","","","fee schedule","268.41","928.29",""
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","891.58","","","","","","","fee schedule","268.41","928.29",""
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","928.29","","","","","","","fee schedule","268.41","928.29",""
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","275.65","","","","","","","fee schedule","268.41","928.29","APC"
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","271.04","","","","","","","fee schedule","268.41","928.29","APC"
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","268.41","","","","","","","fee schedule","268.41","928.29","APC"
"Tacrolimus injection","J7525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","276.31","","","","","","","fee schedule","268.41","928.29","APC"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","267.79","","","","","","","fee schedule","10.32","298.1",""
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","286.31","","","","","","","fee schedule","10.32","298.1",""
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","298.1","","","","","","","fee schedule","10.32","298.1",""
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.14","","","","","","","fee schedule","10.32","298.1","APC 277.30"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34.38","","","","","","","fee schedule","10.32","298.1","APC 296.56"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.81","","","","","","","fee schedule","10.32","298.1","APC 308.91"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.6","","","","","","","fee schedule","10.32","298.1","APC"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.42","","","","","","","fee schedule","10.32","298.1","APC"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.32","","","","","","","fee schedule","10.32","298.1","APC"
"Oral busulfan","J8510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.63","","","","","","","fee schedule","10.32","298.1","APC"
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.16","","","","","","","fee schedule","0.04","0.18",""
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.17","","","","","","","fee schedule","0.04","0.18",""
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.18","","","","","","","fee schedule","0.04","0.18",""
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.18","APC"
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.18","APC"
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.18","APC"
"Capecitabine, oral, 50 mg","J8522","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.04","","","","","","","fee schedule","0.04","0.18","APC"
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","58.93","","","","","","","fee schedule","18.84","65.6",""
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","63","","","","","","","fee schedule","18.84","65.6",""
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","65.6","","","","","","","fee schedule","18.84","65.6",""
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.34","","","","","","","fee schedule","18.84","65.6","APC"
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.02","","","","","","","fee schedule","18.84","65.6","APC"
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.84","","","","","","","fee schedule","18.84","65.6","APC"
"Oral methotrexate (jylamvo)","J8611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.39","","","","","","","fee schedule","18.84","65.6","APC"
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","72.06","","","","","","","fee schedule","23.13","80.22",""
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","77.04","","","","","","","fee schedule","23.13","80.22",""
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","80.22","","","","","","","fee schedule","23.13","80.22",""
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.76","","","","","","","fee schedule","23.13","80.22","APC"
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.36","","","","","","","fee schedule","23.13","80.22","APC"
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.13","","","","","","","fee schedule","23.13","80.22","APC"
"Oral methotrexate (xatmep)","J8612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.81","","","","","","","fee schedule","23.13","80.22","APC"
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1302.27","","","","","","","fee schedule","431.35","1449.7",""
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1392.37","","","","","","","fee schedule","431.35","1449.7",""
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1449.7","","","","","","","fee schedule","431.35","1449.7",""
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","442.98","","","","","","","fee schedule","431.35","1449.7","APC"
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","435.58","","","","","","","fee schedule","431.35","1449.7","APC"
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","431.35","","","","","","","fee schedule","431.35","1449.7","APC"
"Netupitant palonosetron oral","J8655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","444.04","","","","","","","fee schedule","431.35","1449.7","APC"
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.96","","","","","","","fee schedule","1.89","5.52",""
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.3","","","","","","","fee schedule","1.89","5.52",""
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.52","","","","","","","fee schedule","1.89","5.52",""
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.94","","","","","","","fee schedule","1.89","5.52","APC"
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.91","","","","","","","fee schedule","1.89","5.52","APC"
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.89","","","","","","","fee schedule","1.89","5.52","APC"
"Rolapitant, oral, 1mg","J8670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.95","","","","","","","fee schedule","1.89","5.52","APC"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","16858.01","","","","","","","fee schedule","3405.65","18766.46",""
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18024.28","","","","","","","fee schedule","3405.65","18766.46",""
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18766.46","","","","","","","fee schedule","3405.65","18766.46",""
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10605.44","","","","","","","fee schedule","3405.65","18766.46","APC 277.30"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11342.04","","","","","","","fee schedule","3405.65","18766.46","APC 296.56"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11814.37","","","","","","","fee schedule","3405.65","18766.46","APC 308.91"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3497.47","","","","","","","fee schedule","3405.65","18766.46","APC"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3439.04","","","","","","","fee schedule","3405.65","18766.46","APC"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3405.65","","","","","","","fee schedule","3405.65","18766.46","APC"
"Aldesleukin injection","J9015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3505.81","","","","","","","fee schedule","3405.65","18766.46","APC"
"Arsenic trioxide injection","J9017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.63","","","","","","","fee schedule","18.63","20.74",""
"Arsenic trioxide injection","J9017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.92","","","","","","","fee schedule","18.63","20.74",""
"Arsenic trioxide injection","J9017","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.74","","","","","","","fee schedule","18.63","20.74",""
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.85","","","","","","","fee schedule","56.58","195.76",""
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","188.02","","","","","","","fee schedule","56.58","195.76",""
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","195.76","","","","","","","fee schedule","56.58","195.76",""
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.11","","","","","","","fee schedule","56.58","195.76","APC"
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.14","","","","","","","fee schedule","56.58","195.76","APC"
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.58","","","","","","","fee schedule","56.58","195.76","APC"
"Inj, aspara, rylaze, 0.1 mg","J9021","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.25","","","","","","","fee schedule","56.58","195.76","APC"
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","289.44","","","","","","","fee schedule","93.17","322.21",""
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","309.47","","","","","","","fee schedule","93.17","322.21",""
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","322.21","","","","","","","fee schedule","93.17","322.21",""
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.68","","","","","","","fee schedule","93.17","322.21","APC"
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.08","","","","","","","fee schedule","93.17","322.21","APC"
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.17","","","","","","","fee schedule","93.17","322.21","APC"
"Inj, atezolizumab,10 mg","J9022","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","95.91","","","","","","","fee schedule","93.17","322.21","APC"
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","318.95","","","","","","","fee schedule","102.09","355.06",""
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","341.02","","","","","","","fee schedule","102.09","355.06",""
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","355.06","","","","","","","fee schedule","102.09","355.06",""
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.84","","","","","","","fee schedule","102.09","355.06","APC"
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","103.09","","","","","","","fee schedule","102.09","355.06","APC"
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","102.09","","","","","","","fee schedule","102.09","355.06","APC"
"Injection, avelumab, 10 mg","J9023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","105.09","","","","","","","fee schedule","102.09","355.06","APC"
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","100.62","","","","","","","fee schedule","32.22","112.01",""
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","107.58","","","","","","","fee schedule","32.22","112.01",""
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","112.01","","","","","","","fee schedule","32.22","112.01",""
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.08","","","","","","","fee schedule","32.22","112.01","APC"
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.53","","","","","","","fee schedule","32.22","112.01","APC"
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.22","","","","","","","fee schedule","32.22","112.01","APC"
"Inj atezolizumb 5mg hya-tqjs","J9024","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.16","","","","","","","fee schedule","32.22","112.01","APC"
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4984.62","","","","","","","fee schedule","1595.93","5548.91",""
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5329.47","","","","","","","fee schedule","1595.93","5548.91",""
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5548.91","","","","","","","fee schedule","1595.93","5548.91",""
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1638.96","","","","","","","fee schedule","1595.93","5548.91","APC"
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1611.58","","","","","","","fee schedule","1595.93","5548.91","APC"
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1595.93","","","","","","","fee schedule","1595.93","5548.91","APC"
"Inj, tarlatamab-dlle, 1 mg","J9026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1642.87","","","","","","","fee schedule","1595.93","5548.91","APC"
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","46.81","","","","","","","fee schedule","4.27","52.11",""
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","50.05","","","","","","","fee schedule","4.27","52.11",""
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","52.11","","","","","","","fee schedule","4.27","52.11",""
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.39","","","","","","","fee schedule","4.27","52.11","APC"
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.32","","","","","","","fee schedule","4.27","52.11","APC"
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.27","","","","","","","fee schedule","4.27","52.11","APC"
"Clofarabine injection","J9027","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","52.11","APC"
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","299.3","","","","","","","fee schedule","96.56","333.18",""
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","320.01","","","","","","","fee schedule","96.56","333.18",""
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","333.18","","","","","","","fee schedule","96.56","333.18",""
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","99.16","","","","","","","fee schedule","96.56","333.18","APC"
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","97.5","","","","","","","fee schedule","96.56","333.18","APC"
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96.56","","","","","","","fee schedule","96.56","333.18","APC"
"Inj, nogapendekin pmln, 1mcg","J9028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99.4","","","","","","","fee schedule","96.56","333.18","APC"
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","201710.74","","","","","","","fee schedule","64609.13","224545.92",""
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","215665.57","","","","","","","fee schedule","64609.13","224545.92",""
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","224545.92","","","","","","","fee schedule","64609.13","224545.92",""
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66351.04","","","","","","","fee schedule","64609.13","224545.92","APC"
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65242.55","","","","","","","fee schedule","64609.13","224545.92","APC"
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","64609.13","","","","","","","fee schedule","64609.13","224545.92","APC"
"Inj, adstiladrin, per tx dos","J9029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","66509.4","","","","","","","fee schedule","64609.13","224545.92","APC"
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","165.49","","","","","","","fee schedule","53.52","184.22",""
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","176.94","","","","","","","fee schedule","53.52","184.22",""
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","184.22","","","","","","","fee schedule","53.52","184.22",""
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.97","","","","","","","fee schedule","53.52","184.22","APC"
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","54.05","","","","","","","fee schedule","53.52","184.22","APC"
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","53.52","","","","","","","fee schedule","53.52","184.22","APC"
"Injection, belinostat, 10mg","J9032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55.1","","","","","","","fee schedule","53.52","184.22","APC"
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.88","","","","","","","fee schedule","1.92","6.55",""
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6.29","","","","","","","fee schedule","1.92","6.55",""
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6.55","","","","","","","fee schedule","1.92","6.55",""
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1.97","","","","","","","fee schedule","1.92","6.55","APC"
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1.94","","","","","","","fee schedule","1.92","6.55","APC"
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1.92","","","","","","","fee schedule","1.92","6.55","APC"
"Inj., treanda 1 mg","J9033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1.98","","","","","","","fee schedule","1.92","6.55","APC"
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","41.72","","","","","","","fee schedule","13.76","46.44",""
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","44.61","","","","","","","fee schedule","13.76","46.44",""
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","46.44","","","","","","","fee schedule","13.76","46.44",""
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.13","","","","","","","fee schedule","13.76","46.44","APC"
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13.89","","","","","","","fee schedule","13.76","46.44","APC"
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13.76","","","","","","","fee schedule","13.76","46.44","APC"
"Inj., bendeka 1 mg","J9034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.16","","","","","","","fee schedule","13.76","46.44","APC"
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","232.3","","","","","","","fee schedule","74.67","258.6",""
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","248.37","","","","","","","fee schedule","74.67","258.6",""
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","258.6","","","","","","","fee schedule","74.67","258.6",""
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.68","","","","","","","fee schedule","74.67","258.6","APC"
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.4","","","","","","","fee schedule","74.67","258.6","APC"
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.67","","","","","","","fee schedule","74.67","258.6","APC"
"Bevacizumab injection","J9035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.86","","","","","","","fee schedule","74.67","258.6","APC"
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.13","","","","","","","fee schedule","12.53","42.44",""
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","40.77","","","","","","","fee schedule","12.53","42.44",""
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.44","","","","","","","fee schedule","12.53","42.44",""
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12.87","","","","","","","fee schedule","12.53","42.44","APC"
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12.65","","","","","","","fee schedule","12.53","42.44","APC"
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12.53","","","","","","","fee schedule","12.53","42.44","APC"
"Inj. belrapzo/bendamustine","J9036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12.9","","","","","","","fee schedule","12.53","42.44","APC"
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","171.97","","","","","","","fee schedule","56.76","191.44",""
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","183.87","","","","","","","fee schedule","56.76","191.44",""
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","191.44","","","","","","","fee schedule","56.76","191.44",""
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.29","","","","","","","fee schedule","56.76","191.44","APC"
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.32","","","","","","","fee schedule","56.76","191.44","APC"
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.76","","","","","","","fee schedule","56.76","191.44","APC"
"Inj axatilimab-csfr 0.1 mg","J9038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.43","","","","","","","fee schedule","56.76","191.44","APC"
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","519.01","","","","","","","fee schedule","167.54","577.76",""
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","554.91","","","","","","","fee schedule","167.54","577.76",""
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","577.76","","","","","","","fee schedule","167.54","577.76",""
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","172.06","","","","","","","fee schedule","167.54","577.76","APC"
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","169.18","","","","","","","fee schedule","167.54","577.76","APC"
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","167.54","","","","","","","fee schedule","167.54","577.76","APC"
"Injection, blinatumomab","J9039","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","172.47","","","","","","","fee schedule","167.54","577.76","APC"
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","822.09","","","","","","","fee schedule","263.81","915.16",""
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","878.97","","","","","","","fee schedule","263.81","915.16",""
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","915.16","","","","","","","fee schedule","263.81","915.16",""
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","270.93","","","","","","","fee schedule","263.81","915.16","APC"
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","266.4","","","","","","","fee schedule","263.81","915.16","APC"
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","263.81","","","","","","","fee schedule","263.81","915.16","APC"
"Brentuximab vedotin inj","J9042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","271.57","","","","","","","fee schedule","263.81","915.16","APC"
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","722.18","","","","","","","fee schedule","231.82","803.93",""
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","772.14","","","","","","","fee schedule","231.82","803.93",""
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","803.93","","","","","","","fee schedule","231.82","803.93",""
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","238.07","","","","","","","fee schedule","231.82","803.93","APC"
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","234.1","","","","","","","fee schedule","231.82","803.93","APC"
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","231.82","","","","","","","fee schedule","231.82","803.93","APC"
"Cabazitaxel injection","J9043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","238.64","","","","","","","fee schedule","231.82","803.93","APC"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.61","","","","","","","fee schedule","3.53","17.38",""
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.69","","","","","","","fee schedule","3.53","17.38",""
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.38","","","","","","","fee schedule","3.53","17.38",""
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.99","","","","","","","fee schedule","3.53","17.38","APC 277.30"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.75","","","","","","","fee schedule","3.53","17.38","APC 296.56"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","12.24","","","","","","","fee schedule","3.53","17.38","APC 308.91"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.62","","","","","","","fee schedule","3.53","17.38","APC"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.56","","","","","","","fee schedule","3.53","17.38","APC"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.53","","","","","","","fee schedule","3.53","17.38","APC"
"Inj, bortezomib, dr. reddy's","J9046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.63","","","","","","","fee schedule","3.53","17.38","APC"
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","175.19","","","","","","","fee schedule","56.76","195.02",""
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","187.31","","","","","","","fee schedule","56.76","195.02",""
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","195.02","","","","","","","fee schedule","56.76","195.02",""
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.29","","","","","","","fee schedule","56.76","195.02","APC"
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.32","","","","","","","fee schedule","56.76","195.02","APC"
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.76","","","","","","","fee schedule","56.76","195.02","APC"
"Injection, carfilzomib, 1 mg","J9047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.43","","","","","","","fee schedule","56.76","195.02","APC"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","52.47","","","","","","","fee schedule","7.11","58.41",""
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","56.1","","","","","","","fee schedule","7.11","58.41",""
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","58.41","","","","","","","fee schedule","7.11","58.41",""
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.14","","","","","","","fee schedule","7.11","58.41","APC 277.30"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.68","","","","","","","fee schedule","7.11","58.41","APC 296.56"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.66","","","","","","","fee schedule","7.11","58.41","APC 308.91"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7.3","","","","","","","fee schedule","7.11","58.41","APC"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7.18","","","","","","","fee schedule","7.11","58.41","APC"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7.11","","","","","","","fee schedule","7.11","58.41","APC"
"Inj, bortezomib freseniuskab","J9048","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7.32","","","","","","","fee schedule","7.11","58.41","APC"
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","552.18","","","","","","","fee schedule","243.23","614.69",""
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","590.38","","","","","","","fee schedule","243.23","614.69",""
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","614.69","","","","","","","fee schedule","243.23","614.69",""
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","249.78","","","","","","","fee schedule","243.23","614.69","APC"
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","245.61","","","","","","","fee schedule","243.23","614.69","APC"
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","243.23","","","","","","","fee schedule","243.23","614.69","APC"
"Carmustine injection","J9050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","250.38","","","","","","","fee schedule","243.23","614.69","APC"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","825.85","","","","","","","fee schedule","264.89","919.34",""
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","882.98","","","","","","","fee schedule","264.89","919.34",""
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","919.34","","","","","","","fee schedule","264.89","919.34",""
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","824.9","","","","","","","fee schedule","264.89","919.34","APC 277.30"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","882.19","","","","","","","fee schedule","264.89","919.34","APC 296.56"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","918.93","","","","","","","fee schedule","264.89","919.34","APC 308.91"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.04","","","","","","","fee schedule","264.89","919.34","APC"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","267.49","","","","","","","fee schedule","264.89","919.34","APC"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","264.89","","","","","","","fee schedule","264.89","919.34","APC"
"Inj, carmustine (accord)","J9052","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","272.68","","","","","","","fee schedule","264.89","919.34","APC"
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","83.35","","","","","","","fee schedule","26.67","92.78",""
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","89.11","","","","","","","fee schedule","26.67","92.78",""
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","92.78","","","","","","","fee schedule","26.67","92.78",""
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.39","","","","","","","fee schedule","26.67","92.78","APC"
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.93","","","","","","","fee schedule","26.67","92.78","APC"
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.67","","","","","","","fee schedule","26.67","92.78","APC"
"Inj bortezomib boruzu 0.1 mg","J9054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.46","","","","","","","fee schedule","26.67","92.78","APC"
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","249.53","","","","","","","fee schedule","79.94","277.78",""
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","266.8","","","","","","","fee schedule","79.94","277.78",""
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","277.78","","","","","","","fee schedule","79.94","277.78",""
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.09","","","","","","","fee schedule","79.94","277.78","APC"
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.72","","","","","","","fee schedule","79.94","277.78","APC"
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.94","","","","","","","fee schedule","79.94","277.78","APC"
"Cetuximab injection","J9055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.29","","","","","","","fee schedule","79.94","277.78","APC"
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.23","","","","","","","fee schedule","30.45","99.33",""
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.4","","","","","","","fee schedule","30.45","99.33",""
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.33","","","","","","","fee schedule","30.45","99.33",""
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.27","","","","","","","fee schedule","30.45","99.33","APC"
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.75","","","","","","","fee schedule","30.45","99.33","APC"
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.45","","","","","","","fee schedule","30.45","99.33","APC"
"Inj, bendamustine, 1 mg","J9056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.34","","","","","","","fee schedule","30.45","99.33","APC"
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","70.63","","","","","","","fee schedule","22.99","78.62",""
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","75.51","","","","","","","fee schedule","22.99","78.62",""
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","78.62","","","","","","","fee schedule","22.99","78.62",""
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23.61","","","","","","","fee schedule","22.99","78.62","APC"
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.22","","","","","","","fee schedule","22.99","78.62","APC"
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22.99","","","","","","","fee schedule","22.99","78.62","APC"
"Inj, amivantamab-vmjw","J9061","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23.67","","","","","","","fee schedule","22.99","78.62","APC"
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","221.07","","","","","","","fee schedule","70.88","246.1",""
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","236.37","","","","","","","fee schedule","70.88","246.1",""
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","246.1","","","","","","","fee schedule","70.88","246.1",""
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","72.79","","","","","","","fee schedule","70.88","246.1","APC"
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","71.57","","","","","","","fee schedule","70.88","246.1","APC"
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","70.88","","","","","","","fee schedule","70.88","246.1","APC"
"Inj, elahere, 1 mg","J9063","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","72.96","","","","","","","fee schedule","70.88","246.1","APC"
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.94","","","","","","","fee schedule","10.89","34.44",""
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.08","","","","","","","fee schedule","10.89","34.44",""
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.44","","","","","","","fee schedule","10.89","34.44",""
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.19","","","","","","","fee schedule","10.89","34.44","APC"
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11","","","","","","","fee schedule","10.89","34.44","APC"
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.89","","","","","","","fee schedule","10.89","34.44","APC"
"Inj cladribine per 1 mg","J9065","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.21","","","","","","","fee schedule","10.89","34.44","APC"
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.48","","","","","","","fee schedule","0.64","2.76",""
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.65","","","","","","","fee schedule","0.64","2.76",""
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.76","","","","","","","fee schedule","0.64","2.76",""
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.66","","","","","","","fee schedule","0.64","2.76","APC"
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.65","","","","","","","fee schedule","0.64","2.76","APC"
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.64","","","","","","","fee schedule","0.64","2.76","APC"
"Inj cyclophosphamd auromedic","J9071","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.66","","","","","","","fee schedule","0.64","2.76","APC"
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.62","","","","","","","fee schedule","9.29","31.86",""
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.6","","","","","","","fee schedule","9.29","31.86",""
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","31.86","","","","","","","fee schedule","9.29","31.86",""
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.54","","","","","","","fee schedule","9.29","31.86","APC"
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.38","","","","","","","fee schedule","9.29","31.86","APC"
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.29","","","","","","","fee schedule","9.29","31.86","APC"
"Inj cyclophos dr.reddy's 5mg","J9072","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.56","","","","","","","fee schedule","9.29","31.86","APC"
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.69","","","","","","","fee schedule","0.8","4.11",""
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.94","","","","","","","fee schedule","0.8","4.11",""
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.11","","","","","","","fee schedule","0.8","4.11",""
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.82","","","","","","","fee schedule","0.8","4.11","APC"
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.81","","","","","","","fee schedule","0.8","4.11","APC"
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.8","","","","","","","fee schedule","0.8","4.11","APC"
"Inj cyclophosphamd (ingenus)","J9073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.82","","","","","","","fee schedule","0.8","4.11","APC"
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.39","","","","","","","fee schedule","4.01","14.9",""
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.31","","","","","","","fee schedule","4.01","14.9",""
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14.9","","","","","","","fee schedule","4.01","14.9",""
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.12","","","","","","","fee schedule","4.01","14.9","APC"
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.05","","","","","","","fee schedule","4.01","14.9","APC"
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.01","","","","","","","fee schedule","4.01","14.9","APC"
"Inj, cyclophosphamd, sandoz","J9074","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.13","","","","","","","fee schedule","4.01","14.9","APC"
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.97","","","","","","","fee schedule","0.49","2.19",""
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.11","","","","","","","fee schedule","0.49","2.19",""
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.19","","","","","","","fee schedule","0.49","2.19",""
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.5","","","","","","","fee schedule","0.49","2.19","APC"
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.5","","","","","","","fee schedule","0.49","2.19","APC"
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.49","","","","","","","fee schedule","0.49","2.19","APC"
"Inj, cyclophosphamide, nos","J9075","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.51","","","","","","","fee schedule","0.49","2.19","APC"
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.27","","","","","","","fee schedule","29.88","101.6",""
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","97.58","","","","","","","fee schedule","29.88","101.6",""
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","101.6","","","","","","","fee schedule","29.88","101.6",""
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.68","","","","","","","fee schedule","29.88","101.6","APC"
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.17","","","","","","","fee schedule","29.88","101.6","APC"
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.88","","","","","","","fee schedule","29.88","101.6","APC"
"Inj., cemiplimab-rwlc, 1 mg","J9119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.76","","","","","","","fee schedule","29.88","101.6","APC"
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","963.29","","","","","","","fee schedule","334.9","1072.34",""
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1029.93","","","","","","","fee schedule","334.9","1072.34",""
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1072.34","","","","","","","fee schedule","334.9","1072.34",""
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","343.93","","","","","","","fee schedule","334.9","1072.34","APC"
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","338.19","","","","","","","fee schedule","334.9","1072.34","APC"
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","334.9","","","","","","","fee schedule","334.9","1072.34","APC"
"Dactinomycin injection","J9120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","344.75","","","","","","","fee schedule","334.9","1072.34","APC"
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","173.85","","","","","","","fee schedule","56.68","193.53",""
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","185.88","","","","","","","fee schedule","56.68","193.53",""
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","193.53","","","","","","","fee schedule","56.68","193.53",""
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.21","","","","","","","fee schedule","56.68","193.53","APC"
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.23","","","","","","","fee schedule","56.68","193.53","APC"
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.68","","","","","","","fee schedule","56.68","193.53","APC"
"Daratumumab, hyaluronidase","J9144","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.35","","","","","","","fee schedule","56.68","193.53","APC"
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","222.09","","","","","","","fee schedule","72.8","247.23",""
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","237.46","","","","","","","fee schedule","72.8","247.23",""
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","247.23","","","","","","","fee schedule","72.8","247.23",""
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","74.76","","","","","","","fee schedule","72.8","247.23","APC"
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","73.51","","","","","","","fee schedule","72.8","247.23","APC"
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","72.8","","","","","","","fee schedule","72.8","247.23","APC"
"Injection, daratumumab 10 mg","J9145","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","74.94","","","","","","","fee schedule","72.8","247.23","APC"
"Daunorubicin injection","J9150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.84","","","","","","","fee schedule","62.84","69.95",""
"Daunorubicin injection","J9150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","67.18","","","","","","","fee schedule","62.84","69.95",""
"Daunorubicin injection","J9150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","69.95","","","","","","","fee schedule","62.84","69.95",""
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","811.19","","","","","","","fee schedule","261.21","903.02",""
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","867.31","","","","","","","fee schedule","261.21","903.02",""
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","903.02","","","","","","","fee schedule","261.21","903.02",""
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","268.25","","","","","","","fee schedule","261.21","903.02","APC"
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","263.77","","","","","","","fee schedule","261.21","903.02","APC"
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","261.21","","","","","","","fee schedule","261.21","903.02","APC"
"Inj daunorubicin, cytarabine","J9153","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","268.89","","","","","","","fee schedule","261.21","903.02","APC"
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13.86","","","","","","","fee schedule","4.54","15.43",""
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14.82","","","","","","","fee schedule","4.54","15.43",""
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","15.43","","","","","","","fee schedule","4.54","15.43",""
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.66","","","","","","","fee schedule","4.54","15.43","APC"
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.58","","","","","","","fee schedule","4.54","15.43","APC"
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.54","","","","","","","fee schedule","4.54","15.43","APC"
"Degarelix injection","J9155","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.67","","","","","","","fee schedule","4.54","15.43","APC"
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","156.07","","","","","","","fee schedule","51.79","173.74",""
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","166.87","","","","","","","fee schedule","51.79","173.74",""
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","173.74","","","","","","","fee schedule","51.79","173.74",""
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.19","","","","","","","fee schedule","51.79","173.74","APC"
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.3","","","","","","","fee schedule","51.79","173.74","APC"
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.79","","","","","","","fee schedule","51.79","173.74","APC"
"Docetaxel (ingenus), 1 mg","J9172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.32","","","","","","","fee schedule","51.79","173.74","APC"
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","271.1","","","","","","","fee schedule","86.82","301.79",""
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","289.85","","","","","","","fee schedule","86.82","301.79",""
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","301.79","","","","","","","fee schedule","86.82","301.79",""
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","89.16","","","","","","","fee schedule","86.82","301.79","APC"
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.67","","","","","","","fee schedule","86.82","301.79","APC"
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.82","","","","","","","fee schedule","86.82","301.79","APC"
"Inj., durvalumab, 10 mg","J9173","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","89.38","","","","","","","fee schedule","86.82","301.79","APC"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","166.85","","","","","","","fee schedule","53.52","185.74",""
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","178.4","","","","","","","fee schedule","53.52","185.74",""
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.74","","","","","","","fee schedule","53.52","185.74",""
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","166.66","","","","","","","fee schedule","53.52","185.74","APC 277.30"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","178.24","","","","","","","fee schedule","53.52","185.74","APC 296.56"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","185.66","","","","","","","fee schedule","53.52","185.74","APC 308.91"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.96","","","","","","","fee schedule","53.52","185.74","APC"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","54.04","","","","","","","fee schedule","53.52","185.74","APC"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","53.52","","","","","","","fee schedule","53.52","185.74","APC"
"Inj, docetaxel (beizray) 1mg","J9174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55.09","","","","","","","fee schedule","53.52","185.74","APC"
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.06","","","","","","","fee schedule","8.04","27.9",""
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.79","","","","","","","fee schedule","8.04","27.9",""
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.9","","","","","","","fee schedule","8.04","27.9",""
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.26","","","","","","","fee schedule","8.04","27.9","APC"
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.12","","","","","","","fee schedule","8.04","27.9","APC"
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.04","","","","","","","fee schedule","8.04","27.9","APC"
"Injection, elotuzumab, 1mg","J9176","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.28","","","","","","","fee schedule","8.04","27.9","APC"
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","116.58","","","","","","","fee schedule","37.48","129.78",""
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","124.64","","","","","","","fee schedule","37.48","129.78",""
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","129.78","","","","","","","fee schedule","37.48","129.78",""
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.49","","","","","","","fee schedule","37.48","129.78","APC"
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.85","","","","","","","fee schedule","37.48","129.78","APC"
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.48","","","","","","","fee schedule","37.48","129.78","APC"
"Inj enfort vedo-ejfv 0.25mg","J9177","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.58","","","","","","","fee schedule","37.48","129.78","APC"
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","332.56","","","","","","","fee schedule","91.13","370.21",""
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","355.57","","","","","","","fee schedule","91.13","370.21",""
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","370.21","","","","","","","fee schedule","91.13","370.21",""
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","93.59","","","","","","","fee schedule","91.13","370.21","APC"
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","92.02","","","","","","","fee schedule","91.13","370.21","APC"
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","91.13","","","","","","","fee schedule","91.13","370.21","APC"
"Eribulin mesylate injection","J9179","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","93.81","","","","","","","fee schedule","91.13","370.21","APC"
"Fludarabine phosphate inj","J9185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","227.85","","","","","","","fee schedule","227.85","253.64",""
"Fludarabine phosphate inj","J9185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","243.61","","","","","","","fee schedule","227.85","253.64",""
"Fludarabine phosphate inj","J9185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","253.64","","","","","","","fee schedule","227.85","253.64",""
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","13119.25","","","","","","","fee schedule","4210.58","14604.45",""
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","14026.87","","","","","","","fee schedule","4210.58","14604.45",""
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","14604.45","","","","","","","fee schedule","4210.58","14604.45",""
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4324.1","","","","","","","fee schedule","4210.58","14604.45","APC"
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4251.86","","","","","","","fee schedule","4210.58","14604.45","APC"
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4210.58","","","","","","","fee schedule","4210.58","14604.45","APC"
"Floxuridine injection","J9200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4334.42","","","","","","","fee schedule","4210.58","14604.45","APC"
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2334.6","","","","","","","fee schedule","748.34","2598.89",""
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2496.11","","","","","","","fee schedule","748.34","2598.89",""
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2598.89","","","","","","","fee schedule","748.34","2598.89",""
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","768.51","","","","","","","fee schedule","748.34","2598.89","APC"
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","755.67","","","","","","","fee schedule","748.34","2598.89","APC"
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","748.34","","","","","","","fee schedule","748.34","2598.89","APC"
"Goserelin acetate implant","J9202","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","770.35","","","","","","","fee schedule","748.34","2598.89","APC"
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","752.45","","","","","","","fee schedule","241.35","837.63",""
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","804.51","","","","","","","fee schedule","241.35","837.63",""
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","837.63","","","","","","","fee schedule","241.35","837.63",""
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","247.86","","","","","","","fee schedule","241.35","837.63","APC"
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","243.71","","","","","","","fee schedule","241.35","837.63","APC"
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","241.35","","","","","","","fee schedule","241.35","837.63","APC"
"Gemtuzumab ozogamicin 0.1 mg","J9203","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","248.45","","","","","","","fee schedule","241.35","837.63","APC"
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","790.23","","","","","","","fee schedule","253.47","879.69",""
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","844.9","","","","","","","fee schedule","253.47","879.69",""
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","879.69","","","","","","","fee schedule","253.47","879.69",""
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","260.3","","","","","","","fee schedule","253.47","879.69","APC"
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","255.95","","","","","","","fee schedule","253.47","879.69","APC"
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","253.47","","","","","","","fee schedule","253.47","879.69","APC"
"Inj mogamulizumab-kpkc, 1 mg","J9204","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","260.92","","","","","","","fee schedule","253.47","879.69","APC"
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","207.53","","","","","","","fee schedule","67.32","231.02",""
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","221.88","","","","","","","fee schedule","67.32","231.02",""
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","231.02","","","","","","","fee schedule","67.32","231.02",""
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","69.13","","","","","","","fee schedule","67.32","231.02","APC"
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.98","","","","","","","fee schedule","67.32","231.02","APC"
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","67.32","","","","","","","fee schedule","67.32","231.02","APC"
"Inj irinotecan liposome 1 mg","J9205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","69.3","","","","","","","fee schedule","67.32","231.02","APC"
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","440.97","","","","","","","fee schedule","142","490.89",""
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","471.48","","","","","","","fee schedule","142","490.89",""
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","490.89","","","","","","","fee schedule","142","490.89",""
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","145.82","","","","","","","fee schedule","142","490.89","APC"
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","143.39","","","","","","","fee schedule","142","490.89","APC"
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","142","","","","","","","fee schedule","142","490.89","APC"
"Ixabepilone injection","J9207","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","146.17","","","","","","","fee schedule","142","490.89","APC"
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1213.62","","","","","","","fee schedule","392.54","1351.01",""
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1297.58","","","","","","","fee schedule","392.54","1351.01",""
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1351.01","","","","","","","fee schedule","392.54","1351.01",""
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","403.13","","","","","","","fee schedule","392.54","1351.01","APC"
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","396.39","","","","","","","fee schedule","392.54","1351.01","APC"
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","392.54","","","","","","","fee schedule","392.54","1351.01","APC"
"Inj., emapalumab-lzsg, 1 mg","J9210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","404.09","","","","","","","fee schedule","392.54","1351.01","APC"
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","494.24","","","","","","","fee schedule","179.98","550.19",""
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","528.43","","","","","","","fee schedule","179.98","550.19",""
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","550.19","","","","","","","fee schedule","179.98","550.19",""
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","184.83","","","","","","","fee schedule","179.98","550.19","APC"
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","181.74","","","","","","","fee schedule","179.98","550.19","APC"
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","179.98","","","","","","","fee schedule","179.98","550.19","APC"
"Leuprolide acetate suspnsion","J9217","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","185.27","","","","","","","fee schedule","179.98","550.19","APC"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.67","","","","","","","fee schedule","10.16","35.26",""
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.86","","","","","","","fee schedule","10.16","35.26",""
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.26","","","","","","","fee schedule","10.16","35.26",""
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.62","","","","","","","fee schedule","10.16","35.26","APC 277.30"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.82","","","","","","","fee schedule","10.16","35.26","APC 296.56"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.23","","","","","","","fee schedule","10.16","35.26","APC 308.91"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.43","","","","","","","fee schedule","10.16","35.26","APC"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.25","","","","","","","fee schedule","10.16","35.26","APC"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.16","","","","","","","fee schedule","10.16","35.26","APC"
"Indigotindisulfonate sod 1mg","J9220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.45","","","","","","","fee schedule","10.16","35.26","APC"
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","655.49","","","","","","","fee schedule","211.27","729.7",""
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","700.84","","","","","","","fee schedule","211.27","729.7",""
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","729.7","","","","","","","fee schedule","211.27","729.7",""
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","216.97","","","","","","","fee schedule","211.27","729.7","APC"
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.34","","","","","","","fee schedule","211.27","729.7","APC"
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.27","","","","","","","fee schedule","211.27","729.7","APC"
"Inj. lurbinectedin, 0.1 mg","J9223","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","217.48","","","","","","","fee schedule","211.27","729.7","APC"
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","144882.04","","","","","","","fee schedule","45921.06","161283.78",""
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","154905.33","","","","","","","fee schedule","45921.06","161283.78",""
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","161283.78","","","","","","","fee schedule","45921.06","161283.78",""
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47159.13","","","","","","","fee schedule","45921.06","161283.78","APC"
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46371.27","","","","","","","fee schedule","45921.06","161283.78","APC"
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45921.06","","","","","","","fee schedule","45921.06","161283.78","APC"
"Supprelin LA implant","J9226","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47271.68","","","","","","","fee schedule","45921.06","161283.78","APC"
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","263.49","","","","","","","fee schedule","83.54","293.32",""
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","281.72","","","","","","","fee schedule","83.54","293.32",""
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","293.32","","","","","","","fee schedule","83.54","293.32",""
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","85.79","","","","","","","fee schedule","83.54","293.32","APC"
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","84.36","","","","","","","fee schedule","83.54","293.32","APC"
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","83.54","","","","","","","fee schedule","83.54","293.32","APC"
"Inj. isatuximab-irfc 10 mg","J9227","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","86","","","","","","","fee schedule","83.54","293.32","APC"
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","583.24","","","","","","","fee schedule","187.15","649.27",""
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","623.59","","","","","","","fee schedule","187.15","649.27",""
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","649.27","","","","","","","fee schedule","187.15","649.27",""
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","192.19","","","","","","","fee schedule","187.15","649.27","APC"
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","188.98","","","","","","","fee schedule","187.15","649.27","APC"
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","187.15","","","","","","","fee schedule","187.15","649.27","APC"
"Ipilimumab injection","J9228","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","192.65","","","","","","","fee schedule","187.15","649.27","APC"
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8579.8","","","","","","","fee schedule","2752.01","9551.1",""
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9173.37","","","","","","","fee schedule","2752.01","9551.1",""
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9551.1","","","","","","","fee schedule","2752.01","9551.1",""
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2826.21","","","","","","","fee schedule","2752.01","9551.1","APC"
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2778.99","","","","","","","fee schedule","2752.01","9551.1","APC"
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2752.01","","","","","","","fee schedule","2752.01","9551.1","APC"
"Inj inotuzumab ozogam 0.1 mg","J9229","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2832.96","","","","","","","fee schedule","2752.01","9551.1","APC"
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","343.54","","","","","","","fee schedule","97.82","382.43",""
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","367.3","","","","","","","fee schedule","97.82","382.43",""
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","382.43","","","","","","","fee schedule","97.82","382.43",""
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.46","","","","","","","fee schedule","97.82","382.43","APC"
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","98.78","","","","","","","fee schedule","97.82","382.43","APC"
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","97.82","","","","","","","fee schedule","97.82","382.43","APC"
"Inj melphalan hydrochl 50 MG","J9245","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","100.7","","","","","","","fee schedule","97.82","382.43","APC"
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","55.24","","","","","","","fee schedule","18.87","61.49",""
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","59.06","","","","","","","fee schedule","18.87","61.49",""
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","61.49","","","","","","","fee schedule","18.87","61.49",""
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.38","","","","","","","fee schedule","18.87","61.49","APC"
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.05","","","","","","","fee schedule","18.87","61.49","APC"
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.87","","","","","","","fee schedule","18.87","61.49","APC"
"Inj., evomela, 1 mg","J9246","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.87","61.49","APC"
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2505.17","","","","","","","fee schedule","810.9","2788.78",""
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2678.49","","","","","","","fee schedule","810.9","2788.78",""
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2788.78","","","","","","","fee schedule","810.9","2788.78",""
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","832.76","","","","","","","fee schedule","810.9","2788.78","APC"
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","818.85","","","","","","","fee schedule","810.9","2788.78","APC"
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","810.9","","","","","","","fee schedule","810.9","2788.78","APC"
"Inj melphalan (hepzato) 1 mg","J9248","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","834.75","","","","","","","fee schedule","810.9","2788.78","APC"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","206","","","","","","","fee schedule","66.07","229.32",""
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","220.25","","","","","","","fee schedule","66.07","229.32",""
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","229.32","","","","","","","fee schedule","66.07","229.32",""
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","205.76","","","","","","","fee schedule","66.07","229.32","APC 277.30"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","220.05","","","","","","","fee schedule","66.07","229.32","APC 296.56"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","229.21","","","","","","","fee schedule","66.07","229.32","APC 308.91"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.85","","","","","","","fee schedule","66.07","229.32","APC"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.72","","","","","","","fee schedule","66.07","229.32","APC"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.07","","","","","","","fee schedule","66.07","229.32","APC"
"Inj, melphalan (apotex) 1 mg","J9249","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.02","","","","","","","fee schedule","66.07","229.32","APC"
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","201.55","","","","","","","fee schedule","81.46","224.37",""
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","215.49","","","","","","","fee schedule","81.46","224.37",""
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","224.37","","","","","","","fee schedule","81.46","224.37",""
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","83.66","","","","","","","fee schedule","81.46","224.37","APC"
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","82.26","","","","","","","fee schedule","81.46","224.37","APC"
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","81.46","","","","","","","fee schedule","81.46","224.37","APC"
"Nelarabine injection","J9261","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.86","","","","","","","fee schedule","81.46","224.37","APC"
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.54","","","","","","","fee schedule","10.75","42.9",""
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.21","","","","","","","fee schedule","10.75","42.9",""
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","42.9","","","","","","","fee schedule","10.75","42.9",""
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.04","","","","","","","fee schedule","10.75","42.9","APC"
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.86","","","","","","","fee schedule","10.75","42.9","APC"
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.75","","","","","","","fee schedule","10.75","42.9","APC"
"Paclitaxel protein bound","J9264","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.07","","","","","","","fee schedule","10.75","42.9","APC"
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","90388.51","","","","","","","fee schedule","28992.54","100621.17",""
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","96641.8","","","","","","","fee schedule","28992.54","100621.17",""
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","100621.17","","","","","","","fee schedule","28992.54","100621.17",""
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29774.2","","","","","","","fee schedule","28992.54","100621.17","APC"
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29276.78","","","","","","","fee schedule","28992.54","100621.17","APC"
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28992.54","","","","","","","fee schedule","28992.54","100621.17","APC"
"Pegaspargase injection","J9266","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29845.26","","","","","","","fee schedule","28992.54","100621.17","APC"
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8089.57","","","","","","","fee schedule","2660.32","9005.37",""
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8649.23","","","","","","","fee schedule","2660.32","9005.37",""
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9005.37","","","","","","","fee schedule","2660.32","9005.37",""
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2732.04","","","","","","","fee schedule","2660.32","9005.37","APC"
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2686.4","","","","","","","fee schedule","2660.32","9005.37","APC"
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2660.32","","","","","","","fee schedule","2660.32","9005.37","APC"
"Pentostatin injection","J9268","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2738.56","","","","","","","fee schedule","2660.32","9005.37","APC"
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1108.61","","","","","","","fee schedule","364.07","1234.11",""
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1185.31","","","","","","","fee schedule","364.07","1234.11",""
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1234.11","","","","","","","fee schedule","364.07","1234.11",""
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","373.88","","","","","","","fee schedule","364.07","1234.11","APC"
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","367.64","","","","","","","fee schedule","364.07","1234.11","APC"
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","364.07","","","","","","","fee schedule","364.07","1234.11","APC"
"Inj. tagraxofusp-erzs 10 mcg","J9269","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","374.78","","","","","","","fee schedule","364.07","1234.11","APC"
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","186.22","","","","","","","fee schedule","61.5","207.3",""
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","199.1","","","","","","","fee schedule","61.5","207.3",""
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","207.3","","","","","","","fee schedule","61.5","207.3",""
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.15","","","","","","","fee schedule","61.5","207.3","APC"
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.1","","","","","","","fee schedule","61.5","207.3","APC"
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61.5","","","","","","","fee schedule","61.5","207.3","APC"
"Inj pembrolizumab","J9271","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63.31","","","","","","","fee schedule","61.5","207.3","APC"
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","775.35","","","","","","","fee schedule","248.59","863.12",""
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","828.99","","","","","","","fee schedule","248.59","863.12",""
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","863.12","","","","","","","fee schedule","248.59","863.12",""
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","255.29","","","","","","","fee schedule","248.59","863.12","APC"
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.02","","","","","","","fee schedule","248.59","863.12","APC"
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.59","","","","","","","fee schedule","248.59","863.12","APC"
"Inj, dostarlimab-gxly, 10 mg","J9272","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.9","","","","","","","fee schedule","248.59","863.12","APC"
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","599.91","","","","","","","fee schedule","192.54","667.82",""
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","641.41","","","","","","","fee schedule","192.54","667.82",""
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","667.82","","","","","","","fee schedule","192.54","667.82",""
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","197.73","","","","","","","fee schedule","192.54","667.82","APC"
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","194.42","","","","","","","fee schedule","192.54","667.82","APC"
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","192.54","","","","","","","fee schedule","192.54","667.82","APC"
"Inj tisotu vedotin-tftv, 1mg","J9273","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","198.2","","","","","","","fee schedule","192.54","667.82","APC"
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","690.35","","","","","","","fee schedule","221.43","768.5",""
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","738.11","","","","","","","fee schedule","221.43","768.5",""
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","768.5","","","","","","","fee schedule","221.43","768.5",""
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","227.4","","","","","","","fee schedule","221.43","768.5","APC"
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","223.6","","","","","","","fee schedule","221.43","768.5","APC"
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","221.43","","","","","","","fee schedule","221.43","768.5","APC"
"Inj, tebentafusp-tebn, 1 mcg","J9274","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","227.94","","","","","","","fee schedule","221.43","768.5","APC"
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79.75","","","","","","","fee schedule","25.55","88.78",""
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.27","","","","","","","fee schedule","25.55","88.78",""
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","88.78","","","","","","","fee schedule","25.55","88.78",""
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.24","","","","","","","fee schedule","25.55","88.78","APC"
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.8","","","","","","","fee schedule","25.55","88.78","APC"
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.55","","","","","","","fee schedule","25.55","88.78","APC"
"Inj zanidatamab-hrii, 2 mg","J9276","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.3","","","","","","","fee schedule","25.55","88.78","APC"
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.9","","","","","","","fee schedule","20.75","100.08",""
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","96.12","","","","","","","fee schedule","20.75","100.08",""
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","100.08","","","","","","","fee schedule","20.75","100.08",""
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.31","","","","","","","fee schedule","20.75","100.08","APC"
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.96","","","","","","","fee schedule","20.75","100.08","APC"
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.75","","","","","","","fee schedule","20.75","100.08","APC"
"Mitomycin injection","J9280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.37","","","","","","","fee schedule","20.75","100.08","APC"
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1009.4","","","","","","","fee schedule","324.9","1123.67",""
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1079.23","","","","","","","fee schedule","324.9","1123.67",""
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1123.67","","","","","","","fee schedule","324.9","1123.67",""
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","333.66","","","","","","","fee schedule","324.9","1123.67","APC"
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","328.09","","","","","","","fee schedule","324.9","1123.67","APC"
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","324.9","","","","","","","fee schedule","324.9","1123.67","APC"
"Mitomycin instillation","J9281","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","334.46","","","","","","","fee schedule","324.9","1123.67","APC"
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","8810.41","","","","","","","fee schedule","2823.24","9807.82",""
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9419.94","","","","","","","fee schedule","2823.24","9807.82",""
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9807.82","","","","","","","fee schedule","2823.24","9807.82",""
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2899.36","","","","","","","fee schedule","2823.24","9807.82","APC"
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2850.92","","","","","","","fee schedule","2823.24","9807.82","APC"
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2823.24","","","","","","","fee schedule","2823.24","9807.82","APC"
"Inj glofitamab gxbm, 2.5 mg","J9286","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2906.28","","","","","","","fee schedule","2823.24","9807.82","APC"
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","85.03","","","","","","","fee schedule","27.91","94.66",""
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","90.92","","","","","","","fee schedule","27.91","94.66",""
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","94.66","","","","","","","fee schedule","27.91","94.66",""
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.66","","","","","","","fee schedule","27.91","94.66","APC"
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.18","","","","","","","fee schedule","27.91","94.66","APC"
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.91","","","","","","","fee schedule","27.91","94.66","APC"
"Inj nivolumab 2 mg hyaluron","J9289","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.73","","","","","","","fee schedule","27.91","94.66","APC"
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","264.83","","","","","","","fee schedule","83.99","294.81",""
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","283.15","","","","","","","fee schedule","83.99","294.81",""
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","294.81","","","","","","","fee schedule","83.99","294.81",""
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","86.25","","","","","","","fee schedule","83.99","294.81","APC"
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","84.81","","","","","","","fee schedule","83.99","294.81","APC"
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","83.99","","","","","","","fee schedule","83.99","294.81","APC"
"Inj, pemetrexed (avyxa) 10mg","J9292","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","86.46","","","","","","","fee schedule","83.99","294.81","APC"
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","94.13","","","","","","","fee schedule","24.35","104.78",""
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","100.64","","","","","","","fee schedule","24.35","104.78",""
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","104.78","","","","","","","fee schedule","24.35","104.78",""
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25.01","","","","","","","fee schedule","24.35","104.78","APC"
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.59","","","","","","","fee schedule","24.35","104.78","APC"
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24.35","","","","","","","fee schedule","24.35","104.78","APC"
"Mitoxantrone hydrochl / 5 MG","J9293","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25.07","","","","","","","fee schedule","24.35","104.78","APC"
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","15.68","","","","","","","fee schedule","3.62","17.45",""
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","16.76","","","","","","","fee schedule","3.62","17.45",""
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","17.45","","","","","","","fee schedule","3.62","17.45",""
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3.72","","","","","","","fee schedule","3.62","17.45","APC"
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3.65","","","","","","","fee schedule","3.62","17.45","APC"
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3.62","","","","","","","fee schedule","3.62","17.45","APC"
"Inj pemetrexed, hospira 10mg","J9294","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3.72","","","","","","","fee schedule","3.62","17.45","APC"
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.22","","","","","","","fee schedule","5.85","20.28",""
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.48","","","","","","","fee schedule","5.85","20.28",""
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.28","","","","","","","fee schedule","5.85","20.28",""
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6","","","","","","","fee schedule","5.85","20.28","APC"
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.9","","","","","","","fee schedule","5.85","20.28","APC"
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.85","","","","","","","fee schedule","5.85","20.28","APC"
"Injection, necitumumab, 1 mg","J9295","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.02","","","","","","","fee schedule","5.85","20.28","APC"
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","30.97","","","","","","","fee schedule","9.93","34.48",""
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","33.12","","","","","","","fee schedule","9.93","34.48",""
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","34.48","","","","","","","fee schedule","9.93","34.48",""
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.2","","","","","","","fee schedule","9.93","34.48","APC"
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.03","","","","","","","fee schedule","9.93","34.48","APC"
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.93","","","","","","","fee schedule","9.93","34.48","APC"
"Inj pemetrexed (accord) 10mg","J9296","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.22","","","","","","","fee schedule","9.93","34.48","APC"
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","628.53","","","","","","","fee schedule","201.79","699.68",""
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","672.01","","","","","","","fee schedule","201.79","699.68",""
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","699.68","","","","","","","fee schedule","201.79","699.68",""
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","207.23","","","","","","","fee schedule","201.79","699.68","APC"
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","203.77","","","","","","","fee schedule","201.79","699.68","APC"
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","201.79","","","","","","","fee schedule","201.79","699.68","APC"
"Inj nivol relatlimab 3mg/1mg","J9298","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","207.72","","","","","","","fee schedule","201.79","699.68","APC"
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","104.94","","","","","","","fee schedule","33.62","116.82",""
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","112.2","","","","","","","fee schedule","33.62","116.82",""
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","116.82","","","","","","","fee schedule","33.62","116.82",""
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34.53","","","","","","","fee schedule","33.62","116.82","APC"
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.95","","","","","","","fee schedule","33.62","116.82","APC"
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.62","","","","","","","fee schedule","33.62","116.82","APC"
"Injection, nivolumab","J9299","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34.61","","","","","","","fee schedule","33.62","116.82","APC"
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","249.5","","","","","","","fee schedule","80.58","277.75",""
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","266.76","","","","","","","fee schedule","80.58","277.75",""
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","277.75","","","","","","","fee schedule","80.58","277.75",""
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.75","","","","","","","fee schedule","80.58","277.75","APC"
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.37","","","","","","","fee schedule","80.58","277.75","APC"
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.58","","","","","","","fee schedule","80.58","277.75","APC"
"Obinutuzumab inj","J9301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.95","","","","","","","fee schedule","80.58","277.75","APC"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","197.89","","","","","","","fee schedule","63.48","220.29",""
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","211.58","","","","","","","fee schedule","63.48","220.29",""
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","220.29","","","","","","","fee schedule","63.48","220.29",""
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","197.68","","","","","","","fee schedule","63.48","220.29","APC 277.30"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","211.41","","","","","","","fee schedule","63.48","220.29","APC 296.56"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","220.21","","","","","","","fee schedule","63.48","220.29","APC 308.91"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.19","","","","","","","fee schedule","63.48","220.29","APC"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64.1","","","","","","","fee schedule","63.48","220.29","APC"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.48","","","","","","","fee schedule","63.48","220.29","APC"
"Ofatumumab injection","J9302","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.35","","","","","","","fee schedule","63.48","220.29","APC"
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","548.71","","","","","","","fee schedule","176.49","610.83",""
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","586.67","","","","","","","fee schedule","176.49","610.83",""
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","610.83","","","","","","","fee schedule","176.49","610.83",""
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","181.25","","","","","","","fee schedule","176.49","610.83","APC"
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","178.22","","","","","","","fee schedule","176.49","610.83","APC"
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","176.49","","","","","","","fee schedule","176.49","610.83","APC"
"Panitumumab injection","J9303","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","181.68","","","","","","","fee schedule","176.49","610.83","APC"
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","167.71","","","","","","","fee schedule","47.25","186.7",""
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","179.32","","","","","","","fee schedule","47.25","186.7",""
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","186.7","","","","","","","fee schedule","47.25","186.7",""
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48.52","","","","","","","fee schedule","47.25","186.7","APC"
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.71","","","","","","","fee schedule","47.25","186.7","APC"
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47.25","","","","","","","fee schedule","47.25","186.7","APC"
"Inj. pemetrexed, 10 mg","J9304","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.64","","","","","","","fee schedule","47.25","186.7","APC"
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","11.86","","","","","","","fee schedule","4.44","13.2",""
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.68","","","","","","","fee schedule","4.44","13.2",""
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.2","","","","","","","fee schedule","4.44","13.2",""
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.56","","","","","","","fee schedule","4.44","13.2","APC"
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.49","","","","","","","fee schedule","4.44","13.2","APC"
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.44","","","","","","","fee schedule","4.44","13.2","APC"
"Pemetrexed injection","J9305","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.57","","","","","","","fee schedule","4.44","13.2","APC"
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","53.71","","","","","","","fee schedule","17.36","59.79",""
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","57.43","","","","","","","fee schedule","17.36","59.79",""
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","59.79","","","","","","","fee schedule","17.36","59.79",""
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17.83","","","","","","","fee schedule","17.36","59.79","APC"
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17.53","","","","","","","fee schedule","17.36","59.79","APC"
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17.36","","","","","","","fee schedule","17.36","59.79","APC"
"Injection, pertuzumab, 1 mg","J9306","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17.87","","","","","","","fee schedule","17.36","59.79","APC"
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1236.48","","","","","","","fee schedule","400.48","1376.46",""
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1322.02","","","","","","","fee schedule","400.48","1376.46",""
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1376.46","","","","","","","fee schedule","400.48","1376.46",""
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","411.28","","","","","","","fee schedule","400.48","1376.46","APC"
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","404.41","","","","","","","fee schedule","400.48","1376.46","APC"
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","400.48","","","","","","","fee schedule","400.48","1376.46","APC"
"Pralatrexate injection","J9307","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","412.26","","","","","","","fee schedule","400.48","1376.46","APC"
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","236.75","","","","","","","fee schedule","75.85","263.55",""
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","253.13","","","","","","","fee schedule","75.85","263.55",""
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","263.55","","","","","","","fee schedule","75.85","263.55",""
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","77.89","","","","","","","fee schedule","75.85","263.55","APC"
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.59","","","","","","","fee schedule","75.85","263.55","APC"
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","75.85","","","","","","","fee schedule","75.85","263.55","APC"
"Injection, ramucirumab","J9308","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.08","","","","","","","fee schedule","75.85","263.55","APC"
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","433.21","","","","","","","fee schedule","139.4","482.25",""
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","463.18","","","","","","","fee schedule","139.4","482.25",""
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","482.25","","","","","","","fee schedule","139.4","482.25",""
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.16","","","","","","","fee schedule","139.4","482.25","APC"
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","140.77","","","","","","","fee schedule","139.4","482.25","APC"
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.4","","","","","","","fee schedule","139.4","482.25","APC"
"Inj, polatuzumab vedotin 1mg","J9309","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.5","","","","","","","fee schedule","139.4","482.25","APC"
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","117.53","","","","","","","fee schedule","37.43","130.84",""
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","125.66","","","","","","","fee schedule","37.43","130.84",""
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","130.84","","","","","","","fee schedule","37.43","130.84",""
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.44","","","","","","","fee schedule","37.43","130.84","APC"
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.79","","","","","","","fee schedule","37.43","130.84","APC"
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.43","","","","","","","fee schedule","37.43","130.84","APC"
"Inj rituximab, hyaluronidase","J9311","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.53","","","","","","","fee schedule","37.43","130.84","APC"
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","241.46","","","","","","","fee schedule","76.72","268.79",""
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","258.16","","","","","","","fee schedule","76.72","268.79",""
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","268.79","","","","","","","fee schedule","76.72","268.79",""
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.79","","","","","","","fee schedule","76.72","268.79","APC"
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.48","","","","","","","fee schedule","76.72","268.79","APC"
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.72","","","","","","","fee schedule","76.72","268.79","APC"
"Inj., rituximab, 10 mg","J9312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.98","","","","","","","fee schedule","76.72","268.79","APC"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","74.38","","","","","","","fee schedule","23.86","82.8",""
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","79.53","","","","","","","fee schedule","23.86","82.8",""
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","82.8","","","","","","","fee schedule","23.86","82.8",""
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","74.31","","","","","","","fee schedule","23.86","82.8","APC 277.30"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","79.47","","","","","","","fee schedule","23.86","82.8","APC 296.56"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","82.78","","","","","","","fee schedule","23.86","82.8","APC 308.91"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.51","","","","","","","fee schedule","23.86","82.8","APC"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24.1","","","","","","","fee schedule","23.86","82.8","APC"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.86","","","","","","","fee schedule","23.86","82.8","APC"
"Inj., lumoxiti, 0.01 mg","J9313","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.56","","","","","","","fee schedule","23.86","82.8","APC"
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","12.05","","","","","","","fee schedule","12.05","16.32",""
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","12.89","","","","","","","fee schedule","12.05","16.32",""
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","13.42","","","","","","","fee schedule","12.05","16.32",""
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16.28","","","","","","","fee schedule","12.05","16.32","APC"
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16.01","","","","","","","fee schedule","12.05","16.32","APC"
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15.85","","","","","","","fee schedule","12.05","16.32","APC"
"Inj pemetrexed (teva) 10mg","J9314","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16.32","","","","","","","fee schedule","12.05","16.32","APC"
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","201.58","","","","","","","fee schedule","63.34","224.4",""
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","215.53","","","","","","","fee schedule","63.34","224.4",""
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","224.4","","","","","","","fee schedule","63.34","224.4",""
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.05","","","","","","","fee schedule","63.34","224.4","APC"
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.96","","","","","","","fee schedule","63.34","224.4","APC"
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.34","","","","","","","fee schedule","63.34","224.4","APC"
"Pertuzu, trastuzu, 10 mg","J9316","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.2","","","","","","","fee schedule","63.34","224.4","APC"
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.31","","","","","","","fee schedule","37","128.36",""
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.28","","","","","","","fee schedule","37","128.36",""
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.36","","","","","","","fee schedule","37","128.36",""
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38","","","","","","","fee schedule","37","128.36","APC"
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.36","","","","","","","fee schedule","37","128.36","APC"
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37","","","","","","","fee schedule","37","128.36","APC"
"Sacituzumab govitecan-hziy","J9317","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.09","","","","","","","fee schedule","37","128.36","APC"
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","90.69","","","","","","","fee schedule","29.09","100.96",""
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","96.97","","","","","","","fee schedule","29.09","100.96",""
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","100.96","","","","","","","fee schedule","29.09","100.96",""
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.87","","","","","","","fee schedule","29.09","100.96","APC"
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.37","","","","","","","fee schedule","29.09","100.96","APC"
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.09","","","","","","","fee schedule","29.09","100.96","APC"
"Inj romidepsin non-lyo 0.1mg","J9318","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.94","","","","","","","fee schedule","29.09","100.96","APC"
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","98.83","","","","","","","fee schedule","31.39","110.02",""
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","105.67","","","","","","","fee schedule","31.39","110.02",""
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","110.02","","","","","","","fee schedule","31.39","110.02",""
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.24","","","","","","","fee schedule","31.39","110.02","APC"
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.7","","","","","","","fee schedule","31.39","110.02","APC"
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.39","","","","","","","fee schedule","31.39","110.02","APC"
"Inj romidepsin lyophil 0.1mg","J9319","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.32","","","","","","","fee schedule","31.39","110.02","APC"
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","177","","","","","","","fee schedule","56.96","197.04",""
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","189.24","","","","","","","fee schedule","56.96","197.04",""
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","197.04","","","","","","","fee schedule","56.96","197.04",""
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.49","","","","","","","fee schedule","56.96","197.04","APC"
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.52","","","","","","","fee schedule","56.96","197.04","APC"
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56.96","","","","","","","fee schedule","56.96","197.04","APC"
"Inj epcoritamab-bysp 0.16 mg","J9321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.63","","","","","","","fee schedule","56.96","197.04","APC"
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","32.88","","","","","","","fee schedule","0.13","36.6",""
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.16","","","","","","","fee schedule","0.13","36.6",""
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.6","","","","","","","fee schedule","0.13","36.6",""
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.13","","","","","","","fee schedule","0.13","36.6","APC"
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.13","","","","","","","fee schedule","0.13","36.6","APC"
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.13","","","","","","","fee schedule","0.13","36.6","APC"
"Inj pemetrexed ditromethamin","J9323","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.13","","","","","","","fee schedule","0.13","36.6","APC"
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","254.72","","","","","","","fee schedule","77.32","283.55",""
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","272.34","","","","","","","fee schedule","77.32","283.55",""
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","283.55","","","","","","","fee schedule","77.32","283.55",""
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.41","","","","","","","fee schedule","77.32","283.55","APC"
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.08","","","","","","","fee schedule","77.32","283.55","APC"
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.32","","","","","","","fee schedule","77.32","283.55","APC"
"Inj, pemrydi rtu, 10 mg","J9324","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.6","","","","","","","fee schedule","77.32","283.55","APC"
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","233.89","","","","","","","fee schedule","75.41","260.37",""
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","250.07","","","","","","","fee schedule","75.41","260.37",""
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","260.37","","","","","","","fee schedule","75.41","260.37",""
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","77.45","","","","","","","fee schedule","75.41","260.37","APC"
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.15","","","","","","","fee schedule","75.41","260.37","APC"
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","75.41","","","","","","","fee schedule","75.41","260.37","APC"
"Inj talimogene laherparepvec","J9325","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","77.63","","","","","","","fee schedule","75.41","260.37","APC"
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.04","","","","","","","fee schedule","10.6","36.78",""
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.33","","","","","","","fee schedule","10.6","36.78",""
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.78","","","","","","","fee schedule","10.6","36.78",""
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.88","","","","","","","fee schedule","10.6","36.78","APC"
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.7","","","","","","","fee schedule","10.6","36.78","APC"
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.6","","","","","","","fee schedule","10.6","36.78","APC"
"Temozolomide injection","J9328","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.91","","","","","","","fee schedule","10.6","36.78","APC"
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.6","","","","","","","fee schedule","58.59","203.27",""
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.23","","","","","","","fee schedule","58.59","203.27",""
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.27","","","","","","","fee schedule","58.59","203.27",""
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.17","","","","","","","fee schedule","58.59","203.27","APC"
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.17","","","","","","","fee schedule","58.59","203.27","APC"
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.59","","","","","","","fee schedule","58.59","203.27","APC"
"Inj, tislelizumab-jsgr","J9329","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.32","","","","","","","fee schedule","58.59","203.27","APC"
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","102.68","","","","","","","fee schedule","27.25","114.31",""
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","109.79","","","","","","","fee schedule","27.25","114.31",""
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.31","","","","","","","fee schedule","27.25","114.31",""
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.98","","","","","","","fee schedule","27.25","114.31","APC"
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.51","","","","","","","fee schedule","27.25","114.31","APC"
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.25","","","","","","","fee schedule","27.25","114.31","APC"
"Temsirolimus injection","J9330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.05","","","","","","","fee schedule","27.25","114.31","APC"
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","268.81","","","","","","","fee schedule","86.26","299.24",""
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","287.4","","","","","","","fee schedule","86.26","299.24",""
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","299.24","","","","","","","fee schedule","86.26","299.24",""
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","88.59","","","","","","","fee schedule","86.26","299.24","APC"
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","87.11","","","","","","","fee schedule","86.26","299.24","APC"
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","86.26","","","","","","","fee schedule","86.26","299.24","APC"
"Inj sirolimus prot part 1 mg","J9331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","88.8","","","","","","","fee schedule","86.26","299.24","APC"
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","103.03","","","","","","","fee schedule","32.79","114.7",""
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","110.16","","","","","","","fee schedule","32.79","114.7",""
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","114.7","","","","","","","fee schedule","32.79","114.7",""
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.67","","","","","","","fee schedule","32.79","114.7","APC"
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.11","","","","","","","fee schedule","32.79","114.7","APC"
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.79","","","","","","","fee schedule","32.79","114.7","APC"
"Inj efgartigimod 2mg","J9332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.75","","","","","","","fee schedule","32.79","114.7","APC"
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","73.65","","","","","","","fee schedule","23.63","81.99",""
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","78.74","","","","","","","fee schedule","23.63","81.99",""
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","81.99","","","","","","","fee schedule","23.63","81.99",""
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24.27","","","","","","","fee schedule","23.63","81.99","APC"
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23.86","","","","","","","fee schedule","23.63","81.99","APC"
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23.63","","","","","","","fee schedule","23.63","81.99","APC"
"Inj ronzanolixizum-noli 1 mg","J9333","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24.32","","","","","","","fee schedule","23.63","81.99","APC"
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","107.29","","","","","","","fee schedule","34.57","119.44",""
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","114.72","","","","","","","fee schedule","34.57","119.44",""
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","119.44","","","","","","","fee schedule","34.57","119.44",""
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.5","","","","","","","fee schedule","34.57","119.44","APC"
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.9","","","","","","","fee schedule","34.57","119.44","APC"
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.57","","","","","","","fee schedule","34.57","119.44","APC"
"Inj efgart-alfa 2mg hya-qvfc","J9334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.58","","","","","","","fee schedule","34.57","119.44","APC"
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","38.92","","","","","","","fee schedule","10.75","43.33",""
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","41.62","","","","","","","fee schedule","10.75","43.33",""
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","43.33","","","","","","","fee schedule","10.75","43.33",""
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.04","","","","","","","fee schedule","10.75","43.33","APC"
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.85","","","","","","","fee schedule","10.75","43.33","APC"
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.75","","","","","","","fee schedule","10.75","43.33","APC"
"Inj thiotepa nos 1 mg","J9342","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.06","","","","","","","fee schedule","10.75","43.33","APC"
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95.34","","","","","","","fee schedule","31.17","106.13",""
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","101.93","","","","","","","fee schedule","31.17","106.13",""
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106.13","","","","","","","fee schedule","31.17","106.13",""
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.01","","","","","","","fee schedule","31.17","106.13","APC"
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.47","","","","","","","fee schedule","31.17","106.13","APC"
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.17","","","","","","","fee schedule","31.17","106.13","APC"
"Inj, retifanlimab-dlwr, 1 mg","J9345","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.08","","","","","","","fee schedule","31.17","106.13","APC"
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","448.92","","","","","","","fee schedule","143.71","499.74",""
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","479.98","","","","","","","fee schedule","143.71","499.74",""
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","499.74","","","","","","","fee schedule","143.71","499.74",""
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","147.59","","","","","","","fee schedule","143.71","499.74","APC"
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","145.12","","","","","","","fee schedule","143.71","499.74","APC"
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","143.71","","","","","","","fee schedule","143.71","499.74","APC"
"Inj, tremelimumab-actl, 1 mg","J9347","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","147.94","","","","","","","fee schedule","143.71","499.74","APC"
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2181.19","","","","","","","fee schedule","699.72","2428.12",""
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2332.09","","","","","","","fee schedule","699.72","2428.12",""
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2428.12","","","","","","","fee schedule","699.72","2428.12",""
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","718.59","","","","","","","fee schedule","699.72","2428.12","APC"
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","706.58","","","","","","","fee schedule","699.72","2428.12","APC"
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","699.72","","","","","","","fee schedule","699.72","2428.12","APC"
"Inj. naxitamab-gqgk, 1 mg","J9348","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","720.3","","","","","","","fee schedule","699.72","2428.12","APC"
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","44.77","","","","","","","fee schedule","14.6","49.84",""
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","47.87","","","","","","","fee schedule","14.6","49.84",""
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","49.84","","","","","","","fee schedule","14.6","49.84",""
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.99","","","","","","","fee schedule","14.6","49.84","APC"
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.74","","","","","","","fee schedule","14.6","49.84","APC"
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.6","","","","","","","fee schedule","14.6","49.84","APC"
"Inj., tafasitamab-cxix","J9349","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15.03","","","","","","","fee schedule","14.6","49.84","APC"
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2075.75","","","","","","","fee schedule","667.72","2310.74",""
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2219.35","","","","","","","fee schedule","667.72","2310.74",""
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2310.74","","","","","","","fee schedule","667.72","2310.74",""
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","685.72","","","","","","","fee schedule","667.72","2310.74","APC"
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","674.27","","","","","","","fee schedule","667.72","2310.74","APC"
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","667.72","","","","","","","fee schedule","667.72","2310.74","APC"
"Inj mosunetuzumab-axgb, 1 mg","J9350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","687.36","","","","","","","fee schedule","667.72","2310.74","APC"
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1218.16","","","","","","","fee schedule","398.89","1356.07",""
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1302.44","","","","","","","fee schedule","398.89","1356.07",""
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1356.07","","","","","","","fee schedule","398.89","1356.07",""
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","409.65","","","","","","","fee schedule","398.89","1356.07","APC"
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","402.8","","","","","","","fee schedule","398.89","1356.07","APC"
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","398.89","","","","","","","fee schedule","398.89","1356.07","APC"
"Injection trabectedin 0.1mg","J9352","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","410.62","","","","","","","fee schedule","398.89","1356.07","APC"
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","160.43","","","","","","","fee schedule","53.54","178.59",""
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","171.53","","","","","","","fee schedule","53.54","178.59",""
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","178.59","","","","","","","fee schedule","53.54","178.59",""
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.98","","","","","","","fee schedule","53.54","178.59","APC"
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","54.06","","","","","","","fee schedule","53.54","178.59","APC"
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","53.54","","","","","","","fee schedule","53.54","178.59","APC"
"Inj. margetuximab-cmkb, 5 mg","J9353","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55.11","","","","","","","fee schedule","53.54","178.59","APC"
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","133.08","","","","","","","fee schedule","43","148.15",""
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","142.29","","","","","","","fee schedule","43","148.15",""
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","148.15","","","","","","","fee schedule","43","148.15",""
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.16","","","","","","","fee schedule","43","148.15","APC"
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","43.42","","","","","","","fee schedule","43","148.15","APC"
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43","","","","","","","fee schedule","43","148.15","APC"
"Inj, ado-trastuzumab emt 1mg","J9354","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.27","","","","","","","fee schedule","43","148.15","APC"
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","242.25","","","","","","","fee schedule","76.53","269.68",""
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","259.01","","","","","","","fee schedule","76.53","269.68",""
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","269.68","","","","","","","fee schedule","76.53","269.68",""
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.59","","","","","","","fee schedule","76.53","269.68","APC"
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.28","","","","","","","fee schedule","76.53","269.68","APC"
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.53","","","","","","","fee schedule","76.53","269.68","APC"
"Trastuzumab injection","J9355","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.78","","","","","","","fee schedule","76.53","269.68","APC"
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","200.24","","","","","","","fee schedule","62.66","222.91",""
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","214.1","","","","","","","fee schedule","62.66","222.91",""
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","222.91","","","","","","","fee schedule","62.66","222.91",""
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.35","","","","","","","fee schedule","62.66","222.91","APC"
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.28","","","","","","","fee schedule","62.66","222.91","APC"
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.66","","","","","","","fee schedule","62.66","222.91","APC"
"Inj. herceptin hylecta, 10mg","J9356","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.51","","","","","","","fee schedule","62.66","222.91","APC"
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4378.19","","","","","","","fee schedule","1349.81","4873.84",""
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4681.09","","","","","","","fee schedule","1349.81","4873.84",""
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4873.84","","","","","","","fee schedule","1349.81","4873.84",""
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1386.2","","","","","","","fee schedule","1349.81","4873.84","APC"
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1363.05","","","","","","","fee schedule","1349.81","4873.84","APC"
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1349.81","","","","","","","fee schedule","1349.81","4873.84","APC"
"Valrubicin injection","J9357","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1389.51","","","","","","","fee schedule","1349.81","4873.84","APC"
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95.4","","","","","","","fee schedule","30.58","106.2",""
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","102","","","","","","","fee schedule","30.58","106.2",""
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","106.2","","","","","","","fee schedule","30.58","106.2",""
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.4","","","","","","","fee schedule","30.58","106.2","APC"
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.88","","","","","","","fee schedule","30.58","106.2","APC"
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.58","","","","","","","fee schedule","30.58","106.2","APC"
"Inj fam-trastu deru-nxki 1mg","J9358","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.48","","","","","","","fee schedule","30.58","106.2","APC"
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","689.23","","","","","","","fee schedule","221.24","767.26",""
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","736.92","","","","","","","fee schedule","221.24","767.26",""
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","767.26","","","","","","","fee schedule","221.24","767.26",""
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","227.21","","","","","","","fee schedule","221.24","767.26","APC"
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","223.41","","","","","","","fee schedule","221.24","767.26","APC"
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","221.24","","","","","","","fee schedule","221.24","767.26","APC"
"Inj lon tesirin-lpyl 0.075mg","J9359","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","227.75","","","","","","","fee schedule","221.24","767.26","APC"
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","105.8","","","","","","","fee schedule","34.25","117.78",""
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","113.12","","","","","","","fee schedule","34.25","117.78",""
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","117.78","","","","","","","fee schedule","34.25","117.78",""
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35.17","","","","","","","fee schedule","34.25","117.78","APC"
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","34.58","","","","","","","fee schedule","34.25","117.78","APC"
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34.25","","","","","","","fee schedule","34.25","117.78","APC"
"Inj teclistamab cqyv 0.5 mg","J9380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35.25","","","","","","","fee schedule","34.25","117.78","APC"
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","119.73","","","","","","","fee schedule","38.42","133.28",""
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","128.01","","","","","","","fee schedule","38.42","133.28",""
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","133.28","","","","","","","fee schedule","38.42","133.28",""
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.45","","","","","","","fee schedule","38.42","133.28","APC"
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.79","","","","","","","fee schedule","38.42","133.28","APC"
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.42","","","","","","","fee schedule","38.42","133.28","APC"
"Inj teplizumab mzwv 5 mcg","J9381","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.55","","","","","","","fee schedule","38.42","133.28","APC"
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","103.73","","","","","","","fee schedule","33.57","115.47",""
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","110.91","","","","","","","fee schedule","33.57","115.47",""
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","115.47","","","","","","","fee schedule","33.57","115.47",""
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34.47","","","","","","","fee schedule","33.57","115.47","APC"
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.9","","","","","","","fee schedule","33.57","115.47","APC"
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33.57","","","","","","","fee schedule","33.57","115.47","APC"
"Inj zenocutuzumab-zbco 1 mg","J9382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34.56","","","","","","","fee schedule","33.57","115.47","APC"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","146.95","","","","","","","fee schedule","42.5","163.58",""
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","157.11","","","","","","","fee schedule","42.5","163.58",""
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","163.58","","","","","","","fee schedule","42.5","163.58",""
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","132.36","","","","","","","fee schedule","42.5","163.58","APC 277.30"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","141.55","","","","","","","fee schedule","42.5","163.58","APC 296.56"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","147.45","","","","","","","fee schedule","42.5","163.58","APC 308.91"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.65","","","","","","","fee schedule","42.5","163.58","APC"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.92","","","","","","","fee schedule","42.5","163.58","APC"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42.5","","","","","","","fee schedule","42.5","163.58","APC"
"Inj, fulvestrant (teva)","J9393","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.75","","","","","","","fee schedule","42.5","163.58","APC"
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.56","","","","","","","fee schedule","10.56","28.11",""
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","11.29","","","","","","","fee schedule","10.56","28.11",""
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.75","","","","","","","fee schedule","10.56","28.11",""
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.04","","","","","","","fee schedule","10.56","28.11","APC"
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.57","","","","","","","fee schedule","10.56","28.11","APC"
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.3","","","","","","","fee schedule","10.56","28.11","APC"
"Inj, fulvestrant (fresenius)","J9394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.11","","","","","","","fee schedule","10.56","28.11","APC"
"Injection, Fulvestrant","J9395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","22.2","","","","","","","fee schedule","22.2","24.71",""
"Injection, Fulvestrant","J9395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","23.73","","","","","","","fee schedule","22.2","24.71",""
"Injection, Fulvestrant","J9395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","24.71","","","","","","","fee schedule","22.2","24.71",""
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25.38","","","","","","","fee schedule","8.04","28.25",""
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","27.13","","","","","","","fee schedule","8.04","28.25",""
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","28.25","","","","","","","fee schedule","8.04","28.25",""
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.25","","","","","","","fee schedule","8.04","28.25","APC"
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.12","","","","","","","fee schedule","8.04","28.25","APC"
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.04","","","","","","","fee schedule","8.04","28.25","APC"
"Inj, ziv-aflibercept, 1mg","J9400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.27","","","","","","","fee schedule","8.04","28.25","APC"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","77046.38","","","","","","","fee schedule","24712.99","85768.61",""
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","82376.63","","","","","","","fee schedule","24712.99","85768.61",""
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","85768.61","","","","","","","fee schedule","24712.99","85768.61",""
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","76958.06","","","","","","","fee schedule","24712.99","85768.61","APC 277.30"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","82303.22","","","","","","","fee schedule","24712.99","85768.61","APC 296.56"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","85730.67","","","","","","","fee schedule","24712.99","85768.61","APC 308.91"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25379.27","","","","","","","fee schedule","24712.99","85768.61","APC"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","24955.27","","","","","","","fee schedule","24712.99","85768.61","APC"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24712.99","","","","","","","fee schedule","24712.99","85768.61","APC"
"Porfimer sodium injection","J9600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25439.84","","","","","","","fee schedule","24712.99","85768.61","APC"
"Removable soft interface le","K0672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.53","","","","","","","fee schedule","103.73","106.78","APC"
"Removable soft interface le","K0672","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","104.75","","","","","","","fee schedule","103.73","106.78","APC"
"Removable soft interface le","K0672","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","103.73","","","","","","","fee schedule","103.73","106.78","APC"
"Removable soft interface le","K0672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","106.79","","","","","","","fee schedule","103.73","106.78","APC"
"Cranial cervical orthosis","L0112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1758.61","","","","","","","fee schedule","1712.44","1762.8","APC"
"Cranial cervical orthosis","L0112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1729.23","","","","","","","fee schedule","1712.44","1762.8","APC"
"Cranial cervical orthosis","L0112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1712.44","","","","","","","fee schedule","1712.44","1762.8","APC"
"Cranial cervical orthosis","L0112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1762.8","","","","","","","fee schedule","1712.44","1762.8","APC"
"Cranial cervical torticollis","L0113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","358.32","","","","","","","fee schedule","348.91","359.17","APC"
"Cranial cervical torticollis","L0113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","352.33","","","","","","","fee schedule","348.91","359.17","APC"
"Cranial cervical torticollis","L0113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","348.91","","","","","","","fee schedule","348.91","359.17","APC"
"Cranial cervical torticollis","L0113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","359.17","","","","","","","fee schedule","348.91","359.17","APC"
"Cerv flex n/adj foam pre ots","L0120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33.66","","","","","","","fee schedule","32.77","33.74","APC"
"Cerv flex n/adj foam pre ots","L0120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","33.09","","","","","","","fee schedule","32.77","33.74","APC"
"Cerv flex n/adj foam pre ots","L0120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.77","","","","","","","fee schedule","32.77","33.74","APC"
"Cerv flex n/adj foam pre ots","L0120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.74","","","","","","","fee schedule","32.77","33.74","APC"
"Flex thermoplastic collar mo","L0130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","237.91","","","","","","","fee schedule","231.66","238.48","APC"
"Flex thermoplastic collar mo","L0130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","233.93","","","","","","","fee schedule","231.66","238.48","APC"
"Flex thermoplastic collar mo","L0130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","231.66","","","","","","","fee schedule","231.66","238.48","APC"
"Flex thermoplastic collar mo","L0130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","238.48","","","","","","","fee schedule","231.66","238.48","APC"
"Cervical semi-rigid adjustab","L0140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.68","","","","","","","fee schedule","76.61","78.87","APC"
"Cervical semi-rigid adjustab","L0140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.36","","","","","","","fee schedule","76.61","78.87","APC"
"Cervical semi-rigid adjustab","L0140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.61","","","","","","","fee schedule","76.61","78.87","APC"
"Cervical semi-rigid adjustab","L0140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.87","","","","","","","fee schedule","76.61","78.87","APC"
"Cerv semi-rig adj molded chn","L0150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","144.32","","","","","","","fee schedule","140.54","144.67","APC"
"Cerv semi-rig adj molded chn","L0150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.91","","","","","","","fee schedule","140.54","144.67","APC"
"Cerv semi-rig adj molded chn","L0150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","140.54","","","","","","","fee schedule","140.54","144.67","APC"
"Cerv semi-rig adj molded chn","L0150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","144.67","","","","","","","fee schedule","140.54","144.67","APC"
"Cerv sr wire occ/man pre ots","L0160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","188.53","","","","","","","fee schedule","183.58","188.98","APC"
"Cerv sr wire occ/man pre ots","L0160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","185.38","","","","","","","fee schedule","183.58","188.98","APC"
"Cerv sr wire occ/man pre ots","L0160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","183.58","","","","","","","fee schedule","183.58","188.98","APC"
"Cerv sr wire occ/man pre ots","L0160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","188.98","","","","","","","fee schedule","183.58","188.98","APC"
"Cervical collar molded to pt","L0170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","776.28","","","","","","","fee schedule","755.9","778.13","APC"
"Cervical collar molded to pt","L0170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","763.31","","","","","","","fee schedule","755.9","778.13","APC"
"Cervical collar molded to pt","L0170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","755.9","","","","","","","fee schedule","755.9","778.13","APC"
"Cervical collar molded to pt","L0170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","778.13","","","","","","","fee schedule","755.9","778.13","APC"
"Cerv col sr foam 2pc pre ots","L0172","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","168.31","","","","","","","fee schedule","163.89","168.71","APC"
"Cerv col sr foam 2pc pre ots","L0172","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","165.5","","","","","","","fee schedule","163.89","168.71","APC"
"Cerv col sr foam 2pc pre ots","L0172","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","163.89","","","","","","","fee schedule","163.89","168.71","APC"
"Cerv col sr foam 2pc pre ots","L0172","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","168.71","","","","","","","fee schedule","163.89","168.71","APC"
"Cerv sr 2pc thor ext pre ots","L0174","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","330.66","","","","","","","fee schedule","321.98","331.45","APC"
"Cerv sr 2pc thor ext pre ots","L0174","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","325.14","","","","","","","fee schedule","321.98","331.45","APC"
"Cerv sr 2pc thor ext pre ots","L0174","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","321.98","","","","","","","fee schedule","321.98","331.45","APC"
"Cerv sr 2pc thor ext pre ots","L0174","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","331.45","","","","","","","fee schedule","321.98","331.45","APC"
"Cer post col occ/man sup adj","L0180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","458.51","","","","","","","fee schedule","446.47","459.61","APC"
"Cer post col occ/man sup adj","L0180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","450.85","","","","","","","fee schedule","446.47","459.61","APC"
"Cer post col occ/man sup adj","L0180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","446.47","","","","","","","fee schedule","446.47","459.61","APC"
"Cer post col occ/man sup adj","L0180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","459.61","","","","","","","fee schedule","446.47","459.61","APC"
"Cerv collar supp adj cerv ba","L0190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","596.27","","","","","","","fee schedule","580.61","597.69","APC"
"Cerv collar supp adj cerv ba","L0190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","586.31","","","","","","","fee schedule","580.61","597.69","APC"
"Cerv collar supp adj cerv ba","L0190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","580.61","","","","","","","fee schedule","580.61","597.69","APC"
"Cerv collar supp adj cerv ba","L0190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","597.69","","","","","","","fee schedule","580.61","597.69","APC"
"Cerv col supp adj bar & thor","L0200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","621.61","","","","","","","fee schedule","605.29","623.09","APC"
"Cerv col supp adj bar & thor","L0200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","611.22","","","","","","","fee schedule","605.29","623.09","APC"
"Cerv col supp adj bar & thor","L0200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","605.29","","","","","","","fee schedule","605.29","623.09","APC"
"Cerv col supp adj bar & thor","L0200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","623.09","","","","","","","fee schedule","605.29","623.09","APC"
"Thor rib belt custom fabrica","L0220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","169.75","","","","","","","fee schedule","165.29","170.15","APC"
"Thor rib belt custom fabrica","L0220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","166.91","","","","","","","fee schedule","165.29","170.15","APC"
"Thor rib belt custom fabrica","L0220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","165.29","","","","","","","fee schedule","165.29","170.15","APC"
"Thor rib belt custom fabrica","L0220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","170.15","","","","","","","fee schedule","165.29","170.15","APC"
"Tlso flex trunk/thor pre ots","L0450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","151.99","","","","","","","fee schedule","148","152.35","APC"
"Tlso flex trunk/thor pre ots","L0450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","149.45","","","","","","","fee schedule","148","152.35","APC"
"Tlso flex trunk/thor pre ots","L0450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","148","","","","","","","fee schedule","148","152.35","APC"
"Tlso flex trunk/thor pre ots","L0450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","152.35","","","","","","","fee schedule","148","152.35","APC"
"Tlso trnk sj-t9 pre cst","L0454","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","435.77","","","","","","","fee schedule","424.33","436.81","APC"
"Tlso trnk sj-t9 pre cst","L0454","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","428.49","","","","","","","fee schedule","424.33","436.81","APC"
"Tlso trnk sj-t9 pre cst","L0454","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","424.33","","","","","","","fee schedule","424.33","436.81","APC"
"Tlso trnk sj-t9 pre cst","L0454","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","436.81","","","","","","","fee schedule","424.33","436.81","APC"
"Tlso flex trnk sj-t9 pre ots","L0455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","282.17","","","","","","","fee schedule","274.76","282.84","APC"
"Tlso flex trnk sj-t9 pre ots","L0455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","277.45","","","","","","","fee schedule","274.76","282.84","APC"
"Tlso flex trnk sj-t9 pre ots","L0455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","274.76","","","","","","","fee schedule","274.76","282.84","APC"
"Tlso flex trnk sj-t9 pre ots","L0455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","282.84","","","","","","","fee schedule","274.76","282.84","APC"
"Tlso flex trnk sj-ss pre cst","L0456","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1249.66","","","","","","","fee schedule","1216.85","1252.64","APC"
"Tlso flex trnk sj-ss pre cst","L0456","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1228.78","","","","","","","fee schedule","1216.85","1252.64","APC"
"Tlso flex trnk sj-ss pre cst","L0456","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1216.85","","","","","","","fee schedule","1216.85","1252.64","APC"
"Tlso flex trnk sj-ss pre cst","L0456","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1252.64","","","","","","","fee schedule","1216.85","1252.64","APC"
"Tlso flex trnk sj-ss pre ots","L0457","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","809.15","","","","","","","fee schedule","787.91","811.08","APC"
"Tlso flex trnk sj-ss pre ots","L0457","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","795.63","","","","","","","fee schedule","787.91","811.08","APC"
"Tlso flex trnk sj-ss pre ots","L0457","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","787.91","","","","","","","fee schedule","787.91","811.08","APC"
"Tlso flex trnk sj-ss pre ots","L0457","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","811.08","","","","","","","fee schedule","787.91","811.08","APC"
"TLSO 2Mod symphis-xipho pre","L0458","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1120.56","","","","","","","fee schedule","1091.14","1123.24","APC"
"TLSO 2Mod symphis-xipho pre","L0458","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1101.84","","","","","","","fee schedule","1091.14","1123.24","APC"
"TLSO 2Mod symphis-xipho pre","L0458","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1091.14","","","","","","","fee schedule","1091.14","1123.24","APC"
"TLSO 2Mod symphis-xipho pre","L0458","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1123.24","","","","","","","fee schedule","1091.14","1123.24","APC"
"Tlso 2 shl symphys-stern cst","L0460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1261.27","","","","","","","fee schedule","1228.16","1264.28","APC"
"Tlso 2 shl symphys-stern cst","L0460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1240.2","","","","","","","fee schedule","1228.16","1264.28","APC"
"Tlso 2 shl symphys-stern cst","L0460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1228.16","","","","","","","fee schedule","1228.16","1264.28","APC"
"Tlso 2 shl symphys-stern cst","L0460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1264.28","","","","","","","fee schedule","1228.16","1264.28","APC"
"TLSO 3Mod sacro-scap pre","L0462","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1568.83","","","","","","","fee schedule","1527.64","1572.57","APC"
"TLSO 3Mod sacro-scap pre","L0462","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1542.62","","","","","","","fee schedule","1527.64","1572.57","APC"
"TLSO 3Mod sacro-scap pre","L0462","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1527.64","","","","","","","fee schedule","1527.64","1572.57","APC"
"TLSO 3Mod sacro-scap pre","L0462","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1572.57","","","","","","","fee schedule","1527.64","1572.57","APC"
"TLSO 4Mod sacro-scap pre","L0464","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1867.66","","","","","","","fee schedule","1818.63","1872.12","APC"
"TLSO 4Mod sacro-scap pre","L0464","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1836.46","","","","","","","fee schedule","1818.63","1872.12","APC"
"TLSO 4Mod sacro-scap pre","L0464","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1818.63","","","","","","","fee schedule","1818.63","1872.12","APC"
"TLSO 4Mod sacro-scap pre","L0464","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1872.12","","","","","","","fee schedule","1818.63","1872.12","APC"
"Tlso r fram soft ant pre cst","L0466","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","453.94","","","","","","","fee schedule","442.03","455.03","APC"
"Tlso r fram soft ant pre cst","L0466","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","446.36","","","","","","","fee schedule","442.03","455.03","APC"
"Tlso r fram soft ant pre cst","L0466","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","442.03","","","","","","","fee schedule","442.03","455.03","APC"
"Tlso r fram soft ant pre cst","L0466","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","455.03","","","","","","","fee schedule","442.03","455.03","APC"
"Tlso r fram soft pre ots","L0467","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","316.45","","","","","","","fee schedule","308.14","317.2","APC"
"Tlso r fram soft pre ots","L0467","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","311.16","","","","","","","fee schedule","308.14","317.2","APC"
"Tlso r fram soft pre ots","L0467","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","308.14","","","","","","","fee schedule","308.14","317.2","APC"
"Tlso r fram soft pre ots","L0467","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","317.21","","","","","","","fee schedule","308.14","317.2","APC"
"Tlso rig fram pelvic pre cst","L0468","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","601.4","","","","","","","fee schedule","585.61","602.84","APC"
"Tlso rig fram pelvic pre cst","L0468","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","591.35","","","","","","","fee schedule","585.61","602.84","APC"
"Tlso rig fram pelvic pre cst","L0468","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","585.61","","","","","","","fee schedule","585.61","602.84","APC"
"Tlso rig fram pelvic pre cst","L0468","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","602.84","","","","","","","fee schedule","585.61","602.84","APC"
"Tlso rig fram pelvic pre ots","L0469","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","403.21","","","","","","","fee schedule","392.63","404.18","APC"
"Tlso rig fram pelvic pre ots","L0469","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","396.48","","","","","","","fee schedule","392.63","404.18","APC"
"Tlso rig fram pelvic pre ots","L0469","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","392.63","","","","","","","fee schedule","392.63","404.18","APC"
"Tlso rig fram pelvic pre ots","L0469","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","404.18","","","","","","","fee schedule","392.63","404.18","APC"
"TLSO rigid frame pre subclav","L0470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","767.42","","","","","","","fee schedule","747.27","769.25","APC"
"TLSO rigid frame pre subclav","L0470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","754.6","","","","","","","fee schedule","747.27","769.25","APC"
"TLSO rigid frame pre subclav","L0470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","747.27","","","","","","","fee schedule","747.27","769.25","APC"
"TLSO rigid frame pre subclav","L0470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","769.25","","","","","","","fee schedule","747.27","769.25","APC"
"TLSO rigid frame hyperex pre","L0472","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","486.71","","","","","","","fee schedule","473.93","487.87","APC"
"TLSO rigid frame hyperex pre","L0472","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","478.58","","","","","","","fee schedule","473.93","487.87","APC"
"TLSO rigid frame hyperex pre","L0472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","473.93","","","","","","","fee schedule","473.93","487.87","APC"
"TLSO rigid frame hyperex pre","L0472","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","487.87","","","","","","","fee schedule","473.93","487.87","APC"
"TLSO rigid plastic custom fa","L0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1713.99","","","","","","","fee schedule","1669","1718.08","APC"
"TLSO rigid plastic custom fa","L0480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1685.36","","","","","","","fee schedule","1669","1718.08","APC"
"TLSO rigid plastic custom fa","L0480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1669","","","","","","","fee schedule","1669","1718.08","APC"
"TLSO rigid plastic custom fa","L0480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1718.08","","","","","","","fee schedule","1669","1718.08","APC"
"TLSO rigid lined custom fab","L0482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1990.88","","","","","","","fee schedule","1938.61","1995.63","APC"
"TLSO rigid lined custom fab","L0482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1957.62","","","","","","","fee schedule","1938.61","1995.63","APC"
"TLSO rigid lined custom fab","L0482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1938.61","","","","","","","fee schedule","1938.61","1995.63","APC"
"TLSO rigid lined custom fab","L0482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1995.63","","","","","","","fee schedule","1938.61","1995.63","APC"
"TLSO rigid plastic cust fab","L0484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2139.14","","","","","","","fee schedule","2082.98","2144.25","APC"
"TLSO rigid plastic cust fab","L0484","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2103.4","","","","","","","fee schedule","2082.98","2144.25","APC"
"TLSO rigid plastic cust fab","L0484","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2082.98","","","","","","","fee schedule","2082.98","2144.25","APC"
"TLSO rigid plastic cust fab","L0484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2144.25","","","","","","","fee schedule","2082.98","2144.25","APC"
"TLSO rigidlined cust fab two","L0486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2269.51","","","","","","","fee schedule","2209.93","2274.93","APC"
"TLSO rigidlined cust fab two","L0486","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2231.6","","","","","","","fee schedule","2209.93","2274.93","APC"
"TLSO rigidlined cust fab two","L0486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2209.93","","","","","","","fee schedule","2209.93","2274.93","APC"
"TLSO rigidlined cust fab two","L0486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2274.93","","","","","","","fee schedule","2209.93","2274.93","APC"
"TLSO rigid lined pre one pie","L0488","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1261.27","","","","","","","fee schedule","1228.16","1264.28","APC"
"TLSO rigid lined pre one pie","L0488","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1240.2","","","","","","","fee schedule","1228.16","1264.28","APC"
"TLSO rigid lined pre one pie","L0488","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1228.16","","","","","","","fee schedule","1228.16","1264.28","APC"
"TLSO rigid lined pre one pie","L0488","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1264.28","","","","","","","fee schedule","1228.16","1264.28","APC"
"TLSO rigid plastic pre one","L0490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","355.45","","","","","","","fee schedule","346.12","356.3","APC"
"TLSO rigid plastic pre one","L0490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","349.51","","","","","","","fee schedule","346.12","356.3","APC"
"TLSO rigid plastic pre one","L0490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","346.12","","","","","","","fee schedule","346.12","356.3","APC"
"TLSO rigid plastic pre one","L0490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","356.3","","","","","","","fee schedule","346.12","356.3","APC"
"TLSO 2 piece rigid shell","L0491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","964.98","","","","","","","fee schedule","939.64","967.28","APC"
"TLSO 2 piece rigid shell","L0491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","948.86","","","","","","","fee schedule","939.64","967.28","APC"
"TLSO 2 piece rigid shell","L0491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","939.64","","","","","","","fee schedule","939.64","967.28","APC"
"TLSO 2 piece rigid shell","L0491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","967.28","","","","","","","fee schedule","939.64","967.28","APC"
"TLSO 3 piece rigid shell","L0492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","634.64","","","","","","","fee schedule","617.98","636.15","APC"
"TLSO 3 piece rigid shell","L0492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","624.04","","","","","","","fee schedule","617.98","636.15","APC"
"TLSO 3 piece rigid shell","L0492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","617.98","","","","","","","fee schedule","617.98","636.15","APC"
"TLSO 3 piece rigid shell","L0492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","636.15","","","","","","","fee schedule","617.98","636.15","APC"
"Sio flex pelvic/sacr pre ots","L0621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","80.13","","","","","","","fee schedule","78.03","80.32","APC"
"Sio flex pelvic/sacr pre ots","L0621","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.8","","","","","","","fee schedule","78.03","80.32","APC"
"Sio flex pelvic/sacr pre ots","L0621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","78.03","","","","","","","fee schedule","78.03","80.32","APC"
"Sio flex pelvic/sacr pre ots","L0621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","80.32","","","","","","","fee schedule","78.03","80.32","APC"
"Sio flex pelvisacral custom","L0622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","363.55","","","","","","","fee schedule","354","364.41","APC"
"Sio flex pelvisacral custom","L0622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","357.47","","","","","","","fee schedule","354","364.41","APC"
"Sio flex pelvisacral custom","L0622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","354","","","","","","","fee schedule","354","364.41","APC"
"Sio flex pelvisacral custom","L0622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","364.41","","","","","","","fee schedule","354","364.41","APC"
"Sio rig pnl pelv/sac pre ots","L0623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.64","","","","","","","fee schedule","139.87","143.99","APC"
"Sio rig pnl pelv/sac pre ots","L0623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.24","","","","","","","fee schedule","139.87","143.99","APC"
"Sio rig pnl pelv/sac pre ots","L0623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","139.87","","","","","","","fee schedule","139.87","143.99","APC"
"Sio rig pnl pelv/sac pre ots","L0623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","143.99","","","","","","","fee schedule","139.87","143.99","APC"
"Lo flex l1-below l5 pre ots","L0625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.83","","","","","","","fee schedule","43.66","44.94","APC"
"Lo flex l1-below l5 pre ots","L0625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44.08","","","","","","","fee schedule","43.66","44.94","APC"
"Lo flex l1-below l5 pre ots","L0625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.66","","","","","","","fee schedule","43.66","44.94","APC"
"Lo flex l1-below l5 pre ots","L0625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.94","","","","","","","fee schedule","43.66","44.94","APC"
"Lo sag rig pnl stays pre cst","L0626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","97.92","","","","","","","fee schedule","95.35","98.15","APC"
"Lo sag rig pnl stays pre cst","L0626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","96.28","","","","","","","fee schedule","95.35","98.15","APC"
"Lo sag rig pnl stays pre cst","L0626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","95.35","","","","","","","fee schedule","95.35","98.15","APC"
"Lo sag rig pnl stays pre cst","L0626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","98.15","","","","","","","fee schedule","95.35","98.15","APC"
"Lo sag ri an/pos pnl pre cst","L0627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","516.5","","","","","","","fee schedule","502.94","517.73","APC"
"Lo sag ri an/pos pnl pre cst","L0627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","507.87","","","","","","","fee schedule","502.94","517.73","APC"
"Lo sag ri an/pos pnl pre cst","L0627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","502.94","","","","","","","fee schedule","502.94","517.73","APC"
"Lo sag ri an/pos pnl pre cst","L0627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","517.73","","","","","","","fee schedule","502.94","517.73","APC"
"Lso flex no ri stays pre ots","L0628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.27","","","","","","","fee schedule","66.47","68.43","APC"
"Lso flex no ri stays pre ots","L0628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.13","","","","","","","fee schedule","66.47","68.43","APC"
"Lso flex no ri stays pre ots","L0628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.47","","","","","","","fee schedule","66.47","68.43","APC"
"Lso flex no ri stays pre ots","L0628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.43","","","","","","","fee schedule","66.47","68.43","APC"
"Lso r post pnl sj-t9 pre cst","L0630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","203.49","","","","","","","fee schedule","198.15","203.97","APC"
"Lso r post pnl sj-t9 pre cst","L0630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.09","","","","","","","fee schedule","198.15","203.97","APC"
"Lso r post pnl sj-t9 pre cst","L0630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.15","","","","","","","fee schedule","198.15","203.97","APC"
"Lso r post pnl sj-t9 pre cst","L0630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","203.97","","","","","","","fee schedule","198.15","203.97","APC"
"Lso sag r an/pos pnl pre cst","L0631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1289.87","","","","","","","fee schedule","1256.01","1292.95","APC"
"Lso sag r an/pos pnl pre cst","L0631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1268.32","","","","","","","fee schedule","1256.01","1292.95","APC"
"Lso sag r an/pos pnl pre cst","L0631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1256.01","","","","","","","fee schedule","1256.01","1292.95","APC"
"Lso sag r an/pos pnl pre cst","L0631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1292.95","","","","","","","fee schedule","1256.01","1292.95","APC"
"Lso sc r pos/lat pnl pre cst","L0633","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","360.31","","","","","","","fee schedule","350.85","361.17","APC"
"Lso sc r pos/lat pnl pre cst","L0633","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","354.29","","","","","","","fee schedule","350.85","361.17","APC"
"Lso sc r pos/lat pnl pre cst","L0633","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","350.85","","","","","","","fee schedule","350.85","361.17","APC"
"Lso sc r pos/lat pnl pre cst","L0633","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","361.17","","","","","","","fee schedule","350.85","361.17","APC"
"Lso sagit rigid panel prefab","L0635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1152.18","","","","","","","fee schedule","1121.93","1154.93","APC"
"Lso sagit rigid panel prefab","L0635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1132.93","","","","","","","fee schedule","1121.93","1154.93","APC"
"Lso sagit rigid panel prefab","L0635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1121.93","","","","","","","fee schedule","1121.93","1154.93","APC"
"Lso sagit rigid panel prefab","L0635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1154.93","","","","","","","fee schedule","1121.93","1154.93","APC"
"Lso sagittal rigid panel cus","L0636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1705.65","","","","","","","fee schedule","1660.88","1709.73","APC"
"Lso sagittal rigid panel cus","L0636","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1677.16","","","","","","","fee schedule","1660.88","1709.73","APC"
"Lso sagittal rigid panel cus","L0636","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1660.88","","","","","","","fee schedule","1660.88","1709.73","APC"
"Lso sagittal rigid panel cus","L0636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1709.73","","","","","","","fee schedule","1660.88","1709.73","APC"
"Lso sc r ant/pos pnl pre cst","L0637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1349.81","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso sc r ant/pos pnl pre cst","L0637","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1327.26","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso sc r ant/pos pnl pre cst","L0637","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1314.37","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso sc r ant/pos pnl pre cst","L0637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1353.03","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso sag-coronal panel custom","L0638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1657.17","","","","","","","fee schedule","1613.66","1661.12","APC"
"Lso sag-coronal panel custom","L0638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1629.48","","","","","","","fee schedule","1613.66","1661.12","APC"
"Lso sag-coronal panel custom","L0638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1613.66","","","","","","","fee schedule","1613.66","1661.12","APC"
"Lso sag-coronal panel custom","L0638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1661.12","","","","","","","fee schedule","1613.66","1661.12","APC"
"Lso s/c shell/panel prefab","L0639","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1349.81","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso s/c shell/panel prefab","L0639","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1327.26","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso s/c shell/panel prefab","L0639","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1314.37","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso s/c shell/panel prefab","L0639","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1353.03","","","","","","","fee schedule","1314.37","1353.03","APC"
"Lso s/c shell/panel custom","L0640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1314.81","","","","","","","fee schedule","1280.29","1317.95","APC"
"Lso s/c shell/panel custom","L0640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1292.85","","","","","","","fee schedule","1280.29","1317.95","APC"
"Lso s/c shell/panel custom","L0640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1280.29","","","","","","","fee schedule","1280.29","1317.95","APC"
"Lso s/c shell/panel custom","L0640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1317.95","","","","","","","fee schedule","1280.29","1317.95","APC"
"Lo rig pos pnl l1-l5 pre ots","L0641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.43","","","","","","","fee schedule","61.76","63.58","APC"
"Lo rig pos pnl l1-l5 pre ots","L0641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.37","","","","","","","fee schedule","61.76","63.58","APC"
"Lo rig pos pnl l1-l5 pre ots","L0641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61.76","","","","","","","fee schedule","61.76","63.58","APC"
"Lo rig pos pnl l1-l5 pre ots","L0641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63.58","","","","","","","fee schedule","61.76","63.58","APC"
"Lo sag ri an/pos pnl pre ots","L0642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","334.5","","","","","","","fee schedule","325.72","335.3","APC"
"Lo sag ri an/pos pnl pre ots","L0642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","328.91","","","","","","","fee schedule","325.72","335.3","APC"
"Lo sag ri an/pos pnl pre ots","L0642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","325.72","","","","","","","fee schedule","325.72","335.3","APC"
"Lo sag ri an/pos pnl pre ots","L0642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","335.3","","","","","","","fee schedule","325.72","335.3","APC"
"Lso sag ctr rigi pos pre ots","L0643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","131.79","","","","","","","fee schedule","128.33","132.1","APC"
"Lso sag ctr rigi pos pre ots","L0643","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","129.58","","","","","","","fee schedule","128.33","132.1","APC"
"Lso sag ctr rigi pos pre ots","L0643","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.33","","","","","","","fee schedule","128.33","132.1","APC"
"Lso sag ctr rigi pos pre ots","L0643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.1","","","","","","","fee schedule","128.33","132.1","APC"
"Lso sag r an/pos pnl pre ots","L0648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","835.37","","","","","","","fee schedule","813.44","837.36","APC"
"Lso sag r an/pos pnl pre ots","L0648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","821.41","","","","","","","fee schedule","813.44","837.36","APC"
"Lso sag r an/pos pnl pre ots","L0648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","813.44","","","","","","","fee schedule","813.44","837.36","APC"
"Lso sag r an/pos pnl pre ots","L0648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","837.36","","","","","","","fee schedule","813.44","837.36","APC"
"Lso sc r pos/lat pnl pre ots","L0649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","233.35","","","","","","","fee schedule","227.23","233.91","APC"
"Lso sc r pos/lat pnl pre ots","L0649","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","229.45","","","","","","","fee schedule","227.23","233.91","APC"
"Lso sc r pos/lat pnl pre ots","L0649","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","227.23","","","","","","","fee schedule","227.23","233.91","APC"
"Lso sc r pos/lat pnl pre ots","L0649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","233.91","","","","","","","fee schedule","227.23","233.91","APC"
"Lso sc r ant/pos pnl pre ots","L0650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","966.58","","","","","","","fee schedule","941.2","968.89","APC"
"Lso sc r ant/pos pnl pre ots","L0650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","950.43","","","","","","","fee schedule","941.2","968.89","APC"
"Lso sc r ant/pos pnl pre ots","L0650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","941.2","","","","","","","fee schedule","941.2","968.89","APC"
"Lso sc r ant/pos pnl pre ots","L0650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","968.89","","","","","","","fee schedule","941.2","968.89","APC"
"LSO sag-co shell pnl pre ots","L0651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","966.58","","","","","","","fee schedule","941.2","968.89","APC"
"LSO sag-co shell pnl pre ots","L0651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","950.43","","","","","","","fee schedule","941.2","968.89","APC"
"LSO sag-co shell pnl pre ots","L0651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","941.2","","","","","","","fee schedule","941.2","968.89","APC"
"LSO sag-co shell pnl pre ots","L0651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","968.89","","","","","","","fee schedule","941.2","968.89","APC"
"Ctlso a-p-l control molded","L0700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2460.72","","","","","","","fee schedule","2396.12","2466.6","APC"
"Ctlso a-p-l control molded","L0700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2419.61","","","","","","","fee schedule","2396.12","2466.6","APC"
"Ctlso a-p-l control molded","L0700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2396.12","","","","","","","fee schedule","2396.12","2466.6","APC"
"Ctlso a-p-l control molded","L0700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2466.6","","","","","","","fee schedule","2396.12","2466.6","APC"
"Ctlso a-p-l control w/ inter","L0710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2513.94","","","","","","","fee schedule","2447.94","2519.94","APC"
"Ctlso a-p-l control w/ inter","L0710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2471.94","","","","","","","fee schedule","2447.94","2519.94","APC"
"Ctlso a-p-l control w/ inter","L0710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2447.94","","","","","","","fee schedule","2447.94","2519.94","APC"
"Ctlso a-p-l control w/ inter","L0710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2519.94","","","","","","","fee schedule","2447.94","2519.94","APC"
"Ctlso a-p-l control custom","L0720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2326.17","","","","","","","fee schedule","2265.1","2331.72","APC"
"Ctlso a-p-l control custom","L0720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2287.31","","","","","","","fee schedule","2265.1","2331.72","APC"
"Ctlso a-p-l control custom","L0720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2265.1","","","","","","","fee schedule","2265.1","2331.72","APC"
"Ctlso a-p-l control custom","L0720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2331.72","","","","","","","fee schedule","2265.1","2331.72","APC"
"Halo cervical into jckt vest","L0810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3144","","","","","","","fee schedule","3061.46","3151.5","APC"
"Halo cervical into jckt vest","L0810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3091.47","","","","","","","fee schedule","3061.46","3151.5","APC"
"Halo cervical into jckt vest","L0810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3061.46","","","","","","","fee schedule","3061.46","3151.5","APC"
"Halo cervical into jckt vest","L0810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3151.5","","","","","","","fee schedule","3061.46","3151.5","APC"
"Halo cervical into body jack","L0820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2821.93","","","","","","","fee schedule","2747.85","2828.67","APC"
"Halo cervical into body jack","L0820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2774.79","","","","","","","fee schedule","2747.85","2828.67","APC"
"Halo cervical into body jack","L0820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2747.85","","","","","","","fee schedule","2747.85","2828.67","APC"
"Halo cervical into body jack","L0820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2828.67","","","","","","","fee schedule","2747.85","2828.67","APC"
"Halo cerv into milwaukee typ","L0830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3976.95","","","","","","","fee schedule","3872.54","3986.44","APC"
"Halo cerv into milwaukee typ","L0830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3910.51","","","","","","","fee schedule","3872.54","3986.44","APC"
"Halo cerv into milwaukee typ","L0830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3872.54","","","","","","","fee schedule","3872.54","3986.44","APC"
"Halo cerv into milwaukee typ","L0830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3986.44","","","","","","","fee schedule","3872.54","3986.44","APC"
"MRI compatible system","L0859","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1657.36","","","","","","","fee schedule","1613.85","1661.32","APC"
"MRI compatible system","L0859","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1629.68","","","","","","","fee schedule","1613.85","1661.32","APC"
"MRI compatible system","L0859","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1613.85","","","","","","","fee schedule","1613.85","1661.32","APC"
"MRI compatible system","L0859","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1661.32","","","","","","","fee schedule","1613.85","1661.32","APC"
"Halo repl liner/interface","L0861","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","270.81","","","","","","","fee schedule","263.7","271.46","APC"
"Halo repl liner/interface","L0861","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","266.29","","","","","","","fee schedule","263.7","271.46","APC"
"Halo repl liner/interface","L0861","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","263.7","","","","","","","fee schedule","263.7","271.46","APC"
"Halo repl liner/interface","L0861","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","271.46","","","","","","","fee schedule","263.7","271.46","APC"
"Tlso corset front","L0970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","161.86","","","","","","","fee schedule","157.61","162.25","APC"
"Tlso corset front","L0970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","159.16","","","","","","","fee schedule","157.61","162.25","APC"
"Tlso corset front","L0970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","157.61","","","","","","","fee schedule","157.61","162.25","APC"
"Tlso corset front","L0970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","162.25","","","","","","","fee schedule","157.61","162.25","APC"
"Lso corset front","L0972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","145.38","","","","","","","fee schedule","141.57","145.73","APC"
"Lso corset front","L0972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","142.95","","","","","","","fee schedule","141.57","145.73","APC"
"Lso corset front","L0972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","141.57","","","","","","","fee schedule","141.57","145.73","APC"
"Lso corset front","L0972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","145.73","","","","","","","fee schedule","141.57","145.73","APC"
"Tlso full corset","L0974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","215.89","","","","","","","fee schedule","210.22","216.4","APC"
"Tlso full corset","L0974","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","212.28","","","","","","","fee schedule","210.22","216.4","APC"
"Tlso full corset","L0974","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","210.22","","","","","","","fee schedule","210.22","216.4","APC"
"Tlso full corset","L0974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","216.4","","","","","","","fee schedule","210.22","216.4","APC"
"Lso full corset","L0976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","192.48","","","","","","","fee schedule","187.42","192.94","APC"
"Lso full corset","L0976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","189.26","","","","","","","fee schedule","187.42","192.94","APC"
"Lso full corset","L0976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","187.42","","","","","","","fee schedule","187.42","192.94","APC"
"Lso full corset","L0976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","192.94","","","","","","","fee schedule","187.42","192.94","APC"
"Axillary crutch extension","L0978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","254.05","","","","","","","fee schedule","247.38","254.66","APC"
"Axillary crutch extension","L0978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","249.81","","","","","","","fee schedule","247.38","254.66","APC"
"Axillary crutch extension","L0978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","247.38","","","","","","","fee schedule","247.38","254.66","APC"
"Axillary crutch extension","L0978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","254.66","","","","","","","fee schedule","247.38","254.66","APC"
"Peroneal straps pair pre ots","L0980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.73","","","","","","","fee schedule","27","27.79","APC"
"Peroneal straps pair pre ots","L0980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.26","","","","","","","fee schedule","27","27.79","APC"
"Peroneal straps pair pre ots","L0980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27","","","","","","","fee schedule","27","27.79","APC"
"Peroneal straps pair pre ots","L0980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.79","","","","","","","fee schedule","27","27.79","APC"
"Stocking sup grips 4 pre ots","L0982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.6","","","","","","","fee schedule","19.08","19.65","APC"
"Stocking sup grips 4 pre ots","L0982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.27","","","","","","","fee schedule","19.08","19.65","APC"
"Stocking sup grips 4 pre ots","L0982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.08","","","","","","","fee schedule","19.08","19.65","APC"
"Stocking sup grips 4 pre ots","L0982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.65","","","","","","","fee schedule","19.08","19.65","APC"
"Protect body sock ea pre ots","L0984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","81.36","","","","","","","fee schedule","79.22","81.55","APC"
"Protect body sock ea pre ots","L0984","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80","","","","","","","fee schedule","79.22","81.55","APC"
"Protect body sock ea pre ots","L0984","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.22","","","","","","","fee schedule","79.22","81.55","APC"
"Protect body sock ea pre ots","L0984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81.55","","","","","","","fee schedule","79.22","81.55","APC"
"Ctlso milwauke initial model","L1000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2468.84","","","","","","","fee schedule","2404.03","2474.73","APC"
"Ctlso milwauke initial model","L1000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2427.6","","","","","","","fee schedule","2404.03","2474.73","APC"
"Ctlso milwauke initial model","L1000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2404.03","","","","","","","fee schedule","2404.03","2474.73","APC"
"Ctlso milwauke initial model","L1000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2474.73","","","","","","","fee schedule","2404.03","2474.73","APC"
"Tension based scoliosis orth","L1005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4021.56","","","","","","","fee schedule","3915.98","4031.16","APC"
"Tension based scoliosis orth","L1005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3954.38","","","","","","","fee schedule","3915.98","4031.16","APC"
"Tension based scoliosis orth","L1005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3915.98","","","","","","","fee schedule","3915.98","4031.16","APC"
"Tension based scoliosis orth","L1005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4031.16","","","","","","","fee schedule","3915.98","4031.16","APC"
"Ctlso axilla sling","L1010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","80.78","","","","","","","fee schedule","78.66","80.98","APC"
"Ctlso axilla sling","L1010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","79.43","","","","","","","fee schedule","78.66","80.98","APC"
"Ctlso axilla sling","L1010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","78.66","","","","","","","fee schedule","78.66","80.98","APC"
"Ctlso axilla sling","L1010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","80.98","","","","","","","fee schedule","78.66","80.98","APC"
"Kyphosis pad","L1020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.05","","","","","","","fee schedule","101.32","104.3","APC"
"Kyphosis pad","L1020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.31","","","","","","","fee schedule","101.32","104.3","APC"
"Kyphosis pad","L1020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.32","","","","","","","fee schedule","101.32","104.3","APC"
"Kyphosis pad","L1020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.3","","","","","","","fee schedule","101.32","104.3","APC"
"Kyphosis pad floating","L1025","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","198.61","","","","","","","fee schedule","193.39","199.08","APC"
"Kyphosis pad floating","L1025","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","195.29","","","","","","","fee schedule","193.39","199.08","APC"
"Kyphosis pad floating","L1025","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","193.39","","","","","","","fee schedule","193.39","199.08","APC"
"Kyphosis pad floating","L1025","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","199.08","","","","","","","fee schedule","193.39","199.08","APC"
"Lumbar bolster pad","L1030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.57","","","","","","","fee schedule","74.56","76.76","APC"
"Lumbar bolster pad","L1030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.29","","","","","","","fee schedule","74.56","76.76","APC"
"Lumbar bolster pad","L1030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.56","","","","","","","fee schedule","74.56","76.76","APC"
"Lumbar bolster pad","L1030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.76","","","","","","","fee schedule","74.56","76.76","APC"
"Lumbar or lumbar rib pad","L1040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.22","","","","","","","fee schedule","97.59","100.46","APC"
"Lumbar or lumbar rib pad","L1040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","98.55","","","","","","","fee schedule","97.59","100.46","APC"
"Lumbar or lumbar rib pad","L1040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","97.59","","","","","","","fee schedule","97.59","100.46","APC"
"Lumbar or lumbar rib pad","L1040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","100.46","","","","","","","fee schedule","97.59","100.46","APC"
"Sternal pad","L1050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","120.8","","","","","","","fee schedule","117.63","121.09","APC"
"Sternal pad","L1050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","118.78","","","","","","","fee schedule","117.63","121.09","APC"
"Sternal pad","L1050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117.63","","","","","","","fee schedule","117.63","121.09","APC"
"Sternal pad","L1050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","121.09","","","","","","","fee schedule","117.63","121.09","APC"
"Thoracic pad","L1060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","144.89","","","","","","","fee schedule","141.09","145.24","APC"
"Thoracic pad","L1060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","142.47","","","","","","","fee schedule","141.09","145.24","APC"
"Thoracic pad","L1060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","141.09","","","","","","","fee schedule","141.09","145.24","APC"
"Thoracic pad","L1060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","145.24","","","","","","","fee schedule","141.09","145.24","APC"
"Trapezius sling","L1070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","141.48","","","","","","","fee schedule","137.76","141.81","APC"
"Trapezius sling","L1070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","139.11","","","","","","","fee schedule","137.76","141.81","APC"
"Trapezius sling","L1070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","137.76","","","","","","","fee schedule","137.76","141.81","APC"
"Trapezius sling","L1070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","141.81","","","","","","","fee schedule","137.76","141.81","APC"
"Outrigger","L1080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.57","","","","","","","fee schedule","77.48","79.76","APC"
"Outrigger","L1080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.24","","","","","","","fee schedule","77.48","79.76","APC"
"Outrigger","L1080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.48","","","","","","","fee schedule","77.48","79.76","APC"
"Outrigger","L1080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.76","","","","","","","fee schedule","77.48","79.76","APC"
"Outrigger bil w/ vert extens","L1085","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","215.29","","","","","","","fee schedule","209.64","215.81","APC"
"Outrigger bil w/ vert extens","L1085","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","211.7","","","","","","","fee schedule","209.64","215.81","APC"
"Outrigger bil w/ vert extens","L1085","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","209.64","","","","","","","fee schedule","209.64","215.81","APC"
"Outrigger bil w/ vert extens","L1085","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","215.81","","","","","","","fee schedule","209.64","215.81","APC"
"Lumbar sling","L1090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","142.42","","","","","","","fee schedule","138.68","142.76","APC"
"Lumbar sling","L1090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","140.04","","","","","","","fee schedule","138.68","142.76","APC"
"Lumbar sling","L1090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","138.68","","","","","","","fee schedule","138.68","142.76","APC"
"Lumbar sling","L1090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","142.76","","","","","","","fee schedule","138.68","142.76","APC"
"Ring flange plastic/leather","L1100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","227.44","","","","","","","fee schedule","221.47","227.99","APC"
"Ring flange plastic/leather","L1100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","223.64","","","","","","","fee schedule","221.47","227.99","APC"
"Ring flange plastic/leather","L1100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","221.47","","","","","","","fee schedule","221.47","227.99","APC"
"Ring flange plastic/leather","L1100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","227.99","","","","","","","fee schedule","221.47","227.99","APC"
"Ring flange plas/leather mol","L1110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","307.43","","","","","","","fee schedule","299.36","308.16","APC"
"Ring flange plas/leather mol","L1110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","302.29","","","","","","","fee schedule","299.36","308.16","APC"
"Ring flange plas/leather mol","L1110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","299.36","","","","","","","fee schedule","299.36","308.16","APC"
"Ring flange plas/leather mol","L1110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","308.16","","","","","","","fee schedule","299.36","308.16","APC"
"Covers for upright each","L1120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.99","","","","","","","fee schedule","50.62","52.11","APC"
"Covers for upright each","L1120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.12","","","","","","","fee schedule","50.62","52.11","APC"
"Covers for upright each","L1120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50.62","","","","","","","fee schedule","50.62","52.11","APC"
"Covers for upright each","L1120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.11","","","","","","","fee schedule","50.62","52.11","APC"
"Furnsh initial orthosis only","L1200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1885.99","","","","","","","fee schedule","1836.48","1890.49","APC"
"Furnsh initial orthosis only","L1200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1854.48","","","","","","","fee schedule","1836.48","1890.49","APC"
"Furnsh initial orthosis only","L1200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1836.48","","","","","","","fee schedule","1836.48","1890.49","APC"
"Furnsh initial orthosis only","L1200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1890.49","","","","","","","fee schedule","1836.48","1890.49","APC"
"Lateral thoracic extension","L1210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","314.96","","","","","","","fee schedule","306.69","315.71","APC"
"Lateral thoracic extension","L1210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","309.7","","","","","","","fee schedule","306.69","315.71","APC"
"Lateral thoracic extension","L1210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","306.69","","","","","","","fee schedule","306.69","315.71","APC"
"Lateral thoracic extension","L1210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","315.71","","","","","","","fee schedule","306.69","315.71","APC"
"Anterior thoracic extension","L1220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","300.88","","","","","","","fee schedule","292.98","301.6","APC"
"Anterior thoracic extension","L1220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","295.86","","","","","","","fee schedule","292.98","301.6","APC"
"Anterior thoracic extension","L1220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","292.98","","","","","","","fee schedule","292.98","301.6","APC"
"Anterior thoracic extension","L1220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","301.6","","","","","","","fee schedule","292.98","301.6","APC"
"Milwaukee type superstructur","L1230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","771.24","","","","","","","fee schedule","751","773.08","APC"
"Milwaukee type superstructur","L1230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","758.36","","","","","","","fee schedule","751","773.08","APC"
"Milwaukee type superstructur","L1230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","751","","","","","","","fee schedule","751","773.08","APC"
"Milwaukee type superstructur","L1230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","773.08","","","","","","","fee schedule","751","773.08","APC"
"Lumbar derotation pad","L1240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.26","","","","","","","fee schedule","101.52","104.51","APC"
"Lumbar derotation pad","L1240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.52","","","","","","","fee schedule","101.52","104.51","APC"
"Lumbar derotation pad","L1240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.52","","","","","","","fee schedule","101.52","104.51","APC"
"Lumbar derotation pad","L1240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.51","","","","","","","fee schedule","101.52","104.51","APC"
"Anterior asis pad","L1250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.26","","","","","","","fee schedule","101.52","104.51","APC"
"Anterior asis pad","L1250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.52","","","","","","","fee schedule","101.52","104.51","APC"
"Anterior asis pad","L1250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.52","","","","","","","fee schedule","101.52","104.51","APC"
"Anterior asis pad","L1250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.51","","","","","","","fee schedule","101.52","104.51","APC"
"Anterior thoracic derotation","L1260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","106.46","","","","","","","fee schedule","103.66","106.71","APC"
"Anterior thoracic derotation","L1260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","104.68","","","","","","","fee schedule","103.66","106.71","APC"
"Anterior thoracic derotation","L1260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","103.66","","","","","","","fee schedule","103.66","106.71","APC"
"Anterior thoracic derotation","L1260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","106.71","","","","","","","fee schedule","103.66","106.71","APC"
"Abdominal pad","L1270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","108.13","","","","","","","fee schedule","105.29","108.39","APC"
"Abdominal pad","L1270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.33","","","","","","","fee schedule","105.29","108.39","APC"
"Abdominal pad","L1270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","105.29","","","","","","","fee schedule","105.29","108.39","APC"
"Abdominal pad","L1270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.39","","","","","","","fee schedule","105.29","108.39","APC"
"Rib gusset (elastic) each","L1280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","124.39","","","","","","","fee schedule","121.12","124.69","APC"
"Rib gusset (elastic) each","L1280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","122.31","","","","","","","fee schedule","121.12","124.69","APC"
"Rib gusset (elastic) each","L1280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","121.12","","","","","","","fee schedule","121.12","124.69","APC"
"Rib gusset (elastic) each","L1280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","124.69","","","","","","","fee schedule","121.12","124.69","APC"
"Lateral trochanteric pad","L1290","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","98.46","","","","","","","fee schedule","95.88","98.7","APC"
"Lateral trochanteric pad","L1290","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","96.82","","","","","","","fee schedule","95.88","98.7","APC"
"Lateral trochanteric pad","L1290","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","95.88","","","","","","","fee schedule","95.88","98.7","APC"
"Lateral trochanteric pad","L1290","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","98.7","","","","","","","fee schedule","95.88","98.7","APC"
"Body jacket mold to patient","L1300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2217.15","","","","","","","fee schedule","2158.94","2222.44","APC"
"Body jacket mold to patient","L1300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2180.11","","","","","","","fee schedule","2158.94","2222.44","APC"
"Body jacket mold to patient","L1300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2158.94","","","","","","","fee schedule","2158.94","2222.44","APC"
"Body jacket mold to patient","L1300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2222.44","","","","","","","fee schedule","2158.94","2222.44","APC"
"Post-operative body jacket","L1310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2278.13","","","","","","","fee schedule","2218.33","2283.57","APC"
"Post-operative body jacket","L1310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2240.07","","","","","","","fee schedule","2218.33","2283.57","APC"
"Post-operative body jacket","L1310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2218.33","","","","","","","fee schedule","2218.33","2283.57","APC"
"Post-operative body jacket","L1310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2283.57","","","","","","","fee schedule","2218.33","2283.57","APC"
"Ho flex frejka w/cov pre cst","L1600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","155.11","","","","","","","fee schedule","151.04","155.48","APC"
"Ho flex frejka w/cov pre cst","L1600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","152.52","","","","","","","fee schedule","151.04","155.48","APC"
"Ho flex frejka w/cov pre cst","L1600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","151.04","","","","","","","fee schedule","151.04","155.48","APC"
"Ho flex frejka w/cov pre cst","L1600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","155.48","","","","","","","fee schedule","151.04","155.48","APC"
"Ho frejka cov only pre cst","L1610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.45","","","","","","","fee schedule","66.66","68.62","APC"
"Ho frejka cov only pre cst","L1610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.31","","","","","","","fee schedule","66.66","68.62","APC"
"Ho frejka cov only pre cst","L1610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.66","","","","","","","fee schedule","66.66","68.62","APC"
"Ho frejka cov only pre cst","L1610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.62","","","","","","","fee schedule","66.66","68.62","APC"
"Ho flex pavlik harns pre cst","L1620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","193.86","","","","","","","fee schedule","188.77","194.32","APC"
"Ho flex pavlik harns pre cst","L1620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.62","","","","","","","fee schedule","188.77","194.32","APC"
"Ho flex pavlik harns pre cst","L1620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.77","","","","","","","fee schedule","188.77","194.32","APC"
"Ho flex pavlik harns pre cst","L1620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.32","","","","","","","fee schedule","188.77","194.32","APC"
"Abduct control hip semi-flex","L1630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","203.97","","","","","","","fee schedule","198.61","204.46","APC"
"Abduct control hip semi-flex","L1630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","200.56","","","","","","","fee schedule","198.61","204.46","APC"
"Abduct control hip semi-flex","L1630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","198.61","","","","","","","fee schedule","198.61","204.46","APC"
"Abduct control hip semi-flex","L1630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","204.46","","","","","","","fee schedule","198.61","204.46","APC"
"Pelv band/spread bar thigh c","L1640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","620.88","","","","","","","fee schedule","604.58","622.37","APC"
"Pelv band/spread bar thigh c","L1640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","610.51","","","","","","","fee schedule","604.58","622.37","APC"
"Pelv band/spread bar thigh c","L1640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","604.58","","","","","","","fee schedule","604.58","622.37","APC"
"Pelv band/spread bar thigh c","L1640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","622.37","","","","","","","fee schedule","604.58","622.37","APC"
"HO abduction hip adjustable","L1650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","314.2","","","","","","","fee schedule","305.95","314.95","APC"
"HO abduction hip adjustable","L1650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","308.95","","","","","","","fee schedule","305.95","314.95","APC"
"HO abduction hip adjustable","L1650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","305.95","","","","","","","fee schedule","305.95","314.95","APC"
"HO abduction hip adjustable","L1650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","314.95","","","","","","","fee schedule","305.95","314.95","APC"
"HO bi thighcuffs w sprdr bar","L1652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","447.87","","","","","","","fee schedule","436.11","448.94","APC"
"HO bi thighcuffs w sprdr bar","L1652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","440.39","","","","","","","fee schedule","436.11","448.94","APC"
"HO bi thighcuffs w sprdr bar","L1652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","436.11","","","","","","","fee schedule","436.11","448.94","APC"
"HO bi thighcuffs w sprdr bar","L1652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","448.94","","","","","","","fee schedule","436.11","448.94","APC"
"HO abduction static plastic","L1660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","206","","","","","","","fee schedule","200.59","206.49","APC"
"HO abduction static plastic","L1660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","202.56","","","","","","","fee schedule","200.59","206.49","APC"
"HO abduction static plastic","L1660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","200.59","","","","","","","fee schedule","200.59","206.49","APC"
"HO abduction static plastic","L1660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","206.49","","","","","","","fee schedule","200.59","206.49","APC"
"Pelvic & hip control thigh c","L1680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1466.62","","","","","","","fee schedule","1428.11","1470.12","APC"
"Pelvic & hip control thigh c","L1680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1442.11","","","","","","","fee schedule","1428.11","1470.12","APC"
"Pelvic & hip control thigh c","L1680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1428.11","","","","","","","fee schedule","1428.11","1470.12","APC"
"Pelvic & hip control thigh c","L1680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1470.12","","","","","","","fee schedule","1428.11","1470.12","APC"
"Ho bilateral hip abduction","L1681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2764.12","","","","","","","fee schedule","2691.56","2770.72","APC"
"Ho bilateral hip abduction","L1681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2717.94","","","","","","","fee schedule","2691.56","2770.72","APC"
"Ho bilateral hip abduction","L1681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2691.56","","","","","","","fee schedule","2691.56","2770.72","APC"
"Ho bilateral hip abduction","L1681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2770.72","","","","","","","fee schedule","2691.56","2770.72","APC"
"Post-op hip abduct custom fa","L1685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1496.76","","","","","","","fee schedule","1457.47","1500.33","APC"
"Post-op hip abduct custom fa","L1685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1471.76","","","","","","","fee schedule","1457.47","1500.33","APC"
"Post-op hip abduct custom fa","L1685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1457.47","","","","","","","fee schedule","1457.47","1500.33","APC"
"Post-op hip abduct custom fa","L1685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1500.33","","","","","","","fee schedule","1457.47","1500.33","APC"
"HO post-op hip abduction","L1686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1382.06","","","","","","","fee schedule","1345.78","1385.36","APC"
"HO post-op hip abduction","L1686","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1358.97","","","","","","","fee schedule","1345.78","1385.36","APC"
"HO post-op hip abduction","L1686","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1345.78","","","","","","","fee schedule","1345.78","1385.36","APC"
"HO post-op hip abduction","L1686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1385.36","","","","","","","fee schedule","1345.78","1385.36","APC"
"Combination bilateral HO","L1690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.72","","","","","","","fee schedule","2365.93","2435.52","APC"
"Combination bilateral HO","L1690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2389.13","","","","","","","fee schedule","2365.93","2435.52","APC"
"Combination bilateral HO","L1690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2365.93","","","","","","","fee schedule","2365.93","2435.52","APC"
"Combination bilateral HO","L1690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2435.52","","","","","","","fee schedule","2365.93","2435.52","APC"
"Leg perthes orth toronto typ","L1700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1838.19","","","","","","","fee schedule","1789.94","1842.58","APC"
"Leg perthes orth toronto typ","L1700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1807.49","","","","","","","fee schedule","1789.94","1842.58","APC"
"Leg perthes orth toronto typ","L1700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1789.94","","","","","","","fee schedule","1789.94","1842.58","APC"
"Leg perthes orth toronto typ","L1700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1842.58","","","","","","","fee schedule","1789.94","1842.58","APC"
"Legg perthes orth newington","L1710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2151.81","","","","","","","fee schedule","2095.31","2156.94","APC"
"Legg perthes orth newington","L1710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2115.86","","","","","","","fee schedule","2095.31","2156.94","APC"
"Legg perthes orth newington","L1710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2095.31","","","","","","","fee schedule","2095.31","2156.94","APC"
"Legg perthes orth newington","L1710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2156.94","","","","","","","fee schedule","2095.31","2156.94","APC"
"Legg perthes orthosis trilat","L1720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1586.13","","","","","","","fee schedule","1544.49","1589.92","APC"
"Legg perthes orthosis trilat","L1720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1559.64","","","","","","","fee schedule","1544.49","1589.92","APC"
"Legg perthes orthosis trilat","L1720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1544.49","","","","","","","fee schedule","1544.49","1589.92","APC"
"Legg perthes orthosis trilat","L1720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1589.92","","","","","","","fee schedule","1544.49","1589.92","APC"
"Legg perthes orth scottish r","L1730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1362.34","","","","","","","fee schedule","1326.57","1365.59","APC"
"Legg perthes orth scottish r","L1730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1339.58","","","","","","","fee schedule","1326.57","1365.59","APC"
"Legg perthes orth scottish r","L1730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1326.57","","","","","","","fee schedule","1326.57","1365.59","APC"
"Legg perthes orth scottish r","L1730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1365.59","","","","","","","fee schedule","1326.57","1365.59","APC"
"Legg perthes patten bottom t","L1755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2161.95","","","","","","","fee schedule","2105.19","2167.11","APC"
"Legg perthes patten bottom t","L1755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2125.83","","","","","","","fee schedule","2105.19","2167.11","APC"
"Legg perthes patten bottom t","L1755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2105.19","","","","","","","fee schedule","2105.19","2167.11","APC"
"Legg perthes patten bottom t","L1755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2167.11","","","","","","","fee schedule","2105.19","2167.11","APC"
"Ko elastic with joints","L1810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","118.55","","","","","","","fee schedule","115.43","118.83","APC"
"Ko elastic with joints","L1810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","116.57","","","","","","","fee schedule","115.43","118.83","APC"
"Ko elastic with joints","L1810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","115.43","","","","","","","fee schedule","115.43","118.83","APC"
"Ko elastic with joints","L1810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","118.83","","","","","","","fee schedule","115.43","118.83","APC"
"Ko elastic w/joints pre ots","L1812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","89.78","","","","","","","fee schedule","87.42","90","APC"
"Ko elastic w/joints pre ots","L1812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","88.28","","","","","","","fee schedule","87.42","90","APC"
"Ko elastic w/joints pre ots","L1812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","87.42","","","","","","","fee schedule","87.42","90","APC"
"Ko elastic w/joints pre ots","L1812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","90","","","","","","","fee schedule","87.42","90","APC"
"Ko elas w/ condyle pads & jo","L1820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183.65","","","","","","","fee schedule","178.83","184.09","APC"
"Ko elas w/ condyle pads & jo","L1820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.58","","","","","","","fee schedule","178.83","184.09","APC"
"Ko elas w/ condyle pads & jo","L1820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178.83","","","","","","","fee schedule","178.83","184.09","APC"
"Ko elas w/ condyle pads & jo","L1820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.09","","","","","","","fee schedule","178.83","184.09","APC"
"Ko immob canvas long pre ots","L1830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","80.9","","","","","","","fee schedule","78.77","81.09","APC"
"Ko immob canvas long pre ots","L1830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","79.55","","","","","","","fee schedule","78.77","81.09","APC"
"Ko immob canvas long pre ots","L1830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","78.77","","","","","","","fee schedule","78.77","81.09","APC"
"Ko immob canvas long pre ots","L1830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81.09","","","","","","","fee schedule","78.77","81.09","APC"
"Knee orth pos locking joint","L1831","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","369.81","","","","","","","fee schedule","360.1","370.69","APC"
"Knee orth pos locking joint","L1831","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","363.63","","","","","","","fee schedule","360.1","370.69","APC"
"Knee orth pos locking joint","L1831","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","360.1","","","","","","","fee schedule","360.1","370.69","APC"
"Knee orth pos locking joint","L1831","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","370.69","","","","","","","fee schedule","360.1","370.69","APC"
"Ko adj jnt pos r sup pre cst","L1832","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","851.29","","","","","","","fee schedule","828.94","853.32","APC"
"Ko adj jnt pos r sup pre cst","L1832","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","837.07","","","","","","","fee schedule","828.94","853.32","APC"
"Ko adj jnt pos r sup pre cst","L1832","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","828.94","","","","","","","fee schedule","828.94","853.32","APC"
"Ko adj jnt pos r sup pre cst","L1832","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","853.32","","","","","","","fee schedule","828.94","853.32","APC"
"Ko adj jnt pos r sup pre ots","L1833","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","582.73","","","","","","","fee schedule","567.44","584.13","APC"
"Ko adj jnt pos r sup pre ots","L1833","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","573","","","","","","","fee schedule","567.44","584.13","APC"
"Ko adj jnt pos r sup pre ots","L1833","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","567.44","","","","","","","fee schedule","567.44","584.13","APC"
"Ko adj jnt pos r sup pre ots","L1833","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","584.13","","","","","","","fee schedule","567.44","584.13","APC"
"Ko w/0 joint rigid molded to","L1834","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","934.39","","","","","","","fee schedule","909.86","936.62","APC"
"Ko w/0 joint rigid molded to","L1834","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","918.78","","","","","","","fee schedule","909.86","936.62","APC"
"Ko w/0 joint rigid molded to","L1834","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","909.86","","","","","","","fee schedule","909.86","936.62","APC"
"Ko w/0 joint rigid molded to","L1834","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","936.62","","","","","","","fee schedule","909.86","936.62","APC"
"Ko rigid w/o joints pre ots","L1836","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","114.39","","","","","","","fee schedule","111.38","114.66","APC"
"Ko rigid w/o joints pre ots","L1836","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","112.48","","","","","","","fee schedule","111.38","114.66","APC"
"Ko rigid w/o joints pre ots","L1836","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","111.38","","","","","","","fee schedule","111.38","114.66","APC"
"Ko rigid w/o joints pre ots","L1836","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","114.66","","","","","","","fee schedule","111.38","114.66","APC"
"Ko derot ant cruciate custom","L1840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1244.64","","","","","","","fee schedule","1211.96","1247.61","APC"
"Ko derot ant cruciate custom","L1840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1223.85","","","","","","","fee schedule","1211.96","1247.61","APC"
"Ko derot ant cruciate custom","L1840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1211.96","","","","","","","fee schedule","1211.96","1247.61","APC"
"Ko derot ant cruciate custom","L1840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1247.61","","","","","","","fee schedule","1211.96","1247.61","APC"
"Ko single upright pre cst","L1843","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1127.38","","","","","","","fee schedule","1097.79","1130.07","APC"
"Ko single upright pre cst","L1843","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1108.55","","","","","","","fee schedule","1097.79","1130.07","APC"
"Ko single upright pre cst","L1843","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1097.79","","","","","","","fee schedule","1097.79","1130.07","APC"
"Ko single upright pre cst","L1843","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1130.07","","","","","","","fee schedule","1097.79","1130.07","APC"
"Ko w/adj jt rot cntrl molded","L1844","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1954.12","","","","","","","fee schedule","1902.82","1958.79","APC"
"Ko w/adj jt rot cntrl molded","L1844","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1921.48","","","","","","","fee schedule","1902.82","1958.79","APC"
"Ko w/adj jt rot cntrl molded","L1844","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1902.82","","","","","","","fee schedule","1902.82","1958.79","APC"
"Ko w/adj jt rot cntrl molded","L1844","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1958.79","","","","","","","fee schedule","1902.82","1958.79","APC"
"Ko double upright pre cst","L1845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1169.93","","","","","","","fee schedule","1139.22","1172.72","APC"
"Ko double upright pre cst","L1845","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1150.39","","","","","","","fee schedule","1139.22","1172.72","APC"
"Ko double upright pre cst","L1845","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1139.22","","","","","","","fee schedule","1139.22","1172.72","APC"
"Ko double upright pre cst","L1845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1172.72","","","","","","","fee schedule","1139.22","1172.72","APC"
"Ko w adj flex/ext rotat mold","L1846","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1434.42","","","","","","","fee schedule","1396.76","1437.84","APC"
"Ko w adj flex/ext rotat mold","L1846","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1410.45","","","","","","","fee schedule","1396.76","1437.84","APC"
"Ko w adj flex/ext rotat mold","L1846","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1396.76","","","","","","","fee schedule","1396.76","1437.84","APC"
"Ko w adj flex/ext rotat mold","L1846","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1437.84","","","","","","","fee schedule","1396.76","1437.84","APC"
"Ko dbl upright w/air pre cst","L1847","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","722.69","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre cst","L1847","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","710.62","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre cst","L1847","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","703.72","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre cst","L1847","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","724.42","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre ots","L1848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","722.69","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre ots","L1848","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","710.62","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre ots","L1848","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","703.72","","","","","","","fee schedule","703.72","724.42","APC"
"Ko dbl upright w/air pre ots","L1848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","724.42","","","","","","","fee schedule","703.72","724.42","APC"
"Ko swedish type pre ots","L1850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","263.45","","","","","","","fee schedule","256.53","264.08","APC"
"Ko swedish type pre ots","L1850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","259.04","","","","","","","fee schedule","256.53","264.08","APC"
"Ko swedish type pre ots","L1850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","256.53","","","","","","","fee schedule","256.53","264.08","APC"
"Ko swedish type pre ots","L1850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","264.08","","","","","","","fee schedule","256.53","264.08","APC"
"Ko single upright prefab ots","L1851","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","769.16","","","","","","","fee schedule","748.97","770.99","APC"
"Ko single upright prefab ots","L1851","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","756.31","","","","","","","fee schedule","748.97","770.99","APC"
"Ko single upright prefab ots","L1851","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","748.97","","","","","","","fee schedule","748.97","770.99","APC"
"Ko single upright prefab ots","L1851","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","770.99","","","","","","","fee schedule","748.97","770.99","APC"
"Ko double upright prefab ots","L1852","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","733.76","","","","","","","fee schedule","714.5","735.51","APC"
"Ko double upright prefab ots","L1852","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","721.5","","","","","","","fee schedule","714.5","735.51","APC"
"Ko double upright prefab ots","L1852","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","714.5","","","","","","","fee schedule","714.5","735.51","APC"
"Ko double upright prefab ots","L1852","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","735.51","","","","","","","fee schedule","714.5","735.51","APC"
"Ko supracondylar socket mold","L1860","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1291.64","","","","","","","fee schedule","1257.73","1294.72","APC"
"Ko supracondylar socket mold","L1860","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1270.06","","","","","","","fee schedule","1257.73","1294.72","APC"
"Ko supracondylar socket mold","L1860","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1257.73","","","","","","","fee schedule","1257.73","1294.72","APC"
"Ko supracondylar socket mold","L1860","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1294.72","","","","","","","fee schedule","1257.73","1294.72","APC"
"Afo sprng wir drsflx calf bd","L1900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.74","","","","","","","fee schedule","316.21","325.51","APC"
"Afo sprng wir drsflx calf bd","L1900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","319.31","","","","","","","fee schedule","316.21","325.51","APC"
"Afo sprng wir drsflx calf bd","L1900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","316.21","","","","","","","fee schedule","316.21","325.51","APC"
"Afo sprng wir drsflx calf bd","L1900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","325.51","","","","","","","fee schedule","316.21","325.51","APC"
"Afo ankle gauntlet pre ots","L1902","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","112.21","","","","","","","fee schedule","109.26","112.48","APC"
"Afo ankle gauntlet pre ots","L1902","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","110.33","","","","","","","fee schedule","109.26","112.48","APC"
"Afo ankle gauntlet pre ots","L1902","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","109.26","","","","","","","fee schedule","109.26","112.48","APC"
"Afo ankle gauntlet pre ots","L1902","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","112.48","","","","","","","fee schedule","109.26","112.48","APC"
"Afo molded ankle gauntlet","L1904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","674.79","","","","","","","fee schedule","657.07","676.4","APC"
"Afo molded ankle gauntlet","L1904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","663.52","","","","","","","fee schedule","657.07","676.4","APC"
"Afo molded ankle gauntlet","L1904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","657.07","","","","","","","fee schedule","657.07","676.4","APC"
"Afo molded ankle gauntlet","L1904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","676.4","","","","","","","fee schedule","657.07","676.4","APC"
"Afo multilig ank sup pre ots","L1906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","144.76","","","","","","","fee schedule","140.96","145.11","APC"
"Afo multilig ank sup pre ots","L1906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","142.35","","","","","","","fee schedule","140.96","145.11","APC"
"Afo multilig ank sup pre ots","L1906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","140.96","","","","","","","fee schedule","140.96","145.11","APC"
"Afo multilig ank sup pre ots","L1906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","145.11","","","","","","","fee schedule","140.96","145.11","APC"
"AFO supramalleolar custom","L1907","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","707.01","","","","","","","fee schedule","688.45","708.7","APC"
"AFO supramalleolar custom","L1907","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","695.2","","","","","","","fee schedule","688.45","708.7","APC"
"AFO supramalleolar custom","L1907","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","688.45","","","","","","","fee schedule","688.45","708.7","APC"
"AFO supramalleolar custom","L1907","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","708.7","","","","","","","fee schedule","688.45","708.7","APC"
"Afo sing bar clasp attach sh","L1910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","328.74","","","","","","","fee schedule","320.11","329.52","APC"
"Afo sing bar clasp attach sh","L1910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","323.24","","","","","","","fee schedule","320.11","329.52","APC"
"Afo sing bar clasp attach sh","L1910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","320.11","","","","","","","fee schedule","320.11","329.52","APC"
"Afo sing bar clasp attach sh","L1910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","329.52","","","","","","","fee schedule","320.11","329.52","APC"
"Afo sing upright w/ adjust s","L1920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","420.81","","","","","","","fee schedule","409.76","421.82","APC"
"Afo sing upright w/ adjust s","L1920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","413.78","","","","","","","fee schedule","409.76","421.82","APC"
"Afo sing upright w/ adjust s","L1920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","409.76","","","","","","","fee schedule","409.76","421.82","APC"
"Afo sing upright w/ adjust s","L1920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","421.82","","","","","","","fee schedule","409.76","421.82","APC"
"Afo plastic","L1930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","284.75","","","","","","","fee schedule","277.28","285.43","APC"
"Afo plastic","L1930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","280","","","","","","","fee schedule","277.28","285.43","APC"
"Afo plastic","L1930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","277.28","","","","","","","fee schedule","277.28","285.43","APC"
"Afo plastic","L1930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","285.43","","","","","","","fee schedule","277.28","285.43","APC"
"Afo rig ant tib prefab TCF/=","L1932","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1121.23","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib prefab TCF/=","L1932","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1102.5","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib prefab TCF/=","L1932","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1091.8","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib prefab TCF/=","L1932","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1123.91","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib tcf/= ots","L1933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1121.23","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib tcf/= ots","L1933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1102.5","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib tcf/= ots","L1933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1091.8","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo rig ant tib tcf/= ots","L1933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1123.91","","","","","","","fee schedule","1091.8","1123.91","APC"
"Afo molded to patient plasti","L1940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","595.29","","","","","","","fee schedule","579.67","596.72","APC"
"Afo molded to patient plasti","L1940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","585.35","","","","","","","fee schedule","579.67","596.72","APC"
"Afo molded to patient plasti","L1940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","579.67","","","","","","","fee schedule","579.67","596.72","APC"
"Afo molded to patient plasti","L1940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","596.72","","","","","","","fee schedule","579.67","596.72","APC"
"Afo molded plas rig ant tib","L1945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1423.23","","","","","","","fee schedule","1385.86","1426.62","APC"
"Afo molded plas rig ant tib","L1945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1399.45","","","","","","","fee schedule","1385.86","1426.62","APC"
"Afo molded plas rig ant tib","L1945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1385.86","","","","","","","fee schedule","1385.86","1426.62","APC"
"Afo molded plas rig ant tib","L1945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1426.62","","","","","","","fee schedule","1385.86","1426.62","APC"
"Afo spiral molded to pt plas","L1950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","943.66","","","","","","","fee schedule","918.89","945.91","APC"
"Afo spiral molded to pt plas","L1950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","927.9","","","","","","","fee schedule","918.89","945.91","APC"
"Afo spiral molded to pt plas","L1950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","918.89","","","","","","","fee schedule","918.89","945.91","APC"
"Afo spiral molded to pt plas","L1950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","945.91","","","","","","","fee schedule","918.89","945.91","APC"
"AFO spiral prefabricated","L1951","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1055.22","","","","","","","fee schedule","1027.52","1057.74","APC"
"AFO spiral prefabricated","L1951","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1037.59","","","","","","","fee schedule","1027.52","1057.74","APC"
"AFO spiral prefabricated","L1951","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1027.52","","","","","","","fee schedule","1027.52","1057.74","APC"
"AFO spiral prefabricated","L1951","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1057.74","","","","","","","fee schedule","1027.52","1057.74","APC"
"Afo spiral prefab ots","L1952","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1055.22","","","","","","","fee schedule","1027.52","1057.74","APC"
"Afo spiral prefab ots","L1952","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1037.59","","","","","","","fee schedule","1027.52","1057.74","APC"
"Afo spiral prefab ots","L1952","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1027.52","","","","","","","fee schedule","1027.52","1057.74","APC"
"Afo spiral prefab ots","L1952","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1057.74","","","","","","","fee schedule","1027.52","1057.74","APC"
"Afo pos solid ank plastic mo","L1960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.73","","","","","","","fee schedule","693.05","713.43","APC"
"Afo pos solid ank plastic mo","L1960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.84","","","","","","","fee schedule","693.05","713.43","APC"
"Afo pos solid ank plastic mo","L1960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","693.05","","","","","","","fee schedule","693.05","713.43","APC"
"Afo pos solid ank plastic mo","L1960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","713.43","","","","","","","fee schedule","693.05","713.43","APC"
"Afo plastic molded w/ankle j","L1970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","856.52","","","","","","","fee schedule","834.03","858.56","APC"
"Afo plastic molded w/ankle j","L1970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","842.21","","","","","","","fee schedule","834.03","858.56","APC"
"Afo plastic molded w/ankle j","L1970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","834.03","","","","","","","fee schedule","834.03","858.56","APC"
"Afo plastic molded w/ankle j","L1970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","858.56","","","","","","","fee schedule","834.03","858.56","APC"
"AFO w/ankle joint, prefab","L1971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","588.94","","","","","","","fee schedule","573.47","590.34","APC"
"AFO w/ankle joint, prefab","L1971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","579.1","","","","","","","fee schedule","573.47","590.34","APC"
"AFO w/ankle joint, prefab","L1971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","573.47","","","","","","","fee schedule","573.47","590.34","APC"
"AFO w/ankle joint, prefab","L1971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","590.34","","","","","","","fee schedule","573.47","590.34","APC"
"Afo sing solid stirrup calf","L1980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","441.76","","","","","","","fee schedule","430.16","442.82","APC"
"Afo sing solid stirrup calf","L1980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","434.38","","","","","","","fee schedule","430.16","442.82","APC"
"Afo sing solid stirrup calf","L1980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","430.16","","","","","","","fee schedule","430.16","442.82","APC"
"Afo sing solid stirrup calf","L1980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","442.82","","","","","","","fee schedule","430.16","442.82","APC"
"Afo doub solid stirrup calf","L1990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","536.55","","","","","","","fee schedule","522.46","537.83","APC"
"Afo doub solid stirrup calf","L1990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","527.59","","","","","","","fee schedule","522.46","537.83","APC"
"Afo doub solid stirrup calf","L1990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","522.46","","","","","","","fee schedule","522.46","537.83","APC"
"Afo doub solid stirrup calf","L1990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","537.83","","","","","","","fee schedule","522.46","537.83","APC"
"Kafo sing fre stirr thi/calf","L2000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1271.16","","","","","","","fee schedule","1237.79","1274.2","APC"
"Kafo sing fre stirr thi/calf","L2000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1249.93","","","","","","","fee schedule","1237.79","1274.2","APC"
"Kafo sing fre stirr thi/calf","L2000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1237.79","","","","","","","fee schedule","1237.79","1274.2","APC"
"Kafo sing fre stirr thi/calf","L2000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1274.2","","","","","","","fee schedule","1237.79","1274.2","APC"
"KAFO sng/dbl mechanical act","L2005","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5148.68","","","","","","","fee schedule","5013.51","5160.97","APC"
"KAFO sng/dbl mechanical act","L2005","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5062.67","","","","","","","fee schedule","5013.51","5160.97","APC"
"KAFO sng/dbl mechanical act","L2005","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5013.51","","","","","","","fee schedule","5013.51","5160.97","APC"
"KAFO sng/dbl mechanical act","L2005","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5160.97","","","","","","","fee schedule","5013.51","5160.97","APC"
"Kafo sng solid stirrup w/o j","L2010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1185.83","","","","","","","fee schedule","1154.7","1188.66","APC"
"Kafo sng solid stirrup w/o j","L2010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1166.02","","","","","","","fee schedule","1154.7","1188.66","APC"
"Kafo sng solid stirrup w/o j","L2010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1154.7","","","","","","","fee schedule","1154.7","1188.66","APC"
"Kafo sng solid stirrup w/o j","L2010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1188.66","","","","","","","fee schedule","1154.7","1188.66","APC"
"Kafo dbl solid stirrup band/","L2020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1493.11","","","","","","","fee schedule","1453.91","1496.67","APC"
"Kafo dbl solid stirrup band/","L2020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1468.16","","","","","","","fee schedule","1453.91","1496.67","APC"
"Kafo dbl solid stirrup band/","L2020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1453.91","","","","","","","fee schedule","1453.91","1496.67","APC"
"Kafo dbl solid stirrup band/","L2020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1496.67","","","","","","","fee schedule","1453.91","1496.67","APC"
"Kafo dbl solid stirrup w/o j","L2030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1355.4","","","","","","","fee schedule","1319.82","1358.64","APC"
"Kafo dbl solid stirrup w/o j","L2030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1332.76","","","","","","","fee schedule","1319.82","1358.64","APC"
"Kafo dbl solid stirrup w/o j","L2030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1319.82","","","","","","","fee schedule","1319.82","1358.64","APC"
"Kafo dbl solid stirrup w/o j","L2030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1358.64","","","","","","","fee schedule","1319.82","1358.64","APC"
"Kafo pla sin up w/wo k/a cus","L2034","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2560.08","","","","","","","fee schedule","2492.87","2566.19","APC"
"Kafo pla sin up w/wo k/a cus","L2034","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2517.31","","","","","","","fee schedule","2492.87","2566.19","APC"
"Kafo pla sin up w/wo k/a cus","L2034","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2492.87","","","","","","","fee schedule","2492.87","2566.19","APC"
"Kafo pla sin up w/wo k/a cus","L2034","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2566.19","","","","","","","fee schedule","2492.87","2566.19","APC"
"KAFO plastic pediatric size","L2035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","219.86","","","","","","","fee schedule","214.09","220.38","APC"
"KAFO plastic pediatric size","L2035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","216.19","","","","","","","fee schedule","214.09","220.38","APC"
"KAFO plastic pediatric size","L2035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","214.09","","","","","","","fee schedule","214.09","220.38","APC"
"KAFO plastic pediatric size","L2035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","220.38","","","","","","","fee schedule","214.09","220.38","APC"
"Kafo plas doub free knee mol","L2036","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2314.3","","","","","","","fee schedule","2253.55","2319.83","APC"
"Kafo plas doub free knee mol","L2036","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2275.64","","","","","","","fee schedule","2253.55","2319.83","APC"
"Kafo plas doub free knee mol","L2036","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2253.55","","","","","","","fee schedule","2253.55","2319.83","APC"
"Kafo plas doub free knee mol","L2036","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2319.83","","","","","","","fee schedule","2253.55","2319.83","APC"
"Kafo plas sing free knee mol","L2037","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2159.12","","","","","","","fee schedule","2102.43","2164.27","APC"
"Kafo plas sing free knee mol","L2037","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2123.05","","","","","","","fee schedule","2102.43","2164.27","APC"
"Kafo plas sing free knee mol","L2037","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2102.43","","","","","","","fee schedule","2102.43","2164.27","APC"
"Kafo plas sing free knee mol","L2037","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2164.27","","","","","","","fee schedule","2102.43","2164.27","APC"
"Kafo w/o joint multi-axis an","L2038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2193.32","","","","","","","fee schedule","2135.74","2198.55","APC"
"Kafo w/o joint multi-axis an","L2038","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2156.68","","","","","","","fee schedule","2135.74","2198.55","APC"
"Kafo w/o joint multi-axis an","L2038","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2135.74","","","","","","","fee schedule","2135.74","2198.55","APC"
"Kafo w/o joint multi-axis an","L2038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2198.55","","","","","","","fee schedule","2135.74","2198.55","APC"
"Hkafo torsion bil rot straps","L2040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","266.01","","","","","","","fee schedule","259.03","266.65","APC"
"Hkafo torsion bil rot straps","L2040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","261.57","","","","","","","fee schedule","259.03","266.65","APC"
"Hkafo torsion bil rot straps","L2040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","259.03","","","","","","","fee schedule","259.03","266.65","APC"
"Hkafo torsion bil rot straps","L2040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","266.65","","","","","","","fee schedule","259.03","266.65","APC"
"Hkafo torsion cable hip pelv","L2050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","573.39","","","","","","","fee schedule","558.34","574.76","APC"
"Hkafo torsion cable hip pelv","L2050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","563.81","","","","","","","fee schedule","558.34","574.76","APC"
"Hkafo torsion cable hip pelv","L2050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","558.34","","","","","","","fee schedule","558.34","574.76","APC"
"Hkafo torsion cable hip pelv","L2050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","574.76","","","","","","","fee schedule","558.34","574.76","APC"
"Hkafo torsion ball bearing j","L2060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","698.86","","","","","","","fee schedule","680.51","700.53","APC"
"Hkafo torsion ball bearing j","L2060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","687.19","","","","","","","fee schedule","680.51","700.53","APC"
"Hkafo torsion ball bearing j","L2060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","680.51","","","","","","","fee schedule","680.51","700.53","APC"
"Hkafo torsion ball bearing j","L2060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","700.53","","","","","","","fee schedule","680.51","700.53","APC"
"Hkafo torsion unilat rot str","L2070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","179.47","","","","","","","fee schedule","174.76","179.9","APC"
"Hkafo torsion unilat rot str","L2070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","176.47","","","","","","","fee schedule","174.76","179.9","APC"
"Hkafo torsion unilat rot str","L2070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","174.76","","","","","","","fee schedule","174.76","179.9","APC"
"Hkafo torsion unilat rot str","L2070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","179.9","","","","","","","fee schedule","174.76","179.9","APC"
"Hkafo unilat torsion cable","L2080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","432.95","","","","","","","fee schedule","421.59","433.99","APC"
"Hkafo unilat torsion cable","L2080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","425.72","","","","","","","fee schedule","421.59","433.99","APC"
"Hkafo unilat torsion cable","L2080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","421.59","","","","","","","fee schedule","421.59","433.99","APC"
"Hkafo unilat torsion cable","L2080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","433.99","","","","","","","fee schedule","421.59","433.99","APC"
"Hkafo unilat torsion ball br","L2090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","527.81","","","","","","","fee schedule","513.96","529.07","APC"
"Hkafo unilat torsion ball br","L2090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","519","","","","","","","fee schedule","513.96","529.07","APC"
"Hkafo unilat torsion ball br","L2090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","513.96","","","","","","","fee schedule","513.96","529.07","APC"
"Hkafo unilat torsion ball br","L2090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","529.07","","","","","","","fee schedule","513.96","529.07","APC"
"Afo tib fx cast plaster mold","L2106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","818.42","","","","","","","fee schedule","796.94","820.38","APC"
"Afo tib fx cast plaster mold","L2106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","804.75","","","","","","","fee schedule","796.94","820.38","APC"
"Afo tib fx cast plaster mold","L2106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","796.94","","","","","","","fee schedule","796.94","820.38","APC"
"Afo tib fx cast plaster mold","L2106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","820.38","","","","","","","fee schedule","796.94","820.38","APC"
"Afo tib fx cast molded to pt","L2108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1425.02","","","","","","","fee schedule","1387.61","1428.42","APC"
"Afo tib fx cast molded to pt","L2108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1401.21","","","","","","","fee schedule","1387.61","1428.42","APC"
"Afo tib fx cast molded to pt","L2108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1387.61","","","","","","","fee schedule","1387.61","1428.42","APC"
"Afo tib fx cast molded to pt","L2108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1428.42","","","","","","","fee schedule","1387.61","1428.42","APC"
"Afo tibial fracture soft","L2112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","655.44","","","","","","","fee schedule","638.23","657.01","APC"
"Afo tibial fracture soft","L2112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","644.49","","","","","","","fee schedule","638.23","657.01","APC"
"Afo tibial fracture soft","L2112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","638.23","","","","","","","fee schedule","638.23","657.01","APC"
"Afo tibial fracture soft","L2112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","657.01","","","","","","","fee schedule","638.23","657.01","APC"
"Afo tib fx semi-rigid","L2114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","822.1","","","","","","","fee schedule","800.52","824.06","APC"
"Afo tib fx semi-rigid","L2114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","808.36","","","","","","","fee schedule","800.52","824.06","APC"
"Afo tib fx semi-rigid","L2114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","800.52","","","","","","","fee schedule","800.52","824.06","APC"
"Afo tib fx semi-rigid","L2114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","824.06","","","","","","","fee schedule","800.52","824.06","APC"
"Afo tibial fracture rigid","L2116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","945.9","","","","","","","fee schedule","921.07","948.16","APC"
"Afo tibial fracture rigid","L2116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","930.1","","","","","","","fee schedule","921.07","948.16","APC"
"Afo tibial fracture rigid","L2116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","921.07","","","","","","","fee schedule","921.07","948.16","APC"
"Afo tibial fracture rigid","L2116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","948.16","","","","","","","fee schedule","921.07","948.16","APC"
"Kafo fem fx cast thermoplas","L2126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1582.32","","","","","","","fee schedule","1540.78","1586.1","APC"
"Kafo fem fx cast thermoplas","L2126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1555.89","","","","","","","fee schedule","1540.78","1586.1","APC"
"Kafo fem fx cast thermoplas","L2126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1540.78","","","","","","","fee schedule","1540.78","1586.1","APC"
"Kafo fem fx cast thermoplas","L2126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1586.1","","","","","","","fee schedule","1540.78","1586.1","APC"
"Kafo fem fx cast molded to p","L2128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2240.67","","","","","","","fee schedule","2181.84","2246.01","APC"
"Kafo fem fx cast molded to p","L2128","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2203.23","","","","","","","fee schedule","2181.84","2246.01","APC"
"Kafo fem fx cast molded to p","L2128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2181.84","","","","","","","fee schedule","2181.84","2246.01","APC"
"Kafo fem fx cast molded to p","L2128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2246.01","","","","","","","fee schedule","2181.84","2246.01","APC"
"Kafo femoral fx cast soft","L2132","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1214.82","","","","","","","fee schedule","1182.92","1217.72","APC"
"Kafo femoral fx cast soft","L2132","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1194.52","","","","","","","fee schedule","1182.92","1217.72","APC"
"Kafo femoral fx cast soft","L2132","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1182.92","","","","","","","fee schedule","1182.92","1217.72","APC"
"Kafo femoral fx cast soft","L2132","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1217.72","","","","","","","fee schedule","1182.92","1217.72","APC"
"Kafo fem fx cast semi-rigid","L2134","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1296.3","","","","","","","fee schedule","1262.27","1299.4","APC"
"Kafo fem fx cast semi-rigid","L2134","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1274.65","","","","","","","fee schedule","1262.27","1299.4","APC"
"Kafo fem fx cast semi-rigid","L2134","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1262.27","","","","","","","fee schedule","1262.27","1299.4","APC"
"Kafo fem fx cast semi-rigid","L2134","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1299.4","","","","","","","fee schedule","1262.27","1299.4","APC"
"Kafo femoral fx cast rigid","L2136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1547.22","","","","","","","fee schedule","1506.6","1550.91","APC"
"Kafo femoral fx cast rigid","L2136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1521.37","","","","","","","fee schedule","1506.6","1550.91","APC"
"Kafo femoral fx cast rigid","L2136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1506.6","","","","","","","fee schedule","1506.6","1550.91","APC"
"Kafo femoral fx cast rigid","L2136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1550.91","","","","","","","fee schedule","1506.6","1550.91","APC"
"Plas shoe insert w ank joint","L2180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","144.38","","","","","","","fee schedule","140.59","144.72","APC"
"Plas shoe insert w ank joint","L2180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.96","","","","","","","fee schedule","140.59","144.72","APC"
"Plas shoe insert w ank joint","L2180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","140.59","","","","","","","fee schedule","140.59","144.72","APC"
"Plas shoe insert w ank joint","L2180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","144.72","","","","","","","fee schedule","140.59","144.72","APC"
"Drop lock knee","L2182","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","119.63","","","","","","","fee schedule","116.49","119.92","APC"
"Drop lock knee","L2182","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","117.64","","","","","","","fee schedule","116.49","119.92","APC"
"Drop lock knee","L2182","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","116.49","","","","","","","fee schedule","116.49","119.92","APC"
"Drop lock knee","L2182","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","119.92","","","","","","","fee schedule","116.49","119.92","APC"
"Limited motion knee joint","L2184","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","163.55","","","","","","","fee schedule","159.25","163.94","APC"
"Limited motion knee joint","L2184","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","160.81","","","","","","","fee schedule","159.25","163.94","APC"
"Limited motion knee joint","L2184","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.25","","","","","","","fee schedule","159.25","163.94","APC"
"Limited motion knee joint","L2184","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","163.94","","","","","","","fee schedule","159.25","163.94","APC"
"Adj motion knee jnt lerman t","L2186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","226.85","","","","","","","fee schedule","220.89","227.39","APC"
"Adj motion knee jnt lerman t","L2186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","223.06","","","","","","","fee schedule","220.89","227.39","APC"
"Adj motion knee jnt lerman t","L2186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","220.89","","","","","","","fee schedule","220.89","227.39","APC"
"Adj motion knee jnt lerman t","L2186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","227.39","","","","","","","fee schedule","220.89","227.39","APC"
"Quadrilateral brim","L2188","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","434.42","","","","","","","fee schedule","423.01","435.46","APC"
"Quadrilateral brim","L2188","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","427.16","","","","","","","fee schedule","423.01","435.46","APC"
"Quadrilateral brim","L2188","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","423.01","","","","","","","fee schedule","423.01","435.46","APC"
"Quadrilateral brim","L2188","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","435.46","","","","","","","fee schedule","423.01","435.46","APC"
"Waist belt","L2190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","112.24","","","","","","","fee schedule","109.29","112.51","APC"
"Waist belt","L2190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","110.36","","","","","","","fee schedule","109.29","112.51","APC"
"Waist belt","L2190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","109.29","","","","","","","fee schedule","109.29","112.51","APC"
"Waist belt","L2190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","112.51","","","","","","","fee schedule","109.29","112.51","APC"
"Pelvic band & belt thigh fla","L2192","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","492.9","","","","","","","fee schedule","479.96","494.08","APC"
"Pelvic band & belt thigh fla","L2192","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","484.67","","","","","","","fee schedule","479.96","494.08","APC"
"Pelvic band & belt thigh fla","L2192","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","479.96","","","","","","","fee schedule","479.96","494.08","APC"
"Pelvic band & belt thigh fla","L2192","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","494.08","","","","","","","fee schedule","479.96","494.08","APC"
"Limited ankle motion ea jnt","L2200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57.22","","","","","","","fee schedule","55.72","57.36","APC"
"Limited ankle motion ea jnt","L2200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","56.27","","","","","","","fee schedule","55.72","57.36","APC"
"Limited ankle motion ea jnt","L2200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","55.72","","","","","","","fee schedule","55.72","57.36","APC"
"Limited ankle motion ea jnt","L2200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57.36","","","","","","","fee schedule","55.72","57.36","APC"
"Dorsiflexion assist each joi","L2210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.85","","","","","","","fee schedule","80.67","83.04","APC"
"Dorsiflexion assist each joi","L2210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.46","","","","","","","fee schedule","80.67","83.04","APC"
"Dorsiflexion assist each joi","L2210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.67","","","","","","","fee schedule","80.67","83.04","APC"
"Dorsiflexion assist each joi","L2210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.04","","","","","","","fee schedule","80.67","83.04","APC"
"Dorsi & plantar flex ass/res","L2220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","98.57","","","","","","","fee schedule","95.98","98.8","APC"
"Dorsi & plantar flex ass/res","L2220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","96.92","","","","","","","fee schedule","95.98","98.8","APC"
"Dorsi & plantar flex ass/res","L2220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","95.98","","","","","","","fee schedule","95.98","98.8","APC"
"Dorsi & plantar flex ass/res","L2220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","98.8","","","","","","","fee schedule","95.98","98.8","APC"
"Split flat caliper stirr & p","L2230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","92.36","","","","","","","fee schedule","89.93","92.58","APC"
"Split flat caliper stirr & p","L2230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","90.82","","","","","","","fee schedule","89.93","92.58","APC"
"Split flat caliper stirr & p","L2230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","89.93","","","","","","","fee schedule","89.93","92.58","APC"
"Split flat caliper stirr & p","L2230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.58","","","","","","","fee schedule","89.93","92.58","APC"
"Rocker bottom, contact AFO","L2232","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","125.05","","","","","","","fee schedule","121.77","125.35","APC"
"Rocker bottom, contact AFO","L2232","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","122.96","","","","","","","fee schedule","121.77","125.35","APC"
"Rocker bottom, contact AFO","L2232","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","121.77","","","","","","","fee schedule","121.77","125.35","APC"
"Rocker bottom, contact AFO","L2232","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","125.35","","","","","","","fee schedule","121.77","125.35","APC"
"Round caliper and plate atta","L2240","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","114.32","","","","","","","fee schedule","111.32","114.6","APC"
"Round caliper and plate atta","L2240","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","112.41","","","","","","","fee schedule","111.32","114.6","APC"
"Round caliper and plate atta","L2240","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","111.32","","","","","","","fee schedule","111.32","114.6","APC"
"Round caliper and plate atta","L2240","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","114.6","","","","","","","fee schedule","111.32","114.6","APC"
"Foot plate molded stirrup at","L2250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","463.48","","","","","","","fee schedule","451.31","464.58","APC"
"Foot plate molded stirrup at","L2250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","455.73","","","","","","","fee schedule","451.31","464.58","APC"
"Foot plate molded stirrup at","L2250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","451.31","","","","","","","fee schedule","451.31","464.58","APC"
"Foot plate molded stirrup at","L2250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","464.58","","","","","","","fee schedule","451.31","464.58","APC"
"Reinforced solid stirrup","L2260","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","241.29","","","","","","","fee schedule","234.96","241.87","APC"
"Reinforced solid stirrup","L2260","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","237.26","","","","","","","fee schedule","234.96","241.87","APC"
"Reinforced solid stirrup","L2260","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","234.96","","","","","","","fee schedule","234.96","241.87","APC"
"Reinforced solid stirrup","L2260","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","241.87","","","","","","","fee schedule","234.96","241.87","APC"
"Long tongue stirrup","L2265","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","141.76","","","","","","","fee schedule","138.04","142.1","APC"
"Long tongue stirrup","L2265","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","139.39","","","","","","","fee schedule","138.04","142.1","APC"
"Long tongue stirrup","L2265","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","138.04","","","","","","","fee schedule","138.04","142.1","APC"
"Long tongue stirrup","L2265","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","142.1","","","","","","","fee schedule","138.04","142.1","APC"
"Varus/valgus strap padded/li","L2270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66.45","","","","","","","fee schedule","64.71","66.61","APC"
"Varus/valgus strap padded/li","L2270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65.34","","","","","","","fee schedule","64.71","66.61","APC"
"Varus/valgus strap padded/li","L2270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","64.71","","","","","","","fee schedule","64.71","66.61","APC"
"Varus/valgus strap padded/li","L2270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","66.61","","","","","","","fee schedule","64.71","66.61","APC"
"Plastic mod low ext pad/line","L2275","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","156.7","","","","","","","fee schedule","152.58","157.07","APC"
"Plastic mod low ext pad/line","L2275","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","154.08","","","","","","","fee schedule","152.58","157.07","APC"
"Plastic mod low ext pad/line","L2275","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","152.58","","","","","","","fee schedule","152.58","157.07","APC"
"Plastic mod low ext pad/line","L2275","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","157.07","","","","","","","fee schedule","152.58","157.07","APC"
"Molded inner boot","L2280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","547.95","","","","","","","fee schedule","533.56","549.26","APC"
"Molded inner boot","L2280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","538.79","","","","","","","fee schedule","533.56","549.26","APC"
"Molded inner boot","L2280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","533.56","","","","","","","fee schedule","533.56","549.26","APC"
"Molded inner boot","L2280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","549.26","","","","","","","fee schedule","533.56","549.26","APC"
"Abduction bar jointed adjust","L2300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","343.59","","","","","","","fee schedule","334.57","344.41","APC"
"Abduction bar jointed adjust","L2300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","337.85","","","","","","","fee schedule","334.57","344.41","APC"
"Abduction bar jointed adjust","L2300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","334.57","","","","","","","fee schedule","334.57","344.41","APC"
"Abduction bar jointed adjust","L2300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","344.41","","","","","","","fee schedule","334.57","344.41","APC"
"Abduction bar-straight","L2310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","172.05","","","","","","","fee schedule","167.54","172.46","APC"
"Abduction bar-straight","L2310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","169.18","","","","","","","fee schedule","167.54","172.46","APC"
"Abduction bar-straight","L2310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","167.54","","","","","","","fee schedule","167.54","172.46","APC"
"Abduction bar-straight","L2310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","172.46","","","","","","","fee schedule","167.54","172.46","APC"
"Non-molded lacer","L2320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","247.67","","","","","","","fee schedule","241.17","248.26","APC"
"Non-molded lacer","L2320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","243.53","","","","","","","fee schedule","241.17","248.26","APC"
"Non-molded lacer","L2320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","241.17","","","","","","","fee schedule","241.17","248.26","APC"
"Non-molded lacer","L2320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","248.26","","","","","","","fee schedule","241.17","248.26","APC"
"Lacer molded to patient mode","L2330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","518.43","","","","","","","fee schedule","504.82","519.67","APC"
"Lacer molded to patient mode","L2330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","509.77","","","","","","","fee schedule","504.82","519.67","APC"
"Lacer molded to patient mode","L2330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","504.82","","","","","","","fee schedule","504.82","519.67","APC"
"Lacer molded to patient mode","L2330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","519.67","","","","","","","fee schedule","504.82","519.67","APC"
"Anterior swing band","L2335","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","320.07","","","","","","","fee schedule","311.67","320.84","APC"
"Anterior swing band","L2335","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","314.73","","","","","","","fee schedule","311.67","320.84","APC"
"Anterior swing band","L2335","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","311.67","","","","","","","fee schedule","311.67","320.84","APC"
"Anterior swing band","L2335","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","320.84","","","","","","","fee schedule","311.67","320.84","APC"
"Pre-tibial shell molded to p","L2340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","692.93","","","","","","","fee schedule","674.74","694.59","APC"
"Pre-tibial shell molded to p","L2340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","681.36","","","","","","","fee schedule","674.74","694.59","APC"
"Pre-tibial shell molded to p","L2340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","674.74","","","","","","","fee schedule","674.74","694.59","APC"
"Pre-tibial shell molded to p","L2340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","694.59","","","","","","","fee schedule","674.74","694.59","APC"
"Prosthetic type socket molde","L2350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1196.75","","","","","","","fee schedule","1165.33","1199.6","APC"
"Prosthetic type socket molde","L2350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1176.75","","","","","","","fee schedule","1165.33","1199.6","APC"
"Prosthetic type socket molde","L2350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1165.33","","","","","","","fee schedule","1165.33","1199.6","APC"
"Prosthetic type socket molde","L2350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1199.6","","","","","","","fee schedule","1165.33","1199.6","APC"
"Extended steel shank","L2360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.27","","","","","","","fee schedule","60.64","62.42","APC"
"Extended steel shank","L2360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.23","","","","","","","fee schedule","60.64","62.42","APC"
"Extended steel shank","L2360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","60.64","","","","","","","fee schedule","60.64","62.42","APC"
"Extended steel shank","L2360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62.42","","","","","","","fee schedule","60.64","62.42","APC"
"Patten bottom","L2370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","403.56","","","","","","","fee schedule","392.97","404.52","APC"
"Patten bottom","L2370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","396.82","","","","","","","fee schedule","392.97","404.52","APC"
"Patten bottom","L2370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","392.97","","","","","","","fee schedule","392.97","404.52","APC"
"Patten bottom","L2370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","404.52","","","","","","","fee schedule","392.97","404.52","APC"
"Torsion ank & half solid sti","L2375","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","170.46","","","","","","","fee schedule","165.98","170.87","APC"
"Torsion ank & half solid sti","L2375","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","167.61","","","","","","","fee schedule","165.98","170.87","APC"
"Torsion ank & half solid sti","L2375","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","165.98","","","","","","","fee schedule","165.98","170.87","APC"
"Torsion ank & half solid sti","L2375","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","170.87","","","","","","","fee schedule","165.98","170.87","APC"
"Torsion straight knee joint","L2380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","148.19","","","","","","","fee schedule","144.3","148.54","APC"
"Torsion straight knee joint","L2380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","145.71","","","","","","","fee schedule","144.3","148.54","APC"
"Torsion straight knee joint","L2380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","144.3","","","","","","","fee schedule","144.3","148.54","APC"
"Torsion straight knee joint","L2380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","148.54","","","","","","","fee schedule","144.3","148.54","APC"
"Straight knee joint heavy du","L2385","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","161.23","","","","","","","fee schedule","157","161.62","APC"
"Straight knee joint heavy du","L2385","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","158.54","","","","","","","fee schedule","157","161.62","APC"
"Straight knee joint heavy du","L2385","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","157","","","","","","","fee schedule","157","161.62","APC"
"Straight knee joint heavy du","L2385","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","161.62","","","","","","","fee schedule","157","161.62","APC"
"Add le poly knee custom kafo","L2387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","232.29","","","","","","","fee schedule","226.2","232.85","APC"
"Add le poly knee custom kafo","L2387","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","228.41","","","","","","","fee schedule","226.2","232.85","APC"
"Add le poly knee custom kafo","L2387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","226.2","","","","","","","fee schedule","226.2","232.85","APC"
"Add le poly knee custom kafo","L2387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","232.85","","","","","","","fee schedule","226.2","232.85","APC"
"Offset knee joint each","L2390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","135.01","","","","","","","fee schedule","131.47","135.33","APC"
"Offset knee joint each","L2390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.76","","","","","","","fee schedule","131.47","135.33","APC"
"Offset knee joint each","L2390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.47","","","","","","","fee schedule","131.47","135.33","APC"
"Offset knee joint each","L2390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.33","","","","","","","fee schedule","131.47","135.33","APC"
"Offset knee joint heavy duty","L2395","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","188.34","","","","","","","fee schedule","183.4","188.79","APC"
"Offset knee joint heavy duty","L2395","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","185.19","","","","","","","fee schedule","183.4","188.79","APC"
"Offset knee joint heavy duty","L2395","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","183.4","","","","","","","fee schedule","183.4","188.79","APC"
"Offset knee joint heavy duty","L2395","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","188.79","","","","","","","fee schedule","183.4","188.79","APC"
"Suspension sleeve lower ext","L2397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","146.72","","","","","","","fee schedule","142.87","147.07","APC"
"Suspension sleeve lower ext","L2397","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","144.27","","","","","","","fee schedule","142.87","147.07","APC"
"Suspension sleeve lower ext","L2397","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","142.87","","","","","","","fee schedule","142.87","147.07","APC"
"Suspension sleeve lower ext","L2397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","147.07","","","","","","","fee schedule","142.87","147.07","APC"
"Knee joint drop lock ea jnt","L2405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","109.54","","","","","","","fee schedule","106.66","109.8","APC"
"Knee joint drop lock ea jnt","L2405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","107.71","","","","","","","fee schedule","106.66","109.8","APC"
"Knee joint drop lock ea jnt","L2405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","106.66","","","","","","","fee schedule","106.66","109.8","APC"
"Knee joint drop lock ea jnt","L2405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","109.8","","","","","","","fee schedule","106.66","109.8","APC"
"Knee joint cam lock each joi","L2415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","152.61","","","","","","","fee schedule","148.6","152.97","APC"
"Knee joint cam lock each joi","L2415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","150.06","","","","","","","fee schedule","148.6","152.97","APC"
"Knee joint cam lock each joi","L2415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","148.6","","","","","","","fee schedule","148.6","152.97","APC"
"Knee joint cam lock each joi","L2415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","152.97","","","","","","","fee schedule","148.6","152.97","APC"
"Knee disc/dial lock/adj flex","L2425","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","180.1","","","","","","","fee schedule","175.37","180.53","APC"
"Knee disc/dial lock/adj flex","L2425","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","177.09","","","","","","","fee schedule","175.37","180.53","APC"
"Knee disc/dial lock/adj flex","L2425","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","175.37","","","","","","","fee schedule","175.37","180.53","APC"
"Knee disc/dial lock/adj flex","L2425","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","180.53","","","","","","","fee schedule","175.37","180.53","APC"
"Knee jnt ratchet lock ea jnt","L2430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","180.1","","","","","","","fee schedule","175.37","180.53","APC"
"Knee jnt ratchet lock ea jnt","L2430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","177.09","","","","","","","fee schedule","175.37","180.53","APC"
"Knee jnt ratchet lock ea jnt","L2430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","175.37","","","","","","","fee schedule","175.37","180.53","APC"
"Knee jnt ratchet lock ea jnt","L2430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","180.53","","","","","","","fee schedule","175.37","180.53","APC"
"Knee lift loop drop lock rin","L2492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","163.53","","","","","","","fee schedule","159.23","163.92","APC"
"Knee lift loop drop lock rin","L2492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","160.79","","","","","","","fee schedule","159.23","163.92","APC"
"Knee lift loop drop lock rin","L2492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.23","","","","","","","fee schedule","159.23","163.92","APC"
"Knee lift loop drop lock rin","L2492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","163.92","","","","","","","fee schedule","159.23","163.92","APC"
"Thi/glut/ischia wgt bearing","L2500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","391.2","","","","","","","fee schedule","380.93","392.13","APC"
"Thi/glut/ischia wgt bearing","L2500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","384.66","","","","","","","fee schedule","380.93","392.13","APC"
"Thi/glut/ischia wgt bearing","L2500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","380.93","","","","","","","fee schedule","380.93","392.13","APC"
"Thi/glut/ischia wgt bearing","L2500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","392.13","","","","","","","fee schedule","380.93","392.13","APC"
"Th/wght bear quad-lat brim m","L2510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","877.72","","","","","","","fee schedule","854.68","879.82","APC"
"Th/wght bear quad-lat brim m","L2510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","863.06","","","","","","","fee schedule","854.68","879.82","APC"
"Th/wght bear quad-lat brim m","L2510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","854.68","","","","","","","fee schedule","854.68","879.82","APC"
"Th/wght bear quad-lat brim m","L2510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","879.82","","","","","","","fee schedule","854.68","879.82","APC"
"Th/wght bear quad-lat brim c","L2520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","579","","","","","","","fee schedule","563.79","580.38","APC"
"Th/wght bear quad-lat brim c","L2520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","569.32","","","","","","","fee schedule","563.79","580.38","APC"
"Th/wght bear quad-lat brim c","L2520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","563.79","","","","","","","fee schedule","563.79","580.38","APC"
"Th/wght bear quad-lat brim c","L2520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","580.38","","","","","","","fee schedule","563.79","580.38","APC"
"Th/wght bear nar m-l brim mo","L2525","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1562.12","","","","","","","fee schedule","1521.11","1565.84","APC"
"Th/wght bear nar m-l brim mo","L2525","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1536.02","","","","","","","fee schedule","1521.11","1565.84","APC"
"Th/wght bear nar m-l brim mo","L2525","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1521.11","","","","","","","fee schedule","1521.11","1565.84","APC"
"Th/wght bear nar m-l brim mo","L2525","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1565.84","","","","","","","fee schedule","1521.11","1565.84","APC"
"Th/wght bear nar m-l brim cu","L2526","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","891.44","","","","","","","fee schedule","868.04","893.57","APC"
"Th/wght bear nar m-l brim cu","L2526","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","876.55","","","","","","","fee schedule","868.04","893.57","APC"
"Th/wght bear nar m-l brim cu","L2526","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","868.04","","","","","","","fee schedule","868.04","893.57","APC"
"Th/wght bear nar m-l brim cu","L2526","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","893.57","","","","","","","fee schedule","868.04","893.57","APC"
"Thigh/wght bear lacer non-mo","L2530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","282.81","","","","","","","fee schedule","275.39","283.49","APC"
"Thigh/wght bear lacer non-mo","L2530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","278.09","","","","","","","fee schedule","275.39","283.49","APC"
"Thigh/wght bear lacer non-mo","L2530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","275.39","","","","","","","fee schedule","275.39","283.49","APC"
"Thigh/wght bear lacer non-mo","L2530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","283.49","","","","","","","fee schedule","275.39","283.49","APC"
"Thigh/wght bear lacer molded","L2540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","508.91","","","","","","","fee schedule","495.55","510.12","APC"
"Thigh/wght bear lacer molded","L2540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","500.4","","","","","","","fee schedule","495.55","510.12","APC"
"Thigh/wght bear lacer molded","L2540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","495.55","","","","","","","fee schedule","495.55","510.12","APC"
"Thigh/wght bear lacer molded","L2540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","510.12","","","","","","","fee schedule","495.55","510.12","APC"
"Thigh/wght bear high roll cu","L2550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","345.72","","","","","","","fee schedule","336.64","346.54","APC"
"Thigh/wght bear high roll cu","L2550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","339.94","","","","","","","fee schedule","336.64","346.54","APC"
"Thigh/wght bear high roll cu","L2550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","336.64","","","","","","","fee schedule","336.64","346.54","APC"
"Thigh/wght bear high roll cu","L2550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","346.54","","","","","","","fee schedule","336.64","346.54","APC"
"Hip clevis type 2 posit jnt","L2570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","573.34","","","","","","","fee schedule","558.29","574.71","APC"
"Hip clevis type 2 posit jnt","L2570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","563.76","","","","","","","fee schedule","558.29","574.71","APC"
"Hip clevis type 2 posit jnt","L2570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","558.29","","","","","","","fee schedule","558.29","574.71","APC"
"Hip clevis type 2 posit jnt","L2570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","574.71","","","","","","","fee schedule","558.29","574.71","APC"
"Pelvic control pelvic sling","L2580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558.65","","","","","","","fee schedule","543.99","559.99","APC"
"Pelvic control pelvic sling","L2580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.32","","","","","","","fee schedule","543.99","559.99","APC"
"Pelvic control pelvic sling","L2580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543.99","","","","","","","fee schedule","543.99","559.99","APC"
"Pelvic control pelvic sling","L2580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559.99","","","","","","","fee schedule","543.99","559.99","APC"
"Hip clevis/thrust bearing fr","L2600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","305.92","","","","","","","fee schedule","297.89","306.65","APC"
"Hip clevis/thrust bearing fr","L2600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","300.81","","","","","","","fee schedule","297.89","306.65","APC"
"Hip clevis/thrust bearing fr","L2600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","297.89","","","","","","","fee schedule","297.89","306.65","APC"
"Hip clevis/thrust bearing fr","L2600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","306.65","","","","","","","fee schedule","297.89","306.65","APC"
"Hip clevis/thrust bearing lo","L2610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","324.02","","","","","","","fee schedule","315.52","324.8","APC"
"Hip clevis/thrust bearing lo","L2610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","318.61","","","","","","","fee schedule","315.52","324.8","APC"
"Hip clevis/thrust bearing lo","L2610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","315.52","","","","","","","fee schedule","315.52","324.8","APC"
"Hip clevis/thrust bearing lo","L2610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","324.8","","","","","","","fee schedule","315.52","324.8","APC"
"Pelvic control hip heavy dut","L2620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","364.34","","","","","","","fee schedule","354.78","365.21","APC"
"Pelvic control hip heavy dut","L2620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","358.25","","","","","","","fee schedule","354.78","365.21","APC"
"Pelvic control hip heavy dut","L2620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","354.78","","","","","","","fee schedule","354.78","365.21","APC"
"Pelvic control hip heavy dut","L2620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","365.21","","","","","","","fee schedule","354.78","365.21","APC"
"Hip joint adjustable flexion","L2622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","413.05","","","","","","","fee schedule","402.21","414.04","APC"
"Hip joint adjustable flexion","L2622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","406.15","","","","","","","fee schedule","402.21","414.04","APC"
"Hip joint adjustable flexion","L2622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","402.21","","","","","","","fee schedule","402.21","414.04","APC"
"Hip joint adjustable flexion","L2622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","414.04","","","","","","","fee schedule","402.21","414.04","APC"
"Hip adj flex ext abduct cont","L2624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","398.59","","","","","","","fee schedule","388.13","399.55","APC"
"Hip adj flex ext abduct cont","L2624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","391.94","","","","","","","fee schedule","388.13","399.55","APC"
"Hip adj flex ext abduct cont","L2624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","388.13","","","","","","","fee schedule","388.13","399.55","APC"
"Hip adj flex ext abduct cont","L2624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","399.55","","","","","","","fee schedule","388.13","399.55","APC"
"Plastic mold recipro hip & c","L2627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2175.04","","","","","","","fee schedule","2117.94","2180.23","APC"
"Plastic mold recipro hip & c","L2627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2138.7","","","","","","","fee schedule","2117.94","2180.23","APC"
"Plastic mold recipro hip & c","L2627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2117.94","","","","","","","fee schedule","2117.94","2180.23","APC"
"Plastic mold recipro hip & c","L2627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2180.23","","","","","","","fee schedule","2117.94","2180.23","APC"
"Metal frame recipro hip & ca","L2628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2139.47","","","","","","","fee schedule","2083.3","2144.57","APC"
"Metal frame recipro hip & ca","L2628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2103.72","","","","","","","fee schedule","2083.3","2144.57","APC"
"Metal frame recipro hip & ca","L2628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2083.3","","","","","","","fee schedule","2083.3","2144.57","APC"
"Metal frame recipro hip & ca","L2628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2144.57","","","","","","","fee schedule","2083.3","2144.57","APC"
"Pelvic control band & belt u","L2630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","298.07","","","","","","","fee schedule","290.24","298.78","APC"
"Pelvic control band & belt u","L2630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","293.09","","","","","","","fee schedule","290.24","298.78","APC"
"Pelvic control band & belt u","L2630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","290.24","","","","","","","fee schedule","290.24","298.78","APC"
"Pelvic control band & belt u","L2630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","298.78","","","","","","","fee schedule","290.24","298.78","APC"
"Pelvic control band & belt b","L2640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","404.51","","","","","","","fee schedule","393.89","405.48","APC"
"Pelvic control band & belt b","L2640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","397.76","","","","","","","fee schedule","393.89","405.48","APC"
"Pelvic control band & belt b","L2640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","393.89","","","","","","","fee schedule","393.89","405.48","APC"
"Pelvic control band & belt b","L2640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","405.48","","","","","","","fee schedule","393.89","405.48","APC"
"Pelv & thor control gluteal","L2650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","172.23","","","","","","","fee schedule","167.71","172.64","APC"
"Pelv & thor control gluteal","L2650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","169.35","","","","","","","fee schedule","167.71","172.64","APC"
"Pelv & thor control gluteal","L2650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","167.71","","","","","","","fee schedule","167.71","172.64","APC"
"Pelv & thor control gluteal","L2650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","172.64","","","","","","","fee schedule","167.71","172.64","APC"
"Thoracic control thoracic ba","L2660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","224.34","","","","","","","fee schedule","218.45","224.88","APC"
"Thoracic control thoracic ba","L2660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","220.6","","","","","","","fee schedule","218.45","224.88","APC"
"Thoracic control thoracic ba","L2660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","218.45","","","","","","","fee schedule","218.45","224.88","APC"
"Thoracic control thoracic ba","L2660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","224.88","","","","","","","fee schedule","218.45","224.88","APC"
"Thorac cont paraspinal uprig","L2670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","217.56","","","","","","","fee schedule","211.84","218.07","APC"
"Thorac cont paraspinal uprig","L2670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","213.92","","","","","","","fee schedule","211.84","218.07","APC"
"Thorac cont paraspinal uprig","L2670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","211.84","","","","","","","fee schedule","211.84","218.07","APC"
"Thorac cont paraspinal uprig","L2670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","218.07","","","","","","","fee schedule","211.84","218.07","APC"
"Thorac cont lat support upri","L2680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.52","","","","","","","fee schedule","196.23","202","APC"
"Thorac cont lat support upri","L2680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","198.15","","","","","","","fee schedule","196.23","202","APC"
"Thorac cont lat support upri","L2680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","196.23","","","","","","","fee schedule","196.23","202","APC"
"Thorac cont lat support upri","L2680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","202","","","","","","","fee schedule","196.23","202","APC"
"Plating chrome/nickel pr bar","L2750","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","100.61","","","","","","","fee schedule","97.97","100.85","APC"
"Plating chrome/nickel pr bar","L2750","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","98.93","","","","","","","fee schedule","97.97","100.85","APC"
"Plating chrome/nickel pr bar","L2750","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","97.97","","","","","","","fee schedule","97.97","100.85","APC"
"Plating chrome/nickel pr bar","L2750","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","100.85","","","","","","","fee schedule","97.97","100.85","APC"
"Carbon graphite lamination","L2755","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","164.14","","","","","","","fee schedule","159.83","164.54","APC"
"Carbon graphite lamination","L2755","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","161.4","","","","","","","fee schedule","159.83","164.54","APC"
"Carbon graphite lamination","L2755","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.83","","","","","","","fee schedule","159.83","164.54","APC"
"Carbon graphite lamination","L2755","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","164.54","","","","","","","fee schedule","159.83","164.54","APC"
"Extension per extension per","L2760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.14","","","","","","","fee schedule","71.22","73.31","APC"
"Extension per extension per","L2760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","71.91","","","","","","","fee schedule","71.22","73.31","APC"
"Extension per extension per","L2760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.22","","","","","","","fee schedule","71.22","73.31","APC"
"Extension per extension per","L2760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.31","","","","","","","fee schedule","71.22","73.31","APC"
"Ortho sidebar disconnect","L2768","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","163.68","","","","","","","fee schedule","159.39","164.07","APC"
"Ortho sidebar disconnect","L2768","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","160.95","","","","","","","fee schedule","159.39","164.07","APC"
"Ortho sidebar disconnect","L2768","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","159.39","","","","","","","fee schedule","159.39","164.07","APC"
"Ortho sidebar disconnect","L2768","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","164.07","","","","","","","fee schedule","159.39","164.07","APC"
"Non-corrosive finish","L2780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","81.46","","","","","","","fee schedule","79.33","81.66","APC"
"Non-corrosive finish","L2780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.1","","","","","","","fee schedule","79.33","81.66","APC"
"Non-corrosive finish","L2780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.33","","","","","","","fee schedule","79.33","81.66","APC"
"Non-corrosive finish","L2780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81.66","","","","","","","fee schedule","79.33","81.66","APC"
"Drop lock retainer each","L2785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.31","","","","","","","fee schedule","37.3","38.4","APC"
"Drop lock retainer each","L2785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.67","","","","","","","fee schedule","37.3","38.4","APC"
"Drop lock retainer each","L2785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.3","","","","","","","fee schedule","37.3","38.4","APC"
"Drop lock retainer each","L2785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.4","","","","","","","fee schedule","37.3","38.4","APC"
"Knee control full kneecap","L2795","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","103.89","","","","","","","fee schedule","101.16","104.14","APC"
"Knee control full kneecap","L2795","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.16","","","","","","","fee schedule","101.16","104.14","APC"
"Knee control full kneecap","L2795","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.16","","","","","","","fee schedule","101.16","104.14","APC"
"Knee control full kneecap","L2795","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.14","","","","","","","fee schedule","101.16","104.14","APC"
"Knee cap medial or lateral p","L2800","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","159.69","","","","","","","fee schedule","155.5","160.07","APC"
"Knee cap medial or lateral p","L2800","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","157.02","","","","","","","fee schedule","155.5","160.07","APC"
"Knee cap medial or lateral p","L2800","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","155.5","","","","","","","fee schedule","155.5","160.07","APC"
"Knee cap medial or lateral p","L2800","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","160.07","","","","","","","fee schedule","155.5","160.07","APC"
"Knee control condylar pad","L2810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","125.35","","","","","","","fee schedule","122.06","125.65","APC"
"Knee control condylar pad","L2810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","123.26","","","","","","","fee schedule","122.06","125.65","APC"
"Knee control condylar pad","L2810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","122.06","","","","","","","fee schedule","122.06","125.65","APC"
"Knee control condylar pad","L2810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","125.65","","","","","","","fee schedule","122.06","125.65","APC"
"Soft interface below knee se","L2820","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.53","","","","","","","fee schedule","101.79","104.78","APC"
"Soft interface below knee se","L2820","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.78","","","","","","","fee schedule","101.79","104.78","APC"
"Soft interface below knee se","L2820","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.79","","","","","","","fee schedule","101.79","104.78","APC"
"Soft interface below knee se","L2820","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.78","","","","","","","fee schedule","101.79","104.78","APC"
"Soft interface above knee se","L2830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","113.09","","","","","","","fee schedule","110.12","113.36","APC"
"Soft interface above knee se","L2830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","111.2","","","","","","","fee schedule","110.12","113.36","APC"
"Soft interface above knee se","L2830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","110.12","","","","","","","fee schedule","110.12","113.36","APC"
"Soft interface above knee se","L2830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","113.36","","","","","","","fee schedule","110.12","113.36","APC"
"Tibial length sock fx or equ","L2840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66.85","","","","","","","fee schedule","65.1","67.01","APC"
"Tibial length sock fx or equ","L2840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65.73","","","","","","","fee schedule","65.1","67.01","APC"
"Tibial length sock fx or equ","L2840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.1","","","","","","","fee schedule","65.1","67.01","APC"
"Tibial length sock fx or equ","L2840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.01","","","","","","","fee schedule","65.1","67.01","APC"
"Femoral lgth sock fx or equa","L2850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","74.53","","","","","","","fee schedule","72.57","74.71","APC"
"Femoral lgth sock fx or equa","L2850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","73.28","","","","","","","fee schedule","72.57","74.71","APC"
"Femoral lgth sock fx or equa","L2850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","72.57","","","","","","","fee schedule","72.57","74.71","APC"
"Femoral lgth sock fx or equa","L2850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","74.71","","","","","","","fee schedule","72.57","74.71","APC"
"Ft insert ucb berkeley shell","L3000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.7","","","","","","","fee schedule","384.34","395.64","APC"
"Ft insert ucb berkeley shell","L3000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","388.1","","","","","","","fee schedule","384.34","395.64","APC"
"Ft insert ucb berkeley shell","L3000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","384.34","","","","","","","fee schedule","384.34","395.64","APC"
"Ft insert ucb berkeley shell","L3000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.64","","","","","","","fee schedule","384.34","395.64","APC"
"Foot insert remov molded spe","L3001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","166.2","","","","","","","fee schedule","161.83","166.59","APC"
"Foot insert remov molded spe","L3001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","163.42","","","","","","","fee schedule","161.83","166.59","APC"
"Foot insert remov molded spe","L3001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","161.83","","","","","","","fee schedule","161.83","166.59","APC"
"Foot insert remov molded spe","L3001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","166.59","","","","","","","fee schedule","161.83","166.59","APC"
"Foot insert plastazote or eq","L3002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","202.93","","","","","","","fee schedule","197.6","203.42","APC"
"Foot insert plastazote or eq","L3002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.54","","","","","","","fee schedule","197.6","203.42","APC"
"Foot insert plastazote or eq","L3002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.6","","","","","","","fee schedule","197.6","203.42","APC"
"Foot insert plastazote or eq","L3002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","203.42","","","","","","","fee schedule","197.6","203.42","APC"
"Foot insert silicone gel eac","L3003","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","218.97","","","","","","","fee schedule","213.22","219.49","APC"
"Foot insert silicone gel eac","L3003","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","215.31","","","","","","","fee schedule","213.22","219.49","APC"
"Foot insert silicone gel eac","L3003","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","213.22","","","","","","","fee schedule","213.22","219.49","APC"
"Foot insert silicone gel eac","L3003","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","219.49","","","","","","","fee schedule","213.22","219.49","APC"
"Foot longitudinal arch suppo","L3010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","218.97","","","","","","","fee schedule","213.22","219.49","APC"
"Foot longitudinal arch suppo","L3010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","215.31","","","","","","","fee schedule","213.22","219.49","APC"
"Foot longitudinal arch suppo","L3010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","213.22","","","","","","","fee schedule","213.22","219.49","APC"
"Foot longitudinal arch suppo","L3010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","219.49","","","","","","","fee schedule","213.22","219.49","APC"
"Foot longitud/metatarsal sup","L3020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","249.27","","","","","","","fee schedule","242.73","249.87","APC"
"Foot longitud/metatarsal sup","L3020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","245.11","","","","","","","fee schedule","242.73","249.87","APC"
"Foot longitud/metatarsal sup","L3020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","242.73","","","","","","","fee schedule","242.73","249.87","APC"
"Foot longitud/metatarsal sup","L3020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","249.87","","","","","","","fee schedule","242.73","249.87","APC"
"Foot arch support remov prem","L3030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.9","","","","","","","fee schedule","93.38","96.13","APC"
"Foot arch support remov prem","L3030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.3","","","","","","","fee schedule","93.38","96.13","APC"
"Foot arch support remov prem","L3030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.38","","","","","","","fee schedule","93.38","96.13","APC"
"Foot arch support remov prem","L3030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.13","","","","","","","fee schedule","93.38","96.13","APC"
"Foot lamin/prepreg composite","L3031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","153.9","","","","","","","fee schedule","149.86","154.27","APC"
"Foot lamin/prepreg composite","L3031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","151.33","","","","","","","fee schedule","149.86","154.27","APC"
"Foot lamin/prepreg composite","L3031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","149.86","","","","","","","fee schedule","149.86","154.27","APC"
"Foot lamin/prepreg composite","L3031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","154.27","","","","","","","fee schedule","149.86","154.27","APC"
"Ft arch suprt premold longit","L3040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59.13","","","","","","","fee schedule","57.58","59.27","APC"
"Ft arch suprt premold longit","L3040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","58.14","","","","","","","fee schedule","57.58","59.27","APC"
"Ft arch suprt premold longit","L3040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.58","","","","","","","fee schedule","57.58","59.27","APC"
"Ft arch suprt premold longit","L3040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59.27","","","","","","","fee schedule","57.58","59.27","APC"
"Foot arch supp premold metat","L3050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59.13","","","","","","","fee schedule","57.58","59.27","APC"
"Foot arch supp premold metat","L3050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","58.14","","","","","","","fee schedule","57.58","59.27","APC"
"Foot arch supp premold metat","L3050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.58","","","","","","","fee schedule","57.58","59.27","APC"
"Foot arch supp premold metat","L3050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59.27","","","","","","","fee schedule","57.58","59.27","APC"
"Foot arch supp longitud/meta","L3060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","92.65","","","","","","","fee schedule","90.22","92.87","APC"
"Foot arch supp longitud/meta","L3060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","91.1","","","","","","","fee schedule","90.22","92.87","APC"
"Foot arch supp longitud/meta","L3060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","90.22","","","","","","","fee schedule","90.22","92.87","APC"
"Foot arch supp longitud/meta","L3060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.87","","","","","","","fee schedule","90.22","92.87","APC"
"Arch suprt att to sho longit","L3070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.92","","","","","","","fee schedule","38.87","40.02","APC"
"Arch suprt att to sho longit","L3070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.25","","","","","","","fee schedule","38.87","40.02","APC"
"Arch suprt att to sho longit","L3070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.87","","","","","","","fee schedule","38.87","40.02","APC"
"Arch suprt att to sho longit","L3070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.02","","","","","","","fee schedule","38.87","40.02","APC"
"Arch supp att to shoe metata","L3080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.92","","","","","","","fee schedule","38.87","40.02","APC"
"Arch supp att to shoe metata","L3080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.25","","","","","","","fee schedule","38.87","40.02","APC"
"Arch supp att to shoe metata","L3080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.87","","","","","","","fee schedule","38.87","40.02","APC"
"Arch supp att to shoe metata","L3080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.02","","","","","","","fee schedule","38.87","40.02","APC"
"Arch supp att to shoe long/m","L3090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.15","","","","","","","fee schedule","49.81","51.27","APC"
"Arch supp att to shoe long/m","L3090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.29","","","","","","","fee schedule","49.81","51.27","APC"
"Arch supp att to shoe long/m","L3090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.81","","","","","","","fee schedule","49.81","51.27","APC"
"Arch supp att to shoe long/m","L3090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.27","","","","","","","fee schedule","49.81","51.27","APC"
"Hallus-valgus nt dyn pre ots","L3100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.32","","","","","","","fee schedule","52.9","54.45","APC"
"Hallus-valgus nt dyn pre ots","L3100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.42","","","","","","","fee schedule","52.9","54.45","APC"
"Hallus-valgus nt dyn pre ots","L3100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.9","","","","","","","fee schedule","52.9","54.45","APC"
"Hallus-valgus nt dyn pre ots","L3100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.45","","","","","","","fee schedule","52.9","54.45","APC"
"Abduction rotation bar shoe","L3140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","111.87","","","","","","","fee schedule","108.94","112.14","APC"
"Abduction rotation bar shoe","L3140","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","110","","","","","","","fee schedule","108.94","112.14","APC"
"Abduction rotation bar shoe","L3140","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","108.94","","","","","","","fee schedule","108.94","112.14","APC"
"Abduction rotation bar shoe","L3140","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","112.14","","","","","","","fee schedule","108.94","112.14","APC"
"Abduct rotation bar w/o shoe","L3150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","102.27","","","","","","","fee schedule","99.58","102.51","APC"
"Abduct rotation bar w/o shoe","L3150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","100.56","","","","","","","fee schedule","99.58","102.51","APC"
"Abduct rotation bar w/o shoe","L3150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","99.58","","","","","","","fee schedule","99.58","102.51","APC"
"Abduct rotation bar w/o shoe","L3150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","102.51","","","","","","","fee schedule","99.58","102.51","APC"
"Foot plas heel stabi pre ots","L3170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.94","","","","","","","fee schedule","62.26","64.09","APC"
"Foot plas heel stabi pre ots","L3170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.87","","","","","","","fee schedule","62.26","64.09","APC"
"Foot plas heel stabi pre ots","L3170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.26","","","","","","","fee schedule","62.26","64.09","APC"
"Foot plas heel stabi pre ots","L3170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.09","","","","","","","fee schedule","62.26","64.09","APC"
"Woman's shoe oxford brace","L3224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","80.07","","","","","","","fee schedule","77.97","80.26","APC"
"Woman's shoe oxford brace","L3224","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.73","","","","","","","fee schedule","77.97","80.26","APC"
"Woman's shoe oxford brace","L3224","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.97","","","","","","","fee schedule","77.97","80.26","APC"
"Woman's shoe oxford brace","L3224","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","80.26","","","","","","","fee schedule","77.97","80.26","APC"
"Man's shoe oxford brace","L3225","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","82.22","","","","","","","fee schedule","80.06","82.41","APC"
"Man's shoe oxford brace","L3225","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.84","","","","","","","fee schedule","80.06","82.41","APC"
"Man's shoe oxford brace","L3225","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","80.06","","","","","","","fee schedule","80.06","82.41","APC"
"Man's shoe oxford brace","L3225","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","82.41","","","","","","","fee schedule","80.06","82.41","APC"
"Sho lift taper to metatarsal","L3300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","65.52","","","","","","","fee schedule","63.8","65.68","APC"
"Sho lift taper to metatarsal","L3300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","64.43","","","","","","","fee schedule","63.8","65.68","APC"
"Sho lift taper to metatarsal","L3300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.8","","","","","","","fee schedule","63.8","65.68","APC"
"Sho lift taper to metatarsal","L3300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65.68","","","","","","","fee schedule","63.8","65.68","APC"
"Shoe lift elev heel/sole neo","L3310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","102.27","","","","","","","fee schedule","99.58","102.51","APC"
"Shoe lift elev heel/sole neo","L3310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","100.56","","","","","","","fee schedule","99.58","102.51","APC"
"Shoe lift elev heel/sole neo","L3310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","99.58","","","","","","","fee schedule","99.58","102.51","APC"
"Shoe lift elev heel/sole neo","L3310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","102.51","","","","","","","fee schedule","99.58","102.51","APC"
"Lifts elevation metal extens","L3330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","711.11","","","","","","","fee schedule","692.44","712.8","APC"
"Lifts elevation metal extens","L3330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","699.23","","","","","","","fee schedule","692.44","712.8","APC"
"Lifts elevation metal extens","L3330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","692.44","","","","","","","fee schedule","692.44","712.8","APC"
"Lifts elevation metal extens","L3330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","712.8","","","","","","","fee schedule","692.44","712.8","APC"
"Shoe lifts tapered to one-ha","L3332","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","92.65","","","","","","","fee schedule","90.22","92.87","APC"
"Shoe lifts tapered to one-ha","L3332","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","91.1","","","","","","","fee schedule","90.22","92.87","APC"
"Shoe lifts tapered to one-ha","L3332","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","90.22","","","","","","","fee schedule","90.22","92.87","APC"
"Shoe lifts tapered to one-ha","L3332","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.87","","","","","","","fee schedule","90.22","92.87","APC"
"Shoe lifts elevation heel /i","L3334","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47.95","","","","","","","fee schedule","46.7","48.07","APC"
"Shoe lifts elevation heel /i","L3334","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","47.15","","","","","","","fee schedule","46.7","48.07","APC"
"Shoe lifts elevation heel /i","L3334","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46.7","","","","","","","fee schedule","46.7","48.07","APC"
"Shoe lifts elevation heel /i","L3334","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48.07","","","","","","","fee schedule","46.7","48.07","APC"
"Shoe wedge sach","L3340","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.12","","","","","","","fee schedule","104.31","107.37","APC"
"Shoe wedge sach","L3340","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.33","","","","","","","fee schedule","104.31","107.37","APC"
"Shoe wedge sach","L3340","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.31","","","","","","","fee schedule","104.31","107.37","APC"
"Shoe wedge sach","L3340","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.37","","","","","","","fee schedule","104.31","107.37","APC"
"Shoe heel wedge","L3350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.79","","","","","","","fee schedule","28.03","28.85","APC"
"Shoe heel wedge","L3350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.3","","","","","","","fee schedule","28.03","28.85","APC"
"Shoe heel wedge","L3350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.03","","","","","","","fee schedule","28.03","28.85","APC"
"Shoe heel wedge","L3350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.85","","","","","","","fee schedule","28.03","28.85","APC"
"Shoe sole wedge outside sole","L3360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44.75","","","","","","","fee schedule","43.57","44.86","APC"
"Shoe sole wedge outside sole","L3360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44","","","","","","","fee schedule","43.57","44.86","APC"
"Shoe sole wedge outside sole","L3360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43.57","","","","","","","fee schedule","43.57","44.86","APC"
"Shoe sole wedge outside sole","L3360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44.86","","","","","","","fee schedule","43.57","44.86","APC"
"Shoe sole wedge between sole","L3370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.28","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe sole wedge between sole","L3370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.24","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe sole wedge between sole","L3370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","60.65","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe sole wedge between sole","L3370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62.43","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe clubfoot wedge","L3380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.28","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe clubfoot wedge","L3380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.24","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe clubfoot wedge","L3380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","60.65","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe clubfoot wedge","L3380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62.43","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe outflare wedge","L3390","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62.28","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe outflare wedge","L3390","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","61.24","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe outflare wedge","L3390","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","60.65","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe outflare wedge","L3390","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62.43","","","","","","","fee schedule","60.65","62.43","APC"
"Shoe metatarsal bar wedge ro","L3400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.15","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe metatarsal bar wedge ro","L3400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.29","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe metatarsal bar wedge ro","L3400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.81","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe metatarsal bar wedge ro","L3400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.27","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe metatarsal bar between","L3410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","116.64","","","","","","","fee schedule","113.58","116.92","APC"
"Shoe metatarsal bar between","L3410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","114.69","","","","","","","fee schedule","113.58","116.92","APC"
"Shoe metatarsal bar between","L3410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","113.58","","","","","","","fee schedule","113.58","116.92","APC"
"Shoe metatarsal bar between","L3410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","116.92","","","","","","","fee schedule","113.58","116.92","APC"
"Full sole/heel wedge btween","L3420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","68.74","","","","","","","fee schedule","66.93","68.9","APC"
"Full sole/heel wedge btween","L3420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","67.59","","","","","","","fee schedule","66.93","68.9","APC"
"Full sole/heel wedge btween","L3420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","66.93","","","","","","","fee schedule","66.93","68.9","APC"
"Full sole/heel wedge btween","L3420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","68.9","","","","","","","fee schedule","66.93","68.9","APC"
"Sho heel count plast reinfor","L3430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","201.35","","","","","","","fee schedule","196.06","201.83","APC"
"Sho heel count plast reinfor","L3430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","197.99","","","","","","","fee schedule","196.06","201.83","APC"
"Sho heel count plast reinfor","L3430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","196.06","","","","","","","fee schedule","196.06","201.83","APC"
"Sho heel count plast reinfor","L3430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.83","","","","","","","fee schedule","196.06","201.83","APC"
"Heel leather reinforced","L3440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.9","","","","","","","fee schedule","93.38","96.13","APC"
"Heel leather reinforced","L3440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.3","","","","","","","fee schedule","93.38","96.13","APC"
"Heel leather reinforced","L3440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.38","","","","","","","fee schedule","93.38","96.13","APC"
"Heel leather reinforced","L3440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.13","","","","","","","fee schedule","93.38","96.13","APC"
"Shoe heel sach cushion type","L3450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","132.66","","","","","","","fee schedule","129.17","132.97","APC"
"Shoe heel sach cushion type","L3450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","130.44","","","","","","","fee schedule","129.17","132.97","APC"
"Shoe heel sach cushion type","L3450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","129.17","","","","","","","fee schedule","129.17","132.97","APC"
"Shoe heel sach cushion type","L3450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.97","","","","","","","fee schedule","129.17","132.97","APC"
"Shoe heel new leather standa","L3455","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51.15","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe heel new leather standa","L3455","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.29","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe heel new leather standa","L3455","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.81","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe heel new leather standa","L3455","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.27","","","","","","","fee schedule","49.81","51.27","APC"
"Shoe heel new rubber standar","L3460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43.12","","","","","","","fee schedule","41.98","43.22","APC"
"Shoe heel new rubber standar","L3460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","42.39","","","","","","","fee schedule","41.98","43.22","APC"
"Shoe heel new rubber standar","L3460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.98","","","","","","","fee schedule","41.98","43.22","APC"
"Shoe heel new rubber standar","L3460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43.22","","","","","","","fee schedule","41.98","43.22","APC"
"Shoe heel thomas with wedge","L3465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73.49","","","","","","","fee schedule","71.56","73.67","APC"
"Shoe heel thomas with wedge","L3465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","72.26","","","","","","","fee schedule","71.56","73.67","APC"
"Shoe heel thomas with wedge","L3465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71.56","","","","","","","fee schedule","71.56","73.67","APC"
"Shoe heel thomas with wedge","L3465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73.67","","","","","","","fee schedule","71.56","73.67","APC"
"Shoe heel thomas extend to b","L3470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.29","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel thomas extend to b","L3470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.98","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel thomas extend to b","L3470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.23","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel thomas extend to b","L3470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.48","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel pad & depress for","L3480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.29","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel pad & depress for","L3480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","76.98","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel pad & depress for","L3480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.23","","","","","","","fee schedule","76.23","78.48","APC"
"Shoe heel pad & depress for","L3480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.48","","","","","","","fee schedule","76.23","78.48","APC"
"Ortho shoe add leather insol","L3500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.79","36.84","APC"
"Ortho shoe add leather insol","L3500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.79","36.84","APC"
"Ortho shoe add leather insol","L3500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.79","36.84","APC"
"Ortho shoe add leather insol","L3500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.79","36.84","APC"
"Orthopedic shoe add rub insl","L3510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36.76","","","","","","","fee schedule","35.79","36.84","APC"
"Orthopedic shoe add rub insl","L3510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36.14","","","","","","","fee schedule","35.79","36.84","APC"
"Orthopedic shoe add rub insl","L3510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35.79","","","","","","","fee schedule","35.79","36.84","APC"
"Orthopedic shoe add rub insl","L3510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36.84","","","","","","","fee schedule","35.79","36.84","APC"
"O shoe add felt w leath insl","L3520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.92","","","","","","","fee schedule","38.87","40.02","APC"
"O shoe add felt w leath insl","L3520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.25","","","","","","","fee schedule","38.87","40.02","APC"
"O shoe add felt w leath insl","L3520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.87","","","","","","","fee schedule","38.87","40.02","APC"
"O shoe add felt w leath insl","L3520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.02","","","","","","","fee schedule","38.87","40.02","APC"
"Ortho shoe add half sole","L3530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.92","","","","","","","fee schedule","38.87","40.02","APC"
"Ortho shoe add half sole","L3530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.25","","","","","","","fee schedule","38.87","40.02","APC"
"Ortho shoe add half sole","L3530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.87","","","","","","","fee schedule","38.87","40.02","APC"
"Ortho shoe add half sole","L3530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.02","","","","","","","fee schedule","38.87","40.02","APC"
"Ortho shoe add full sole","L3540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.94","","","","","","","fee schedule","62.26","64.09","APC"
"Ortho shoe add full sole","L3540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.87","","","","","","","fee schedule","62.26","64.09","APC"
"Ortho shoe add full sole","L3540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.26","","","","","","","fee schedule","62.26","64.09","APC"
"Ortho shoe add full sole","L3540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.09","","","","","","","fee schedule","62.26","64.09","APC"
"O shoe add standard toe tap","L3550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.16","","","","","","","fee schedule","10.86","11.18","APC"
"O shoe add standard toe tap","L3550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.97","","","","","","","fee schedule","10.86","11.18","APC"
"O shoe add standard toe tap","L3550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10.86","","","","","","","fee schedule","10.86","11.18","APC"
"O shoe add standard toe tap","L3550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.18","","","","","","","fee schedule","10.86","11.18","APC"
"O shoe add horseshoe toe tap","L3560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.79","","","","","","","fee schedule","28.03","28.85","APC"
"O shoe add horseshoe toe tap","L3560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.3","","","","","","","fee schedule","28.03","28.85","APC"
"O shoe add horseshoe toe tap","L3560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.03","","","","","","","fee schedule","28.03","28.85","APC"
"O shoe add horseshoe toe tap","L3560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.85","","","","","","","fee schedule","28.03","28.85","APC"
"O shoe add instep extension","L3570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","107.12","","","","","","","fee schedule","104.31","107.37","APC"
"O shoe add instep extension","L3570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","105.33","","","","","","","fee schedule","104.31","107.37","APC"
"O shoe add instep extension","L3570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","104.31","","","","","","","fee schedule","104.31","107.37","APC"
"O shoe add instep extension","L3570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107.37","","","","","","","fee schedule","104.31","107.37","APC"
"O shoe add instep velcro clo","L3580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","81.51","","","","","","","fee schedule","79.37","81.7","APC"
"O shoe add instep velcro clo","L3580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.14","","","","","","","fee schedule","79.37","81.7","APC"
"O shoe add instep velcro clo","L3580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.37","","","","","","","fee schedule","79.37","81.7","APC"
"O shoe add instep velcro clo","L3580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81.7","","","","","","","fee schedule","79.37","81.7","APC"
"O shoe convert to sof counte","L3590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.11","","","","","","","fee schedule","65.35","67.27","APC"
"O shoe convert to sof counte","L3590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","65.99","","","","","","","fee schedule","65.35","67.27","APC"
"O shoe convert to sof counte","L3590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.35","","","","","","","fee schedule","65.35","67.27","APC"
"O shoe convert to sof counte","L3590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.27","","","","","","","fee schedule","65.35","67.27","APC"
"Ortho shoe add march bar","L3595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52.72","","","","","","","fee schedule","51.34","52.85","APC"
"Ortho shoe add march bar","L3595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.84","","","","","","","fee schedule","51.34","52.85","APC"
"Ortho shoe add march bar","L3595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.34","","","","","","","fee schedule","51.34","52.85","APC"
"Ortho shoe add march bar","L3595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.85","","","","","","","fee schedule","51.34","52.85","APC"
"Trans shoe calip plate exist","L3600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.9","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe calip plate exist","L3600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.3","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe calip plate exist","L3600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.38","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe calip plate exist","L3600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.13","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe caliper plate new","L3610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","126.23","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe caliper plate new","L3610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","124.13","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe caliper plate new","L3610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","122.92","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe caliper plate new","L3610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","126.54","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe solid stirrup exi","L3620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","95.9","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe solid stirrup exi","L3620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.3","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe solid stirrup exi","L3620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.38","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe solid stirrup exi","L3620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.13","","","","","","","fee schedule","93.38","96.13","APC"
"Trans shoe solid stirrup new","L3630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","126.23","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe solid stirrup new","L3630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","124.13","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe solid stirrup new","L3630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","122.92","","","","","","","fee schedule","122.92","126.54","APC"
"Trans shoe solid stirrup new","L3630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","126.54","","","","","","","fee schedule","122.92","126.54","APC"
"Shoe dennis browne splint bo","L3640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54.32","","","","","","","fee schedule","52.9","54.45","APC"
"Shoe dennis browne splint bo","L3640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","53.42","","","","","","","fee schedule","52.9","54.45","APC"
"Shoe dennis browne splint bo","L3640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.9","","","","","","","fee schedule","52.9","54.45","APC"
"Shoe dennis browne splint bo","L3640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54.45","","","","","","","fee schedule","52.9","54.45","APC"
"So 8 abd restraint pre ots","L3650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","80.04","","","","","","","fee schedule","77.94","80.23","APC"
"So 8 abd restraint pre ots","L3650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.7","","","","","","","fee schedule","77.94","80.23","APC"
"So 8 abd restraint pre ots","L3650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.94","","","","","","","fee schedule","77.94","80.23","APC"
"So 8 abd restraint pre ots","L3650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","80.23","","","","","","","fee schedule","77.94","80.23","APC"
"So 8 ab rstr can/web pre ots","L3660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","121.06","","","","","","","fee schedule","117.88","121.35","APC"
"So 8 ab rstr can/web pre ots","L3660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","119.04","","","","","","","fee schedule","117.88","121.35","APC"
"So 8 ab rstr can/web pre ots","L3660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117.88","","","","","","","fee schedule","117.88","121.35","APC"
"So 8 ab rstr can/web pre ots","L3660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","121.35","","","","","","","fee schedule","117.88","121.35","APC"
"So acro/clav can web pre ots","L3670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","159.98","","","","","","","fee schedule","155.78","160.37","APC"
"So acro/clav can web pre ots","L3670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","157.31","","","","","","","fee schedule","155.78","160.37","APC"
"So acro/clav can web pre ots","L3670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","155.78","","","","","","","fee schedule","155.78","160.37","APC"
"So acro/clav can web pre ots","L3670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","160.37","","","","","","","fee schedule","155.78","160.37","APC"
"SO cap design w/o jnts CF","L3671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1030.4","","","","","","","fee schedule","1003.35","1032.86","APC"
"SO cap design w/o jnts CF","L3671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1013.19","","","","","","","fee schedule","1003.35","1032.86","APC"
"SO cap design w/o jnts CF","L3671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1003.35","","","","","","","fee schedule","1003.35","1032.86","APC"
"SO cap design w/o jnts CF","L3671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1032.86","","","","","","","fee schedule","1003.35","1032.86","APC"
"SO airplane w/wo joint CF","L3674","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1351.66","","","","","","","fee schedule","1316.18","1354.89","APC"
"SO airplane w/wo joint CF","L3674","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1329.08","","","","","","","fee schedule","1316.18","1354.89","APC"
"SO airplane w/wo joint CF","L3674","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1316.18","","","","","","","fee schedule","1316.18","1354.89","APC"
"SO airplane w/wo joint CF","L3674","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1354.89","","","","","","","fee schedule","1316.18","1354.89","APC"
"So vest canvas/web pre ots","L3675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","200.68","","","","","","","fee schedule","195.41","201.16","APC"
"So vest canvas/web pre ots","L3675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","197.33","","","","","","","fee schedule","195.41","201.16","APC"
"So vest canvas/web pre ots","L3675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","195.41","","","","","","","fee schedule","195.41","201.16","APC"
"So vest canvas/web pre ots","L3675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","201.16","","","","","","","fee schedule","195.41","201.16","APC"
"EO w/o joints CF","L3702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","330.18","","","","","","","fee schedule","321.51","330.97","APC"
"EO w/o joints CF","L3702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","324.67","","","","","","","fee schedule","321.51","330.97","APC"
"EO w/o joints CF","L3702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","321.51","","","","","","","fee schedule","321.51","330.97","APC"
"EO w/o joints CF","L3702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","330.97","","","","","","","fee schedule","321.51","330.97","APC"
"Eo elas w/metal jnts pre ots","L3710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","184.07","","","","","","","fee schedule","179.23","184.51","APC"
"Eo elas w/metal jnts pre ots","L3710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","180.99","","","","","","","fee schedule","179.23","184.51","APC"
"Eo elas w/metal jnts pre ots","L3710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","179.23","","","","","","","fee schedule","179.23","184.51","APC"
"Eo elas w/metal jnts pre ots","L3710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184.51","","","","","","","fee schedule","179.23","184.51","APC"
"Forearm/arm cuffs free motio","L3720","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","821.3","","","","","","","fee schedule","799.74","823.26","APC"
"Forearm/arm cuffs free motio","L3720","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","807.58","","","","","","","fee schedule","799.74","823.26","APC"
"Forearm/arm cuffs free motio","L3720","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","799.74","","","","","","","fee schedule","799.74","823.26","APC"
"Forearm/arm cuffs free motio","L3720","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","823.26","","","","","","","fee schedule","799.74","823.26","APC"
"Forearm/arm cuffs ext/flex a","L3730","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1061.81","","","","","","","fee schedule","1033.93","1064.34","APC"
"Forearm/arm cuffs ext/flex a","L3730","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1044.07","","","","","","","fee schedule","1033.93","1064.34","APC"
"Forearm/arm cuffs ext/flex a","L3730","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1033.93","","","","","","","fee schedule","1033.93","1064.34","APC"
"Forearm/arm cuffs ext/flex a","L3730","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1064.34","","","","","","","fee schedule","1033.93","1064.34","APC"
"Cuffs adj lock w/ active con","L3740","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1258.86","","","","","","","fee schedule","1225.82","1261.87","APC"
"Cuffs adj lock w/ active con","L3740","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1237.83","","","","","","","fee schedule","1225.82","1261.87","APC"
"Cuffs adj lock w/ active con","L3740","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1225.82","","","","","","","fee schedule","1225.82","1261.87","APC"
"Cuffs adj lock w/ active con","L3740","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1261.87","","","","","","","fee schedule","1225.82","1261.87","APC"
"EO withjoint, Prefabricated","L3760","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","571.83","","","","","","","fee schedule","556.82","573.2","APC"
"EO withjoint, Prefabricated","L3760","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","562.28","","","","","","","fee schedule","556.82","573.2","APC"
"EO withjoint, Prefabricated","L3760","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","556.82","","","","","","","fee schedule","556.82","573.2","APC"
"EO withjoint, Prefabricated","L3760","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","573.2","","","","","","","fee schedule","556.82","573.2","APC"
"Eo, adj lock joint prefab ot","L3761","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","571.83","","","","","","","fee schedule","556.82","573.2","APC"
"Eo, adj lock joint prefab ot","L3761","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","562.28","","","","","","","fee schedule","556.82","573.2","APC"
"Eo, adj lock joint prefab ot","L3761","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","556.82","","","","","","","fee schedule","556.82","573.2","APC"
"Eo, adj lock joint prefab ot","L3761","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","573.2","","","","","","","fee schedule","556.82","573.2","APC"
"Eo rigid w/o joints pre ots","L3762","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","122.96","","","","","","","fee schedule","119.73","123.25","APC"
"Eo rigid w/o joints pre ots","L3762","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","120.9","","","","","","","fee schedule","119.73","123.25","APC"
"Eo rigid w/o joints pre ots","L3762","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","119.73","","","","","","","fee schedule","119.73","123.25","APC"
"Eo rigid w/o joints pre ots","L3762","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","123.25","","","","","","","fee schedule","119.73","123.25","APC"
"EWHO rigid w/o jnts CF","L3763","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","802.68","","","","","","","fee schedule","781.61","804.59","APC"
"EWHO rigid w/o jnts CF","L3763","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","789.27","","","","","","","fee schedule","781.61","804.59","APC"
"EWHO rigid w/o jnts CF","L3763","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","781.61","","","","","","","fee schedule","781.61","804.59","APC"
"EWHO rigid w/o jnts CF","L3763","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","804.59","","","","","","","fee schedule","781.61","804.59","APC"
"EWHO w/joint(s) CF","L3764","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1047.68","","","","","","","fee schedule","1020.17","1050.18","APC"
"EWHO w/joint(s) CF","L3764","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1030.18","","","","","","","fee schedule","1020.17","1050.18","APC"
"EWHO w/joint(s) CF","L3764","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1020.17","","","","","","","fee schedule","1020.17","1050.18","APC"
"EWHO w/joint(s) CF","L3764","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1050.18","","","","","","","fee schedule","1020.17","1050.18","APC"
"EWHFO rigid w/o jnts CF","L3765","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1466.25","","","","","","","fee schedule","1427.76","1469.75","APC"
"EWHFO rigid w/o jnts CF","L3765","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1441.75","","","","","","","fee schedule","1427.76","1469.75","APC"
"EWHFO rigid w/o jnts CF","L3765","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1427.76","","","","","","","fee schedule","1427.76","1469.75","APC"
"EWHFO rigid w/o jnts CF","L3765","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1469.75","","","","","","","fee schedule","1427.76","1469.75","APC"
"EWHFO w/joint(s) CF","L3766","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1552.65","","","","","","","fee schedule","1511.88","1556.35","APC"
"EWHFO w/joint(s) CF","L3766","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1526.71","","","","","","","fee schedule","1511.88","1556.35","APC"
"EWHFO w/joint(s) CF","L3766","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1511.88","","","","","","","fee schedule","1511.88","1556.35","APC"
"EWHFO w/joint(s) CF","L3766","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1556.35","","","","","","","fee schedule","1511.88","1556.35","APC"
"WHFO w/joint(s) custom fab","L3806","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","519.44","","","","","","","fee schedule","505.81","520.68","APC"
"WHFO w/joint(s) custom fab","L3806","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","510.77","","","","","","","fee schedule","505.81","520.68","APC"
"WHFO w/joint(s) custom fab","L3806","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","505.81","","","","","","","fee schedule","505.81","520.68","APC"
"WHFO w/joint(s) custom fab","L3806","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","520.68","","","","","","","fee schedule","505.81","520.68","APC"
"Whfo w/o joints pre cst","L3807","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.94","","","","","","","fee schedule","278.43","286.62","APC"
"Whfo w/o joints pre cst","L3807","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.16","","","","","","","fee schedule","278.43","286.62","APC"
"Whfo w/o joints pre cst","L3807","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.43","","","","","","","fee schedule","278.43","286.62","APC"
"Whfo w/o joints pre cst","L3807","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.62","","","","","","","fee schedule","278.43","286.62","APC"
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","410.44","","","","","","","fee schedule","410.44","428.63",""
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","410.44","","","","","","","fee schedule","410.44","428.63",""
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","410.44","","","","","","","fee schedule","410.44","428.63",""
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","427.61","","","","","","","fee schedule","410.44","428.63","APC"
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","420.47","","","","","","","fee schedule","410.44","428.63","APC"
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","416.38","","","","","","","fee schedule","410.44","428.63","APC"
"WHFO, rigid w/o joints","L3808","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","428.63","","","","","","","fee schedule","410.44","428.63","APC"
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","274.45","","","","","","","fee schedule","274.45","286.62",""
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","274.45","","","","","","","fee schedule","274.45","286.62",""
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","274.45","","","","","","","fee schedule","274.45","286.62",""
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","285.94","","","","","","","fee schedule","274.45","286.62","APC"
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","281.16","","","","","","","fee schedule","274.45","286.62","APC"
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","278.43","","","","","","","fee schedule","274.45","286.62","APC"
"Whfo w/o joints pre ots","L3809","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","286.62","","","","","","","fee schedule","274.45","286.62","APC"
"Hinge extension/flex wrist/f","L3900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1667.36","","","","","","","fee schedule","1623.58","1671.34","APC"
"Hinge extension/flex wrist/f","L3900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1639.5","","","","","","","fee schedule","1623.58","1671.34","APC"
"Hinge extension/flex wrist/f","L3900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1623.58","","","","","","","fee schedule","1623.58","1671.34","APC"
"Hinge extension/flex wrist/f","L3900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1671.34","","","","","","","fee schedule","1623.58","1671.34","APC"
"Hinge ext/flex wrist finger","L3901","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1893.48","","","","","","","fee schedule","1843.77","1898","APC"
"Hinge ext/flex wrist finger","L3901","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1861.85","","","","","","","fee schedule","1843.77","1898","APC"
"Hinge ext/flex wrist finger","L3901","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1843.77","","","","","","","fee schedule","1843.77","1898","APC"
"Hinge ext/flex wrist finger","L3901","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1898","","","","","","","fee schedule","1843.77","1898","APC"
"Whfo electric custom fitted","L3904","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3449.38","","","","","","","fee schedule","3358.82","3457.61","APC"
"Whfo electric custom fitted","L3904","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3391.75","","","","","","","fee schedule","3358.82","3457.61","APC"
"Whfo electric custom fitted","L3904","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3358.82","","","","","","","fee schedule","3358.82","3457.61","APC"
"Whfo electric custom fitted","L3904","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3457.61","","","","","","","fee schedule","3358.82","3457.61","APC"
"Who w/nontorsion jnt(s) cf","L3905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1134.04","","","","","","","fee schedule","1104.27","1136.75","APC"
"Who w/nontorsion jnt(s) cf","L3905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1115.1","","","","","","","fee schedule","1104.27","1136.75","APC"
"Who w/nontorsion jnt(s) cf","L3905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1104.27","","","","","","","fee schedule","1104.27","1136.75","APC"
"Who w/nontorsion jnt(s) cf","L3905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1136.75","","","","","","","fee schedule","1104.27","1136.75","APC"
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","483.3","","","","","","","fee schedule","483.3","504.69",""
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","483.3","","","","","","","fee schedule","483.3","504.69",""
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","483.3","","","","","","","fee schedule","483.3","504.69",""
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","503.49","","","","","","","fee schedule","483.3","504.69","APC"
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","495.08","","","","","","","fee schedule","483.3","504.69","APC"
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","490.27","","","","","","","fee schedule","483.3","504.69","APC"
"Who w/o joints cf","L3906","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","504.69","","","","","","","fee schedule","483.3","504.69","APC"
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","76.06","","","","","","","fee schedule","76.06","79.42",""
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","76.06","","","","","","","fee schedule","76.06","79.42",""
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","76.06","","","","","","","fee schedule","76.06","79.42",""
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.23","","","","","","","fee schedule","76.06","79.42","APC"
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.91","","","","","","","fee schedule","76.06","79.42","APC"
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.15","","","","","","","fee schedule","76.06","79.42","APC"
"Who cock-up nonmolde pre ots","L3908","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.42","","","","","","","fee schedule","76.06","79.42","APC"
"Hfo flexion glove pre ots","L3912","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.26","","","","","","","fee schedule","133.66","137.59","APC"
"Hfo flexion glove pre ots","L3912","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","134.97","","","","","","","fee schedule","133.66","137.59","APC"
"Hfo flexion glove pre ots","L3912","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.66","","","","","","","fee schedule","133.66","137.59","APC"
"Hfo flexion glove pre ots","L3912","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.59","","","","","","","fee schedule","133.66","137.59","APC"
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","297.28","","","","","","","fee schedule","297.28","310.44",""
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","297.28","","","","","","","fee schedule","297.28","310.44",""
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","297.28","","","","","","","fee schedule","297.28","310.44",""
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","309.7","","","","","","","fee schedule","297.28","310.44","APC"
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","304.53","","","","","","","fee schedule","297.28","310.44","APC"
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","301.57","","","","","","","fee schedule","297.28","310.44","APC"
"HFO w/o joints CF","L3913","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","310.44","","","","","","","fee schedule","297.28","310.44","APC"
"Who nontorsion jnts pre cst","L3915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","607.84","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre cst","L3915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","597.69","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre cst","L3915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","591.89","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre cst","L3915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","609.29","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre ots","L3916","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","607.84","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre ots","L3916","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","597.69","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre ots","L3916","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","591.89","","","","","","","fee schedule","591.89","609.29","APC"
"Who nontorsion jnts pre ots","L3916","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","609.29","","","","","","","fee schedule","591.89","609.29","APC"
"Metacarp fx orthosis pre cst","L3917","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","120.85","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre cst","L3917","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","118.83","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre cst","L3917","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117.68","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre cst","L3917","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","121.14","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre ots","L3918","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","120.85","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre ots","L3918","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","118.83","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre ots","L3918","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117.68","","","","","","","fee schedule","117.68","121.14","APC"
"Metacarp fx orthosis pre ots","L3918","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","121.14","","","","","","","fee schedule","117.68","121.14","APC"
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","297.28","","","","","","","fee schedule","297.28","310.44",""
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","297.28","","","","","","","fee schedule","297.28","310.44",""
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","297.28","","","","","","","fee schedule","297.28","310.44",""
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","309.7","","","","","","","fee schedule","297.28","310.44","APC"
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","304.53","","","","","","","fee schedule","297.28","310.44","APC"
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","301.57","","","","","","","fee schedule","297.28","310.44","APC"
"HO w/o joints CF","L3919","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","310.44","","","","","","","fee schedule","297.28","310.44","APC"
"HFO w/joint(s) CF","L3921","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","367.32","","","","","","","fee schedule","357.67","368.19","APC"
"HFO w/joint(s) CF","L3921","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","361.18","","","","","","","fee schedule","357.67","368.19","APC"
"HFO w/joint(s) CF","L3921","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","357.67","","","","","","","fee schedule","357.67","368.19","APC"
"HFO w/joint(s) CF","L3921","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","368.19","","","","","","","fee schedule","357.67","368.19","APC"
"Hfo without joints pre cst","L3923","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","110.38","","","","","","","fee schedule","107.48","110.64","APC"
"Hfo without joints pre cst","L3923","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","108.53","","","","","","","fee schedule","107.48","110.64","APC"
"Hfo without joints pre cst","L3923","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","107.48","","","","","","","fee schedule","107.48","110.64","APC"
"Hfo without joints pre cst","L3923","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","110.64","","","","","","","fee schedule","107.48","110.64","APC"
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","105.93","","","","","","","fee schedule","105.93","110.64",""
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","105.93","","","","","","","fee schedule","105.93","110.64",""
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","105.93","","","","","","","fee schedule","105.93","110.64",""
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","110.38","","","","","","","fee schedule","105.93","110.64","APC"
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","108.53","","","","","","","fee schedule","105.93","110.64","APC"
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","107.48","","","","","","","fee schedule","105.93","110.64","APC"
"Hfo without joints pre ots","L3924","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","110.64","","","","","","","fee schedule","105.93","110.64","APC"
"Fo pip dip jnt/sprng pre ots","L3925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59.19","","","","","","","fee schedule","57.64","59.34","APC"
"Fo pip dip jnt/sprng pre ots","L3925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","58.21","","","","","","","fee schedule","57.64","59.34","APC"
"Fo pip dip jnt/sprng pre ots","L3925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.64","","","","","","","fee schedule","57.64","59.34","APC"
"Fo pip dip jnt/sprng pre ots","L3925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59.34","","","","","","","fee schedule","57.64","59.34","APC"
"Fo pip dip no jt spr pre ots","L3927","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.98","","","","","","","fee schedule","38.93","40.08","APC"
"Fo pip dip no jt spr pre ots","L3927","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","39.32","","","","","","","fee schedule","38.93","40.08","APC"
"Fo pip dip no jt spr pre ots","L3927","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.93","","","","","","","fee schedule","38.93","40.08","APC"
"Fo pip dip no jt spr pre ots","L3927","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40.08","","","","","","","fee schedule","38.93","40.08","APC"
"Hfo nontorsion jnts pre cst","L3929","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.88","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre cst","L3929","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","103.12","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre cst","L3929","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","102.12","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre cst","L3929","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","105.13","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre ots","L3930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104.88","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre ots","L3930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","103.12","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre ots","L3930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","102.12","","","","","","","fee schedule","102.12","105.13","APC"
"Hfo nontorsion jnts pre ots","L3930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","105.13","","","","","","","fee schedule","102.12","105.13","APC"
"WHFO nontorsion joint prefab","L3931","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","214.78","","","","","","","fee schedule","209.14","215.29","APC"
"WHFO nontorsion joint prefab","L3931","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","211.19","","","","","","","fee schedule","209.14","215.29","APC"
"WHFO nontorsion joint prefab","L3931","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","209.14","","","","","","","fee schedule","209.14","215.29","APC"
"WHFO nontorsion joint prefab","L3931","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","215.29","","","","","","","fee schedule","209.14","215.29","APC"
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","234.17","","","","","","","fee schedule","234.17","244.53",""
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","234.17","","","","","","","fee schedule","234.17","244.53",""
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","234.17","","","","","","","fee schedule","234.17","244.53",""
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","243.95","","","","","","","fee schedule","234.17","244.53","APC"
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.88","","","","","","","fee schedule","234.17","244.53","APC"
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.55","","","","","","","fee schedule","234.17","244.53","APC"
"FO w/o joints CF","L3933","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.53","","","","","","","fee schedule","234.17","244.53","APC"
"FO nontorsion joint CF","L3935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","252.6","","","","","","","fee schedule","245.97","253.21","APC"
"FO nontorsion joint CF","L3935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","248.38","","","","","","","fee schedule","245.97","253.21","APC"
"FO nontorsion joint CF","L3935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.97","","","","","","","fee schedule","245.97","253.21","APC"
"FO nontorsion joint CF","L3935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","253.21","","","","","","","fee schedule","245.97","253.21","APC"
"Sewho airplan desig abdu pos","L3960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","866.45","","","","","","","fee schedule","843.7","868.52","APC"
"Sewho airplan desig abdu pos","L3960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","851.97","","","","","","","fee schedule","843.7","868.52","APC"
"Sewho airplan desig abdu pos","L3960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","843.7","","","","","","","fee schedule","843.7","868.52","APC"
"Sewho airplan desig abdu pos","L3960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","868.52","","","","","","","fee schedule","843.7","868.52","APC"
"Sewho cap design w/o jnts cf","L3961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1921.21","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewho cap design w/o jnts cf","L3961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1889.11","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewho cap design w/o jnts cf","L3961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1870.77","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewho cap design w/o jnts cf","L3961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1925.79","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewho erbs palsey design abd","L3962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","845.12","","","","","","","fee schedule","822.94","847.14","APC"
"Sewho erbs palsey design abd","L3962","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","831","","","","","","","fee schedule","822.94","847.14","APC"
"Sewho erbs palsey design abd","L3962","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","822.94","","","","","","","fee schedule","822.94","847.14","APC"
"Sewho erbs palsey design abd","L3962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","847.14","","","","","","","fee schedule","822.94","847.14","APC"
"Sewho airplane w/o jnts cf","L3967","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2268.32","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho airplane w/o jnts cf","L3967","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2230.42","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho airplane w/o jnts cf","L3967","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2208.77","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho airplane w/o jnts cf","L3967","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2273.73","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho cap design w/jnt(s) cf","L3971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2153.17","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewho cap design w/jnt(s) cf","L3971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2117.2","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewho cap design w/jnt(s) cf","L3971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2096.64","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewho cap design w/jnt(s) cf","L3971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2158.31","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewho airplane w/jnt(s) cf","L3973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2268.32","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho airplane w/jnt(s) cf","L3973","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2230.42","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho airplane w/jnt(s) cf","L3973","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2208.77","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewho airplane w/jnt(s) cf","L3973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2273.73","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewhfo cap design w/o jnt cf","L3975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1921.21","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo cap design w/o jnt cf","L3975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1889.11","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo cap design w/o jnt cf","L3975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1870.77","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo cap design w/o jnt cf","L3975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1925.79","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo airplane w/o jnts cf","L3976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1921.21","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo airplane w/o jnts cf","L3976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1889.11","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo airplane w/o jnts cf","L3976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1870.77","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo airplane w/o jnts cf","L3976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1925.79","","","","","","","fee schedule","1870.77","1925.79","APC"
"Sewhfo cap desgn w/jnt(s) cf","L3977","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2153.17","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewhfo cap desgn w/jnt(s) cf","L3977","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2117.2","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewhfo cap desgn w/jnt(s) cf","L3977","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2096.64","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewhfo cap desgn w/jnt(s) cf","L3977","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2158.31","","","","","","","fee schedule","2096.64","2158.31","APC"
"Sewhfo airplane w/jnt(s) cf","L3978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2268.32","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewhfo airplane w/jnt(s) cf","L3978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2230.42","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewhfo airplane w/jnt(s) cf","L3978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2208.77","","","","","","","fee schedule","2208.77","2273.73","APC"
"Sewhfo airplane w/jnt(s) cf","L3978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2273.73","","","","","","","fee schedule","2208.77","2273.73","APC"
"Up ext fx orthos humeral nos","L3980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","377.17","","","","","","","fee schedule","367.27","378.07","APC"
"Up ext fx orthos humeral nos","L3980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","370.87","","","","","","","fee schedule","367.27","378.07","APC"
"Up ext fx orthos humeral nos","L3980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","367.27","","","","","","","fee schedule","367.27","378.07","APC"
"Up ext fx orthos humeral nos","L3980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","378.07","","","","","","","fee schedule","367.27","378.07","APC"
"Ue fx orth shoul cap forearm","L3981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1151.02","","","","","","","fee schedule","1120.81","1153.77","APC"
"Ue fx orth shoul cap forearm","L3981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1131.79","","","","","","","fee schedule","1120.81","1153.77","APC"
"Ue fx orth shoul cap forearm","L3981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1120.81","","","","","","","fee schedule","1120.81","1153.77","APC"
"Ue fx orth shoul cap forearm","L3981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1153.77","","","","","","","fee schedule","1120.81","1153.77","APC"
"Upper ext fx orthosis rad/ul","L3982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","439.72","","","","","","","fee schedule","428.18","440.77","APC"
"Upper ext fx orthosis rad/ul","L3982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","432.37","","","","","","","fee schedule","428.18","440.77","APC"
"Upper ext fx orthosis rad/ul","L3982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","428.18","","","","","","","fee schedule","428.18","440.77","APC"
"Upper ext fx orthosis rad/ul","L3982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","440.77","","","","","","","fee schedule","428.18","440.77","APC"
"Upper ext fx orthosis wrist","L3984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","405.41","","","","","","","fee schedule","394.77","406.38","APC"
"Upper ext fx orthosis wrist","L3984","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","398.64","","","","","","","fee schedule","394.77","406.38","APC"
"Upper ext fx orthosis wrist","L3984","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","394.77","","","","","","","fee schedule","394.77","406.38","APC"
"Upper ext fx orthosis wrist","L3984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","406.38","","","","","","","fee schedule","394.77","406.38","APC"
"Sock fracture or equal each","L3995","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.02","","","","","","","fee schedule","40.91","42.12","APC"
"Sock fracture or equal each","L3995","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.31","","","","","","","fee schedule","40.91","42.12","APC"
"Sock fracture or equal each","L3995","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.91","","","","","","","fee schedule","40.91","42.12","APC"
"Sock fracture or equal each","L3995","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.12","","","","","","","fee schedule","40.91","42.12","APC"
"Repl girdle milwaukee orth","L4000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1657.03","","","","","","","fee schedule","1613.53","1660.98","APC"
"Repl girdle milwaukee orth","L4000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1629.35","","","","","","","fee schedule","1613.53","1660.98","APC"
"Repl girdle milwaukee orth","L4000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1613.53","","","","","","","fee schedule","1613.53","1660.98","APC"
"Repl girdle milwaukee orth","L4000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1660.98","","","","","","","fee schedule","1613.53","1660.98","APC"
"Replace trilateral socket br","L4010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","807.82","","","","","","","fee schedule","786.61","809.75","APC"
"Replace trilateral socket br","L4010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","794.33","","","","","","","fee schedule","786.61","809.75","APC"
"Replace trilateral socket br","L4010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","786.61","","","","","","","fee schedule","786.61","809.75","APC"
"Replace trilateral socket br","L4010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","809.75","","","","","","","fee schedule","786.61","809.75","APC"
"Replace quadlat socket brim","L4020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1129.77","","","","","","","fee schedule","1100.11","1132.47","APC"
"Replace quadlat socket brim","L4020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1110.9","","","","","","","fee schedule","1100.11","1132.47","APC"
"Replace quadlat socket brim","L4020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1100.11","","","","","","","fee schedule","1100.11","1132.47","APC"
"Replace quadlat socket brim","L4020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1132.47","","","","","","","fee schedule","1100.11","1132.47","APC"
"Replace socket brim cust fit","L4030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","607.73","","","","","","","fee schedule","591.77","609.18","APC"
"Replace socket brim cust fit","L4030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","597.58","","","","","","","fee schedule","591.77","609.18","APC"
"Replace socket brim cust fit","L4030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","591.77","","","","","","","fee schedule","591.77","609.18","APC"
"Replace socket brim cust fit","L4030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","609.18","","","","","","","fee schedule","591.77","609.18","APC"
"Replace molded thigh lacer","L4040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","495.92","","","","","","","fee schedule","482.9","497.1","APC"
"Replace molded thigh lacer","L4040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","487.63","","","","","","","fee schedule","482.9","497.1","APC"
"Replace molded thigh lacer","L4040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","482.9","","","","","","","fee schedule","482.9","497.1","APC"
"Replace molded thigh lacer","L4040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","497.1","","","","","","","fee schedule","482.9","497.1","APC"
"Replace non-molded thigh lac","L4045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","394.84","","","","","","","fee schedule","384.48","395.79","APC"
"Replace non-molded thigh lac","L4045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","388.25","","","","","","","fee schedule","384.48","395.79","APC"
"Replace non-molded thigh lac","L4045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","384.48","","","","","","","fee schedule","384.48","395.79","APC"
"Replace non-molded thigh lac","L4045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","395.79","","","","","","","fee schedule","384.48","395.79","APC"
"Replace molded calf lacer","L4050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","496.93","","","","","","","fee schedule","483.89","498.12","APC"
"Replace molded calf lacer","L4050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","488.63","","","","","","","fee schedule","483.89","498.12","APC"
"Replace molded calf lacer","L4050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","483.89","","","","","","","fee schedule","483.89","498.12","APC"
"Replace molded calf lacer","L4050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","498.12","","","","","","","fee schedule","483.89","498.12","APC"
"Replace non-molded calf lace","L4055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","321.79","","","","","","","fee schedule","313.34","322.56","APC"
"Replace non-molded calf lace","L4055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","316.42","","","","","","","fee schedule","313.34","322.56","APC"
"Replace non-molded calf lace","L4055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","313.34","","","","","","","fee schedule","313.34","322.56","APC"
"Replace non-molded calf lace","L4055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","322.56","","","","","","","fee schedule","313.34","322.56","APC"
"Replace high roll cuff","L4060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","382.54","","","","","","","fee schedule","372.49","383.45","APC"
"Replace high roll cuff","L4060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.15","","","","","","","fee schedule","372.49","383.45","APC"
"Replace high roll cuff","L4060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","372.49","","","","","","","fee schedule","372.49","383.45","APC"
"Replace high roll cuff","L4060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","383.45","","","","","","","fee schedule","372.49","383.45","APC"
"Replace prox & dist upright","L4070","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","338.75","","","","","","","fee schedule","329.86","339.56","APC"
"Replace prox & dist upright","L4070","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","333.09","","","","","","","fee schedule","329.86","339.56","APC"
"Replace prox & dist upright","L4070","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","329.86","","","","","","","fee schedule","329.86","339.56","APC"
"Replace prox & dist upright","L4070","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","339.56","","","","","","","fee schedule","329.86","339.56","APC"
"Repl met band kafo-afo prox","L4080","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","138.96","","","","","","","fee schedule","135.31","139.29","APC"
"Repl met band kafo-afo prox","L4080","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","136.64","","","","","","","fee schedule","135.31","139.29","APC"
"Repl met band kafo-afo prox","L4080","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","135.31","","","","","","","fee schedule","135.31","139.29","APC"
"Repl met band kafo-afo prox","L4080","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","139.29","","","","","","","fee schedule","135.31","139.29","APC"
"Repl met band kafo-afo calf/","L4090","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","109.64","","","","","","","fee schedule","106.76","109.9","APC"
"Repl met band kafo-afo calf/","L4090","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","107.81","","","","","","","fee schedule","106.76","109.9","APC"
"Repl met band kafo-afo calf/","L4090","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","106.76","","","","","","","fee schedule","106.76","109.9","APC"
"Repl met band kafo-afo calf/","L4090","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","109.9","","","","","","","fee schedule","106.76","109.9","APC"
"Repl leath cuff kafo prox th","L4100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","143.98","","","","","","","fee schedule","140.2","144.32","APC"
"Repl leath cuff kafo prox th","L4100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","141.57","","","","","","","fee schedule","140.2","144.32","APC"
"Repl leath cuff kafo prox th","L4100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","140.2","","","","","","","fee schedule","140.2","144.32","APC"
"Repl leath cuff kafo prox th","L4100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","144.32","","","","","","","fee schedule","140.2","144.32","APC"
"Repl leath cuff kafo-afo cal","L4110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","108.45","","","","","","","fee schedule","105.6","108.71","APC"
"Repl leath cuff kafo-afo cal","L4110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.64","","","","","","","fee schedule","105.6","108.71","APC"
"Repl leath cuff kafo-afo cal","L4110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","105.6","","","","","","","fee schedule","105.6","108.71","APC"
"Repl leath cuff kafo-afo cal","L4110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.71","","","","","","","fee schedule","105.6","108.71","APC"
"Replace pretibial shell","L4130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","608.18","","","","","","","fee schedule","592.21","609.63","APC"
"Replace pretibial shell","L4130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","598.02","","","","","","","fee schedule","592.21","609.63","APC"
"Replace pretibial shell","L4130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","592.21","","","","","","","fee schedule","592.21","609.63","APC"
"Replace pretibial shell","L4130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","609.63","","","","","","","fee schedule","592.21","609.63","APC"
"Ortho dvc repair per 15 min","L4205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.34","","","","","","","fee schedule","30.52","31.42","APC"
"Ortho dvc repair per 15 min","L4205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.82","","","","","","","fee schedule","30.52","31.42","APC"
"Ortho dvc repair per 15 min","L4205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.52","","","","","","","fee schedule","30.52","31.42","APC"
"Ortho dvc repair per 15 min","L4205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.42","","","","","","","fee schedule","30.52","31.42","APC"
"Ankle control ortho pre ots","L4350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","120.48","","","","","","","fee schedule","117.32","120.77","APC"
"Ankle control ortho pre ots","L4350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","118.47","","","","","","","fee schedule","117.32","120.77","APC"
"Ankle control ortho pre ots","L4350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117.32","","","","","","","fee schedule","117.32","120.77","APC"
"Ankle control ortho pre ots","L4350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120.77","","","","","","","fee schedule","117.32","120.77","APC"
"Pneumat walking boot pre cst","L4360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","370.39","","","","","","","fee schedule","360.66","371.27","APC"
"Pneumat walking boot pre cst","L4360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","364.2","","","","","","","fee schedule","360.66","371.27","APC"
"Pneumat walking boot pre cst","L4360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","360.66","","","","","","","fee schedule","360.66","371.27","APC"
"Pneumat walking boot pre cst","L4360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","371.27","","","","","","","fee schedule","360.66","371.27","APC"
"Pneuma/vac walk boot pre ots","L4361","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","370.39","","","","","","","fee schedule","360.66","371.27","APC"
"Pneuma/vac walk boot pre ots","L4361","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","364.2","","","","","","","fee schedule","360.66","371.27","APC"
"Pneuma/vac walk boot pre ots","L4361","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","360.66","","","","","","","fee schedule","360.66","371.27","APC"
"Pneuma/vac walk boot pre ots","L4361","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","371.27","","","","","","","fee schedule","360.66","371.27","APC"
"Pneum full leg splnt pre ots","L4370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","244.93","","","","","","","fee schedule","238.5","245.51","APC"
"Pneum full leg splnt pre ots","L4370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","240.83","","","","","","","fee schedule","238.5","245.51","APC"
"Pneum full leg splnt pre ots","L4370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","238.5","","","","","","","fee schedule","238.5","245.51","APC"
"Pneum full leg splnt pre ots","L4370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","245.51","","","","","","","fee schedule","238.5","245.51","APC"
"Non-pneum walk boot pre cst","L4386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","199.19","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre cst","L4386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","195.86","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre cst","L4386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","193.96","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre cst","L4386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","199.67","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre ots","L4387","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","199.19","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre ots","L4387","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","195.86","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre ots","L4387","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","193.96","","","","","","","fee schedule","193.96","199.67","APC"
"Non-pneum walk boot pre ots","L4387","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","199.67","","","","","","","fee schedule","193.96","199.67","APC"
"Replace AFO soft interface","L4392","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","28.78","29.63","APC"
"Replace AFO soft interface","L4392","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","28.78","29.63","APC"
"Replace AFO soft interface","L4392","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","28.78","29.63","APC"
"Replace AFO soft interface","L4392","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","28.78","29.63","APC"
"Replace foot drop spint","L4394","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.56","","","","","","","fee schedule","20.99","21.61","APC"
"Replace foot drop spint","L4394","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.2","","","","","","","fee schedule","20.99","21.61","APC"
"Replace foot drop spint","L4394","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.99","","","","","","","fee schedule","20.99","21.61","APC"
"Replace foot drop spint","L4394","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.61","","","","","","","fee schedule","20.99","21.61","APC"
"Static or dynami afo pre cst","L4396","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","210.82","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre cst","L4396","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","207.3","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre cst","L4396","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","205.29","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre cst","L4396","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","211.32","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre ots","L4397","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","210.82","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre ots","L4397","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","207.3","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre ots","L4397","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","205.29","","","","","","","fee schedule","205.29","211.32","APC"
"Static or dynami afo pre ots","L4397","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","211.32","","","","","","","fee schedule","205.29","211.32","APC"
"Foot drop splint pre ots","L4398","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","97.07","","","","","","","fee schedule","94.52","97.3","APC"
"Foot drop splint pre ots","L4398","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","95.45","","","","","","","fee schedule","94.52","97.3","APC"
"Foot drop splint pre ots","L4398","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","94.52","","","","","","","fee schedule","94.52","97.3","APC"
"Foot drop splint pre ots","L4398","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","97.3","","","","","","","fee schedule","94.52","97.3","APC"
"Afo, walk boot type, cus fab","L4631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2003.49","","","","","","","fee schedule","1950.89","2008.27","APC"
"Afo, walk boot type, cus fab","L4631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1970.02","","","","","","","fee schedule","1950.89","2008.27","APC"
"Afo, walk boot type, cus fab","L4631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1950.89","","","","","","","fee schedule","1950.89","2008.27","APC"
"Afo, walk boot type, cus fab","L4631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2008.27","","","","","","","fee schedule","1950.89","2008.27","APC"
"Sho insert w arch toe filler","L5000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","714.74","","","","","","","fee schedule","695.98","716.45","APC"
"Sho insert w arch toe filler","L5000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","702.8","","","","","","","fee schedule","695.98","716.45","APC"
"Sho insert w arch toe filler","L5000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","695.98","","","","","","","fee schedule","695.98","716.45","APC"
"Sho insert w arch toe filler","L5000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","716.45","","","","","","","fee schedule","695.98","716.45","APC"
"Mold socket ank hgt w/ toe f","L5010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1561.25","","","","","","","fee schedule","1520.26","1564.97","APC"
"Mold socket ank hgt w/ toe f","L5010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1535.16","","","","","","","fee schedule","1520.26","1564.97","APC"
"Mold socket ank hgt w/ toe f","L5010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1520.26","","","","","","","fee schedule","1520.26","1564.97","APC"
"Mold socket ank hgt w/ toe f","L5010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1564.97","","","","","","","fee schedule","1520.26","1564.97","APC"
"Tibial tubercle hgt w/ toe f","L5020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2541.39","","","","","","","fee schedule","2474.67","2547.46","APC"
"Tibial tubercle hgt w/ toe f","L5020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2498.93","","","","","","","fee schedule","2474.67","2547.46","APC"
"Tibial tubercle hgt w/ toe f","L5020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2474.67","","","","","","","fee schedule","2474.67","2547.46","APC"
"Tibial tubercle hgt w/ toe f","L5020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2547.46","","","","","","","fee schedule","2474.67","2547.46","APC"
"Ank symes mold sckt sach ft","L5050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2943.05","","","","","","","fee schedule","2865.78","2950.07","APC"
"Ank symes mold sckt sach ft","L5050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2893.88","","","","","","","fee schedule","2865.78","2950.07","APC"
"Ank symes mold sckt sach ft","L5050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2865.78","","","","","","","fee schedule","2865.78","2950.07","APC"
"Ank symes mold sckt sach ft","L5050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2950.07","","","","","","","fee schedule","2865.78","2950.07","APC"
"Symes met fr leath socket ar","L5060","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3542","","","","","","","fee schedule","3449.01","3550.45","APC"
"Symes met fr leath socket ar","L5060","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3482.82","","","","","","","fee schedule","3449.01","3550.45","APC"
"Symes met fr leath socket ar","L5060","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3449.01","","","","","","","fee schedule","3449.01","3550.45","APC"
"Symes met fr leath socket ar","L5060","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3550.45","","","","","","","fee schedule","3449.01","3550.45","APC"
"Molded socket shin sach foot","L5100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3065.86","","","","","","","fee schedule","2985.38","3073.18","APC"
"Molded socket shin sach foot","L5100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3014.65","","","","","","","fee schedule","2985.38","3073.18","APC"
"Molded socket shin sach foot","L5100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2985.38","","","","","","","fee schedule","2985.38","3073.18","APC"
"Molded socket shin sach foot","L5100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3073.18","","","","","","","fee schedule","2985.38","3073.18","APC"
"Plast socket jts/thgh lacer","L5105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4866.19","","","","","","","fee schedule","4738.44","4877.81","APC"
"Plast socket jts/thgh lacer","L5105","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4784.9","","","","","","","fee schedule","4738.44","4877.81","APC"
"Plast socket jts/thgh lacer","L5105","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4738.44","","","","","","","fee schedule","4738.44","4877.81","APC"
"Plast socket jts/thgh lacer","L5105","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4877.81","","","","","","","fee schedule","4738.44","4877.81","APC"
"Mold sckt ext knee shin sach","L5150","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4503.39","","","","","","","fee schedule","4385.16","4514.14","APC"
"Mold sckt ext knee shin sach","L5150","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4428.16","","","","","","","fee schedule","4385.16","4514.14","APC"
"Mold sckt ext knee shin sach","L5150","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4385.16","","","","","","","fee schedule","4385.16","4514.14","APC"
"Mold sckt ext knee shin sach","L5150","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4514.14","","","","","","","fee schedule","4385.16","4514.14","APC"
"Mold socket bent knee shin s","L5160","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4898.24","","","","","","","fee schedule","4769.64","4909.93","APC"
"Mold socket bent knee shin s","L5160","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4816.4","","","","","","","fee schedule","4769.64","4909.93","APC"
"Mold socket bent knee shin s","L5160","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4769.64","","","","","","","fee schedule","4769.64","4909.93","APC"
"Mold socket bent knee shin s","L5160","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4909.93","","","","","","","fee schedule","4769.64","4909.93","APC"
"Kne sing axis fric shin sach","L5200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4266.79","","","","","","","fee schedule","4154.78","4276.98","APC"
"Kne sing axis fric shin sach","L5200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4195.51","","","","","","","fee schedule","4154.78","4276.98","APC"
"Kne sing axis fric shin sach","L5200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4154.78","","","","","","","fee schedule","4154.78","4276.98","APC"
"Kne sing axis fric shin sach","L5200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4276.98","","","","","","","fee schedule","4154.78","4276.98","APC"
"No knee/ankle joints w/ ft b","L5210","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3111.84","","","","","","","fee schedule","3030.14","3119.27","APC"
"No knee/ankle joints w/ ft b","L5210","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3059.85","","","","","","","fee schedule","3030.14","3119.27","APC"
"No knee/ankle joints w/ ft b","L5210","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3030.14","","","","","","","fee schedule","3030.14","3119.27","APC"
"No knee/ankle joints w/ ft b","L5210","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3119.27","","","","","","","fee schedule","3030.14","3119.27","APC"
"No knee joint with artic ali","L5220","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3537.18","","","","","","","fee schedule","3444.32","3545.62","APC"
"No knee joint with artic ali","L5220","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3478.08","","","","","","","fee schedule","3444.32","3545.62","APC"
"No knee joint with artic ali","L5220","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3444.32","","","","","","","fee schedule","3444.32","3545.62","APC"
"No knee joint with artic ali","L5220","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3545.62","","","","","","","fee schedule","3444.32","3545.62","APC"
"Fem focal defic constant fri","L5230","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4878.46","","","","","","","fee schedule","4750.38","4890.1","APC"
"Fem focal defic constant fri","L5230","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4796.96","","","","","","","fee schedule","4750.38","4890.1","APC"
"Fem focal defic constant fri","L5230","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4750.38","","","","","","","fee schedule","4750.38","4890.1","APC"
"Fem focal defic constant fri","L5230","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4890.1","","","","","","","fee schedule","4750.38","4890.1","APC"
"Hip canad sing axi cons fric","L5250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6653.79","","","","","","","fee schedule","6479.11","6669.67","APC"
"Hip canad sing axi cons fric","L5250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6542.63","","","","","","","fee schedule","6479.11","6669.67","APC"
"Hip canad sing axi cons fric","L5250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6479.11","","","","","","","fee schedule","6479.11","6669.67","APC"
"Hip canad sing axi cons fric","L5250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6669.67","","","","","","","fee schedule","6479.11","6669.67","APC"
"Tilt table locking hip sing","L5270","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6595.5","","","","","","","fee schedule","6422.35","6611.24","APC"
"Tilt table locking hip sing","L5270","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6485.31","","","","","","","fee schedule","6422.35","6611.24","APC"
"Tilt table locking hip sing","L5270","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6422.35","","","","","","","fee schedule","6422.35","6611.24","APC"
"Tilt table locking hip sing","L5270","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6611.24","","","","","","","fee schedule","6422.35","6611.24","APC"
"Hemipelvect canad sing axis","L5280","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6529.55","","","","","","","fee schedule","6358.13","6545.13","APC"
"Hemipelvect canad sing axis","L5280","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6420.46","","","","","","","fee schedule","6358.13","6545.13","APC"
"Hemipelvect canad sing axis","L5280","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6358.13","","","","","","","fee schedule","6358.13","6545.13","APC"
"Hemipelvect canad sing axis","L5280","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6545.13","","","","","","","fee schedule","6358.13","6545.13","APC"
"Bk mold socket sach ft endo","L5301","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2944.42","","","","","","","fee schedule","2867.12","2951.44","APC"
"Bk mold socket sach ft endo","L5301","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2895.23","","","","","","","fee schedule","2867.12","2951.44","APC"
"Bk mold socket sach ft endo","L5301","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2867.12","","","","","","","fee schedule","2867.12","2951.44","APC"
"Bk mold socket sach ft endo","L5301","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2951.44","","","","","","","fee schedule","2867.12","2951.44","APC"
"Knee disart, SACH ft, endo","L5312","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4229.98","","","","","","","fee schedule","4118.93","4240.08","APC"
"Knee disart, SACH ft, endo","L5312","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4159.32","","","","","","","fee schedule","4118.93","4240.08","APC"
"Knee disart, SACH ft, endo","L5312","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4118.93","","","","","","","fee schedule","4118.93","4240.08","APC"
"Knee disart, SACH ft, endo","L5312","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4240.08","","","","","","","fee schedule","4118.93","4240.08","APC"
"Ak open end sach","L5321","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4214.86","","","","","","","fee schedule","4104.2","4224.92","APC"
"Ak open end sach","L5321","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4144.44","","","","","","","fee schedule","4104.2","4224.92","APC"
"Ak open end sach","L5321","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4104.2","","","","","","","fee schedule","4104.2","4224.92","APC"
"Ak open end sach","L5321","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4224.92","","","","","","","fee schedule","4104.2","4224.92","APC"
"Hip disart canadian sach ft","L5331","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5964.18","","","","","","","fee schedule","5807.6","5978.42","APC"
"Hip disart canadian sach ft","L5331","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5864.54","","","","","","","fee schedule","5807.6","5978.42","APC"
"Hip disart canadian sach ft","L5331","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5807.6","","","","","","","fee schedule","5807.6","5978.42","APC"
"Hip disart canadian sach ft","L5331","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5978.42","","","","","","","fee schedule","5807.6","5978.42","APC"
"Hemipelvectomy canadian sach","L5341","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6481.2","","","","","","","fee schedule","6311.05","6496.66","APC"
"Hemipelvectomy canadian sach","L5341","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6372.92","","","","","","","fee schedule","6311.05","6496.66","APC"
"Hemipelvectomy canadian sach","L5341","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6311.05","","","","","","","fee schedule","6311.05","6496.66","APC"
"Hemipelvectomy canadian sach","L5341","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6496.67","","","","","","","fee schedule","6311.05","6496.66","APC"
"Postop dress & 1 cast chg bk","L5400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1543.42","","","","","","","fee schedule","1502.9","1547.1","APC"
"Postop dress & 1 cast chg bk","L5400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1517.63","","","","","","","fee schedule","1502.9","1547.1","APC"
"Postop dress & 1 cast chg bk","L5400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1502.9","","","","","","","fee schedule","1502.9","1547.1","APC"
"Postop dress & 1 cast chg bk","L5400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1547.1","","","","","","","fee schedule","1502.9","1547.1","APC"
"Postop dsg bk ea add cast ch","L5410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","676.2","","","","","","","fee schedule","658.45","677.82","APC"
"Postop dsg bk ea add cast ch","L5410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","664.91","","","","","","","fee schedule","658.45","677.82","APC"
"Postop dsg bk ea add cast ch","L5410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","658.45","","","","","","","fee schedule","658.45","677.82","APC"
"Postop dsg bk ea add cast ch","L5410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","677.82","","","","","","","fee schedule","658.45","677.82","APC"
"Postop dsg & 1 cast chg ak/d","L5420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1949.27","","","","","","","fee schedule","1898.1","1953.92","APC"
"Postop dsg & 1 cast chg ak/d","L5420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1916.71","","","","","","","fee schedule","1898.1","1953.92","APC"
"Postop dsg & 1 cast chg ak/d","L5420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1898.1","","","","","","","fee schedule","1898.1","1953.92","APC"
"Postop dsg & 1 cast chg ak/d","L5420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1953.92","","","","","","","fee schedule","1898.1","1953.92","APC"
"Postop dsg ak ea add cast ch","L5430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","860.44","","","","","","","fee schedule","837.85","862.49","APC"
"Postop dsg ak ea add cast ch","L5430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","846.06","","","","","","","fee schedule","837.85","862.49","APC"
"Postop dsg ak ea add cast ch","L5430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","837.85","","","","","","","fee schedule","837.85","862.49","APC"
"Postop dsg ak ea add cast ch","L5430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","862.49","","","","","","","fee schedule","837.85","862.49","APC"
"Postop app non-wgt bear dsg","L5450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","550.43","","","","","","","fee schedule","535.98","551.74","APC"
"Postop app non-wgt bear dsg","L5450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","541.23","","","","","","","fee schedule","535.98","551.74","APC"
"Postop app non-wgt bear dsg","L5450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","535.98","","","","","","","fee schedule","535.98","551.74","APC"
"Postop app non-wgt bear dsg","L5450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","551.74","","","","","","","fee schedule","535.98","551.74","APC"
"Postop app non-wgt bear dsg","L5460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","811.29","","","","","","","fee schedule","789.99","813.22","APC"
"Postop app non-wgt bear dsg","L5460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","797.74","","","","","","","fee schedule","789.99","813.22","APC"
"Postop app non-wgt bear dsg","L5460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","789.99","","","","","","","fee schedule","789.99","813.22","APC"
"Postop app non-wgt bear dsg","L5460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","813.22","","","","","","","fee schedule","789.99","813.22","APC"
"Init bk ptb plaster direct","L5500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1647.02","","","","","","","fee schedule","1603.78","1650.95","APC"
"Init bk ptb plaster direct","L5500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1619.5","","","","","","","fee schedule","1603.78","1650.95","APC"
"Init bk ptb plaster direct","L5500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1603.78","","","","","","","fee schedule","1603.78","1650.95","APC"
"Init bk ptb plaster direct","L5500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1650.95","","","","","","","fee schedule","1603.78","1650.95","APC"
"Init ak ischal plstr direct","L5505","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2230.49","","","","","","","fee schedule","2171.94","2235.82","APC"
"Init ak ischal plstr direct","L5505","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2193.23","","","","","","","fee schedule","2171.94","2235.82","APC"
"Init ak ischal plstr direct","L5505","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2171.94","","","","","","","fee schedule","2171.94","2235.82","APC"
"Init ak ischal plstr direct","L5505","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2235.82","","","","","","","fee schedule","2171.94","2235.82","APC"
"Prep BK ptb plaster molded","L5510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1867","","","","","","","fee schedule","1817.99","1871.46","APC"
"Prep BK ptb plaster molded","L5510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1835.81","","","","","","","fee schedule","1817.99","1871.46","APC"
"Prep BK ptb plaster molded","L5510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1817.99","","","","","","","fee schedule","1817.99","1871.46","APC"
"Prep BK ptb plaster molded","L5510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1871.46","","","","","","","fee schedule","1817.99","1871.46","APC"
"Perp BK ptb thermopls direct","L5520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1844.16","","","","","","","fee schedule","1795.74","1848.56","APC"
"Perp BK ptb thermopls direct","L5520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1813.35","","","","","","","fee schedule","1795.74","1848.56","APC"
"Perp BK ptb thermopls direct","L5520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1795.74","","","","","","","fee schedule","1795.74","1848.56","APC"
"Perp BK ptb thermopls direct","L5520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1848.56","","","","","","","fee schedule","1795.74","1848.56","APC"
"Prep BK ptb thermopls molded","L5530","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2334.33","","","","","","","fee schedule","2273.05","2339.9","APC"
"Prep BK ptb thermopls molded","L5530","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2295.33","","","","","","","fee schedule","2273.05","2339.9","APC"
"Prep BK ptb thermopls molded","L5530","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2273.05","","","","","","","fee schedule","2273.05","2339.9","APC"
"Prep BK ptb thermopls molded","L5530","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2339.9","","","","","","","fee schedule","2273.05","2339.9","APC"
"Prep BK ptb open end socket","L5535","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2300.46","","","","","","","fee schedule","2240.06","2305.95","APC"
"Prep BK ptb open end socket","L5535","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2262.02","","","","","","","fee schedule","2240.06","2305.95","APC"
"Prep BK ptb open end socket","L5535","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2240.06","","","","","","","fee schedule","2240.06","2305.95","APC"
"Prep BK ptb open end socket","L5535","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2305.95","","","","","","","fee schedule","2240.06","2305.95","APC"
"Prep BK ptb laminated socket","L5540","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2429.17","","","","","","","fee schedule","2365.4","2434.97","APC"
"Prep BK ptb laminated socket","L5540","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2388.59","","","","","","","fee schedule","2365.4","2434.97","APC"
"Prep BK ptb laminated socket","L5540","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2365.4","","","","","","","fee schedule","2365.4","2434.97","APC"
"Prep BK ptb laminated socket","L5540","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2434.97","","","","","","","fee schedule","2365.4","2434.97","APC"
"Prep AK ischial plast molded","L5560","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2492.45","","","","","","","fee schedule","2427.02","2498.4","APC"
"Prep AK ischial plast molded","L5560","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2450.81","","","","","","","fee schedule","2427.02","2498.4","APC"
"Prep AK ischial plast molded","L5560","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2427.02","","","","","","","fee schedule","2427.02","2498.4","APC"
"Prep AK ischial plast molded","L5560","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2498.4","","","","","","","fee schedule","2427.02","2498.4","APC"
"Prep AK ischial direct form","L5570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2591.26","","","","","","","fee schedule","2523.24","2597.45","APC"
"Prep AK ischial direct form","L5570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2547.97","","","","","","","fee schedule","2523.24","2597.45","APC"
"Prep AK ischial direct form","L5570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2523.24","","","","","","","fee schedule","2523.24","2597.45","APC"
"Prep AK ischial direct form","L5570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2597.45","","","","","","","fee schedule","2523.24","2597.45","APC"
"Prep AK ischial thermo mold","L5580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3025.12","","","","","","","fee schedule","2945.7","3032.34","APC"
"Prep AK ischial thermo mold","L5580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2974.58","","","","","","","fee schedule","2945.7","3032.34","APC"
"Prep AK ischial thermo mold","L5580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2945.7","","","","","","","fee schedule","2945.7","3032.34","APC"
"Prep AK ischial thermo mold","L5580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3032.34","","","","","","","fee schedule","2945.7","3032.34","APC"
"Prep AK ischial open end","L5585","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3281.09","","","","","","","fee schedule","3194.96","3288.93","APC"
"Prep AK ischial open end","L5585","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3226.28","","","","","","","fee schedule","3194.96","3288.93","APC"
"Prep AK ischial open end","L5585","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3194.96","","","","","","","fee schedule","3194.96","3288.93","APC"
"Prep AK ischial open end","L5585","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3288.93","","","","","","","fee schedule","3194.96","3288.93","APC"
"Prep AK ischial laminated","L5590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3082.8","","","","","","","fee schedule","3001.87","3090.16","APC"
"Prep AK ischial laminated","L5590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3031.3","","","","","","","fee schedule","3001.87","3090.16","APC"
"Prep AK ischial laminated","L5590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3001.87","","","","","","","fee schedule","3001.87","3090.16","APC"
"Prep AK ischial laminated","L5590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3090.16","","","","","","","fee schedule","3001.87","3090.16","APC"
"Hip disartic sach thermopls","L5595","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5418.73","","","","","","","fee schedule","5276.47","5431.66","APC"
"Hip disartic sach thermopls","L5595","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5328.2","","","","","","","fee schedule","5276.47","5431.66","APC"
"Hip disartic sach thermopls","L5595","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5276.47","","","","","","","fee schedule","5276.47","5431.66","APC"
"Hip disartic sach thermopls","L5595","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5431.66","","","","","","","fee schedule","5276.47","5431.66","APC"
"Hip disart sach laminat mold","L5600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5910.34","","","","","","","fee schedule","5755.18","5924.45","APC"
"Hip disart sach laminat mold","L5600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5811.6","","","","","","","fee schedule","5755.18","5924.45","APC"
"Hip disart sach laminat mold","L5600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5755.18","","","","","","","fee schedule","5755.18","5924.45","APC"
"Hip disart sach laminat mold","L5600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5924.45","","","","","","","fee schedule","5755.18","5924.45","APC"
"Above knee hydracadence","L5610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2655.06","","","","","","","fee schedule","2585.35","2661.39","APC"
"Above knee hydracadence","L5610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2610.7","","","","","","","fee schedule","2585.35","2661.39","APC"
"Above knee hydracadence","L5610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2585.35","","","","","","","fee schedule","2585.35","2661.39","APC"
"Above knee hydracadence","L5610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2661.39","","","","","","","fee schedule","2585.35","2661.39","APC"
"Ak 4 bar link w/fric swing","L5611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2066.16","","","","","","","fee schedule","2011.92","2071.09","APC"
"Ak 4 bar link w/fric swing","L5611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2031.64","","","","","","","fee schedule","2011.92","2071.09","APC"
"Ak 4 bar link w/fric swing","L5611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2011.92","","","","","","","fee schedule","2011.92","2071.09","APC"
"Ak 4 bar link w/fric swing","L5611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2071.09","","","","","","","fee schedule","2011.92","2071.09","APC"
"Ak 4 bar ling w/hydraul swig","L5613","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3142.77","","","","","","","fee schedule","3060.27","3150.27","APC"
"Ak 4 bar ling w/hydraul swig","L5613","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3090.27","","","","","","","fee schedule","3060.27","3150.27","APC"
"Ak 4 bar ling w/hydraul swig","L5613","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3060.27","","","","","","","fee schedule","3060.27","3150.27","APC"
"Ak 4 bar ling w/hydraul swig","L5613","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3150.27","","","","","","","fee schedule","3060.27","3150.27","APC"
"4-bar link above knee w/swng","L5614","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2124.39","","","","","","","fee schedule","2068.62","2129.46","APC"
"4-bar link above knee w/swng","L5614","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2088.9","","","","","","","fee schedule","2068.62","2129.46","APC"
"4-bar link above knee w/swng","L5614","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2068.62","","","","","","","fee schedule","2068.62","2129.46","APC"
"4-bar link above knee w/swng","L5614","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2129.46","","","","","","","fee schedule","2068.62","2129.46","APC"
"Ak 4 bar link hydl swg/stanc","L5615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7158.23","","","","","","","fee schedule","6970.3","7175.31","APC"
"Ak 4 bar link hydl swg/stanc","L5615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7038.64","","","","","","","fee schedule","6970.3","7175.31","APC"
"Ak 4 bar link hydl swg/stanc","L5615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6970.3","","","","","","","fee schedule","6970.3","7175.31","APC"
"Ak 4 bar link hydl swg/stanc","L5615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7175.31","","","","","","","fee schedule","6970.3","7175.31","APC"
"Ak univ multiplex sys frict","L5616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1741.7","","","","","","","fee schedule","1695.97","1745.86","APC"
"Ak univ multiplex sys frict","L5616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1712.6","","","","","","","fee schedule","1695.97","1745.86","APC"
"Ak univ multiplex sys frict","L5616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1695.97","","","","","","","fee schedule","1695.97","1745.86","APC"
"Ak univ multiplex sys frict","L5616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1745.86","","","","","","","fee schedule","1695.97","1745.86","APC"
"AK/BK self-aligning unit ea","L5617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","704.36","","","","","","","fee schedule","685.87","706.04","APC"
"AK/BK self-aligning unit ea","L5617","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","692.59","","","","","","","fee schedule","685.87","706.04","APC"
"AK/BK self-aligning unit ea","L5617","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","685.87","","","","","","","fee schedule","685.87","706.04","APC"
"AK/BK self-aligning unit ea","L5617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","706.04","","","","","","","fee schedule","685.87","706.04","APC"
"Test socket symes","L5618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","405.78","","","","","","","fee schedule","395.13","406.75","APC"
"Test socket symes","L5618","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","399","","","","","","","fee schedule","395.13","406.75","APC"
"Test socket symes","L5618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","395.13","","","","","","","fee schedule","395.13","406.75","APC"
"Test socket symes","L5618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","406.75","","","","","","","fee schedule","395.13","406.75","APC"
"Test socket below knee","L5620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","356.53","","","","","","","fee schedule","347.17","357.38","APC"
"Test socket below knee","L5620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","350.57","","","","","","","fee schedule","347.17","357.38","APC"
"Test socket below knee","L5620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","347.17","","","","","","","fee schedule","347.17","357.38","APC"
"Test socket below knee","L5620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","357.38","","","","","","","fee schedule","347.17","357.38","APC"
"Test socket knee disarticula","L5622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","544.48","","","","","","","fee schedule","530.19","545.78","APC"
"Test socket knee disarticula","L5622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","535.38","","","","","","","fee schedule","530.19","545.78","APC"
"Test socket knee disarticula","L5622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","530.19","","","","","","","fee schedule","530.19","545.78","APC"
"Test socket knee disarticula","L5622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","545.78","","","","","","","fee schedule","530.19","545.78","APC"
"Test socket above knee","L5624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","519.5","","","","","","","fee schedule","505.86","520.74","APC"
"Test socket above knee","L5624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","510.82","","","","","","","fee schedule","505.86","520.74","APC"
"Test socket above knee","L5624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","505.86","","","","","","","fee schedule","505.86","520.74","APC"
"Test socket above knee","L5624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","520.74","","","","","","","fee schedule","505.86","520.74","APC"
"Test socket hip disarticulat","L5626","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","730.23","","","","","","","fee schedule","711.06","731.98","APC"
"Test socket hip disarticulat","L5626","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","718.03","","","","","","","fee schedule","711.06","731.98","APC"
"Test socket hip disarticulat","L5626","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","711.06","","","","","","","fee schedule","711.06","731.98","APC"
"Test socket hip disarticulat","L5626","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","731.98","","","","","","","fee schedule","711.06","731.98","APC"
"Test socket hemipelvectomy","L5628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","691.62","","","","","","","fee schedule","673.47","693.27","APC"
"Test socket hemipelvectomy","L5628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","680.07","","","","","","","fee schedule","673.47","693.27","APC"
"Test socket hemipelvectomy","L5628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","673.47","","","","","","","fee schedule","673.47","693.27","APC"
"Test socket hemipelvectomy","L5628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","693.27","","","","","","","fee schedule","673.47","693.27","APC"
"Below knee acrylic socket","L5629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","528.16","","","","","","","fee schedule","514.29","529.42","APC"
"Below knee acrylic socket","L5629","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","519.34","","","","","","","fee schedule","514.29","529.42","APC"
"Below knee acrylic socket","L5629","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","514.29","","","","","","","fee schedule","514.29","529.42","APC"
"Below knee acrylic socket","L5629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","529.42","","","","","","","fee schedule","514.29","529.42","APC"
"Syme typ expandabl wall sckt","L5630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","575.54","","","","","","","fee schedule","560.43","576.91","APC"
"Syme typ expandabl wall sckt","L5630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","565.92","","","","","","","fee schedule","560.43","576.91","APC"
"Syme typ expandabl wall sckt","L5630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","560.43","","","","","","","fee schedule","560.43","576.91","APC"
"Syme typ expandabl wall sckt","L5630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","576.91","","","","","","","fee schedule","560.43","576.91","APC"
"Ak/knee disartic acrylic soc","L5631","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","688.24","","","","","","","fee schedule","670.17","689.88","APC"
"Ak/knee disartic acrylic soc","L5631","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","676.74","","","","","","","fee schedule","670.17","689.88","APC"
"Ak/knee disartic acrylic soc","L5631","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","670.17","","","","","","","fee schedule","670.17","689.88","APC"
"Ak/knee disartic acrylic soc","L5631","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","689.88","","","","","","","fee schedule","670.17","689.88","APC"
"Symes type ptb brim design s","L5632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","284.74","","","","","","","fee schedule","277.27","285.42","APC"
"Symes type ptb brim design s","L5632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","279.98","","","","","","","fee schedule","277.27","285.42","APC"
"Symes type ptb brim design s","L5632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","277.27","","","","","","","fee schedule","277.27","285.42","APC"
"Symes type ptb brim design s","L5632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","285.42","","","","","","","fee schedule","277.27","285.42","APC"
"Symes type poster opening so","L5634","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","390.09","","","","","","","fee schedule","379.85","391.02","APC"
"Symes type poster opening so","L5634","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","383.57","","","","","","","fee schedule","379.85","391.02","APC"
"Symes type poster opening so","L5634","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","379.85","","","","","","","fee schedule","379.85","391.02","APC"
"Symes type poster opening so","L5634","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","391.02","","","","","","","fee schedule","379.85","391.02","APC"
"Symes type medial opening so","L5636","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","326.76","","","","","","","fee schedule","318.18","327.54","APC"
"Symes type medial opening so","L5636","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","321.3","","","","","","","fee schedule","318.18","327.54","APC"
"Symes type medial opening so","L5636","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","318.18","","","","","","","fee schedule","318.18","327.54","APC"
"Symes type medial opening so","L5636","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","327.54","","","","","","","fee schedule","318.18","327.54","APC"
"Below knee total contact","L5637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","436.47","","","","","","","fee schedule","425.01","437.51","APC"
"Below knee total contact","L5637","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","429.18","","","","","","","fee schedule","425.01","437.51","APC"
"Below knee total contact","L5637","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","425.01","","","","","","","fee schedule","425.01","437.51","APC"
"Below knee total contact","L5637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","437.51","","","","","","","fee schedule","425.01","437.51","APC"
"Below knee leather socket","L5638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","624.09","","","","","","","fee schedule","607.71","625.58","APC"
"Below knee leather socket","L5638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","613.66","","","","","","","fee schedule","607.71","625.58","APC"
"Below knee leather socket","L5638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","607.71","","","","","","","fee schedule","607.71","625.58","APC"
"Below knee leather socket","L5638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","625.58","","","","","","","fee schedule","607.71","625.58","APC"
"Below knee wood socket","L5639","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1464.09","","","","","","","fee schedule","1425.65","1467.58","APC"
"Below knee wood socket","L5639","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1439.63","","","","","","","fee schedule","1425.65","1467.58","APC"
"Below knee wood socket","L5639","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1425.65","","","","","","","fee schedule","1425.65","1467.58","APC"
"Below knee wood socket","L5639","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1467.58","","","","","","","fee schedule","1425.65","1467.58","APC"
"Knee disarticulat leather so","L5640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","891.4","","","","","","","fee schedule","868","893.53","APC"
"Knee disarticulat leather so","L5640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","876.51","","","","","","","fee schedule","868","893.53","APC"
"Knee disarticulat leather so","L5640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","868","","","","","","","fee schedule","868","893.53","APC"
"Knee disarticulat leather so","L5640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","893.53","","","","","","","fee schedule","868","893.53","APC"
"Above knee leather socket","L5642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","798.04","","","","","","","fee schedule","777.09","799.94","APC"
"Above knee leather socket","L5642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","784.71","","","","","","","fee schedule","777.09","799.94","APC"
"Above knee leather socket","L5642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","777.09","","","","","","","fee schedule","777.09","799.94","APC"
"Above knee leather socket","L5642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","799.94","","","","","","","fee schedule","777.09","799.94","APC"
"Hip flex inner socket ext fr","L5643","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1995.97","","","","","","","fee schedule","1943.57","2000.73","APC"
"Hip flex inner socket ext fr","L5643","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1962.62","","","","","","","fee schedule","1943.57","2000.73","APC"
"Hip flex inner socket ext fr","L5643","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1943.57","","","","","","","fee schedule","1943.57","2000.73","APC"
"Hip flex inner socket ext fr","L5643","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2000.73","","","","","","","fee schedule","1943.57","2000.73","APC"
"Above knee wood socket","L5644","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","757.44","","","","","","","fee schedule","737.55","759.24","APC"
"Above knee wood socket","L5644","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","744.78","","","","","","","fee schedule","737.55","759.24","APC"
"Above knee wood socket","L5644","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","737.55","","","","","","","fee schedule","737.55","759.24","APC"
"Above knee wood socket","L5644","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","759.24","","","","","","","fee schedule","737.55","759.24","APC"
"Bk flex inner socket ext fra","L5645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1023.21","","","","","","","fee schedule","996.35","1025.65","APC"
"Bk flex inner socket ext fra","L5645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1006.11","","","","","","","fee schedule","996.35","1025.65","APC"
"Bk flex inner socket ext fra","L5645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","996.35","","","","","","","fee schedule","996.35","1025.65","APC"
"Bk flex inner socket ext fra","L5645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1025.65","","","","","","","fee schedule","996.35","1025.65","APC"
"Below knee cushion socket","L5646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","702.63","","","","","","","fee schedule","684.19","704.31","APC"
"Below knee cushion socket","L5646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","690.89","","","","","","","fee schedule","684.19","704.31","APC"
"Below knee cushion socket","L5646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","684.19","","","","","","","fee schedule","684.19","704.31","APC"
"Below knee cushion socket","L5646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","704.31","","","","","","","fee schedule","684.19","704.31","APC"
"Below knee suction socket","L5647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1020.1","","","","","","","fee schedule","993.32","1022.53","APC"
"Below knee suction socket","L5647","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1003.06","","","","","","","fee schedule","993.32","1022.53","APC"
"Below knee suction socket","L5647","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","993.32","","","","","","","fee schedule","993.32","1022.53","APC"
"Below knee suction socket","L5647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1022.53","","","","","","","fee schedule","993.32","1022.53","APC"
"Above knee cushion socket","L5648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","844.3","","","","","","","fee schedule","822.13","846.31","APC"
"Above knee cushion socket","L5648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","830.19","","","","","","","fee schedule","822.13","846.31","APC"
"Above knee cushion socket","L5648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","822.13","","","","","","","fee schedule","822.13","846.31","APC"
"Above knee cushion socket","L5648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","846.31","","","","","","","fee schedule","822.13","846.31","APC"
"Isch containmt/narrow m-l so","L5649","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2563.18","","","","","","","fee schedule","2495.89","2569.3","APC"
"Isch containmt/narrow m-l so","L5649","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2520.36","","","","","","","fee schedule","2495.89","2569.3","APC"
"Isch containmt/narrow m-l so","L5649","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2495.89","","","","","","","fee schedule","2495.89","2569.3","APC"
"Isch containmt/narrow m-l so","L5649","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2569.3","","","","","","","fee schedule","2495.89","2569.3","APC"
"Tot contact ak/knee disart s","L5650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","626.05","","","","","","","fee schedule","609.61","627.54","APC"
"Tot contact ak/knee disart s","L5650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","615.59","","","","","","","fee schedule","609.61","627.54","APC"
"Tot contact ak/knee disart s","L5650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","609.61","","","","","","","fee schedule","609.61","627.54","APC"
"Tot contact ak/knee disart s","L5650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","627.54","","","","","","","fee schedule","609.61","627.54","APC"
"Ak flex inner socket ext fra","L5651","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1540.06","","","","","","","fee schedule","1499.62","1543.73","APC"
"Ak flex inner socket ext fra","L5651","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1514.33","","","","","","","fee schedule","1499.62","1543.73","APC"
"Ak flex inner socket ext fra","L5651","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1499.62","","","","","","","fee schedule","1499.62","1543.73","APC"
"Ak flex inner socket ext fra","L5651","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1543.73","","","","","","","fee schedule","1499.62","1543.73","APC"
"Suction susp ak/knee disart","L5652","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","559.1","","","","","","","fee schedule","544.42","560.44","APC"
"Suction susp ak/knee disart","L5652","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549.76","","","","","","","fee schedule","544.42","560.44","APC"
"Suction susp ak/knee disart","L5652","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","544.42","","","","","","","fee schedule","544.42","560.44","APC"
"Suction susp ak/knee disart","L5652","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","560.44","","","","","","","fee schedule","544.42","560.44","APC"
"Knee disart expand wall sock","L5653","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","746.35","","","","","","","fee schedule","726.76","748.14","APC"
"Knee disart expand wall sock","L5653","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","733.89","","","","","","","fee schedule","726.76","748.14","APC"
"Knee disart expand wall sock","L5653","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","726.76","","","","","","","fee schedule","726.76","748.14","APC"
"Knee disart expand wall sock","L5653","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","748.14","","","","","","","fee schedule","726.76","748.14","APC"
"Socket insert symes","L5654","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","425.31","","","","","","","fee schedule","414.14","426.32","APC"
"Socket insert symes","L5654","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","418.2","","","","","","","fee schedule","414.14","426.32","APC"
"Socket insert symes","L5654","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","414.14","","","","","","","fee schedule","414.14","426.32","APC"
"Socket insert symes","L5654","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","426.32","","","","","","","fee schedule","414.14","426.32","APC"
"Socket insert below knee","L5655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","360.09","","","","","","","fee schedule","350.64","360.95","APC"
"Socket insert below knee","L5655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","354.07","","","","","","","fee schedule","350.64","360.95","APC"
"Socket insert below knee","L5655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","350.64","","","","","","","fee schedule","350.64","360.95","APC"
"Socket insert below knee","L5655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","360.95","","","","","","","fee schedule","350.64","360.95","APC"
"Socket insert knee articulat","L5656","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","507.26","","","","","","","fee schedule","493.95","508.47","APC"
"Socket insert knee articulat","L5656","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","498.79","","","","","","","fee schedule","493.95","508.47","APC"
"Socket insert knee articulat","L5656","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","493.95","","","","","","","fee schedule","493.95","508.47","APC"
"Socket insert knee articulat","L5656","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","508.47","","","","","","","fee schedule","493.95","508.47","APC"
"Socket insert above knee","L5658","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","494","","","","","","","fee schedule","481.03","495.18","APC"
"Socket insert above knee","L5658","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","485.75","","","","","","","fee schedule","481.03","495.18","APC"
"Socket insert above knee","L5658","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","481.03","","","","","","","fee schedule","481.03","495.18","APC"
"Socket insert above knee","L5658","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","495.18","","","","","","","fee schedule","481.03","495.18","APC"
"Multi-durometer symes","L5661","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","858.46","","","","","","","fee schedule","835.92","860.51","APC"
"Multi-durometer symes","L5661","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","844.12","","","","","","","fee schedule","835.92","860.51","APC"
"Multi-durometer symes","L5661","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","835.92","","","","","","","fee schedule","835.92","860.51","APC"
"Multi-durometer symes","L5661","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","860.51","","","","","","","fee schedule","835.92","860.51","APC"
"Multi-durometer below knee","L5665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","656.61","","","","","","","fee schedule","639.38","658.18","APC"
"Multi-durometer below knee","L5665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","645.65","","","","","","","fee schedule","639.38","658.18","APC"
"Multi-durometer below knee","L5665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","639.38","","","","","","","fee schedule","639.38","658.18","APC"
"Multi-durometer below knee","L5665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","658.18","","","","","","","fee schedule","639.38","658.18","APC"
"Below knee cuff suspension","L5666","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","97.57","","","","","","","fee schedule","95.01","97.81","APC"
"Below knee cuff suspension","L5666","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","95.94","","","","","","","fee schedule","95.01","97.81","APC"
"Below knee cuff suspension","L5666","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","95.01","","","","","","","fee schedule","95.01","97.81","APC"
"Below knee cuff suspension","L5666","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","97.81","","","","","","","fee schedule","95.01","97.81","APC"
"Bk molded distal cushion","L5668","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","130.28","","","","","","","fee schedule","126.86","130.59","APC"
"Bk molded distal cushion","L5668","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","128.1","","","","","","","fee schedule","126.86","130.59","APC"
"Bk molded distal cushion","L5668","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","126.86","","","","","","","fee schedule","126.86","130.59","APC"
"Bk molded distal cushion","L5668","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","130.59","","","","","","","fee schedule","126.86","130.59","APC"
"Bk molded supracondylar susp","L5670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","396.59","","","","","","","fee schedule","386.18","397.54","APC"
"Bk molded supracondylar susp","L5670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","389.97","","","","","","","fee schedule","386.18","397.54","APC"
"Bk molded supracondylar susp","L5670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","386.18","","","","","","","fee schedule","386.18","397.54","APC"
"Bk molded supracondylar susp","L5670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","397.54","","","","","","","fee schedule","386.18","397.54","APC"
"Bk/ak locking mechanism","L5671","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.89","","","","","","","fee schedule","621.14","639.41","APC"
"Bk/ak locking mechanism","L5671","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","627.23","","","","","","","fee schedule","621.14","639.41","APC"
"Bk/ak locking mechanism","L5671","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","621.14","","","","","","","fee schedule","621.14","639.41","APC"
"Bk/ak locking mechanism","L5671","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","639.41","","","","","","","fee schedule","621.14","639.41","APC"
"Bk removable medial brim sus","L5672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","484.57","","","","","","","fee schedule","471.85","485.73","APC"
"Bk removable medial brim sus","L5672","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","476.48","","","","","","","fee schedule","471.85","485.73","APC"
"Bk removable medial brim sus","L5672","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","471.85","","","","","","","fee schedule","471.85","485.73","APC"
"Bk removable medial brim sus","L5672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","485.73","","","","","","","fee schedule","471.85","485.73","APC"
"Socket insert w lock mech","L5673","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","900.95","","","","","","","fee schedule","877.3","903.1","APC"
"Socket insert w lock mech","L5673","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","885.9","","","","","","","fee schedule","877.3","903.1","APC"
"Socket insert w lock mech","L5673","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","877.3","","","","","","","fee schedule","877.3","903.1","APC"
"Socket insert w lock mech","L5673","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","903.1","","","","","","","fee schedule","877.3","903.1","APC"
"Bk knee joints single axis p","L5676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","464.7","","","","","","","fee schedule","452.5","465.81","APC"
"Bk knee joints single axis p","L5676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","456.94","","","","","","","fee schedule","452.5","465.81","APC"
"Bk knee joints single axis p","L5676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","452.5","","","","","","","fee schedule","452.5","465.81","APC"
"Bk knee joints single axis p","L5676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","465.81","","","","","","","fee schedule","452.5","465.81","APC"
"Bk knee joints polycentric p","L5677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","632.29","","","","","","","fee schedule","615.69","633.8","APC"
"Bk knee joints polycentric p","L5677","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","621.73","","","","","","","fee schedule","615.69","633.8","APC"
"Bk knee joints polycentric p","L5677","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","615.69","","","","","","","fee schedule","615.69","633.8","APC"
"Bk knee joints polycentric p","L5677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","633.8","","","","","","","fee schedule","615.69","633.8","APC"
"Bk joint covers pair","L5678","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50.92","","","","","","","fee schedule","49.58","51.04","APC"
"Bk joint covers pair","L5678","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","50.07","","","","","","","fee schedule","49.58","51.04","APC"
"Bk joint covers pair","L5678","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49.58","","","","","","","fee schedule","49.58","51.04","APC"
"Bk joint covers pair","L5678","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51.04","","","","","","","fee schedule","49.58","51.04","APC"
"Socket insert w/o lock mech","L5679","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","750.79","","","","","","","fee schedule","731.07","752.58","APC"
"Socket insert w/o lock mech","L5679","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","738.24","","","","","","","fee schedule","731.07","752.58","APC"
"Socket insert w/o lock mech","L5679","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","731.07","","","","","","","fee schedule","731.07","752.58","APC"
"Socket insert w/o lock mech","L5679","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","752.58","","","","","","","fee schedule","731.07","752.58","APC"
"Bk thigh lacer non-molded","L5680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","444.14","","","","","","","fee schedule","432.48","445.2","APC"
"Bk thigh lacer non-molded","L5680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","436.72","","","","","","","fee schedule","432.48","445.2","APC"
"Bk thigh lacer non-molded","L5680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","432.48","","","","","","","fee schedule","432.48","445.2","APC"
"Bk thigh lacer non-molded","L5680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","445.2","","","","","","","fee schedule","432.48","445.2","APC"
"Intl custm cong/latyp insert","L5681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1655.99","","","","","","","fee schedule","1612.52","1659.94","APC"
"Intl custm cong/latyp insert","L5681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1628.33","","","","","","","fee schedule","1612.52","1659.94","APC"
"Intl custm cong/latyp insert","L5681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1612.52","","","","","","","fee schedule","1612.52","1659.94","APC"
"Intl custm cong/latyp insert","L5681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1659.95","","","","","","","fee schedule","1612.52","1659.94","APC"
"Bk thigh lacer glut/ischia m","L5682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","802","","","","","","","fee schedule","780.94","803.91","APC"
"Bk thigh lacer glut/ischia m","L5682","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","788.6","","","","","","","fee schedule","780.94","803.91","APC"
"Bk thigh lacer glut/ischia m","L5682","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","780.94","","","","","","","fee schedule","780.94","803.91","APC"
"Bk thigh lacer glut/ischia m","L5682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","803.91","","","","","","","fee schedule","780.94","803.91","APC"
"Initial custom socket insert","L5683","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1655.99","","","","","","","fee schedule","1612.52","1659.94","APC"
"Initial custom socket insert","L5683","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1628.33","","","","","","","fee schedule","1612.52","1659.94","APC"
"Initial custom socket insert","L5683","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1612.52","","","","","","","fee schedule","1612.52","1659.94","APC"
"Initial custom socket insert","L5683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1659.95","","","","","","","fee schedule","1612.52","1659.94","APC"
"Bk fork strap","L5684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","61.73","","","","","","","fee schedule","60.11","61.88","APC"
"Bk fork strap","L5684","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","60.7","","","","","","","fee schedule","60.11","61.88","APC"
"Bk fork strap","L5684","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","60.11","","","","","","","fee schedule","60.11","61.88","APC"
"Bk fork strap","L5684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","61.88","","","","","","","fee schedule","60.11","61.88","APC"
"Below knee sus/seal sleeve","L5685","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","161.25","","","","","","","fee schedule","157.02","161.64","APC"
"Below knee sus/seal sleeve","L5685","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","158.56","","","","","","","fee schedule","157.02","161.64","APC"
"Below knee sus/seal sleeve","L5685","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","157.02","","","","","","","fee schedule","157.02","161.64","APC"
"Below knee sus/seal sleeve","L5685","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","161.64","","","","","","","fee schedule","157.02","161.64","APC"
"Bk back check","L5686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","83.26","","","","","","","fee schedule","81.07","83.45","APC"
"Bk back check","L5686","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","81.86","","","","","","","fee schedule","81.07","83.45","APC"
"Bk back check","L5686","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","81.07","","","","","","","fee schedule","81.07","83.45","APC"
"Bk back check","L5686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83.45","","","","","","","fee schedule","81.07","83.45","APC"
"Bk waist belt webbing","L5688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78.33","","","","","","","fee schedule","76.28","78.52","APC"
"Bk waist belt webbing","L5688","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","77.02","","","","","","","fee schedule","76.28","78.52","APC"
"Bk waist belt webbing","L5688","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76.28","","","","","","","fee schedule","76.28","78.52","APC"
"Bk waist belt webbing","L5688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","78.52","","","","","","","fee schedule","76.28","78.52","APC"
"Bk waist belt padded and lin","L5690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","151.68","","","","","","","fee schedule","147.7","152.04","APC"
"Bk waist belt padded and lin","L5690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","149.14","","","","","","","fee schedule","147.7","152.04","APC"
"Bk waist belt padded and lin","L5690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","147.7","","","","","","","fee schedule","147.7","152.04","APC"
"Bk waist belt padded and lin","L5690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","152.04","","","","","","","fee schedule","147.7","152.04","APC"
"Ak pelvic control belt light","L5692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","176.05","","","","","","","fee schedule","171.43","176.47","APC"
"Ak pelvic control belt light","L5692","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","173.11","","","","","","","fee schedule","171.43","176.47","APC"
"Ak pelvic control belt light","L5692","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","171.43","","","","","","","fee schedule","171.43","176.47","APC"
"Ak pelvic control belt light","L5692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","176.47","","","","","","","fee schedule","171.43","176.47","APC"
"Ak pelvic control belt pad/l","L5694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","232.65","","","","","","","fee schedule","226.54","233.2","APC"
"Ak pelvic control belt pad/l","L5694","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","228.76","","","","","","","fee schedule","226.54","233.2","APC"
"Ak pelvic control belt pad/l","L5694","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","226.54","","","","","","","fee schedule","226.54","233.2","APC"
"Ak pelvic control belt pad/l","L5694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","233.2","","","","","","","fee schedule","226.54","233.2","APC"
"Ak sleeve susp neoprene/equa","L5695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","244.05","","","","","","","fee schedule","237.64","244.63","APC"
"Ak sleeve susp neoprene/equa","L5695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","239.97","","","","","","","fee schedule","237.64","244.63","APC"
"Ak sleeve susp neoprene/equa","L5695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","237.64","","","","","","","fee schedule","237.64","244.63","APC"
"Ak sleeve susp neoprene/equa","L5695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","244.63","","","","","","","fee schedule","237.64","244.63","APC"
"Ak/knee disartic pelvic join","L5696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","266.71","","","","","","","fee schedule","259.71","267.35","APC"
"Ak/knee disartic pelvic join","L5696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","262.26","","","","","","","fee schedule","259.71","267.35","APC"
"Ak/knee disartic pelvic join","L5696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","259.71","","","","","","","fee schedule","259.71","267.35","APC"
"Ak/knee disartic pelvic join","L5696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","267.35","","","","","","","fee schedule","259.71","267.35","APC"
"Ak/knee disartic pelvic band","L5697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","108.34","","","","","","","fee schedule","105.5","108.6","APC"
"Ak/knee disartic pelvic band","L5697","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.53","","","","","","","fee schedule","105.5","108.6","APC"
"Ak/knee disartic pelvic band","L5697","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","105.5","","","","","","","fee schedule","105.5","108.6","APC"
"Ak/knee disartic pelvic band","L5697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.6","","","","","","","fee schedule","105.5","108.6","APC"
"Ak/knee disartic silesian ba","L5698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","134.75","","","","","","","fee schedule","131.21","135.07","APC"
"Ak/knee disartic silesian ba","L5698","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","132.5","","","","","","","fee schedule","131.21","135.07","APC"
"Ak/knee disartic silesian ba","L5698","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","131.21","","","","","","","fee schedule","131.21","135.07","APC"
"Ak/knee disartic silesian ba","L5698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","135.07","","","","","","","fee schedule","131.21","135.07","APC"
"Shoulder harness","L5699","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","239.1","","","","","","","fee schedule","232.83","239.67","APC"
"Shoulder harness","L5699","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","235.11","","","","","","","fee schedule","232.83","239.67","APC"
"Shoulder harness","L5699","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","232.83","","","","","","","fee schedule","232.83","239.67","APC"
"Shoulder harness","L5699","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","239.67","","","","","","","fee schedule","232.83","239.67","APC"
"Replace socket below knee","L5700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3694.49","","","","","","","fee schedule","3597.5","3703.31","APC"
"Replace socket below knee","L5700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3632.77","","","","","","","fee schedule","3597.5","3703.31","APC"
"Replace socket below knee","L5700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3597.5","","","","","","","fee schedule","3597.5","3703.31","APC"
"Replace socket below knee","L5700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3703.31","","","","","","","fee schedule","3597.5","3703.31","APC"
"Replace socket above knee","L5701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4583.35","","","","","","","fee schedule","4463.02","4594.29","APC"
"Replace socket above knee","L5701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4506.78","","","","","","","fee schedule","4463.02","4594.29","APC"
"Replace socket above knee","L5701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4463.02","","","","","","","fee schedule","4463.02","4594.29","APC"
"Replace socket above knee","L5701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4594.29","","","","","","","fee schedule","4463.02","4594.29","APC"
"Replace socket hip","L5702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5776.64","","","","","","","fee schedule","5624.98","5790.42","APC"
"Replace socket hip","L5702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5680.13","","","","","","","fee schedule","5624.98","5790.42","APC"
"Replace socket hip","L5702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5624.98","","","","","","","fee schedule","5624.98","5790.42","APC"
"Replace socket hip","L5702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5790.42","","","","","","","fee schedule","5624.98","5790.42","APC"
"Symes ankle w/o (sach) foot","L5703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2682.61","","","","","","","fee schedule","2612.18","2689.01","APC"
"Symes ankle w/o (sach) foot","L5703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2637.79","","","","","","","fee schedule","2612.18","2689.01","APC"
"Symes ankle w/o (sach) foot","L5703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2612.18","","","","","","","fee schedule","2612.18","2689.01","APC"
"Symes ankle w/o (sach) foot","L5703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2689.01","","","","","","","fee schedule","2612.18","2689.01","APC"
"Custom shape cover bk","L5704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","753.29","","","","","","","fee schedule","733.51","755.09","APC"
"Custom shape cover bk","L5704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","740.7","","","","","","","fee schedule","733.51","755.09","APC"
"Custom shape cover bk","L5704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","733.51","","","","","","","fee schedule","733.51","755.09","APC"
"Custom shape cover bk","L5704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","755.09","","","","","","","fee schedule","733.51","755.09","APC"
"Custom shape cover ak","L5705","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1381.09","","","","","","","fee schedule","1344.83","1384.38","APC"
"Custom shape cover ak","L5705","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1358.01","","","","","","","fee schedule","1344.83","1384.38","APC"
"Custom shape cover ak","L5705","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1344.83","","","","","","","fee schedule","1344.83","1384.38","APC"
"Custom shape cover ak","L5705","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1384.38","","","","","","","fee schedule","1344.83","1384.38","APC"
"Custom shape cvr knee disart","L5706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1347.07","","","","","","","fee schedule","1311.71","1350.29","APC"
"Custom shape cvr knee disart","L5706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1324.57","","","","","","","fee schedule","1311.71","1350.29","APC"
"Custom shape cvr knee disart","L5706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1311.71","","","","","","","fee schedule","1311.71","1350.29","APC"
"Custom shape cvr knee disart","L5706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1350.29","","","","","","","fee schedule","1311.71","1350.29","APC"
"Custom shape cvr hip disart","L5707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1809.78","","","","","","","fee schedule","1762.26","1814.1","APC"
"Custom shape cvr hip disart","L5707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1779.54","","","","","","","fee schedule","1762.26","1814.1","APC"
"Custom shape cvr hip disart","L5707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1762.26","","","","","","","fee schedule","1762.26","1814.1","APC"
"Custom shape cvr hip disart","L5707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1814.1","","","","","","","fee schedule","1762.26","1814.1","APC"
"Kne-shin exo sng axi mnl loc","L5710","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","461.22","","","","","","","fee schedule","449.12","462.33","APC"
"Kne-shin exo sng axi mnl loc","L5710","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","453.52","","","","","","","fee schedule","449.12","462.33","APC"
"Kne-shin exo sng axi mnl loc","L5710","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","449.12","","","","","","","fee schedule","449.12","462.33","APC"
"Kne-shin exo sng axi mnl loc","L5710","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","462.33","","","","","","","fee schedule","449.12","462.33","APC"
"Knee-shin exo mnl lock ultra","L5711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","699.68","","","","","","","fee schedule","681.31","701.35","APC"
"Knee-shin exo mnl lock ultra","L5711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","687.99","","","","","","","fee schedule","681.31","701.35","APC"
"Knee-shin exo mnl lock ultra","L5711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","681.31","","","","","","","fee schedule","681.31","701.35","APC"
"Knee-shin exo mnl lock ultra","L5711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","701.35","","","","","","","fee schedule","681.31","701.35","APC"
"Knee-shin exo frict swg & st","L5712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","552.58","","","","","","","fee schedule","538.07","553.9","APC"
"Knee-shin exo frict swg & st","L5712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","543.35","","","","","","","fee schedule","538.07","553.9","APC"
"Knee-shin exo frict swg & st","L5712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","538.07","","","","","","","fee schedule","538.07","553.9","APC"
"Knee-shin exo frict swg & st","L5712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","553.9","","","","","","","fee schedule","538.07","553.9","APC"
"Knee-shin exo variable frict","L5714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","569.85","","","","","","","fee schedule","554.89","571.21","APC"
"Knee-shin exo variable frict","L5714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","560.33","","","","","","","fee schedule","554.89","571.21","APC"
"Knee-shin exo variable frict","L5714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","554.89","","","","","","","fee schedule","554.89","571.21","APC"
"Knee-shin exo variable frict","L5714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","571.21","","","","","","","fee schedule","554.89","571.21","APC"
"Knee-shin exo mech stance ph","L5716","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","934.66","","","","","","","fee schedule","910.13","936.89","APC"
"Knee-shin exo mech stance ph","L5716","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","919.05","","","","","","","fee schedule","910.13","936.89","APC"
"Knee-shin exo mech stance ph","L5716","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","910.13","","","","","","","fee schedule","910.13","936.89","APC"
"Knee-shin exo mech stance ph","L5716","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","936.89","","","","","","","fee schedule","910.13","936.89","APC"
"Knee-shin exo frct swg & sta","L5718","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1168.23","","","","","","","fee schedule","1137.57","1171.02","APC"
"Knee-shin exo frct swg & sta","L5718","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1148.72","","","","","","","fee schedule","1137.57","1171.02","APC"
"Knee-shin exo frct swg & sta","L5718","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1137.57","","","","","","","fee schedule","1137.57","1171.02","APC"
"Knee-shin exo frct swg & sta","L5718","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1171.02","","","","","","","fee schedule","1137.57","1171.02","APC"
"Knee-shin pneum swg frct exo","L5722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1219.09","","","","","","","fee schedule","1187.09","1222","APC"
"Knee-shin pneum swg frct exo","L5722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1198.72","","","","","","","fee schedule","1187.09","1222","APC"
"Knee-shin pneum swg frct exo","L5722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1187.09","","","","","","","fee schedule","1187.09","1222","APC"
"Knee-shin pneum swg frct exo","L5722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1222","","","","","","","fee schedule","1187.09","1222","APC"
"Knee-shin exo fluid swing ph","L5724","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1935.68","","","","","","","fee schedule","1884.86","1940.3","APC"
"Knee-shin exo fluid swing ph","L5724","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1903.34","","","","","","","fee schedule","1884.86","1940.3","APC"
"Knee-shin exo fluid swing ph","L5724","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1884.86","","","","","","","fee schedule","1884.86","1940.3","APC"
"Knee-shin exo fluid swing ph","L5724","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1940.3","","","","","","","fee schedule","1884.86","1940.3","APC"
"Knee-shin ext jnts fld swg e","L5726","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2541.75","","","","","","","fee schedule","2475.02","2547.81","APC"
"Knee-shin ext jnts fld swg e","L5726","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2499.28","","","","","","","fee schedule","2475.02","2547.81","APC"
"Knee-shin ext jnts fld swg e","L5726","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2475.02","","","","","","","fee schedule","2475.02","2547.81","APC"
"Knee-shin ext jnts fld swg e","L5726","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2547.81","","","","","","","fee schedule","2475.02","2547.81","APC"
"Knee-shin fluid swg & stance","L5728","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3166.68","","","","","","","fee schedule","3083.54","3174.23","APC"
"Knee-shin fluid swg & stance","L5728","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3113.77","","","","","","","fee schedule","3083.54","3174.23","APC"
"Knee-shin fluid swg & stance","L5728","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3083.54","","","","","","","fee schedule","3083.54","3174.23","APC"
"Knee-shin fluid swg & stance","L5728","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3174.23","","","","","","","fee schedule","3083.54","3174.23","APC"
"Knee-shin pneum/hydra pneum","L5780","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1526.82","","","","","","","fee schedule","1486.73","1530.46","APC"
"Knee-shin pneum/hydra pneum","L5780","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1501.31","","","","","","","fee schedule","1486.73","1530.46","APC"
"Knee-shin pneum/hydra pneum","L5780","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1486.73","","","","","","","fee schedule","1486.73","1530.46","APC"
"Knee-shin pneum/hydra pneum","L5780","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1530.46","","","","","","","fee schedule","1486.73","1530.46","APC"
"Lower limb pros vacuum pump","L5781","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5037.19","","","","","","","fee schedule","4904.95","5049.21","APC"
"Lower limb pros vacuum pump","L5781","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4953.03","","","","","","","fee schedule","4904.95","5049.21","APC"
"Lower limb pros vacuum pump","L5781","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4904.95","","","","","","","fee schedule","4904.95","5049.21","APC"
"Lower limb pros vacuum pump","L5781","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5049.21","","","","","","","fee schedule","4904.95","5049.21","APC"
"HD low limb pros vacuum pump","L5782","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5310.32","","","","","","","fee schedule","5170.91","5323","APC"
"HD low limb pros vacuum pump","L5782","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5221.61","","","","","","","fee schedule","5170.91","5323","APC"
"HD low limb pros vacuum pump","L5782","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5170.91","","","","","","","fee schedule","5170.91","5323","APC"
"HD low limb pros vacuum pump","L5782","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5323","","","","","","","fee schedule","5170.91","5323","APC"
"Add low ext mec limb vol sys","L5783","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3299.7","","","","","","","fee schedule","3213.07","3307.57","APC"
"Add low ext mec limb vol sys","L5783","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3244.57","","","","","","","fee schedule","3213.07","3307.57","APC"
"Add low ext mec limb vol sys","L5783","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3213.07","","","","","","","fee schedule","3213.07","3307.57","APC"
"Add low ext mec limb vol sys","L5783","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3307.57","","","","","","","fee schedule","3213.07","3307.57","APC"
"Exoskeletal bk ultralt mater","L5785","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","666.27","","","","","","","fee schedule","648.78","667.86","APC"
"Exoskeletal bk ultralt mater","L5785","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","655.14","","","","","","","fee schedule","648.78","667.86","APC"
"Exoskeletal bk ultralt mater","L5785","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","648.78","","","","","","","fee schedule","648.78","667.86","APC"
"Exoskeletal bk ultralt mater","L5785","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","667.86","","","","","","","fee schedule","648.78","667.86","APC"
"Exoskeletal ak ultra-light m","L5790","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","922.07","","","","","","","fee schedule","897.87","924.27","APC"
"Exoskeletal ak ultra-light m","L5790","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","906.67","","","","","","","fee schedule","897.87","924.27","APC"
"Exoskeletal ak ultra-light m","L5790","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","897.87","","","","","","","fee schedule","897.87","924.27","APC"
"Exoskeletal ak ultra-light m","L5790","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","924.27","","","","","","","fee schedule","897.87","924.27","APC"
"Exoskel hip ultra-light mate","L5795","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1376.9","","","","","","","fee schedule","1340.75","1380.18","APC"
"Exoskel hip ultra-light mate","L5795","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1353.89","","","","","","","fee schedule","1340.75","1380.18","APC"
"Exoskel hip ultra-light mate","L5795","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1340.75","","","","","","","fee schedule","1340.75","1380.18","APC"
"Exoskel hip ultra-light mate","L5795","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1380.18","","","","","","","fee schedule","1340.75","1380.18","APC"
"Endoskel knee-shin mnl lock","L5810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","640.55","","","","","","","fee schedule","623.73","642.08","APC"
"Endoskel knee-shin mnl lock","L5810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","629.84","","","","","","","fee schedule","623.73","642.08","APC"
"Endoskel knee-shin mnl lock","L5810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","623.73","","","","","","","fee schedule","623.73","642.08","APC"
"Endoskel knee-shin mnl lock","L5810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","642.08","","","","","","","fee schedule","623.73","642.08","APC"
"Endo knee-shin mnl lck ultra","L5811","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","935.27","","","","","","","fee schedule","910.72","937.5","APC"
"Endo knee-shin mnl lck ultra","L5811","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","919.65","","","","","","","fee schedule","910.72","937.5","APC"
"Endo knee-shin mnl lck ultra","L5811","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","910.72","","","","","","","fee schedule","910.72","937.5","APC"
"Endo knee-shin mnl lck ultra","L5811","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","937.5","","","","","","","fee schedule","910.72","937.5","APC"
"Endo knee-shin frct swg & st","L5812","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","724.93","","","","","","","fee schedule","705.9","726.66","APC"
"Endo knee-shin frct swg & st","L5812","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","712.82","","","","","","","fee schedule","705.9","726.66","APC"
"Endo knee-shin frct swg & st","L5812","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","705.9","","","","","","","fee schedule","705.9","726.66","APC"
"Endo knee-shin frct swg & st","L5812","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","726.66","","","","","","","fee schedule","705.9","726.66","APC"
"Endo knee-shin hydral swg ph","L5814","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4675.45","","","","","","","fee schedule","4552.71","4686.61","APC"
"Endo knee-shin hydral swg ph","L5814","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4597.34","","","","","","","fee schedule","4552.71","4686.61","APC"
"Endo knee-shin hydral swg ph","L5814","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4552.71","","","","","","","fee schedule","4552.71","4686.61","APC"
"Endo knee-shin hydral swg ph","L5814","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4686.61","","","","","","","fee schedule","4552.71","4686.61","APC"
"Endo knee-shin polyc mch sta","L5816","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1090.62","","","","","","","fee schedule","1061.98","1093.22","APC"
"Endo knee-shin polyc mch sta","L5816","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1072.39","","","","","","","fee schedule","1061.98","1093.22","APC"
"Endo knee-shin polyc mch sta","L5816","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1061.98","","","","","","","fee schedule","1061.98","1093.22","APC"
"Endo knee-shin polyc mch sta","L5816","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1093.22","","","","","","","fee schedule","1061.98","1093.22","APC"
"Endo knee-shin frct swg & st","L5818","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1231.51","","","","","","","fee schedule","1199.18","1234.45","APC"
"Endo knee-shin frct swg & st","L5818","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1210.94","","","","","","","fee schedule","1199.18","1234.45","APC"
"Endo knee-shin frct swg & st","L5818","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1199.18","","","","","","","fee schedule","1199.18","1234.45","APC"
"Endo knee-shin frct swg & st","L5818","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1234.45","","","","","","","fee schedule","1199.18","1234.45","APC"
"Endo knee-shin pneum swg frc","L5822","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2389.24","","","","","","","fee schedule","2326.52","2394.95","APC"
"Endo knee-shin pneum swg frc","L5822","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2349.33","","","","","","","fee schedule","2326.52","2394.95","APC"
"Endo knee-shin pneum swg frc","L5822","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2326.52","","","","","","","fee schedule","2326.52","2394.95","APC"
"Endo knee-shin pneum swg frc","L5822","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2394.95","","","","","","","fee schedule","2326.52","2394.95","APC"
"Endo knee-shin fluid swing p","L5824","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1966.64","","","","","","","fee schedule","1915.01","1971.33","APC"
"Endo knee-shin fluid swing p","L5824","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1933.78","","","","","","","fee schedule","1915.01","1971.33","APC"
"Endo knee-shin fluid swing p","L5824","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1915.01","","","","","","","fee schedule","1915.01","1971.33","APC"
"Endo knee-shin fluid swing p","L5824","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1971.33","","","","","","","fee schedule","1915.01","1971.33","APC"
"Miniature knee joint","L5826","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3970.82","","","","","","","fee schedule","3866.58","3980.3","APC"
"Miniature knee joint","L5826","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3904.48","","","","","","","fee schedule","3866.58","3980.3","APC"
"Miniature knee joint","L5826","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3866.58","","","","","","","fee schedule","3866.58","3980.3","APC"
"Miniature knee joint","L5826","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3980.3","","","","","","","fee schedule","3866.58","3980.3","APC"
"Endo knee shin single axis","L5827","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7359.05","","","","","","","fee schedule","7165.86","7376.62","APC"
"Endo knee shin single axis","L5827","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7236.11","","","","","","","fee schedule","7165.86","7376.62","APC"
"Endo knee shin single axis","L5827","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7165.86","","","","","","","fee schedule","7165.86","7376.62","APC"
"Endo knee shin single axis","L5827","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7376.62","","","","","","","fee schedule","7165.86","7376.62","APC"
"Endo knee-shin fluid swg/sta","L5828","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3748.81","","","","","","","fee schedule","3650.4","3757.76","APC"
"Endo knee-shin fluid swg/sta","L5828","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3686.18","","","","","","","fee schedule","3650.4","3757.76","APC"
"Endo knee-shin fluid swg/sta","L5828","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3650.4","","","","","","","fee schedule","3650.4","3757.76","APC"
"Endo knee-shin fluid swg/sta","L5828","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3757.76","","","","","","","fee schedule","3650.4","3757.76","APC"
"Endo knee-shin pneum/swg pha","L5830","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2663.71","","","","","","","fee schedule","2593.78","2670.07","APC"
"Endo knee-shin pneum/swg pha","L5830","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2619.21","","","","","","","fee schedule","2593.78","2670.07","APC"
"Endo knee-shin pneum/swg pha","L5830","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2593.78","","","","","","","fee schedule","2593.78","2670.07","APC"
"Endo knee-shin pneum/swg pha","L5830","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2670.07","","","","","","","fee schedule","2593.78","2670.07","APC"
"Multi-axial knee/shin system","L5840","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4697.12","","","","","","","fee schedule","4573.8","4708.33","APC"
"Multi-axial knee/shin system","L5840","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4618.64","","","","","","","fee schedule","4573.8","4708.33","APC"
"Multi-axial knee/shin system","L5840","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4573.8","","","","","","","fee schedule","4573.8","4708.33","APC"
"Multi-axial knee/shin system","L5840","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4708.33","","","","","","","fee schedule","4573.8","4708.33","APC"
"Addition endoskletl knee-shi","L5841","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3198.16","","","","","","","fee schedule","3114.2","3205.8","APC"
"Addition endoskletl knee-shi","L5841","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3144.73","","","","","","","fee schedule","3114.2","3205.8","APC"
"Addition endoskletl knee-shi","L5841","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3114.2","","","","","","","fee schedule","3114.2","3205.8","APC"
"Addition endoskletl knee-shi","L5841","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3205.8","","","","","","","fee schedule","3114.2","3205.8","APC"
"Knee-shin sys stance flexion","L5845","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2256.47","","","","","","","fee schedule","2197.23","2261.86","APC"
"Knee-shin sys stance flexion","L5845","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2218.77","","","","","","","fee schedule","2197.23","2261.86","APC"
"Knee-shin sys stance flexion","L5845","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2197.23","","","","","","","fee schedule","2197.23","2261.86","APC"
"Knee-shin sys stance flexion","L5845","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2261.86","","","","","","","fee schedule","2197.23","2261.86","APC"
"Knee-shin sys hydraul stance","L5848","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1353.77","","","","","","","fee schedule","1318.23","1357","APC"
"Knee-shin sys hydraul stance","L5848","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1331.15","","","","","","","fee schedule","1318.23","1357","APC"
"Knee-shin sys hydraul stance","L5848","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1318.23","","","","","","","fee schedule","1318.23","1357","APC"
"Knee-shin sys hydraul stance","L5848","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1357","","","","","","","fee schedule","1318.23","1357","APC"
"Endo ak/hip knee extens assi","L5850","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","170.32","","","","","","","fee schedule","165.85","170.73","APC"
"Endo ak/hip knee extens assi","L5850","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","167.48","","","","","","","fee schedule","165.85","170.73","APC"
"Endo ak/hip knee extens assi","L5850","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","165.85","","","","","","","fee schedule","165.85","170.73","APC"
"Endo ak/hip knee extens assi","L5850","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","170.73","","","","","","","fee schedule","165.85","170.73","APC"
"Mech hip extension assist","L5855","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","396.05","","","","","","","fee schedule","385.65","396.99","APC"
"Mech hip extension assist","L5855","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","389.43","","","","","","","fee schedule","385.65","396.99","APC"
"Mech hip extension assist","L5855","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","385.65","","","","","","","fee schedule","385.65","396.99","APC"
"Mech hip extension assist","L5855","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","396.99","","","","","","","fee schedule","385.65","396.99","APC"
"Elec knee-shin swing/stance","L5856","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30221.66","","","","","","","fee schedule","29428.25","30293.79","APC"
"Elec knee-shin swing/stance","L5856","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29716.77","","","","","","","fee schedule","29428.25","30293.79","APC"
"Elec knee-shin swing/stance","L5856","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29428.25","","","","","","","fee schedule","29428.25","30293.79","APC"
"Elec knee-shin swing/stance","L5856","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30293.79","","","","","","","fee schedule","29428.25","30293.79","APC"
"Elec knee-shin swing only","L5857","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10723.83","","","","","","","fee schedule","10442.3","10749.43","APC"
"Elec knee-shin swing only","L5857","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10544.68","","","","","","","fee schedule","10442.3","10749.43","APC"
"Elec knee-shin swing only","L5857","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10442.3","","","","","","","fee schedule","10442.3","10749.43","APC"
"Elec knee-shin swing only","L5857","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10749.43","","","","","","","fee schedule","10442.3","10749.43","APC"
"Stance phase only","L5858","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23397.45","","","","","","","fee schedule","22783.2","23453.29","APC"
"Stance phase only","L5858","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23006.56","","","","","","","fee schedule","22783.2","23453.29","APC"
"Stance phase only","L5858","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22783.2","","","","","","","fee schedule","22783.2","23453.29","APC"
"Stance phase only","L5858","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23453.29","","","","","","","fee schedule","22783.2","23453.29","APC"
"Knee-shin pro flex/ext cont","L5859","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18266.2","","","","","","","fee schedule","17786.66","18309.79","APC"
"Knee-shin pro flex/ext cont","L5859","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17961.04","","","","","","","fee schedule","17786.66","18309.79","APC"
"Knee-shin pro flex/ext cont","L5859","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17786.66","","","","","","","fee schedule","17786.66","18309.79","APC"
"Knee-shin pro flex/ext cont","L5859","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18309.8","","","","","","","fee schedule","17786.66","18309.79","APC"
"Endo below knee alignable sy","L5910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","467.75","","","","","","","fee schedule","455.47","468.87","APC"
"Endo below knee alignable sy","L5910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","459.94","","","","","","","fee schedule","455.47","468.87","APC"
"Endo below knee alignable sy","L5910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","455.47","","","","","","","fee schedule","455.47","468.87","APC"
"Endo below knee alignable sy","L5910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","468.87","","","","","","","fee schedule","455.47","468.87","APC"
"Endo ak/hip alignable system","L5920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","680.44","","","","","","","fee schedule","662.57","682.06","APC"
"Endo ak/hip alignable system","L5920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","669.07","","","","","","","fee schedule","662.57","682.06","APC"
"Endo ak/hip alignable system","L5920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","662.57","","","","","","","fee schedule","662.57","682.06","APC"
"Endo ak/hip alignable system","L5920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","682.06","","","","","","","fee schedule","662.57","682.06","APC"
"Above knee manual lock","L5925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","430.9","","","","","","","fee schedule","419.59","431.93","APC"
"Above knee manual lock","L5925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","423.7","","","","","","","fee schedule","419.59","431.93","APC"
"Above knee manual lock","L5925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","419.59","","","","","","","fee schedule","419.59","431.93","APC"
"Above knee manual lock","L5925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","431.93","","","","","","","fee schedule","419.59","431.93","APC"
"Endoskel posit rotat unit","L5926","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","734.78","","","","","","","fee schedule","715.49","736.53","APC"
"Endoskel posit rotat unit","L5926","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","722.5","","","","","","","fee schedule","715.49","736.53","APC"
"Endoskel posit rotat unit","L5926","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","715.49","","","","","","","fee schedule","715.49","736.53","APC"
"Endoskel posit rotat unit","L5926","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","736.53","","","","","","","fee schedule","715.49","736.53","APC"
"High activity knee frame","L5930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4237.46","","","","","","","fee schedule","4126.22","4247.58","APC"
"High activity knee frame","L5930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4166.67","","","","","","","fee schedule","4126.22","4247.58","APC"
"High activity knee frame","L5930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4126.22","","","","","","","fee schedule","4126.22","4247.58","APC"
"High activity knee frame","L5930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4247.58","","","","","","","fee schedule","4126.22","4247.58","APC"
"Endo bk ultra-light material","L5940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","643.27","","","","","","","fee schedule","626.38","644.8","APC"
"Endo bk ultra-light material","L5940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","632.52","","","","","","","fee schedule","626.38","644.8","APC"
"Endo bk ultra-light material","L5940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","626.38","","","","","","","fee schedule","626.38","644.8","APC"
"Endo bk ultra-light material","L5940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","644.81","","","","","","","fee schedule","626.38","644.8","APC"
"Endo ak ultra-light material","L5950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1086.7","","","","","","","fee schedule","1058.17","1089.29","APC"
"Endo ak ultra-light material","L5950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1068.54","","","","","","","fee schedule","1058.17","1089.29","APC"
"Endo ak ultra-light material","L5950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1058.17","","","","","","","fee schedule","1058.17","1089.29","APC"
"Endo ak ultra-light material","L5950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1089.29","","","","","","","fee schedule","1058.17","1089.29","APC"
"Endo hip ultra-light materia","L5960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1301.7","","","","","","","fee schedule","1267.52","1304.8","APC"
"Endo hip ultra-light materia","L5960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1279.95","","","","","","","fee schedule","1267.52","1304.8","APC"
"Endo hip ultra-light materia","L5960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1267.52","","","","","","","fee schedule","1267.52","1304.8","APC"
"Endo hip ultra-light materia","L5960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1304.8","","","","","","","fee schedule","1267.52","1304.8","APC"
"Endo poly hip, pneu/hyd/rot","L5961","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5834.23","","","","","","","fee schedule","5681.06","5848.15","APC"
"Endo poly hip, pneu/hyd/rot","L5961","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5736.76","","","","","","","fee schedule","5681.06","5848.15","APC"
"Endo poly hip, pneu/hyd/rot","L5961","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5681.06","","","","","","","fee schedule","5681.06","5848.15","APC"
"Endo poly hip, pneu/hyd/rot","L5961","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5848.15","","","","","","","fee schedule","5681.06","5848.15","APC"
"Below knee flex cover system","L5962","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","753.78","","","","","","","fee schedule","733.99","755.58","APC"
"Below knee flex cover system","L5962","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","741.19","","","","","","","fee schedule","733.99","755.58","APC"
"Below knee flex cover system","L5962","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","733.99","","","","","","","fee schedule","733.99","755.58","APC"
"Below knee flex cover system","L5962","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","755.58","","","","","","","fee schedule","733.99","755.58","APC"
"Above knee flex cover system","L5964","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1350.19","","","","","","","fee schedule","1314.74","1353.41","APC"
"Above knee flex cover system","L5964","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1327.63","","","","","","","fee schedule","1314.74","1353.41","APC"
"Above knee flex cover system","L5964","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1314.74","","","","","","","fee schedule","1314.74","1353.41","APC"
"Above knee flex cover system","L5964","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1353.41","","","","","","","fee schedule","1314.74","1353.41","APC"
"Hip flexible cover system","L5966","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1739.26","","","","","","","fee schedule","1693.6","1743.41","APC"
"Hip flexible cover system","L5966","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1710.2","","","","","","","fee schedule","1693.6","1743.41","APC"
"Hip flexible cover system","L5966","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1693.6","","","","","","","fee schedule","1693.6","1743.41","APC"
"Hip flexible cover system","L5966","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1743.41","","","","","","","fee schedule","1693.6","1743.41","APC"
"Multiaxial ankle w dorsiflex","L5968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4574.85","","","","","","","fee schedule","4454.75","4585.77","APC"
"Multiaxial ankle w dorsiflex","L5968","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4498.42","","","","","","","fee schedule","4454.75","4585.77","APC"
"Multiaxial ankle w dorsiflex","L5968","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4454.75","","","","","","","fee schedule","4454.75","4585.77","APC"
"Multiaxial ankle w dorsiflex","L5968","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4585.77","","","","","","","fee schedule","4454.75","4585.77","APC"
"Foot external keel sach foot","L5970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","281.53","","","","","","","fee schedule","274.14","282.2","APC"
"Foot external keel sach foot","L5970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","276.82","","","","","","","fee schedule","274.14","282.2","APC"
"Foot external keel sach foot","L5970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","274.14","","","","","","","fee schedule","274.14","282.2","APC"
"Foot external keel sach foot","L5970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","282.2","","","","","","","fee schedule","274.14","282.2","APC"
"SACH foot, replacement","L5971","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","281.53","","","","","","","fee schedule","274.14","282.2","APC"
"SACH foot, replacement","L5971","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","276.82","","","","","","","fee schedule","274.14","282.2","APC"
"SACH foot, replacement","L5971","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","274.14","","","","","","","fee schedule","274.14","282.2","APC"
"SACH foot, replacement","L5971","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","282.2","","","","","","","fee schedule","274.14","282.2","APC"
"Flexible keel foot","L5972","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","451.95","","","","","","","fee schedule","440.09","453.03","APC"
"Flexible keel foot","L5972","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","444.4","","","","","","","fee schedule","440.09","453.03","APC"
"Flexible keel foot","L5972","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","440.09","","","","","","","fee schedule","440.09","453.03","APC"
"Flexible keel foot","L5972","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","453.03","","","","","","","fee schedule","440.09","453.03","APC"
"Ank-foot sys dors-plant flex","L5973","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22040.45","","","","","","","fee schedule","21461.82","22093.05","APC"
"Ank-foot sys dors-plant flex","L5973","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21672.23","","","","","","","fee schedule","21461.82","22093.05","APC"
"Ank-foot sys dors-plant flex","L5973","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21461.82","","","","","","","fee schedule","21461.82","22093.05","APC"
"Ank-foot sys dors-plant flex","L5973","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22093.05","","","","","","","fee schedule","21461.82","22093.05","APC"
"Foot single axis ankle/foot","L5974","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","381.31","","","","","","","fee schedule","371.3","382.22","APC"
"Foot single axis ankle/foot","L5974","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","374.94","","","","","","","fee schedule","371.3","382.22","APC"
"Foot single axis ankle/foot","L5974","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","371.3","","","","","","","fee schedule","371.3","382.22","APC"
"Foot single axis ankle/foot","L5974","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","382.22","","","","","","","fee schedule","371.3","382.22","APC"
"Combo ankle/foot prosthesis","L5975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","583.61","","","","","","","fee schedule","568.29","585.01","APC"
"Combo ankle/foot prosthesis","L5975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","573.86","","","","","","","fee schedule","568.29","585.01","APC"
"Combo ankle/foot prosthesis","L5975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","568.29","","","","","","","fee schedule","568.29","585.01","APC"
"Combo ankle/foot prosthesis","L5975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","585.01","","","","","","","fee schedule","568.29","585.01","APC"
"Energy storing foot","L5976","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","718.18","","","","","","","fee schedule","699.32","719.89","APC"
"Energy storing foot","L5976","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","706.18","","","","","","","fee schedule","699.32","719.89","APC"
"Energy storing foot","L5976","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","699.32","","","","","","","fee schedule","699.32","719.89","APC"
"Energy storing foot","L5976","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","719.89","","","","","","","fee schedule","699.32","719.89","APC"
"Ft prosth multiaxial ankl/ft","L5978","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","374.24","","","","","","","fee schedule","364.42","375.13","APC"
"Ft prosth multiaxial ankl/ft","L5978","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","367.99","","","","","","","fee schedule","364.42","375.13","APC"
"Ft prosth multiaxial ankl/ft","L5978","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","364.42","","","","","","","fee schedule","364.42","375.13","APC"
"Ft prosth multiaxial ankl/ft","L5978","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","375.13","","","","","","","fee schedule","364.42","375.13","APC"
"Multi-axial ankle/ft prosth","L5979","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3003.04","","","","","","","fee schedule","2924.2","3010.2","APC"
"Multi-axial ankle/ft prosth","L5979","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2952.87","","","","","","","fee schedule","2924.2","3010.2","APC"
"Multi-axial ankle/ft prosth","L5979","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2924.2","","","","","","","fee schedule","2924.2","3010.2","APC"
"Multi-axial ankle/ft prosth","L5979","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3010.2","","","","","","","fee schedule","2924.2","3010.2","APC"
"Flex foot system","L5980","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4754.76","","","","","","","fee schedule","4629.93","4766.11","APC"
"Flex foot system","L5980","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4675.32","","","","","","","fee schedule","4629.93","4766.11","APC"
"Flex foot system","L5980","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4629.93","","","","","","","fee schedule","4629.93","4766.11","APC"
"Flex foot system","L5980","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4766.11","","","","","","","fee schedule","4629.93","4766.11","APC"
"Flex-walk sys low ext prosth","L5981","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4109.86","","","","","","","fee schedule","4001.96","4119.66","APC"
"Flex-walk sys low ext prosth","L5981","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4041.19","","","","","","","fee schedule","4001.96","4119.66","APC"
"Flex-walk sys low ext prosth","L5981","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4001.96","","","","","","","fee schedule","4001.96","4119.66","APC"
"Flex-walk sys low ext prosth","L5981","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4119.66","","","","","","","fee schedule","4001.96","4119.66","APC"
"Exoskeletal axial rotation u","L5982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","741.37","","","","","","","fee schedule","721.9","743.14","APC"
"Exoskeletal axial rotation u","L5982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","728.98","","","","","","","fee schedule","721.9","743.14","APC"
"Exoskeletal axial rotation u","L5982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","721.9","","","","","","","fee schedule","721.9","743.14","APC"
"Exoskeletal axial rotation u","L5982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","743.14","","","","","","","fee schedule","721.9","743.14","APC"
"Endoskeletal axial rotation","L5984","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","734.78","","","","","","","fee schedule","715.49","736.53","APC"
"Endoskeletal axial rotation","L5984","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","722.5","","","","","","","fee schedule","715.49","736.53","APC"
"Endoskeletal axial rotation","L5984","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","715.49","","","","","","","fee schedule","715.49","736.53","APC"
"Endoskeletal axial rotation","L5984","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","736.53","","","","","","","fee schedule","715.49","736.53","APC"
"Lwr ext dynamic prosth pylon","L5985","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","355.51","","","","","","","fee schedule","346.18","356.36","APC"
"Lwr ext dynamic prosth pylon","L5985","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","349.57","","","","","","","fee schedule","346.18","356.36","APC"
"Lwr ext dynamic prosth pylon","L5985","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","346.18","","","","","","","fee schedule","346.18","356.36","APC"
"Lwr ext dynamic prosth pylon","L5985","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","356.36","","","","","","","fee schedule","346.18","356.36","APC"
"Multi-axial rotation unit","L5986","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","816.95","","","","","","","fee schedule","795.5","818.9","APC"
"Multi-axial rotation unit","L5986","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","803.3","","","","","","","fee schedule","795.5","818.9","APC"
"Multi-axial rotation unit","L5986","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","795.5","","","","","","","fee schedule","795.5","818.9","APC"
"Multi-axial rotation unit","L5986","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","818.9","","","","","","","fee schedule","795.5","818.9","APC"
"Shank ft w vert load pylon","L5987","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9056.38","","","","","","","fee schedule","8818.62","9078","APC"
"Shank ft w vert load pylon","L5987","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8905.08","","","","","","","fee schedule","8818.62","9078","APC"
"Shank ft w vert load pylon","L5987","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8818.62","","","","","","","fee schedule","8818.62","9078","APC"
"Shank ft w vert load pylon","L5987","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9078","","","","","","","fee schedule","8818.62","9078","APC"
"Vertical shock reducing pylo","L5988","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2514.98","","","","","","","fee schedule","2448.96","2520.99","APC"
"Vertical shock reducing pylo","L5988","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2472.97","","","","","","","fee schedule","2448.96","2520.99","APC"
"Vertical shock reducing pylo","L5988","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2448.96","","","","","","","fee schedule","2448.96","2520.99","APC"
"Vertical shock reducing pylo","L5988","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2520.99","","","","","","","fee schedule","2448.96","2520.99","APC"
"User adjustable heel height","L5990","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2283.98","","","","","","","fee schedule","2224.02","2289.43","APC"
"User adjustable heel height","L5990","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2245.82","","","","","","","fee schedule","2224.02","2289.43","APC"
"User adjustable heel height","L5990","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2224.02","","","","","","","fee schedule","2224.02","2289.43","APC"
"User adjustable heel height","L5990","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2289.43","","","","","","","fee schedule","2224.02","2289.43","APC"
"Low pros ext osseo connector","L5991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12313.4","","","","","","","fee schedule","11990.14","12342.79","APC"
"Low pros ext osseo connector","L5991","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12107.69","","","","","","","fee schedule","11990.14","12342.79","APC"
"Low pros ext osseo connector","L5991","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11990.14","","","","","","","fee schedule","11990.14","12342.79","APC"
"Low pros ext osseo connector","L5991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12342.79","","","","","","","fee schedule","11990.14","12342.79","APC"
"Part hand thumb rem","L6000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1703.92","","","","","","","fee schedule","1659.18","1707.98","APC"
"Part hand thumb rem","L6000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1675.45","","","","","","","fee schedule","1659.18","1707.98","APC"
"Part hand thumb rem","L6000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1659.18","","","","","","","fee schedule","1659.18","1707.98","APC"
"Part hand thumb rem","L6000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1707.98","","","","","","","fee schedule","1659.18","1707.98","APC"
"Part hand little/ring","L6010","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1896.17","","","","","","","fee schedule","1846.39","1900.7","APC"
"Part hand little/ring","L6010","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1864.5","","","","","","","fee schedule","1846.39","1900.7","APC"
"Part hand little/ring","L6010","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1846.39","","","","","","","fee schedule","1846.39","1900.7","APC"
"Part hand little/ring","L6010","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1900.7","","","","","","","fee schedule","1846.39","1900.7","APC"
"Part hand no fingers","L6020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1767.88","","","","","","","fee schedule","1721.46","1772.1","APC"
"Part hand no fingers","L6020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1738.34","","","","","","","fee schedule","1721.46","1772.1","APC"
"Part hand no fingers","L6020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1721.46","","","","","","","fee schedule","1721.46","1772.1","APC"
"Part hand no fingers","L6020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1772.1","","","","","","","fee schedule","1721.46","1772.1","APC"
"Part hand myo exclu term dev","L6026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5423.13","","","","","","","fee schedule","5280.75","5436.07","APC"
"Part hand myo exclu term dev","L6026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5332.53","","","","","","","fee schedule","5280.75","5436.07","APC"
"Part hand myo exclu term dev","L6026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5280.75","","","","","","","fee schedule","5280.75","5436.07","APC"
"Part hand myo exclu term dev","L6026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5436.07","","","","","","","fee schedule","5280.75","5436.07","APC"
"Wrst MLd sck flx hng tri pad","L6050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2436.07","","","","","","","fee schedule","2372.11","2441.88","APC"
"Wrst MLd sck flx hng tri pad","L6050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2395.37","","","","","","","fee schedule","2372.11","2441.88","APC"
"Wrst MLd sck flx hng tri pad","L6050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2372.11","","","","","","","fee schedule","2372.11","2441.88","APC"
"Wrst MLd sck flx hng tri pad","L6050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2441.88","","","","","","","fee schedule","2372.11","2441.88","APC"
"Wrst mold sock w/exp interfa","L6055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3872.23","","","","","","","fee schedule","3770.57","3881.47","APC"
"Wrst mold sock w/exp interfa","L6055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3807.54","","","","","","","fee schedule","3770.57","3881.47","APC"
"Wrst mold sock w/exp interfa","L6055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3770.57","","","","","","","fee schedule","3770.57","3881.47","APC"
"Wrst mold sock w/exp interfa","L6055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3881.47","","","","","","","fee schedule","3770.57","3881.47","APC"
"Elb mold sock flex hinge pad","L6100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2468.11","","","","","","","fee schedule","2403.31","2474","APC"
"Elb mold sock flex hinge pad","L6100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2426.88","","","","","","","fee schedule","2403.31","2474","APC"
"Elb mold sock flex hinge pad","L6100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2403.31","","","","","","","fee schedule","2403.31","2474","APC"
"Elb mold sock flex hinge pad","L6100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2474","","","","","","","fee schedule","2403.31","2474","APC"
"Elbow mold sock suspension t","L6110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2617.85","","","","","","","fee schedule","2549.12","2624.1","APC"
"Elbow mold sock suspension t","L6110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2574.11","","","","","","","fee schedule","2549.12","2624.1","APC"
"Elbow mold sock suspension t","L6110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2549.12","","","","","","","fee schedule","2549.12","2624.1","APC"
"Elbow mold sock suspension t","L6110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2624.1","","","","","","","fee schedule","2549.12","2624.1","APC"
"Elbow mold doub splt soc ste","L6120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3050.73","","","","","","","fee schedule","2970.64","3058.01","APC"
"Elbow mold doub splt soc ste","L6120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2999.76","","","","","","","fee schedule","2970.64","3058.01","APC"
"Elbow mold doub splt soc ste","L6120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2970.64","","","","","","","fee schedule","2970.64","3058.01","APC"
"Elbow mold doub splt soc ste","L6120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3058.01","","","","","","","fee schedule","2970.64","3058.01","APC"
"Elbow stump activated lock h","L6130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3319.76","","","","","","","fee schedule","3232.6","3327.68","APC"
"Elbow stump activated lock h","L6130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3264.3","","","","","","","fee schedule","3232.6","3327.68","APC"
"Elbow stump activated lock h","L6130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3232.6","","","","","","","fee schedule","3232.6","3327.68","APC"
"Elbow stump activated lock h","L6130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3327.68","","","","","","","fee schedule","3232.6","3327.68","APC"
"Elbow mold outsid lock hinge","L6200","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3498.49","","","","","","","fee schedule","3406.65","3506.84","APC"
"Elbow mold outsid lock hinge","L6200","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3440.05","","","","","","","fee schedule","3406.65","3506.84","APC"
"Elbow mold outsid lock hinge","L6200","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3406.65","","","","","","","fee schedule","3406.65","3506.84","APC"
"Elbow mold outsid lock hinge","L6200","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3506.84","","","","","","","fee schedule","3406.65","3506.84","APC"
"Elbow molded w/ expand inter","L6205","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5829.85","","","","","","","fee schedule","5676.8","5843.76","APC"
"Elbow molded w/ expand inter","L6205","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5732.45","","","","","","","fee schedule","5676.8","5843.76","APC"
"Elbow molded w/ expand inter","L6205","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5676.8","","","","","","","fee schedule","5676.8","5843.76","APC"
"Elbow molded w/ expand inter","L6205","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5843.76","","","","","","","fee schedule","5676.8","5843.76","APC"
"Elbow inter loc elbow forarm","L6250","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3443.68","","","","","","","fee schedule","3353.27","3451.9","APC"
"Elbow inter loc elbow forarm","L6250","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3386.15","","","","","","","fee schedule","3353.27","3451.9","APC"
"Elbow inter loc elbow forarm","L6250","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3353.27","","","","","","","fee schedule","3353.27","3451.9","APC"
"Elbow inter loc elbow forarm","L6250","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3451.9","","","","","","","fee schedule","3353.27","3451.9","APC"
"Shlder disart int lock elbow","L6300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4777.74","","","","","","","fee schedule","4652.31","4789.14","APC"
"Shlder disart int lock elbow","L6300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4697.92","","","","","","","fee schedule","4652.31","4789.14","APC"
"Shlder disart int lock elbow","L6300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4652.31","","","","","","","fee schedule","4652.31","4789.14","APC"
"Shlder disart int lock elbow","L6300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4789.14","","","","","","","fee schedule","4652.31","4789.14","APC"
"Shoulder passive restor comp","L6310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3929.07","","","","","","","fee schedule","3825.92","3938.44","APC"
"Shoulder passive restor comp","L6310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3863.43","","","","","","","fee schedule","3825.92","3938.44","APC"
"Shoulder passive restor comp","L6310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3825.92","","","","","","","fee schedule","3825.92","3938.44","APC"
"Shoulder passive restor comp","L6310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3938.44","","","","","","","fee schedule","3825.92","3938.44","APC"
"Shoulder passive restor cap","L6320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2191.53","","","","","","","fee schedule","2133.99","2196.76","APC"
"Shoulder passive restor cap","L6320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2154.91","","","","","","","fee schedule","2133.99","2196.76","APC"
"Shoulder passive restor cap","L6320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2133.99","","","","","","","fee schedule","2133.99","2196.76","APC"
"Shoulder passive restor cap","L6320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2196.76","","","","","","","fee schedule","2133.99","2196.76","APC"
"Thoracic intern lock elbow","L6350","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5023.07","","","","","","","fee schedule","4891.2","5035.05","APC"
"Thoracic intern lock elbow","L6350","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4939.15","","","","","","","fee schedule","4891.2","5035.05","APC"
"Thoracic intern lock elbow","L6350","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4891.2","","","","","","","fee schedule","4891.2","5035.05","APC"
"Thoracic intern lock elbow","L6350","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5035.05","","","","","","","fee schedule","4891.2","5035.05","APC"
"Thoracic passive restor comp","L6360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4123.66","","","","","","","fee schedule","4015.4","4133.5","APC"
"Thoracic passive restor comp","L6360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4054.77","","","","","","","fee schedule","4015.4","4133.5","APC"
"Thoracic passive restor comp","L6360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4015.4","","","","","","","fee schedule","4015.4","4133.5","APC"
"Thoracic passive restor comp","L6360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4133.5","","","","","","","fee schedule","4015.4","4133.5","APC"
"Thoracic passive restor cap","L6370","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3104.45","","","","","","","fee schedule","3022.95","3111.86","APC"
"Thoracic passive restor cap","L6370","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3052.59","","","","","","","fee schedule","3022.95","3111.86","APC"
"Thoracic passive restor cap","L6370","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3022.95","","","","","","","fee schedule","3022.95","3111.86","APC"
"Thoracic passive restor cap","L6370","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3111.86","","","","","","","fee schedule","3022.95","3111.86","APC"
"Postop dsg cast chg wrst/elb","L6380","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1676.68","","","","","","","fee schedule","1632.66","1680.68","APC"
"Postop dsg cast chg wrst/elb","L6380","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1648.67","","","","","","","fee schedule","1632.66","1680.68","APC"
"Postop dsg cast chg wrst/elb","L6380","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1632.66","","","","","","","fee schedule","1632.66","1680.68","APC"
"Postop dsg cast chg wrst/elb","L6380","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1680.68","","","","","","","fee schedule","1632.66","1680.68","APC"
"Postop dsg cast chg elb dis/","L6382","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2006.38","","","","","","","fee schedule","1953.71","2011.17","APC"
"Postop dsg cast chg elb dis/","L6382","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1972.86","","","","","","","fee schedule","1953.71","2011.17","APC"
"Postop dsg cast chg elb dis/","L6382","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1953.71","","","","","","","fee schedule","1953.71","2011.17","APC"
"Postop dsg cast chg elb dis/","L6382","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2011.17","","","","","","","fee schedule","1953.71","2011.17","APC"
"Postop dsg cast chg shlder/t","L6384","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2448.36","","","","","","","fee schedule","2384.09","2454.21","APC"
"Postop dsg cast chg shlder/t","L6384","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2407.46","","","","","","","fee schedule","2384.09","2454.21","APC"
"Postop dsg cast chg shlder/t","L6384","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2384.09","","","","","","","fee schedule","2384.09","2454.21","APC"
"Postop dsg cast chg shlder/t","L6384","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2454.21","","","","","","","fee schedule","2384.09","2454.21","APC"
"Postop ea cast chg & realign","L6386","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","587.13","","","","","","","fee schedule","571.72","588.54","APC"
"Postop ea cast chg & realign","L6386","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","577.33","","","","","","","fee schedule","571.72","588.54","APC"
"Postop ea cast chg & realign","L6386","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","571.72","","","","","","","fee schedule","571.72","588.54","APC"
"Postop ea cast chg & realign","L6386","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","588.54","","","","","","","fee schedule","571.72","588.54","APC"
"Postop applicat rigid dsg on","L6388","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","563.77","","","","","","","fee schedule","548.97","565.12","APC"
"Postop applicat rigid dsg on","L6388","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","554.36","","","","","","","fee schedule","548.97","565.12","APC"
"Postop applicat rigid dsg on","L6388","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","548.97","","","","","","","fee schedule","548.97","565.12","APC"
"Postop applicat rigid dsg on","L6388","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","565.12","","","","","","","fee schedule","548.97","565.12","APC"
"Below elbow prosth tiss shap","L6400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2981.95","","","","","","","fee schedule","2903.66","2989.07","APC"
"Below elbow prosth tiss shap","L6400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2932.13","","","","","","","fee schedule","2903.66","2989.07","APC"
"Below elbow prosth tiss shap","L6400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2903.66","","","","","","","fee schedule","2903.66","2989.07","APC"
"Below elbow prosth tiss shap","L6400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2989.07","","","","","","","fee schedule","2903.66","2989.07","APC"
"Elb disart prosth tiss shap","L6450","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3953.75","","","","","","","fee schedule","3849.95","3963.18","APC"
"Elb disart prosth tiss shap","L6450","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3887.69","","","","","","","fee schedule","3849.95","3963.18","APC"
"Elb disart prosth tiss shap","L6450","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3849.95","","","","","","","fee schedule","3849.95","3963.18","APC"
"Elb disart prosth tiss shap","L6450","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3963.18","","","","","","","fee schedule","3849.95","3963.18","APC"
"Above elbow prosth tiss shap","L6500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3956.97","","","","","","","fee schedule","3853.09","3966.42","APC"
"Above elbow prosth tiss shap","L6500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3890.87","","","","","","","fee schedule","3853.09","3966.42","APC"
"Above elbow prosth tiss shap","L6500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3853.09","","","","","","","fee schedule","3853.09","3966.42","APC"
"Above elbow prosth tiss shap","L6500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3966.42","","","","","","","fee schedule","3853.09","3966.42","APC"
"Shldr disar prosth tiss shap","L6550","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4890.11","","","","","","","fee schedule","4761.73","4901.78","APC"
"Shldr disar prosth tiss shap","L6550","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4808.41","","","","","","","fee schedule","4761.73","4901.78","APC"
"Shldr disar prosth tiss shap","L6550","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4761.73","","","","","","","fee schedule","4761.73","4901.78","APC"
"Shldr disar prosth tiss shap","L6550","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4901.78","","","","","","","fee schedule","4761.73","4901.78","APC"
"Scap thorac prosth tiss shap","L6570","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5933.38","","","","","","","fee schedule","5777.61","5947.54","APC"
"Scap thorac prosth tiss shap","L6570","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5834.25","","","","","","","fee schedule","5777.61","5947.54","APC"
"Scap thorac prosth tiss shap","L6570","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5777.61","","","","","","","fee schedule","5777.61","5947.54","APC"
"Scap thorac prosth tiss shap","L6570","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5947.54","","","","","","","fee schedule","5777.61","5947.54","APC"
"Wrist/elbow bowden cable mol","L6580","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2071.13","","","","","","","fee schedule","2016.75","2076.07","APC"
"Wrist/elbow bowden cable mol","L6580","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2036.53","","","","","","","fee schedule","2016.75","2076.07","APC"
"Wrist/elbow bowden cable mol","L6580","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2016.75","","","","","","","fee schedule","2016.75","2076.07","APC"
"Wrist/elbow bowden cable mol","L6580","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2076.07","","","","","","","fee schedule","2016.75","2076.07","APC"
"Wrist/elbow bowden cbl dir f","L6582","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1764.97","","","","","","","fee schedule","1718.64","1769.19","APC"
"Wrist/elbow bowden cbl dir f","L6582","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1735.49","","","","","","","fee schedule","1718.64","1769.19","APC"
"Wrist/elbow bowden cbl dir f","L6582","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1718.64","","","","","","","fee schedule","1718.64","1769.19","APC"
"Wrist/elbow bowden cbl dir f","L6582","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1769.19","","","","","","","fee schedule","1718.64","1769.19","APC"
"Elbow fair lead cable molded","L6584","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2858.96","","","","","","","fee schedule","2783.91","2865.79","APC"
"Elbow fair lead cable molded","L6584","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2811.2","","","","","","","fee schedule","2783.91","2865.79","APC"
"Elbow fair lead cable molded","L6584","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2783.91","","","","","","","fee schedule","2783.91","2865.79","APC"
"Elbow fair lead cable molded","L6584","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2865.79","","","","","","","fee schedule","2783.91","2865.79","APC"
"Elbow fair lead cable dir fo","L6586","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2500.99","","","","","","","fee schedule","2435.33","2506.96","APC"
"Elbow fair lead cable dir fo","L6586","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2459.21","","","","","","","fee schedule","2435.33","2506.96","APC"
"Elbow fair lead cable dir fo","L6586","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2435.33","","","","","","","fee schedule","2435.33","2506.96","APC"
"Elbow fair lead cable dir fo","L6586","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2506.96","","","","","","","fee schedule","2435.33","2506.96","APC"
"Shdr fair lead cable molded","L6588","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4128.55","","","","","","","fee schedule","4020.17","4138.41","APC"
"Shdr fair lead cable molded","L6588","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4059.58","","","","","","","fee schedule","4020.17","4138.41","APC"
"Shdr fair lead cable molded","L6588","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4020.17","","","","","","","fee schedule","4020.17","4138.41","APC"
"Shdr fair lead cable molded","L6588","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4138.41","","","","","","","fee schedule","4020.17","4138.41","APC"
"Shdr fair lead cable direct","L6590","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3776.47","","","","","","","fee schedule","3677.32","3785.48","APC"
"Shdr fair lead cable direct","L6590","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3713.38","","","","","","","fee schedule","3677.32","3785.48","APC"
"Shdr fair lead cable direct","L6590","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3677.32","","","","","","","fee schedule","3677.32","3785.48","APC"
"Shdr fair lead cable direct","L6590","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3785.48","","","","","","","fee schedule","3677.32","3785.48","APC"
"Polycentric hinge pair","L6600","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","254.81","","","","","","","fee schedule","248.13","255.42","APC"
"Polycentric hinge pair","L6600","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","250.56","","","","","","","fee schedule","248.13","255.42","APC"
"Polycentric hinge pair","L6600","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","248.13","","","","","","","fee schedule","248.13","255.42","APC"
"Polycentric hinge pair","L6600","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","255.42","","","","","","","fee schedule","248.13","255.42","APC"
"Single pivot hinge pair","L6605","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","237.86","","","","","","","fee schedule","231.61","238.42","APC"
"Single pivot hinge pair","L6605","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","233.88","","","","","","","fee schedule","231.61","238.42","APC"
"Single pivot hinge pair","L6605","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","231.61","","","","","","","fee schedule","231.61","238.42","APC"
"Single pivot hinge pair","L6605","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","238.42","","","","","","","fee schedule","231.61","238.42","APC"
"Flexible metal hinge pair","L6610","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","213.51","","","","","","","fee schedule","207.91","214.02","APC"
"Flexible metal hinge pair","L6610","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","209.94","","","","","","","fee schedule","207.91","214.02","APC"
"Flexible metal hinge pair","L6610","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","207.91","","","","","","","fee schedule","207.91","214.02","APC"
"Flexible metal hinge pair","L6610","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","214.02","","","","","","","fee schedule","207.91","214.02","APC"
"Additional switch, ext power","L6611","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","518.36","","","","","","","fee schedule","504.75","519.59","APC"
"Additional switch, ext power","L6611","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","509.7","","","","","","","fee schedule","504.75","519.59","APC"
"Additional switch, ext power","L6611","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","504.75","","","","","","","fee schedule","504.75","519.59","APC"
"Additional switch, ext power","L6611","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","519.59","","","","","","","fee schedule","504.75","519.59","APC"
"Disconnect locking wrist uni","L6615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","263.28","","","","","","","fee schedule","256.37","263.91","APC"
"Disconnect locking wrist uni","L6615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","258.88","","","","","","","fee schedule","256.37","263.91","APC"
"Disconnect locking wrist uni","L6615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","256.37","","","","","","","fee schedule","256.37","263.91","APC"
"Disconnect locking wrist uni","L6615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","263.91","","","","","","","fee schedule","256.37","263.91","APC"
"Disconnect insert locking wr","L6616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","110.91","","","","","","","fee schedule","108","111.17","APC"
"Disconnect insert locking wr","L6616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","109.06","","","","","","","fee schedule","108","111.17","APC"
"Disconnect insert locking wr","L6616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","108","","","","","","","fee schedule","108","111.17","APC"
"Disconnect insert locking wr","L6616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","111.17","","","","","","","fee schedule","108","111.17","APC"
"Flexion/extension wrist unit","L6620","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","413.18","","","","","","","fee schedule","402.33","414.16","APC"
"Flexion/extension wrist unit","L6620","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","406.27","","","","","","","fee schedule","402.33","414.16","APC"
"Flexion/extension wrist unit","L6620","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","402.33","","","","","","","fee schedule","402.33","414.16","APC"
"Flexion/extension wrist unit","L6620","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","414.16","","","","","","","fee schedule","402.33","414.16","APC"
"Flex/ext wrist w/wo friction","L6621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2879.56","","","","","","","fee schedule","2803.96","2886.43","APC"
"Flex/ext wrist w/wo friction","L6621","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2831.45","","","","","","","fee schedule","2803.96","2886.43","APC"
"Flex/ext wrist w/wo friction","L6621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2803.96","","","","","","","fee schedule","2803.96","2886.43","APC"
"Flex/ext wrist w/wo friction","L6621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2886.43","","","","","","","fee schedule","2803.96","2886.43","APC"
"Spring-ass rot wrst w/ latch","L6623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","945.78","","","","","","","fee schedule","920.95","948.03","APC"
"Spring-ass rot wrst w/ latch","L6623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","929.98","","","","","","","fee schedule","920.95","948.03","APC"
"Spring-ass rot wrst w/ latch","L6623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","920.95","","","","","","","fee schedule","920.95","948.03","APC"
"Spring-ass rot wrst w/ latch","L6623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","948.03","","","","","","","fee schedule","920.95","948.03","APC"
"Flex/ext/rotation wrist unit","L6624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4741.27","","","","","","","fee schedule","4616.8","4752.58","APC"
"Flex/ext/rotation wrist unit","L6624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4662.06","","","","","","","fee schedule","4616.8","4752.58","APC"
"Flex/ext/rotation wrist unit","L6624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4616.8","","","","","","","fee schedule","4616.8","4752.58","APC"
"Flex/ext/rotation wrist unit","L6624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4752.58","","","","","","","fee schedule","4616.8","4752.58","APC"
"Rotation wrst w/ cable lock","L6625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","688.22","","","","","","","fee schedule","670.15","689.86","APC"
"Rotation wrst w/ cable lock","L6625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","676.72","","","","","","","fee schedule","670.15","689.86","APC"
"Rotation wrst w/ cable lock","L6625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","670.15","","","","","","","fee schedule","670.15","689.86","APC"
"Rotation wrst w/ cable lock","L6625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","689.86","","","","","","","fee schedule","670.15","689.86","APC"
"Quick disconn hook adapter o","L6628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","703.31","","","","","","","fee schedule","684.85","704.99","APC"
"Quick disconn hook adapter o","L6628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","691.56","","","","","","","fee schedule","684.85","704.99","APC"
"Quick disconn hook adapter o","L6628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","684.85","","","","","","","fee schedule","684.85","704.99","APC"
"Quick disconn hook adapter o","L6628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","704.99","","","","","","","fee schedule","684.85","704.99","APC"
"Lamination collar w/ couplin","L6629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","187.62","","","","","","","fee schedule","182.69","188.07","APC"
"Lamination collar w/ couplin","L6629","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","184.48","","","","","","","fee schedule","182.69","188.07","APC"
"Lamination collar w/ couplin","L6629","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","182.69","","","","","","","fee schedule","182.69","188.07","APC"
"Lamination collar w/ couplin","L6629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","188.07","","","","","","","fee schedule","182.69","188.07","APC"
"Stainless steel any wrist","L6630","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","276.38","","","","","","","fee schedule","269.13","277.04","APC"
"Stainless steel any wrist","L6630","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","271.77","","","","","","","fee schedule","269.13","277.04","APC"
"Stainless steel any wrist","L6630","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","269.13","","","","","","","fee schedule","269.13","277.04","APC"
"Stainless steel any wrist","L6630","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","277.04","","","","","","","fee schedule","269.13","277.04","APC"
"Latex suspension sleeve each","L6632","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","92.19","","","","","","","fee schedule","89.77","92.41","APC"
"Latex suspension sleeve each","L6632","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","90.65","","","","","","","fee schedule","89.77","92.41","APC"
"Latex suspension sleeve each","L6632","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","89.77","","","","","","","fee schedule","89.77","92.41","APC"
"Latex suspension sleeve each","L6632","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","92.41","","","","","","","fee schedule","89.77","92.41","APC"
"Lift assist for elbow","L6635","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","256","","","","","","","fee schedule","249.28","256.61","APC"
"Lift assist for elbow","L6635","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","251.72","","","","","","","fee schedule","249.28","256.61","APC"
"Lift assist for elbow","L6635","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","249.28","","","","","","","fee schedule","249.28","256.61","APC"
"Lift assist for elbow","L6635","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","256.61","","","","","","","fee schedule","249.28","256.61","APC"
"Nudge control elbow lock","L6637","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","531.4","","","","","","","fee schedule","517.45","532.66","APC"
"Nudge control elbow lock","L6637","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","522.52","","","","","","","fee schedule","517.45","532.66","APC"
"Nudge control elbow lock","L6637","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","517.45","","","","","","","fee schedule","517.45","532.66","APC"
"Nudge control elbow lock","L6637","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","532.67","","","","","","","fee schedule","517.45","532.66","APC"
"Elec lock on manual pw elbow","L6638","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3148.25","","","","","","","fee schedule","3065.6","3155.76","APC"
"Elec lock on manual pw elbow","L6638","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3095.65","","","","","","","fee schedule","3065.6","3155.76","APC"
"Elec lock on manual pw elbow","L6638","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3065.6","","","","","","","fee schedule","3065.6","3155.76","APC"
"Elec lock on manual pw elbow","L6638","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3155.76","","","","","","","fee schedule","3065.6","3155.76","APC"
"Shoulder abduction joint pai","L6640","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","362.63","","","","","","","fee schedule","353.11","363.5","APC"
"Shoulder abduction joint pai","L6640","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","356.58","","","","","","","fee schedule","353.11","363.5","APC"
"Shoulder abduction joint pai","L6640","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","353.11","","","","","","","fee schedule","353.11","363.5","APC"
"Shoulder abduction joint pai","L6640","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","363.5","","","","","","","fee schedule","353.11","363.5","APC"
"Excursion amplifier pulley t","L6641","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","241.01","","","","","","","fee schedule","234.68","241.58","APC"
"Excursion amplifier pulley t","L6641","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","236.98","","","","","","","fee schedule","234.68","241.58","APC"
"Excursion amplifier pulley t","L6641","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","234.68","","","","","","","fee schedule","234.68","241.58","APC"
"Excursion amplifier pulley t","L6641","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","241.58","","","","","","","fee schedule","234.68","241.58","APC"
"Excursion amplifier lever ty","L6642","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","343.15","","","","","","","fee schedule","334.14","343.97","APC"
"Excursion amplifier lever ty","L6642","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","337.42","","","","","","","fee schedule","334.14","343.97","APC"
"Excursion amplifier lever ty","L6642","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","334.14","","","","","","","fee schedule","334.14","343.97","APC"
"Excursion amplifier lever ty","L6642","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","343.97","","","","","","","fee schedule","334.14","343.97","APC"
"Shoulder flexion-abduction j","L6645","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","416.72","","","","","","","fee schedule","405.78","417.71","APC"
"Shoulder flexion-abduction j","L6645","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","409.75","","","","","","","fee schedule","405.78","417.71","APC"
"Shoulder flexion-abduction j","L6645","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","405.78","","","","","","","fee schedule","405.78","417.71","APC"
"Shoulder flexion-abduction j","L6645","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","417.71","","","","","","","fee schedule","405.78","417.71","APC"
"Multipo locking shoulder jnt","L6646","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3970.66","","","","","","","fee schedule","3866.42","3980.14","APC"
"Multipo locking shoulder jnt","L6646","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3904.33","","","","","","","fee schedule","3866.42","3980.14","APC"
"Multipo locking shoulder jnt","L6646","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3866.42","","","","","","","fee schedule","3866.42","3980.14","APC"
"Multipo locking shoulder jnt","L6646","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3980.14","","","","","","","fee schedule","3866.42","3980.14","APC"
"Shoulder lock actuator","L6647","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","653.68","","","","","","","fee schedule","636.52","655.24","APC"
"Shoulder lock actuator","L6647","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","642.76","","","","","","","fee schedule","636.52","655.24","APC"
"Shoulder lock actuator","L6647","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","636.52","","","","","","","fee schedule","636.52","655.24","APC"
"Shoulder lock actuator","L6647","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","655.24","","","","","","","fee schedule","636.52","655.24","APC"
"Ext pwrd shlder lock/unlock","L6648","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4095.16","","","","","","","fee schedule","3987.65","4104.93","APC"
"Ext pwrd shlder lock/unlock","L6648","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4026.74","","","","","","","fee schedule","3987.65","4104.93","APC"
"Ext pwrd shlder lock/unlock","L6648","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3987.65","","","","","","","fee schedule","3987.65","4104.93","APC"
"Ext pwrd shlder lock/unlock","L6648","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4104.93","","","","","","","fee schedule","3987.65","4104.93","APC"
"Shoulder universal joint","L6650","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","434.07","","","","","","","fee schedule","422.68","435.11","APC"
"Shoulder universal joint","L6650","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","426.82","","","","","","","fee schedule","422.68","435.11","APC"
"Shoulder universal joint","L6650","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","422.68","","","","","","","fee schedule","422.68","435.11","APC"
"Shoulder universal joint","L6650","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","435.11","","","","","","","fee schedule","422.68","435.11","APC"
"Standard control cable extra","L6655","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","96.34","","","","","","","fee schedule","93.81","96.57","APC"
"Standard control cable extra","L6655","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","94.73","","","","","","","fee schedule","93.81","96.57","APC"
"Standard control cable extra","L6655","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93.81","","","","","","","fee schedule","93.81","96.57","APC"
"Standard control cable extra","L6655","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96.57","","","","","","","fee schedule","93.81","96.57","APC"
"Heavy duty control cable","L6660","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","117.71","","","","","","","fee schedule","114.62","117.99","APC"
"Heavy duty control cable","L6660","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","115.74","","","","","","","fee schedule","114.62","117.99","APC"
"Heavy duty control cable","L6660","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","114.62","","","","","","","fee schedule","114.62","117.99","APC"
"Heavy duty control cable","L6660","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","117.99","","","","","","","fee schedule","114.62","117.99","APC"
"Teflon or equal cable lining","L6665","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67.3","","","","","","","fee schedule","65.54","67.46","APC"
"Teflon or equal cable lining","L6665","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","66.18","","","","","","","fee schedule","65.54","67.46","APC"
"Teflon or equal cable lining","L6665","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65.54","","","","","","","fee schedule","65.54","67.46","APC"
"Teflon or equal cable lining","L6665","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67.46","","","","","","","fee schedule","65.54","67.46","APC"
"Hook to hand cable adapter","L6670","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.8","","","","","","","fee schedule","62.13","63.96","APC"
"Hook to hand cable adapter","L6670","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.74","","","","","","","fee schedule","62.13","63.96","APC"
"Hook to hand cable adapter","L6670","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","62.13","","","","","","","fee schedule","62.13","63.96","APC"
"Hook to hand cable adapter","L6670","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63.96","","","","","","","fee schedule","62.13","63.96","APC"
"Harness chest/shlder saddle","L6672","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","216.24","","","","","","","fee schedule","210.56","216.75","APC"
"Harness chest/shlder saddle","L6672","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","212.62","","","","","","","fee schedule","210.56","216.75","APC"
"Harness chest/shlder saddle","L6672","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","210.56","","","","","","","fee schedule","210.56","216.75","APC"
"Harness chest/shlder saddle","L6672","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","216.75","","","","","","","fee schedule","210.56","216.75","APC"
"Harness figure of 8 sing con","L6675","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","154","","","","","","","fee schedule","149.96","154.37","APC"
"Harness figure of 8 sing con","L6675","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","151.43","","","","","","","fee schedule","149.96","154.37","APC"
"Harness figure of 8 sing con","L6675","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","149.96","","","","","","","fee schedule","149.96","154.37","APC"
"Harness figure of 8 sing con","L6675","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","154.37","","","","","","","fee schedule","149.96","154.37","APC"
"Harness figure of 8 dual con","L6676","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","155.52","","","","","","","fee schedule","151.44","155.89","APC"
"Harness figure of 8 dual con","L6676","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","152.92","","","","","","","fee schedule","151.44","155.89","APC"
"Harness figure of 8 dual con","L6676","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","151.44","","","","","","","fee schedule","151.44","155.89","APC"
"Harness figure of 8 dual con","L6676","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","155.89","","","","","","","fee schedule","151.44","155.89","APC"
"UE triple control harness","L6677","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","373.45","","","","","","","fee schedule","363.65","374.35","APC"
"UE triple control harness","L6677","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","367.22","","","","","","","fee schedule","363.65","374.35","APC"
"UE triple control harness","L6677","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","363.65","","","","","","","fee schedule","363.65","374.35","APC"
"UE triple control harness","L6677","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","374.35","","","","","","","fee schedule","363.65","374.35","APC"
"Test sock wrist disart/bel e","L6680","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","297.52","","","","","","","fee schedule","289.71","298.23","APC"
"Test sock wrist disart/bel e","L6680","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","292.55","","","","","","","fee schedule","289.71","298.23","APC"
"Test sock wrist disart/bel e","L6680","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","289.71","","","","","","","fee schedule","289.71","298.23","APC"
"Test sock wrist disart/bel e","L6680","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","298.23","","","","","","","fee schedule","289.71","298.23","APC"
"Test sock elbw disart/above","L6682","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","333.45","","","","","","","fee schedule","324.7","334.25","APC"
"Test sock elbw disart/above","L6682","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","327.88","","","","","","","fee schedule","324.7","334.25","APC"
"Test sock elbw disart/above","L6682","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","324.7","","","","","","","fee schedule","324.7","334.25","APC"
"Test sock elbw disart/above","L6682","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","334.25","","","","","","","fee schedule","324.7","334.25","APC"
"Test socket shldr disart/tho","L6684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","447.01","","","","","","","fee schedule","435.27","448.08","APC"
"Test socket shldr disart/tho","L6684","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","439.54","","","","","","","fee schedule","435.27","448.08","APC"
"Test socket shldr disart/tho","L6684","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","435.27","","","","","","","fee schedule","435.27","448.08","APC"
"Test socket shldr disart/tho","L6684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","448.08","","","","","","","fee schedule","435.27","448.08","APC"
"Suction socket","L6686","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","831.25","","","","","","","fee schedule","809.43","833.24","APC"
"Suction socket","L6686","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","817.37","","","","","","","fee schedule","809.43","833.24","APC"
"Suction socket","L6686","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","809.43","","","","","","","fee schedule","809.43","833.24","APC"
"Suction socket","L6686","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","833.24","","","","","","","fee schedule","809.43","833.24","APC"
"Frame typ socket bel elbow/w","L6687","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","739.7","","","","","","","fee schedule","720.28","741.47","APC"
"Frame typ socket bel elbow/w","L6687","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","727.34","","","","","","","fee schedule","720.28","741.47","APC"
"Frame typ socket bel elbow/w","L6687","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","720.28","","","","","","","fee schedule","720.28","741.47","APC"
"Frame typ socket bel elbow/w","L6687","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","741.47","","","","","","","fee schedule","720.28","741.47","APC"
"Frame typ sock above elb/dis","L6688","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","715.54","","","","","","","fee schedule","696.75","717.24","APC"
"Frame typ sock above elb/dis","L6688","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","703.58","","","","","","","fee schedule","696.75","717.24","APC"
"Frame typ sock above elb/dis","L6688","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","696.75","","","","","","","fee schedule","696.75","717.24","APC"
"Frame typ sock above elb/dis","L6688","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","717.24","","","","","","","fee schedule","696.75","717.24","APC"
"Frame typ socket shoulder di","L6689","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","864.08","","","","","","","fee schedule","841.4","866.14","APC"
"Frame typ socket shoulder di","L6689","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","849.65","","","","","","","fee schedule","841.4","866.14","APC"
"Frame typ socket shoulder di","L6689","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","841.4","","","","","","","fee schedule","841.4","866.14","APC"
"Frame typ socket shoulder di","L6689","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","866.14","","","","","","","fee schedule","841.4","866.14","APC"
"Frame typ sock interscap-tho","L6690","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","935.76","","","","","","","fee schedule","911.2","938","APC"
"Frame typ sock interscap-tho","L6690","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","920.13","","","","","","","fee schedule","911.2","938","APC"
"Frame typ sock interscap-tho","L6690","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","911.2","","","","","","","fee schedule","911.2","938","APC"
"Frame typ sock interscap-tho","L6690","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","938","","","","","","","fee schedule","911.2","938","APC"
"Removable insert each","L6691","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","559.62","","","","","","","fee schedule","544.92","560.95","APC"
"Removable insert each","L6691","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","550.27","","","","","","","fee schedule","544.92","560.95","APC"
"Removable insert each","L6691","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","544.92","","","","","","","fee schedule","544.92","560.95","APC"
"Removable insert each","L6691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","560.95","","","","","","","fee schedule","544.92","560.95","APC"
"Silicone gel insert or equal","L6692","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","717.15","","","","","","","fee schedule","698.32","718.86","APC"
"Silicone gel insert or equal","L6692","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","705.17","","","","","","","fee schedule","698.32","718.86","APC"
"Silicone gel insert or equal","L6692","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","698.32","","","","","","","fee schedule","698.32","718.86","APC"
"Silicone gel insert or equal","L6692","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","718.86","","","","","","","fee schedule","698.32","718.86","APC"
"Lockingelbow forearm cntrbal","L6693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3574.1","","","","","","","fee schedule","3480.27","3582.63","APC"
"Lockingelbow forearm cntrbal","L6693","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3514.39","","","","","","","fee schedule","3480.27","3582.63","APC"
"Lockingelbow forearm cntrbal","L6693","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3480.27","","","","","","","fee schedule","3480.27","3582.63","APC"
"Lockingelbow forearm cntrbal","L6693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3582.63","","","","","","","fee schedule","3480.27","3582.63","APC"
"Elbow socket ins use w/lock","L6694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","900.95","","","","","","","fee schedule","877.3","903.1","APC"
"Elbow socket ins use w/lock","L6694","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","885.9","","","","","","","fee schedule","877.3","903.1","APC"
"Elbow socket ins use w/lock","L6694","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","877.3","","","","","","","fee schedule","877.3","903.1","APC"
"Elbow socket ins use w/lock","L6694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","903.1","","","","","","","fee schedule","877.3","903.1","APC"
"Elbow socket ins use w/o lck","L6695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","750.79","","","","","","","fee schedule","731.07","752.58","APC"
"Elbow socket ins use w/o lck","L6695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","738.24","","","","","","","fee schedule","731.07","752.58","APC"
"Elbow socket ins use w/o lck","L6695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","731.07","","","","","","","fee schedule","731.07","752.58","APC"
"Elbow socket ins use w/o lck","L6695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","752.58","","","","","","","fee schedule","731.07","752.58","APC"
"Cus elbo skt in for con/atyp","L6696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1655.99","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in for con/atyp","L6696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1628.33","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in for con/atyp","L6696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1612.52","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in for con/atyp","L6696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1659.95","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in not con/atyp","L6697","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1655.99","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in not con/atyp","L6697","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1628.33","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in not con/atyp","L6697","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1612.52","","","","","","","fee schedule","1612.52","1659.94","APC"
"Cus elbo skt in not con/atyp","L6697","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1659.95","","","","","","","fee schedule","1612.52","1659.94","APC"
"Below/above elbow lock mech","L6698","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","637.89","","","","","","","fee schedule","621.14","639.41","APC"
"Below/above elbow lock mech","L6698","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","627.23","","","","","","","fee schedule","621.14","639.41","APC"
"Below/above elbow lock mech","L6698","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","621.14","","","","","","","fee schedule","621.14","639.41","APC"
"Below/above elbow lock mech","L6698","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","639.41","","","","","","","fee schedule","621.14","639.41","APC"
"Ue add ext power myoel","L6700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30911.92","","","","","","","fee schedule","30100.39","30985.7","APC"
"Ue add ext power myoel","L6700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30395.5","","","","","","","fee schedule","30100.39","30985.7","APC"
"Ue add ext power myoel","L6700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30100.39","","","","","","","fee schedule","30100.39","30985.7","APC"
"Ue add ext power myoel","L6700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30985.7","","","","","","","fee schedule","30100.39","30985.7","APC"
"Term dev, passive hand mitt","L6703","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","453.54","","","","","","","fee schedule","441.63","454.62","APC"
"Term dev, passive hand mitt","L6703","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","445.96","","","","","","","fee schedule","441.63","454.62","APC"
"Term dev, passive hand mitt","L6703","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","441.63","","","","","","","fee schedule","441.63","454.62","APC"
"Term dev, passive hand mitt","L6703","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","454.62","","","","","","","fee schedule","441.63","454.62","APC"
"Term dev, sport/rec/work att","L6704","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","751.02","","","","","","","fee schedule","731.3","752.81","APC"
"Term dev, sport/rec/work att","L6704","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","738.47","","","","","","","fee schedule","731.3","752.81","APC"
"Term dev, sport/rec/work att","L6704","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","731.3","","","","","","","fee schedule","731.3","752.81","APC"
"Term dev, sport/rec/work att","L6704","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","752.81","","","","","","","fee schedule","731.3","752.81","APC"
"Term dev mech hook vol open","L6706","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","447.45","","","","","","","fee schedule","435.7","448.52","APC"
"Term dev mech hook vol open","L6706","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","439.97","","","","","","","fee schedule","435.7","448.52","APC"
"Term dev mech hook vol open","L6706","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","435.7","","","","","","","fee schedule","435.7","448.52","APC"
"Term dev mech hook vol open","L6706","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","448.52","","","","","","","fee schedule","435.7","448.52","APC"
"Term dev mech hook vol close","L6707","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1885.85","","","","","","","fee schedule","1836.34","1890.35","APC"
"Term dev mech hook vol close","L6707","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1854.34","","","","","","","fee schedule","1836.34","1890.35","APC"
"Term dev mech hook vol close","L6707","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1836.34","","","","","","","fee schedule","1836.34","1890.35","APC"
"Term dev mech hook vol close","L6707","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1890.35","","","","","","","fee schedule","1836.34","1890.35","APC"
"Term dev mech hand vol open","L6708","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1072.69","","","","","","","fee schedule","1044.53","1075.25","APC"
"Term dev mech hand vol open","L6708","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1054.77","","","","","","","fee schedule","1044.53","1075.25","APC"
"Term dev mech hand vol open","L6708","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1044.53","","","","","","","fee schedule","1044.53","1075.25","APC"
"Term dev mech hand vol open","L6708","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1075.25","","","","","","","fee schedule","1044.53","1075.25","APC"
"Term dev mech hand vol close","L6709","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1736.07","","","","","","","fee schedule","1690.5","1740.22","APC"
"Term dev mech hand vol close","L6709","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1707.07","","","","","","","fee schedule","1690.5","1740.22","APC"
"Term dev mech hand vol close","L6709","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1690.5","","","","","","","fee schedule","1690.5","1740.22","APC"
"Term dev mech hand vol close","L6709","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1740.22","","","","","","","fee schedule","1690.5","1740.22","APC"
"Ped term dev, hook, vol open","L6711","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","846.38","","","","","","","fee schedule","824.16","848.4","APC"
"Ped term dev, hook, vol open","L6711","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","832.24","","","","","","","fee schedule","824.16","848.4","APC"
"Ped term dev, hook, vol open","L6711","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","824.16","","","","","","","fee schedule","824.16","848.4","APC"
"Ped term dev, hook, vol open","L6711","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","848.4","","","","","","","fee schedule","824.16","848.4","APC"
"Ped term dev, hook, vol clos","L6712","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1558.36","","","","","","","fee schedule","1517.44","1562.07","APC"
"Ped term dev, hook, vol clos","L6712","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1532.32","","","","","","","fee schedule","1517.44","1562.07","APC"
"Ped term dev, hook, vol clos","L6712","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1517.44","","","","","","","fee schedule","1517.44","1562.07","APC"
"Ped term dev, hook, vol clos","L6712","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1562.07","","","","","","","fee schedule","1517.44","1562.07","APC"
"Ped term dev, hand, vol open","L6713","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1966.87","","","","","","","fee schedule","1915.23","1971.56","APC"
"Ped term dev, hand, vol open","L6713","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1934.01","","","","","","","fee schedule","1915.23","1971.56","APC"
"Ped term dev, hand, vol open","L6713","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1915.23","","","","","","","fee schedule","1915.23","1971.56","APC"
"Ped term dev, hand, vol open","L6713","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1971.56","","","","","","","fee schedule","1915.23","1971.56","APC"
"Ped term dev, hand, vol clos","L6714","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1665.89","","","","","","","fee schedule","1622.16","1669.87","APC"
"Ped term dev, hand, vol clos","L6714","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1638.06","","","","","","","fee schedule","1622.16","1669.87","APC"
"Ped term dev, hand, vol clos","L6714","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1622.16","","","","","","","fee schedule","1622.16","1669.87","APC"
"Ped term dev, hand, vol clos","L6714","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1669.87","","","","","","","fee schedule","1622.16","1669.87","APC"
"Term device, multi art digit","L6715","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3974.6","","","","","","","fee schedule","3870.26","3984.09","APC"
"Term device, multi art digit","L6715","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3908.2","","","","","","","fee schedule","3870.26","3984.09","APC"
"Term device, multi art digit","L6715","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3870.26","","","","","","","fee schedule","3870.26","3984.09","APC"
"Term device, multi art digit","L6715","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3984.09","","","","","","","fee schedule","3870.26","3984.09","APC"
"Hook/hand, hvy dty, vol open","L6721","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2960.93","","","","","","","fee schedule","2883.19","2967.99","APC"
"Hook/hand, hvy dty, vol open","L6721","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2911.46","","","","","","","fee schedule","2883.19","2967.99","APC"
"Hook/hand, hvy dty, vol open","L6721","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2883.19","","","","","","","fee schedule","2883.19","2967.99","APC"
"Hook/hand, hvy dty, vol open","L6721","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2967.99","","","","","","","fee schedule","2883.19","2967.99","APC"
"Hook/hand, hvy dty, vol clos","L6722","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2552.56","","","","","","","fee schedule","2485.55","2558.65","APC"
"Hook/hand, hvy dty, vol clos","L6722","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2509.91","","","","","","","fee schedule","2485.55","2558.65","APC"
"Hook/hand, hvy dty, vol clos","L6722","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2485.55","","","","","","","fee schedule","2485.55","2558.65","APC"
"Hook/hand, hvy dty, vol clos","L6722","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2558.65","","","","","","","fee schedule","2485.55","2558.65","APC"
"Term dev modifier wrist unit","L6805","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","461.61","","","","","","","fee schedule","449.49","462.71","APC"
"Term dev modifier wrist unit","L6805","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","453.9","","","","","","","fee schedule","449.49","462.71","APC"
"Term dev modifier wrist unit","L6805","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","449.49","","","","","","","fee schedule","449.49","462.71","APC"
"Term dev modifier wrist unit","L6805","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","462.71","","","","","","","fee schedule","449.49","462.71","APC"
"Term dev precision pinch dev","L6810","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","251.62","","","","","","","fee schedule","245.01","252.22","APC"
"Term dev precision pinch dev","L6810","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","247.42","","","","","","","fee schedule","245.01","252.22","APC"
"Term dev precision pinch dev","L6810","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","245.01","","","","","","","fee schedule","245.01","252.22","APC"
"Term dev precision pinch dev","L6810","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","252.22","","","","","","","fee schedule","245.01","252.22","APC"
"Elec hand ind art digits","L6880","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30078.96","","","","","","","fee schedule","29289.3","30150.75","APC"
"Elec hand ind art digits","L6880","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29576.45","","","","","","","fee schedule","29289.3","30150.75","APC"
"Elec hand ind art digits","L6880","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29289.3","","","","","","","fee schedule","29289.3","30150.75","APC"
"Elec hand ind art digits","L6880","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30150.75","","","","","","","fee schedule","29289.3","30150.75","APC"
"Term dev auto grasp feature","L6881","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5146.82","","","","","","","fee schedule","5011.7","5159.1","APC"
"Term dev auto grasp feature","L6881","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5060.83","","","","","","","fee schedule","5011.7","5159.1","APC"
"Term dev auto grasp feature","L6881","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5011.7","","","","","","","fee schedule","5011.7","5159.1","APC"
"Term dev auto grasp feature","L6881","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5159.1","","","","","","","fee schedule","5011.7","5159.1","APC"
"Microprocessor control uplmb","L6882","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3904.11","","","","","","","fee schedule","3801.61","3913.42","APC"
"Microprocessor control uplmb","L6882","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3838.88","","","","","","","fee schedule","3801.61","3913.42","APC"
"Microprocessor control uplmb","L6882","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3801.61","","","","","","","fee schedule","3801.61","3913.42","APC"
"Microprocessor control uplmb","L6882","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3913.42","","","","","","","fee schedule","3801.61","3913.42","APC"
"Replc sockt below e/w disa","L6883","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2035.01","","","","","","","fee schedule","1981.58","2039.87","APC"
"Replc sockt below e/w disa","L6883","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2001.01","","","","","","","fee schedule","1981.58","2039.87","APC"
"Replc sockt below e/w disa","L6883","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1981.58","","","","","","","fee schedule","1981.58","2039.87","APC"
"Replc sockt below e/w disa","L6883","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2039.87","","","","","","","fee schedule","1981.58","2039.87","APC"
"Replc sockt above elbow disa","L6884","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2862.97","","","","","","","fee schedule","2787.81","2869.81","APC"
"Replc sockt above elbow disa","L6884","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2815.14","","","","","","","fee schedule","2787.81","2869.81","APC"
"Replc sockt above elbow disa","L6884","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2787.81","","","","","","","fee schedule","2787.81","2869.81","APC"
"Replc sockt above elbow disa","L6884","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2869.81","","","","","","","fee schedule","2787.81","2869.81","APC"
"Replc sockt shldr dis/interc","L6885","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4123.66","","","","","","","fee schedule","4015.4","4133.5","APC"
"Replc sockt shldr dis/interc","L6885","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4054.77","","","","","","","fee schedule","4015.4","4133.5","APC"
"Replc sockt shldr dis/interc","L6885","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4015.4","","","","","","","fee schedule","4015.4","4133.5","APC"
"Replc sockt shldr dis/interc","L6885","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4133.5","","","","","","","fee schedule","4015.4","4133.5","APC"
"Prefab glove for term device","L6890","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","218.12","","","","","","","fee schedule","212.39","218.64","APC"
"Prefab glove for term device","L6890","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","214.48","","","","","","","fee schedule","212.39","218.64","APC"
"Prefab glove for term device","L6890","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","212.39","","","","","","","fee schedule","212.39","218.64","APC"
"Prefab glove for term device","L6890","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","218.64","","","","","","","fee schedule","212.39","218.64","APC"
"Custom glove for term device","L6895","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","793.88","","","","","","","fee schedule","773.04","795.77","APC"
"Custom glove for term device","L6895","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","780.62","","","","","","","fee schedule","773.04","795.77","APC"
"Custom glove for term device","L6895","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","773.04","","","","","","","fee schedule","773.04","795.77","APC"
"Custom glove for term device","L6895","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","795.77","","","","","","","fee schedule","773.04","795.77","APC"
"Hand restorat thumb/1 finger","L6900","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2060.36","","","","","","","fee schedule","2006.27","2065.28","APC"
"Hand restorat thumb/1 finger","L6900","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2025.94","","","","","","","fee schedule","2006.27","2065.28","APC"
"Hand restorat thumb/1 finger","L6900","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2006.27","","","","","","","fee schedule","2006.27","2065.28","APC"
"Hand restorat thumb/1 finger","L6900","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2065.28","","","","","","","fee schedule","2006.27","2065.28","APC"
"Hand restoration multiple fi","L6905","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2022.69","","","","","","","fee schedule","1969.59","2027.52","APC"
"Hand restoration multiple fi","L6905","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1988.9","","","","","","","fee schedule","1969.59","2027.52","APC"
"Hand restoration multiple fi","L6905","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1969.59","","","","","","","fee schedule","1969.59","2027.52","APC"
"Hand restoration multiple fi","L6905","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2027.52","","","","","","","fee schedule","1969.59","2027.52","APC"
"Hand restoration no fingers","L6910","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2076.43","","","","","","","fee schedule","2021.92","2081.38","APC"
"Hand restoration no fingers","L6910","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2041.74","","","","","","","fee schedule","2021.92","2081.38","APC"
"Hand restoration no fingers","L6910","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2021.92","","","","","","","fee schedule","2021.92","2081.38","APC"
"Hand restoration no fingers","L6910","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2081.38","","","","","","","fee schedule","2021.92","2081.38","APC"
"Hand restoration replacmnt g","L6915","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","802.81","","","","","","","fee schedule","781.74","804.73","APC"
"Hand restoration replacmnt g","L6915","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","789.4","","","","","","","fee schedule","781.74","804.73","APC"
"Hand restoration replacmnt g","L6915","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","781.74","","","","","","","fee schedule","781.74","804.73","APC"
"Hand restoration replacmnt g","L6915","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","804.73","","","","","","","fee schedule","781.74","804.73","APC"
"Wrist disarticul switch ctrl","L6920","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9885.04","","","","","","","fee schedule","9625.53","9908.63","APC"
"Wrist disarticul switch ctrl","L6920","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9719.89","","","","","","","fee schedule","9625.53","9908.63","APC"
"Wrist disarticul switch ctrl","L6920","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9625.53","","","","","","","fee schedule","9625.53","9908.63","APC"
"Wrist disarticul switch ctrl","L6920","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9908.63","","","","","","","fee schedule","9625.53","9908.63","APC"
"Wrist disart myoelectronic c","L6925","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10836.86","","","","","","","fee schedule","10552.36","10862.72","APC"
"Wrist disart myoelectronic c","L6925","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10655.81","","","","","","","fee schedule","10552.36","10862.72","APC"
"Wrist disart myoelectronic c","L6925","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10552.36","","","","","","","fee schedule","10552.36","10862.72","APC"
"Wrist disart myoelectronic c","L6925","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10862.72","","","","","","","fee schedule","10552.36","10862.72","APC"
"Below elbow switch control","L6930","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9351.47","","","","","","","fee schedule","9105.97","9373.79","APC"
"Below elbow switch control","L6930","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9195.24","","","","","","","fee schedule","9105.97","9373.79","APC"
"Below elbow switch control","L6930","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9105.97","","","","","","","fee schedule","9105.97","9373.79","APC"
"Below elbow switch control","L6930","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9373.79","","","","","","","fee schedule","9105.97","9373.79","APC"
"Below elbow myoelectronic ct","L6935","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11065.84","","","","","","","fee schedule","10775.33","11092.25","APC"
"Below elbow myoelectronic ct","L6935","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10880.97","","","","","","","fee schedule","10775.33","11092.25","APC"
"Below elbow myoelectronic ct","L6935","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10775.33","","","","","","","fee schedule","10775.33","11092.25","APC"
"Below elbow myoelectronic ct","L6935","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11092.25","","","","","","","fee schedule","10775.33","11092.25","APC"
"Elbow disarticulation switch","L6940","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12191.35","","","","","","","fee schedule","11871.29","12220.45","APC"
"Elbow disarticulation switch","L6940","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11987.68","","","","","","","fee schedule","11871.29","12220.45","APC"
"Elbow disarticulation switch","L6940","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11871.29","","","","","","","fee schedule","11871.29","12220.45","APC"
"Elbow disarticulation switch","L6940","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12220.45","","","","","","","fee schedule","11871.29","12220.45","APC"
"Elbow disart myoelectronic c","L6945","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13635.78","","","","","","","fee schedule","13277.8","13668.32","APC"
"Elbow disart myoelectronic c","L6945","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","13407.97","","","","","","","fee schedule","13277.8","13668.32","APC"
"Elbow disart myoelectronic c","L6945","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13277.8","","","","","","","fee schedule","13277.8","13668.32","APC"
"Elbow disart myoelectronic c","L6945","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13668.32","","","","","","","fee schedule","13277.8","13668.32","APC"
"Above elbow switch control","L6950","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12920.23","","","","","","","fee schedule","12581.04","12951.07","APC"
"Above elbow switch control","L6950","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12704.38","","","","","","","fee schedule","12581.04","12951.07","APC"
"Above elbow switch control","L6950","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12581.04","","","","","","","fee schedule","12581.04","12951.07","APC"
"Above elbow switch control","L6950","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12951.07","","","","","","","fee schedule","12581.04","12951.07","APC"
"Above elbow myoelectronic ct","L6955","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15713.51","","","","","","","fee schedule","15300.98","15751.01","APC"
"Above elbow myoelectronic ct","L6955","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","15450.99","","","","","","","fee schedule","15300.98","15751.01","APC"
"Above elbow myoelectronic ct","L6955","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15300.98","","","","","","","fee schedule","15300.98","15751.01","APC"
"Above elbow myoelectronic ct","L6955","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15751.01","","","","","","","fee schedule","15300.98","15751.01","APC"
"Shldr disartic switch contro","L6960","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16682.27","","","","","","","fee schedule","16244.31","16722.08","APC"
"Shldr disartic switch contro","L6960","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","16403.56","","","","","","","fee schedule","16244.31","16722.08","APC"
"Shldr disartic switch contro","L6960","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16244.31","","","","","","","fee schedule","16244.31","16722.08","APC"
"Shldr disartic switch contro","L6960","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16722.08","","","","","","","fee schedule","16244.31","16722.08","APC"
"Shldr disartic myoelectronic","L6965","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19109.5","","","","","","","fee schedule","18607.82","19155.11","APC"
"Shldr disartic myoelectronic","L6965","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","18790.25","","","","","","","fee schedule","18607.82","19155.11","APC"
"Shldr disartic myoelectronic","L6965","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18607.82","","","","","","","fee schedule","18607.82","19155.11","APC"
"Shldr disartic myoelectronic","L6965","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19155.11","","","","","","","fee schedule","18607.82","19155.11","APC"
"Interscapular-thor switch ct","L6970","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20538.89","","","","","","","fee schedule","19999.68","20587.91","APC"
"Interscapular-thor switch ct","L6970","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20195.76","","","","","","","fee schedule","19999.68","20587.91","APC"
"Interscapular-thor switch ct","L6970","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19999.68","","","","","","","fee schedule","19999.68","20587.91","APC"
"Interscapular-thor switch ct","L6970","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20587.91","","","","","","","fee schedule","19999.68","20587.91","APC"
"Interscap-thor myoelectronic","L6975","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22675.19","","","","","","","fee schedule","22079.9","22729.31","APC"
"Interscap-thor myoelectronic","L6975","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","22296.37","","","","","","","fee schedule","22079.9","22729.31","APC"
"Interscap-thor myoelectronic","L6975","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22079.9","","","","","","","fee schedule","22079.9","22729.31","APC"
"Interscap-thor myoelectronic","L6975","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22729.31","","","","","","","fee schedule","22079.9","22729.31","APC"
"Adult electric hand","L7007","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4651.3","","","","","","","fee schedule","4529.19","4662.4","APC"
"Adult electric hand","L7007","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4573.59","","","","","","","fee schedule","4529.19","4662.4","APC"
"Adult electric hand","L7007","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4529.19","","","","","","","fee schedule","4529.19","4662.4","APC"
"Adult electric hand","L7007","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4662.4","","","","","","","fee schedule","4529.19","4662.4","APC"
"Pediatric electric hand","L7008","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7857.76","","","","","","","fee schedule","7651.47","7876.51","APC"
"Pediatric electric hand","L7008","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7726.48","","","","","","","fee schedule","7651.47","7876.51","APC"
"Pediatric electric hand","L7008","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7651.47","","","","","","","fee schedule","7651.47","7876.51","APC"
"Pediatric electric hand","L7008","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7876.51","","","","","","","fee schedule","7651.47","7876.51","APC"
"Adult electric hook","L7009","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4756.51","","","","","","","fee schedule","4631.64","4767.86","APC"
"Adult electric hook","L7009","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4677.04","","","","","","","fee schedule","4631.64","4767.86","APC"
"Adult electric hook","L7009","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4631.64","","","","","","","fee schedule","4631.64","4767.86","APC"
"Adult electric hook","L7009","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4767.86","","","","","","","fee schedule","4631.64","4767.86","APC"
"Prehensile actuator","L7040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3730.57","","","","","","","fee schedule","3632.63","3739.47","APC"
"Prehensile actuator","L7040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3668.24","","","","","","","fee schedule","3632.63","3739.47","APC"
"Prehensile actuator","L7040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3632.63","","","","","","","fee schedule","3632.63","3739.47","APC"
"Prehensile actuator","L7040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3739.47","","","","","","","fee schedule","3632.63","3739.47","APC"
"Pediatric electric hook","L7045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2072.78","","","","","","","fee schedule","2018.37","2077.73","APC"
"Pediatric electric hook","L7045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2038.15","","","","","","","fee schedule","2018.37","2077.73","APC"
"Pediatric electric hook","L7045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2018.37","","","","","","","fee schedule","2018.37","2077.73","APC"
"Pediatric electric hook","L7045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2077.73","","","","","","","fee schedule","2018.37","2077.73","APC"
"Electronic elbow hosmer swit","L7170","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7519.35","","","","","","","fee schedule","7321.95","7537.3","APC"
"Electronic elbow hosmer swit","L7170","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7393.73","","","","","","","fee schedule","7321.95","7537.3","APC"
"Electronic elbow hosmer swit","L7170","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7321.95","","","","","","","fee schedule","7321.95","7537.3","APC"
"Electronic elbow hosmer swit","L7170","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7537.3","","","","","","","fee schedule","7321.95","7537.3","APC"
"Electronic elbow sequential","L7180","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44775.75","","","","","","","fee schedule","43600.26","44882.62","APC"
"Electronic elbow sequential","L7180","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","44027.71","","","","","","","fee schedule","43600.26","44882.62","APC"
"Electronic elbow sequential","L7180","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43600.26","","","","","","","fee schedule","43600.26","44882.62","APC"
"Electronic elbow sequential","L7180","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44882.62","","","","","","","fee schedule","43600.26","44882.62","APC"
"Electronic elbo simultaneous","L7181","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50442.89","","","","","","","fee schedule","49118.61","50563.28","APC"
"Electronic elbo simultaneous","L7181","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","49600.16","","","","","","","fee schedule","49118.61","50563.28","APC"
"Electronic elbo simultaneous","L7181","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49118.61","","","","","","","fee schedule","49118.61","50563.28","APC"
"Electronic elbo simultaneous","L7181","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50563.28","","","","","","","fee schedule","49118.61","50563.28","APC"
"Electron elbow adolescent sw","L7185","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7698.58","","","","","","","fee schedule","7496.47","7716.95","APC"
"Electron elbow adolescent sw","L7185","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","7569.96","","","","","","","fee schedule","7496.47","7716.95","APC"
"Electron elbow adolescent sw","L7185","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7496.47","","","","","","","fee schedule","7496.47","7716.95","APC"
"Electron elbow adolescent sw","L7185","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7716.95","","","","","","","fee schedule","7496.47","7716.95","APC"
"Electron elbow child switch","L7186","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11756.36","","","","","","","fee schedule","11447.73","11784.42","APC"
"Electron elbow child switch","L7186","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11559.96","","","","","","","fee schedule","11447.73","11784.42","APC"
"Electron elbow child switch","L7186","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11447.73","","","","","","","fee schedule","11447.73","11784.42","APC"
"Electron elbow child switch","L7186","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11784.42","","","","","","","fee schedule","11447.73","11784.42","APC"
"Elbow adolescent myoelectron","L7190","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10023.26","","","","","","","fee schedule","9760.11","10047.18","APC"
"Elbow adolescent myoelectron","L7190","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9855.8","","","","","","","fee schedule","9760.11","10047.18","APC"
"Elbow adolescent myoelectron","L7190","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9760.11","","","","","","","fee schedule","9760.11","10047.18","APC"
"Elbow adolescent myoelectron","L7190","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10047.18","","","","","","","fee schedule","9760.11","10047.18","APC"
"Elbow child myoelectronic ct","L7191","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12662.58","","","","","","","fee schedule","12330.15","12692.8","APC"
"Elbow child myoelectronic ct","L7191","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","12451.03","","","","","","","fee schedule","12330.15","12692.8","APC"
"Elbow child myoelectronic ct","L7191","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12330.15","","","","","","","fee schedule","12330.15","12692.8","APC"
"Elbow child myoelectronic ct","L7191","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12692.8","","","","","","","fee schedule","12330.15","12692.8","APC"
"Electronic wrist rotator any","L7259","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5347.24","","","","","","","fee schedule","5206.86","5360","APC"
"Electronic wrist rotator any","L7259","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5257.9","","","","","","","fee schedule","5206.86","5360","APC"
"Electronic wrist rotator any","L7259","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5206.86","","","","","","","fee schedule","5206.86","5360","APC"
"Electronic wrist rotator any","L7259","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5360","","","","","","","fee schedule","5206.86","5360","APC"
"Six volt bat otto bock/eq ea","L7360","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","383.19","","","","","","","fee schedule","373.13","384.1","APC"
"Six volt bat otto bock/eq ea","L7360","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","376.78","","","","","","","fee schedule","373.13","384.1","APC"
"Six volt bat otto bock/eq ea","L7360","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","373.13","","","","","","","fee schedule","373.13","384.1","APC"
"Six volt bat otto bock/eq ea","L7360","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","384.1","","","","","","","fee schedule","373.13","384.1","APC"
"Battery chrgr six volt otto","L7362","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","345.2","","","","","","","fee schedule","336.14","346.03","APC"
"Battery chrgr six volt otto","L7362","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","339.44","","","","","","","fee schedule","336.14","346.03","APC"
"Battery chrgr six volt otto","L7362","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","336.14","","","","","","","fee schedule","336.14","346.03","APC"
"Battery chrgr six volt otto","L7362","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","346.03","","","","","","","fee schedule","336.14","346.03","APC"
"Twelve volt battery utah/equ","L7364","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","638.07","","","","","","","fee schedule","621.32","639.6","APC"
"Twelve volt battery utah/equ","L7364","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","627.41","","","","","","","fee schedule","621.32","639.6","APC"
"Twelve volt battery utah/equ","L7364","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","621.32","","","","","","","fee schedule","621.32","639.6","APC"
"Twelve volt battery utah/equ","L7364","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","639.6","","","","","","","fee schedule","621.32","639.6","APC"
"Battery chrgr 12 volt utah/e","L7366","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","859.65","","","","","","","fee schedule","837.08","861.7","APC"
"Battery chrgr 12 volt utah/e","L7366","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","845.29","","","","","","","fee schedule","837.08","861.7","APC"
"Battery chrgr 12 volt utah/e","L7366","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","837.08","","","","","","","fee schedule","837.08","861.7","APC"
"Battery chrgr 12 volt utah/e","L7366","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","861.7","","","","","","","fee schedule","837.08","861.7","APC"
"Replacemnt lithium ionbatter","L7367","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","490.13","","","","","","","fee schedule","477.26","491.3","APC"
"Replacemnt lithium ionbatter","L7367","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","481.94","","","","","","","fee schedule","477.26","491.3","APC"
"Replacemnt lithium ionbatter","L7367","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","477.26","","","","","","","fee schedule","477.26","491.3","APC"
"Replacemnt lithium ionbatter","L7367","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","491.3","","","","","","","fee schedule","477.26","491.3","APC"
"Lithium ion battery charger","L7368","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","635.37","","","","","","","fee schedule","618.69","636.89","APC"
"Lithium ion battery charger","L7368","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","624.76","","","","","","","fee schedule","618.69","636.89","APC"
"Lithium ion battery charger","L7368","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","618.69","","","","","","","fee schedule","618.69","636.89","APC"
"Lithium ion battery charger","L7368","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","636.89","","","","","","","fee schedule","618.69","636.89","APC"
"Add ue prost be/wd, ultlite","L7400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","385.85","","","","","","","fee schedule","375.72","386.77","APC"
"Add ue prost be/wd, ultlite","L7400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","379.4","","","","","","","fee schedule","375.72","386.77","APC"
"Add ue prost be/wd, ultlite","L7400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","375.72","","","","","","","fee schedule","375.72","386.77","APC"
"Add ue prost be/wd, ultlite","L7400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","386.77","","","","","","","fee schedule","375.72","386.77","APC"
"Add ue prost a/e ultlite mat","L7401","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","431.98","","","","","","","fee schedule","420.64","433.01","APC"
"Add ue prost a/e ultlite mat","L7401","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","424.76","","","","","","","fee schedule","420.64","433.01","APC"
"Add ue prost a/e ultlite mat","L7401","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","420.64","","","","","","","fee schedule","420.64","433.01","APC"
"Add ue prost a/e ultlite mat","L7401","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","433.01","","","","","","","fee schedule","420.64","433.01","APC"
"Add ue prost s/d ultlite mat","L7402","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","466.48","","","","","","","fee schedule","454.24","467.6","APC"
"Add ue prost s/d ultlite mat","L7402","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","458.69","","","","","","","fee schedule","454.24","467.6","APC"
"Add ue prost s/d ultlite mat","L7402","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","454.24","","","","","","","fee schedule","454.24","467.6","APC"
"Add ue prost s/d ultlite mat","L7402","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","467.6","","","","","","","fee schedule","454.24","467.6","APC"
"Add UE prost b/e acrylic","L7403","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","463.6","","","","","","","fee schedule","451.43","464.71","APC"
"Add UE prost b/e acrylic","L7403","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","455.86","","","","","","","fee schedule","451.43","464.71","APC"
"Add UE prost b/e acrylic","L7403","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","451.43","","","","","","","fee schedule","451.43","464.71","APC"
"Add UE prost b/e acrylic","L7403","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","464.71","","","","","","","fee schedule","451.43","464.71","APC"
"Add UE prost a/e acrylic","L7404","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","699.75","","","","","","","fee schedule","681.38","701.42","APC"
"Add UE prost a/e acrylic","L7404","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","688.06","","","","","","","fee schedule","681.38","701.42","APC"
"Add UE prost a/e acrylic","L7404","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","681.38","","","","","","","fee schedule","681.38","701.42","APC"
"Add UE prost a/e acrylic","L7404","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","701.42","","","","","","","fee schedule","681.38","701.42","APC"
"Add UE prost s/d acrylic","L7405","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","915.15","","","","","","","fee schedule","891.12","917.33","APC"
"Add UE prost s/d acrylic","L7405","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","899.86","","","","","","","fee schedule","891.12","917.33","APC"
"Add UE prost s/d acrylic","L7405","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","891.12","","","","","","","fee schedule","891.12","917.33","APC"
"Add UE prost s/d acrylic","L7405","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","917.33","","","","","","","fee schedule","891.12","917.33","APC"
"Add to upp extr user adj mec","L7406","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3299.7","","","","","","","fee schedule","3213.07","3307.57","APC"
"Add to upp extr user adj mec","L7406","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3244.57","","","","","","","fee schedule","3213.07","3307.57","APC"
"Add to upp extr user adj mec","L7406","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3213.07","","","","","","","fee schedule","3213.07","3307.57","APC"
"Add to upp extr user adj mec","L7406","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3307.57","","","","","","","fee schedule","3213.07","3307.57","APC"
"Repair prosthesis per 15 min","L7520","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.6","","","","","","","fee schedule","41.48","42.7","APC"
"Repair prosthesis per 15 min","L7520","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.89","","","","","","","fee schedule","41.48","42.7","APC"
"Repair prosthesis per 15 min","L7520","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.48","","","","","","","fee schedule","41.48","42.7","APC"
"Repair prosthesis per 15 min","L7520","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.7","","","","","","","fee schedule","41.48","42.7","APC"
"Pros soc insert gasket/seal","L7700","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","184.8","","","","","","","fee schedule","179.95","185.24","APC"
"Pros soc insert gasket/seal","L7700","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","181.71","","","","","","","fee schedule","179.95","185.24","APC"
"Pros soc insert gasket/seal","L7700","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","179.95","","","","","","","fee schedule","179.95","185.24","APC"
"Pros soc insert gasket/seal","L7700","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","185.24","","","","","","","fee schedule","179.95","185.24","APC"
"Mastectomy bra","L8000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46.82","","","","","","","fee schedule","45.59","46.94","APC"
"Mastectomy bra","L8000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","46.04","","","","","","","fee schedule","45.59","46.94","APC"
"Mastectomy bra","L8000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45.59","","","","","","","fee schedule","45.59","46.94","APC"
"Mastectomy bra","L8000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46.94","","","","","","","fee schedule","45.59","46.94","APC"
"Breast prosthesis bra & form","L8001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","157.93","","","","","","","fee schedule","153.79","158.31","APC"
"Breast prosthesis bra & form","L8001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","155.29","","","","","","","fee schedule","153.79","158.31","APC"
"Breast prosthesis bra & form","L8001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","153.79","","","","","","","fee schedule","153.79","158.31","APC"
"Breast prosthesis bra & form","L8001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","158.31","","","","","","","fee schedule","153.79","158.31","APC"
"Brst prsth bra & bilat form","L8002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","207.69","","","","","","","fee schedule","202.24","208.18","APC"
"Brst prsth bra & bilat form","L8002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","204.22","","","","","","","fee schedule","202.24","208.18","APC"
"Brst prsth bra & bilat form","L8002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","202.24","","","","","","","fee schedule","202.24","208.18","APC"
"Brst prsth bra & bilat form","L8002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","208.18","","","","","","","fee schedule","202.24","208.18","APC"
"Ext breastprosthesis garment","L8015","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","75.47","","","","","","","fee schedule","73.49","75.65","APC"
"Ext breastprosthesis garment","L8015","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","74.21","","","","","","","fee schedule","73.49","75.65","APC"
"Ext breastprosthesis garment","L8015","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","73.49","","","","","","","fee schedule","73.49","75.65","APC"
"Ext breastprosthesis garment","L8015","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","75.65","","","","","","","fee schedule","73.49","75.65","APC"
"Mastectomy form","L8020","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","320.85","","","","","","","fee schedule","312.43","321.62","APC"
"Mastectomy form","L8020","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","315.49","","","","","","","fee schedule","312.43","321.62","APC"
"Mastectomy form","L8020","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","312.43","","","","","","","fee schedule","312.43","321.62","APC"
"Mastectomy form","L8020","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","321.62","","","","","","","fee schedule","312.43","321.62","APC"
"Breast prosthes w/o adhesive","L8030","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.25","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthes w/o adhesive","L8030","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.31","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthes w/o adhesive","L8030","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.35","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthes w/o adhesive","L8030","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.24","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthesis w adhesive","L8031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","415.25","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthesis w adhesive","L8031","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","408.31","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthesis w adhesive","L8031","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","404.35","","","","","","","fee schedule","404.35","416.24","APC"
"Breast prosthesis w adhesive","L8031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","416.24","","","","","","","fee schedule","404.35","416.24","APC"
"Reusable nipple prosthesis","L8032","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.32","","","","","","","fee schedule","48.02","49.43","APC"
"Reusable nipple prosthesis","L8032","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.49","","","","","","","fee schedule","48.02","49.43","APC"
"Reusable nipple prosthesis","L8032","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.02","","","","","","","fee schedule","48.02","49.43","APC"
"Reusable nipple prosthesis","L8032","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.43","","","","","","","fee schedule","48.02","49.43","APC"
"Custom breast prosthesis","L8035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4612.26","","","","","","","fee schedule","4491.17","4623.27","APC"
"Custom breast prosthesis","L8035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4535.2","","","","","","","fee schedule","4491.17","4623.27","APC"
"Custom breast prosthesis","L8035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4491.17","","","","","","","fee schedule","4491.17","4623.27","APC"
"Custom breast prosthesis","L8035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4623.27","","","","","","","fee schedule","4491.17","4623.27","APC"
"Nasal prosthesis","L8040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3208.75","","","","","","","fee schedule","3124.52","3216.41","APC"
"Nasal prosthesis","L8040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3155.15","","","","","","","fee schedule","3124.52","3216.41","APC"
"Nasal prosthesis","L8040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3124.52","","","","","","","fee schedule","3124.52","3216.41","APC"
"Nasal prosthesis","L8040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3216.41","","","","","","","fee schedule","3124.52","3216.41","APC"
"Midfacial prosthesis","L8041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3867.64","","","","","","","fee schedule","3766.11","3876.87","APC"
"Midfacial prosthesis","L8041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3803.03","","","","","","","fee schedule","3766.11","3876.87","APC"
"Midfacial prosthesis","L8041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3766.11","","","","","","","fee schedule","3766.11","3876.87","APC"
"Midfacial prosthesis","L8041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3876.87","","","","","","","fee schedule","3766.11","3876.87","APC"
"Orbital prosthesis","L8042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4345.66","","","","","","","fee schedule","4231.57","4356.03","APC"
"Orbital prosthesis","L8042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4273.06","","","","","","","fee schedule","4231.57","4356.03","APC"
"Orbital prosthesis","L8042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4231.57","","","","","","","fee schedule","4231.57","4356.03","APC"
"Orbital prosthesis","L8042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4356.03","","","","","","","fee schedule","4231.57","4356.03","APC"
"Upper facial prosthesis","L8043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4867.2","","","","","","","fee schedule","4739.42","4878.81","APC"
"Upper facial prosthesis","L8043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4785.88","","","","","","","fee schedule","4739.42","4878.81","APC"
"Upper facial prosthesis","L8043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4739.42","","","","","","","fee schedule","4739.42","4878.81","APC"
"Upper facial prosthesis","L8043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4878.81","","","","","","","fee schedule","4739.42","4878.81","APC"
"Hemi-facial prosthesis","L8044","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5388.59","","","","","","","fee schedule","5247.12","5401.45","APC"
"Hemi-facial prosthesis","L8044","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5298.57","","","","","","","fee schedule","5247.12","5401.45","APC"
"Hemi-facial prosthesis","L8044","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5247.12","","","","","","","fee schedule","5247.12","5401.45","APC"
"Hemi-facial prosthesis","L8044","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5401.45","","","","","","","fee schedule","5247.12","5401.45","APC"
"Auricular prosthesis","L8045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3761.69","","","","","","","fee schedule","3662.93","3770.67","APC"
"Auricular prosthesis","L8045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3698.84","","","","","","","fee schedule","3662.93","3770.67","APC"
"Auricular prosthesis","L8045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3662.93","","","","","","","fee schedule","3662.93","3770.67","APC"
"Auricular prosthesis","L8045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3770.67","","","","","","","fee schedule","3662.93","3770.67","APC"
"Partial facial prosthesis","L8046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3476.5","","","","","","","fee schedule","3385.23","3484.79","APC"
"Partial facial prosthesis","L8046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","3418.42","","","","","","","fee schedule","3385.23","3484.79","APC"
"Partial facial prosthesis","L8046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3385.23","","","","","","","fee schedule","3385.23","3484.79","APC"
"Partial facial prosthesis","L8046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3484.79","","","","","","","fee schedule","3385.23","3484.79","APC"
"Nasal septal prosthesis","L8047","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1781.75","","","","","","","fee schedule","1734.97","1786","APC"
"Nasal septal prosthesis","L8047","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1751.98","","","","","","","fee schedule","1734.97","1786","APC"
"Nasal septal prosthesis","L8047","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1734.97","","","","","","","fee schedule","1734.97","1786","APC"
"Nasal septal prosthesis","L8047","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1786","","","","","","","fee schedule","1734.97","1786","APC"
"Truss single w/ standard pad","L8300","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","108.19","","","","","","","fee schedule","105.35","108.44","APC"
"Truss single w/ standard pad","L8300","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","106.38","","","","","","","fee schedule","105.35","108.44","APC"
"Truss single w/ standard pad","L8300","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","105.35","","","","","","","fee schedule","105.35","108.44","APC"
"Truss single w/ standard pad","L8300","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","108.44","","","","","","","fee schedule","105.35","108.44","APC"
"Truss double w/ standard pad","L8310","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","170.79","","","","","","","fee schedule","166.31","171.2","APC"
"Truss double w/ standard pad","L8310","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","167.94","","","","","","","fee schedule","166.31","171.2","APC"
"Truss double w/ standard pad","L8310","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","166.31","","","","","","","fee schedule","166.31","171.2","APC"
"Truss double w/ standard pad","L8310","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","171.2","","","","","","","fee schedule","166.31","171.2","APC"
"Truss addition to std pad wa","L8320","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","76.57","","","","","","","fee schedule","74.56","76.76","APC"
"Truss addition to std pad wa","L8320","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.29","","","","","","","fee schedule","74.56","76.76","APC"
"Truss addition to std pad wa","L8320","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","74.56","","","","","","","fee schedule","74.56","76.76","APC"
"Truss addition to std pad wa","L8320","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76.76","","","","","","","fee schedule","74.56","76.76","APC"
"Truss add to std pad scrotal","L8330","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63.31","","","","","","","fee schedule","61.65","63.46","APC"
"Truss add to std pad scrotal","L8330","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","62.25","","","","","","","fee schedule","61.65","63.46","APC"
"Truss add to std pad scrotal","L8330","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61.65","","","","","","","fee schedule","61.65","63.46","APC"
"Truss add to std pad scrotal","L8330","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63.46","","","","","","","fee schedule","61.65","63.46","APC"
"Sheath below knee","L8400","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.28","","","","","","","fee schedule","21.7","22.33","APC"
"Sheath below knee","L8400","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.91","","","","","","","fee schedule","21.7","22.33","APC"
"Sheath below knee","L8400","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.7","","","","","","","fee schedule","21.7","22.33","APC"
"Sheath below knee","L8400","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.33","","","","","","","fee schedule","21.7","22.33","APC"
"Sheath above knee","L8410","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.75","","","","","","","fee schedule","28.97","29.82","APC"
"Sheath above knee","L8410","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.25","","","","","","","fee schedule","28.97","29.82","APC"
"Sheath above knee","L8410","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.97","","","","","","","fee schedule","28.97","29.82","APC"
"Sheath above knee","L8410","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.82","","","","","","","fee schedule","28.97","29.82","APC"
"Sheath upper limb","L8415","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.26","","","","","","","fee schedule","28.49","29.33","APC"
"Sheath upper limb","L8415","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.77","","","","","","","fee schedule","28.49","29.33","APC"
"Sheath upper limb","L8415","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.49","","","","","","","fee schedule","28.49","29.33","APC"
"Sheath upper limb","L8415","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.33","","","","","","","fee schedule","28.49","29.33","APC"
"Pros sheath/sock w gel cushn","L8417","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","94.61","","","","","","","fee schedule","92.13","94.84","APC"
"Pros sheath/sock w gel cushn","L8417","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","93.03","","","","","","","fee schedule","92.13","94.84","APC"
"Pros sheath/sock w gel cushn","L8417","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","92.13","","","","","","","fee schedule","92.13","94.84","APC"
"Pros sheath/sock w gel cushn","L8417","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","94.84","","","","","","","fee schedule","92.13","94.84","APC"
"Prosthetic sock multi ply BK","L8420","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.27","","","","","","","fee schedule","25.58","26.33","APC"
"Prosthetic sock multi ply BK","L8420","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.83","","","","","","","fee schedule","25.58","26.33","APC"
"Prosthetic sock multi ply BK","L8420","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.58","","","","","","","fee schedule","25.58","26.33","APC"
"Prosthetic sock multi ply BK","L8420","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.33","","","","","","","fee schedule","25.58","26.33","APC"
"Prosthetic sock multi ply AK","L8430","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.39","","","","","","","fee schedule","27.64","28.46","APC"
"Prosthetic sock multi ply AK","L8430","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.91","","","","","","","fee schedule","27.64","28.46","APC"
"Prosthetic sock multi ply AK","L8430","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.64","","","","","","","fee schedule","27.64","28.46","APC"
"Prosthetic sock multi ply AK","L8430","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.46","","","","","","","fee schedule","27.64","28.46","APC"
"Pros sock multi ply upper lm","L8435","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.96","","","","","","","fee schedule","26.25","27.03","APC"
"Pros sock multi ply upper lm","L8435","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.51","","","","","","","fee schedule","26.25","27.03","APC"
"Pros sock multi ply upper lm","L8435","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.25","","","","","","","fee schedule","26.25","27.03","APC"
"Pros sock multi ply upper lm","L8435","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.03","","","","","","","fee schedule","26.25","27.03","APC"
"Shrinker below knee","L8440","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.63","","","","","","","fee schedule","52.22","53.76","APC"
"Shrinker below knee","L8440","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.74","","","","","","","fee schedule","52.22","53.76","APC"
"Shrinker below knee","L8440","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.22","","","","","","","fee schedule","52.22","53.76","APC"
"Shrinker below knee","L8440","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.76","","","","","","","fee schedule","52.22","53.76","APC"
"Shrinker above knee","L8460","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","85.47","","","","","","","fee schedule","83.22","85.67","APC"
"Shrinker above knee","L8460","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","84.04","","","","","","","fee schedule","83.22","85.67","APC"
"Shrinker above knee","L8460","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","83.22","","","","","","","fee schedule","83.22","85.67","APC"
"Shrinker above knee","L8460","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","85.67","","","","","","","fee schedule","83.22","85.67","APC"
"Shrinker upper limb","L8465","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","75.66","","","","","","","fee schedule","73.67","75.84","APC"
"Shrinker upper limb","L8465","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","74.4","","","","","","","fee schedule","73.67","75.84","APC"
"Shrinker upper limb","L8465","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","73.67","","","","","","","fee schedule","73.67","75.84","APC"
"Shrinker upper limb","L8465","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","75.84","","","","","","","fee schedule","73.67","75.84","APC"
"Pros sock single ply BK","L8470","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.56","","","","","","","fee schedule","8.33","8.58","APC"
"Pros sock single ply BK","L8470","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.42","","","","","","","fee schedule","8.33","8.58","APC"
"Pros sock single ply BK","L8470","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.33","","","","","","","fee schedule","8.33","8.58","APC"
"Pros sock single ply BK","L8470","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.58","","","","","","","fee schedule","8.33","8.58","APC"
"Pros sock single ply AK","L8480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11.81","","","","","","","fee schedule","11.5","11.83","APC"
"Pros sock single ply AK","L8480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","11.61","","","","","","","fee schedule","11.5","11.83","APC"
"Pros sock single ply AK","L8480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11.5","","","","","","","fee schedule","11.5","11.83","APC"
"Pros sock single ply AK","L8480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11.83","","","","","","","fee schedule","11.5","11.83","APC"
"Pros sock single ply upper l","L8485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14.83","","","","","","","fee schedule","14.44","14.87","APC"
"Pros sock single ply upper l","L8485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14.58","","","","","","","fee schedule","14.44","14.87","APC"
"Pros sock single ply upper l","L8485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14.44","","","","","","","fee schedule","14.44","14.87","APC"
"Pros sock single ply upper l","L8485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14.87","","","","","","","fee schedule","14.44","14.87","APC"
"Artificial larynx","L8500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1128.44","","","","","","","fee schedule","1098.82","1131.13","APC"
"Artificial larynx","L8500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1109.59","","","","","","","fee schedule","1098.82","1131.13","APC"
"Artificial larynx","L8500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1098.82","","","","","","","fee schedule","1098.82","1131.13","APC"
"Artificial larynx","L8500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1131.13","","","","","","","fee schedule","1098.82","1131.13","APC"
"Tracheostomy speaking valve","L8501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","154.9","","","","","","","fee schedule","150.84","155.27","APC"
"Tracheostomy speaking valve","L8501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","152.32","","","","","","","fee schedule","150.84","155.27","APC"
"Tracheostomy speaking valve","L8501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","150.84","","","","","","","fee schedule","150.84","155.27","APC"
"Tracheostomy speaking valve","L8501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","155.27","","","","","","","fee schedule","150.84","155.27","APC"
"Trach-esoph voice pros pt in","L8507","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52.73","","","","","","","fee schedule","51.35","52.86","APC"
"Trach-esoph voice pros pt in","L8507","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","51.85","","","","","","","fee schedule","51.35","52.86","APC"
"Trach-esoph voice pros pt in","L8507","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51.35","","","","","","","fee schedule","51.35","52.86","APC"
"Trach-esoph voice pros pt in","L8507","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52.86","","","","","","","fee schedule","51.35","52.86","APC"
"Trach-esoph voice pros md in","L8509","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.47","","","","","","","fee schedule","133.86","137.8","APC"
"Trach-esoph voice pros md in","L8509","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.18","","","","","","","fee schedule","133.86","137.8","APC"
"Trach-esoph voice pros md in","L8509","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.86","","","","","","","fee schedule","133.86","137.8","APC"
"Trach-esoph voice pros md in","L8509","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.8","","","","","","","fee schedule","133.86","137.8","APC"
"Voice amplifier","L8510","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","318.12","","","","","","","fee schedule","309.76","318.87","APC"
"Voice amplifier","L8510","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","312.8","","","","","","","fee schedule","309.76","318.87","APC"
"Voice amplifier","L8510","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","309.76","","","","","","","fee schedule","309.76","318.87","APC"
"Voice amplifier","L8510","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","318.87","","","","","","","fee schedule","309.76","318.87","APC"
"Indwelling trach insert","L8511","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","91.56","","","","","","","fee schedule","89.16","91.78","APC"
"Indwelling trach insert","L8511","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","90.03","","","","","","","fee schedule","89.16","91.78","APC"
"Indwelling trach insert","L8511","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","89.16","","","","","","","fee schedule","89.16","91.78","APC"
"Indwelling trach insert","L8511","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","91.78","","","","","","","fee schedule","89.16","91.78","APC"
"Gel cap for trach voice pros","L8512","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.71","","","","","","","fee schedule","2.64","2.72","APC"
"Gel cap for trach voice pros","L8512","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.67","","","","","","","fee schedule","2.64","2.72","APC"
"Gel cap for trach voice pros","L8512","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.64","","","","","","","fee schedule","2.64","2.72","APC"
"Gel cap for trach voice pros","L8512","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.72","","","","","","","fee schedule","2.64","2.72","APC"
"Trach pros cleaning device","L8513","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.54","","","","","","","fee schedule","6.36","6.55","APC"
"Trach pros cleaning device","L8513","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6.43","","","","","","","fee schedule","6.36","6.55","APC"
"Trach pros cleaning device","L8513","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6.36","","","","","","","fee schedule","6.36","6.55","APC"
"Trach pros cleaning device","L8513","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.55","","","","","","","fee schedule","6.36","6.55","APC"
"Repl trach puncture dilator","L8514","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","118.69","","","","","","","fee schedule","115.58","118.98","APC"
"Repl trach puncture dilator","L8514","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","116.71","","","","","","","fee schedule","115.58","118.98","APC"
"Repl trach puncture dilator","L8514","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","115.58","","","","","","","fee schedule","115.58","118.98","APC"
"Repl trach puncture dilator","L8514","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","118.98","","","","","","","fee schedule","115.58","118.98","APC"
"Gel cap app device for trach","L8515","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","79.44","","","","","","","fee schedule","77.36","79.63","APC"
"Gel cap app device for trach","L8515","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","78.12","","","","","","","fee schedule","77.36","79.63","APC"
"Gel cap app device for trach","L8515","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","77.36","","","","","","","fee schedule","77.36","79.63","APC"
"Gel cap app device for trach","L8515","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79.63","","","","","","","fee schedule","77.36","79.63","APC"
"Coch implant headset replace","L8615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","567.8","","","","","","","fee schedule","552.89","569.15","APC"
"Coch implant headset replace","L8615","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","558.31","","","","","","","fee schedule","552.89","569.15","APC"
"Coch implant headset replace","L8615","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","552.89","","","","","","","fee schedule","552.89","569.15","APC"
"Coch implant headset replace","L8615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","569.15","","","","","","","fee schedule","552.89","569.15","APC"
"Coch implant microphone repl","L8616","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","132.26","","","","","","","fee schedule","128.79","132.57","APC"
"Coch implant microphone repl","L8616","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","130.05","","","","","","","fee schedule","128.79","132.57","APC"
"Coch implant microphone repl","L8616","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","128.79","","","","","","","fee schedule","128.79","132.57","APC"
"Coch implant microphone repl","L8616","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","132.57","","","","","","","fee schedule","128.79","132.57","APC"
"Coch implant trans coil repl","L8617","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","115.51","","","","","","","fee schedule","112.48","115.78","APC"
"Coch implant trans coil repl","L8617","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","113.58","","","","","","","fee schedule","112.48","115.78","APC"
"Coch implant trans coil repl","L8617","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","112.48","","","","","","","fee schedule","112.48","115.78","APC"
"Coch implant trans coil repl","L8617","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","115.78","","","","","","","fee schedule","112.48","115.78","APC"
"Coch implant tran cable repl","L8618","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33","","","","","","","fee schedule","32.13","33.08","APC"
"Coch implant tran cable repl","L8618","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.44","","","","","","","fee schedule","32.13","33.08","APC"
"Coch implant tran cable repl","L8618","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32.13","","","","","","","fee schedule","32.13","33.08","APC"
"Coch implant tran cable repl","L8618","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33.08","","","","","","","fee schedule","32.13","33.08","APC"
"Coch imp ext proc/contr rplc","L8619","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10735.2","","","","","","","fee schedule","10453.37","10760.82","APC"
"Coch imp ext proc/contr rplc","L8619","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10555.85","","","","","","","fee schedule","10453.37","10760.82","APC"
"Coch imp ext proc/contr rplc","L8619","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10453.37","","","","","","","fee schedule","10453.37","10760.82","APC"
"Coch imp ext proc/contr rplc","L8619","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10760.82","","","","","","","fee schedule","10453.37","10760.82","APC"
"Repl zinc air battery","L8621","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.79","","","","","","","fee schedule","0.76","0.79","APC"
"Repl zinc air battery","L8621","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.77","","","","","","","fee schedule","0.76","0.79","APC"
"Repl zinc air battery","L8621","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.76","","","","","","","fee schedule","0.76","0.79","APC"
"Repl zinc air battery","L8621","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.79","","","","","","","fee schedule","0.76","0.79","APC"
"Repl alkaline battery","L8622","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.41","","","","","","","fee schedule","0.4","0.41","APC"
"Repl alkaline battery","L8622","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.4","","","","","","","fee schedule","0.4","0.41","APC"
"Repl alkaline battery","L8622","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.4","","","","","","","fee schedule","0.4","0.41","APC"
"Repl alkaline battery","L8622","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.41","","","","","","","fee schedule","0.4","0.41","APC"
"Lith ion batt cid,non-earlvl","L8623","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","81.44","","","","","","","fee schedule","79.31","81.64","APC"
"Lith ion batt cid,non-earlvl","L8623","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","80.08","","","","","","","fee schedule","79.31","81.64","APC"
"Lith ion batt cid,non-earlvl","L8623","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","79.31","","","","","","","fee schedule","79.31","81.64","APC"
"Lith ion batt cid,non-earlvl","L8623","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81.64","","","","","","","fee schedule","79.31","81.64","APC"
"Lith ion batt cid, ear level","L8624","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","203.03","","","","","","","fee schedule","197.7","203.51","APC"
"Lith ion batt cid, ear level","L8624","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","199.63","","","","","","","fee schedule","197.7","203.51","APC"
"Lith ion batt cid, ear level","L8624","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","197.7","","","","","","","fee schedule","197.7","203.51","APC"
"Lith ion batt cid, ear level","L8624","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","203.51","","","","","","","fee schedule","197.7","203.51","APC"
"Charger coch impl/aoi battry","L8625","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","237.75","","","","","","","fee schedule","231.51","238.32","APC"
"Charger coch impl/aoi battry","L8625","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","233.78","","","","","","","fee schedule","231.51","238.32","APC"
"Charger coch impl/aoi battry","L8625","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","231.51","","","","","","","fee schedule","231.51","238.32","APC"
"Charger coch impl/aoi battry","L8625","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","238.32","","","","","","","fee schedule","231.51","238.32","APC"
"CID ext speech process repl","L8627","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9171.28","","","","","","","fee schedule","8930.51","9193.17","APC"
"CID ext speech process repl","L8627","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9018.06","","","","","","","fee schedule","8930.51","9193.17","APC"
"CID ext speech process repl","L8627","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8930.51","","","","","","","fee schedule","8930.51","9193.17","APC"
"CID ext speech process repl","L8627","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9193.17","","","","","","","fee schedule","8930.51","9193.17","APC"
"CID ext controller repl","L8628","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1563.84","","","","","","","fee schedule","1522.79","1567.58","APC"
"CID ext controller repl","L8628","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1537.72","","","","","","","fee schedule","1522.79","1567.58","APC"
"CID ext controller repl","L8628","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1522.79","","","","","","","fee schedule","1522.79","1567.58","APC"
"CID ext controller repl","L8628","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1567.58","","","","","","","fee schedule","1522.79","1567.58","APC"
"CID transmit coil and cable","L8629","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","225.4","","","","","","","fee schedule","219.48","225.94","APC"
"CID transmit coil and cable","L8629","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","221.64","","","","","","","fee schedule","219.48","225.94","APC"
"CID transmit coil and cable","L8629","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","219.48","","","","","","","fee schedule","219.48","225.94","APC"
"CID transmit coil and cable","L8629","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","225.94","","","","","","","fee schedule","219.48","225.94","APC"
"Pt prgrm for implt neurostim","L8681","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1383.45","","","","","","","fee schedule","1347.13","1386.76","APC"
"Pt prgrm for implt neurostim","L8681","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1360.34","","","","","","","fee schedule","1347.13","1386.76","APC"
"Pt prgrm for implt neurostim","L8681","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1347.13","","","","","","","fee schedule","1347.13","1386.76","APC"
"Pt prgrm for implt neurostim","L8681","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1386.76","","","","","","","fee schedule","1347.13","1386.76","APC"
"Radiofq trsmtr for implt neu","L8683","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6633.86","","","","","","","fee schedule","6459.7","6649.69","APC"
"Radiofq trsmtr for implt neu","L8683","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6523.03","","","","","","","fee schedule","6459.7","6649.69","APC"
"Radiofq trsmtr for implt neu","L8683","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6459.7","","","","","","","fee schedule","6459.7","6649.69","APC"
"Radiofq trsmtr for implt neu","L8683","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6649.69","","","","","","","fee schedule","6459.7","6649.69","APC"
"Radiof trsmtr implt scrl neu","L8684","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1018.35","","","","","","","fee schedule","991.61","1020.78","APC"
"Radiof trsmtr implt scrl neu","L8684","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1001.34","","","","","","","fee schedule","991.61","1020.78","APC"
"Radiof trsmtr implt scrl neu","L8684","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","991.61","","","","","","","fee schedule","991.61","1020.78","APC"
"Radiof trsmtr implt scrl neu","L8684","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1020.78","","","","","","","fee schedule","991.61","1020.78","APC"
"External recharg sys intern","L8689","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2171.58","","","","","","","fee schedule","2114.57","2176.77","APC"
"External recharg sys intern","L8689","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2135.3","","","","","","","fee schedule","2114.57","2176.77","APC"
"External recharg sys intern","L8689","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2114.57","","","","","","","fee schedule","2114.57","2176.77","APC"
"External recharg sys intern","L8689","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2176.77","","","","","","","fee schedule","2114.57","2176.77","APC"
"Osseointegrated snd proc rpl","L8691","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2168.04","","","","","","","fee schedule","2111.12","2173.22","APC"
"Osseointegrated snd proc rpl","L8691","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2131.82","","","","","","","fee schedule","2111.12","2173.22","APC"
"Osseointegrated snd proc rpl","L8691","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2111.12","","","","","","","fee schedule","2111.12","2173.22","APC"
"Osseointegrated snd proc rpl","L8691","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2173.22","","","","","","","fee schedule","2111.12","2173.22","APC"
"Aud osseo dev, abutment","L8693","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1908.94","","","","","","","fee schedule","1858.83","1913.5","APC"
"Aud osseo dev, abutment","L8693","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1877.05","","","","","","","fee schedule","1858.83","1913.5","APC"
"Aud osseo dev, abutment","L8693","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1858.83","","","","","","","fee schedule","1858.83","1913.5","APC"
"Aud osseo dev, abutment","L8693","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1913.5","","","","","","","fee schedule","1858.83","1913.5","APC"
"Aoi transducer/actuator repl","L8694","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1188.89","","","","","","","fee schedule","1157.68","1191.73","APC"
"Aoi transducer/actuator repl","L8694","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1169.03","","","","","","","fee schedule","1157.68","1191.73","APC"
"Aoi transducer/actuator repl","L8694","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1157.68","","","","","","","fee schedule","1157.68","1191.73","APC"
"Aoi transducer/actuator repl","L8694","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1191.73","","","","","","","fee schedule","1157.68","1191.73","APC"
"External recharg sys extern","L8695","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.95","","","","","","","fee schedule","20.4","21","APC"
"External recharg sys extern","L8695","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.6","","","","","","","fee schedule","20.4","21","APC"
"External recharg sys extern","L8695","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.4","","","","","","","fee schedule","20.4","21","APC"
"External recharg sys extern","L8695","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21","","","","","","","fee schedule","20.4","21","APC"
"Ext antenna phren nerve stim","L8696","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","272.86","","","","","","","fee schedule","265.7","273.51","APC"
"Ext antenna phren nerve stim","L8696","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","268.3","","","","","","","fee schedule","265.7","273.51","APC"
"Ext antenna phren nerve stim","L8696","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","265.7","","","","","","","fee schedule","265.7","273.51","APC"
"Ext antenna phren nerve stim","L8696","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","273.51","","","","","","","fee schedule","265.7","273.51","APC"
"Pow ue rom dev ewh uprt cust","L8701","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36631.21","","","","","","","fee schedule","35669.53","36718.64","APC"
"Pow ue rom dev ewh uprt cust","L8701","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","36019.23","","","","","","","fee schedule","35669.53","36718.64","APC"
"Pow ue rom dev ewh uprt cust","L8701","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35669.53","","","","","","","fee schedule","35669.53","36718.64","APC"
"Pow ue rom dev ewh uprt cust","L8701","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36718.64","","","","","","","fee schedule","35669.53","36718.64","APC"
"Pow ue rom dev ewhf uprt cus","L8702","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","72069.79","","","","","","","fee schedule","70177.74","72241.8","APC"
"Pow ue rom dev ewhf uprt cus","L8702","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","70865.76","","","","","","","fee schedule","70177.74","72241.8","APC"
"Pow ue rom dev ewhf uprt cus","L8702","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","70177.74","","","","","","","fee schedule","70177.74","72241.8","APC"
"Pow ue rom dev ewhf uprt cus","L8702","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","72241.8","","","","","","","fee schedule","70177.74","72241.8","APC"
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.95","7.33",""
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.95","","","","","","","fee schedule","4.95","7.33",""
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.95","7.33",""
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.19","","","","","","","fee schedule","4.95","7.33","APC"
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.1","","","","","","","fee schedule","4.95","7.33","APC"
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.95","7.33","APC"
"Cephalin floculation test","P2028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.2","","","","","","","fee schedule","4.95","7.33","APC"
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.95","7.33",""
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.95","","","","","","","fee schedule","4.95","7.33",""
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.95","7.33",""
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.19","","","","","","","fee schedule","4.95","7.33","APC"
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.1","","","","","","","fee schedule","4.95","7.33","APC"
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.95","7.33","APC"
"Congo red blood test","P2029","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.2","","","","","","","fee schedule","4.95","7.33","APC"
"Hair analysis","P2031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.95","7.33",""
"Hair analysis","P2031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.95","","","","","","","fee schedule","4.95","7.33",""
"Hair analysis","P2031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Hair analysis","P2031","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Hair analysis","P2031","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.95","7.33",""
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","4.95","7.33",""
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.95","","","","","","","fee schedule","4.95","7.33",""
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.95","","","","","","","fee schedule","4.95","7.33",""
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","4.95","7.33",""
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.19","","","","","","","fee schedule","4.95","7.33","APC"
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.1","","","","","","","fee schedule","4.95","7.33","APC"
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.95","7.33","APC"
"Blood thymol turbidity","P2033","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.2","","","","","","","fee schedule","4.95","7.33","APC"
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","8.64","","","","","","","fee schedule","4.95","8.64",""
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.95","","","","","","","fee schedule","4.95","8.64",""
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.95","","","","","","","fee schedule","4.95","8.64",""
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.95","","","","","","","fee schedule","4.95","8.64",""
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","8.64","","","","","","","fee schedule","4.95","8.64",""
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.19","","","","","","","fee schedule","4.95","8.64","APC"
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.1","","","","","","","fee schedule","4.95","8.64","APC"
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.05","","","","","","","fee schedule","4.95","8.64","APC"
"Blood mucoprotein","P2038","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.2","","","","","","","fee schedule","4.95","8.64","APC"
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.16","","","","","","","fee schedule","18.16","19.47",""
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","18.16","19.47",""
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","18.16","19.47",""
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","18.16","19.47",""
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.16","","","","","","","fee schedule","18.16","19.47",""
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","18.16","19.47","APC"
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","18.16","19.47","APC"
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","18.16","19.47","APC"
"Screen pap by tech w md supv","P3000","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","18.16","19.47","APC"
"Screening pap smear by phys","P3001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","33.78","","","","","","","fee schedule","33.78","33.78",""
"Screening pap smear by phys","P3001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","33.78","","","","","","","fee schedule","33.78","33.78",""
"Culture bacterial urine","P7001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","18.62","","","","","","","fee schedule","18.62","18.62",""
"Culture bacterial urine","P7001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","18.62","","","","","","","fee schedule","18.62","18.62",""
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","587.34","","","","","","","fee schedule","188.61","654.29","APC 277.30"
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","628.13","","","","","","","fee schedule","188.61","654.29","APC 296.56"
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","654.29","","","","","","","fee schedule","188.61","654.29","APC 308.91"
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","193.69","","","","","","","fee schedule","188.61","654.29","APC"
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.46","","","","","","","fee schedule","188.61","654.29","APC"
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.61","","","","","","","fee schedule","188.61","654.29","APC"
"Rbc leukocytes reduced","P9016","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.16","","","","","","","fee schedule","188.61","654.29","APC"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","177.75","","","","","","","fee schedule","57.08","198.01","APC 277.30"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","190.09","","","","","","","fee schedule","57.08","198.01","APC 296.56"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198.01","","","","","","","fee schedule","57.08","198.01","APC 308.91"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58.62","","","","","","","fee schedule","57.08","198.01","APC"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","57.64","","","","","","","fee schedule","57.08","198.01","APC"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57.08","","","","","","","fee schedule","57.08","198.01","APC"
"Frozen plasma, pooled, sd","P9023","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58.76","","","","","","","fee schedule","57.08","198.01","APC"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","843.04","","","","","","","fee schedule","270.72","939.14","APC 277.30"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","901.59","","","","","","","fee schedule","270.72","939.14","APC 296.56"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","939.14","","","","","","","fee schedule","270.72","939.14","APC 308.91"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","278.02","","","","","","","fee schedule","270.72","939.14","APC"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","273.37","","","","","","","fee schedule","270.72","939.14","APC"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","270.72","","","","","","","fee schedule","270.72","939.14","APC"
"RBC leukoreduced irradiated","P9040","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","278.68","","","","","","","fee schedule","270.72","939.14","APC"
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","168.79","","","","","","","fee schedule","54.14","187.9",""
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","180.47","","","","","","","fee schedule","54.14","187.9",""
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","187.9","","","","","","","fee schedule","54.14","187.9",""
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","55.6","","","","","","","fee schedule","54.14","187.9","APC"
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","54.67","","","","","","","fee schedule","54.14","187.9","APC"
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","54.14","","","","","","","fee schedule","54.14","187.9","APC"
"Albumin (human), 5%, 250 ml","P9045","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55.73","","","","","","","fee schedule","54.14","187.9","APC"
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","67.51","","","","","","","fee schedule","21.66","75.15",""
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","72.18","","","","","","","fee schedule","21.66","75.15",""
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","75.15","","","","","","","fee schedule","21.66","75.15",""
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22.24","","","","","","","fee schedule","21.66","75.15","APC"
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.87","","","","","","","fee schedule","21.66","75.15","APC"
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21.66","","","","","","","fee schedule","21.66","75.15","APC"
"Albumin (human), 25%, 20 ml","P9046","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22.29","","","","","","","fee schedule","21.66","75.15","APC"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","234.32","","","","","","","fee schedule","75.25","261.03","APC 277.30"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","250.59","","","","","","","fee schedule","75.25","261.03","APC 296.56"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","261.03","","","","","","","fee schedule","75.25","261.03","APC 308.91"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","77.27","","","","","","","fee schedule","75.25","261.03","APC"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","75.98","","","","","","","fee schedule","75.25","261.03","APC"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","75.25","","","","","","","fee schedule","75.25","261.03","APC"
"Plasma, frz between 8-24hour","P9059","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","77.46","","","","","","","fee schedule","75.25","261.03","APC"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1929.41","","","","","","","fee schedule","619.58","2149.35","APC 277.30"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2063.42","","","","","","","fee schedule","619.58","2149.35","APC 296.56"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2149.35","","","","","","","fee schedule","619.58","2149.35","APC 308.91"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","636.28","","","","","","","fee schedule","619.58","2149.35","APC"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","625.65","","","","","","","fee schedule","619.58","2149.35","APC"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","619.58","","","","","","","fee schedule","619.58","2149.35","APC"
"Platelets, pathogen reduced","P9073","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","637.8","","","","","","","fee schedule","619.58","2149.35","APC"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","30.6","","","","","","","fee schedule","30.6","203.66",""
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","30.6","","","","","","","fee schedule","30.6","203.66",""
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.82","","","","","","","fee schedule","30.6","203.66","APC 277.30"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.52","","","","","","","fee schedule","30.6","203.66","APC 296.56"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.66","","","","","","","fee schedule","30.6","203.66","APC 308.91"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60.29","","","","","","","fee schedule","30.6","203.66","APC"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","59.28","","","","","","","fee schedule","30.6","203.66","APC"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58.71","","","","","","","fee schedule","30.6","203.66","APC"
"Pathogen test for platelets","P9100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60.44","","","","","","","fee schedule","30.6","203.66","APC"
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3.6","","","","","","","fee schedule","3.6","9.81",""
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.09","","","","","","","fee schedule","3.6","9.81",""
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.09","","","","","","","fee schedule","3.6","9.81",""
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.09","","","","","","","fee schedule","3.6","9.81",""
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3.6","","","","","","","fee schedule","3.6","9.81",""
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.78","","","","","","","fee schedule","3.6","9.81","APC"
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","9.62","","","","","","","fee schedule","3.6","9.81","APC"
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.53","","","","","","","fee schedule","3.6","9.81","APC"
"Catheterize for urine spec","P9612","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.81","","","","","","","fee schedule","3.6","9.81","APC"
"Urine specimen collect mult","P9615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","3.6","","","","","","","fee schedule","3.6","9.09",""
"Urine specimen collect mult","P9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.09","","","","","","","fee schedule","3.6","9.09",""
"Urine specimen collect mult","P9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.09","","","","","","","fee schedule","3.6","9.09",""
"Urine specimen collect mult","P9615","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.09","","","","","","","fee schedule","3.6","9.09",""
"Urine specimen collect mult","P9615","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","3.6","","","","","","","fee schedule","3.6","9.09",""
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","115.76","","","","","","","fee schedule","37.17","128.95","APC 277.30"
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","123.8","","","","","","","fee schedule","37.17","128.95","APC 296.56"
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","128.95","","","","","","","fee schedule","37.17","128.95","APC 308.91"
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.17","","","","","","","fee schedule","37.17","128.95","APC"
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.54","","","","","","","fee schedule","37.17","128.95","APC"
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.17","","","","","","","fee schedule","37.17","128.95","APC"
"Cardiokymography","Q0035","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.26","","","","","","","fee schedule","37.17","128.95","APC"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","10.68","","","","","","","fee schedule","10.68","99.86",""
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","10.68","","","","","","","fee schedule","10.68","99.86",""
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.64","","","","","","","fee schedule","10.68","99.86","APC 277.30"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.86","","","","","","","fee schedule","10.68","99.86","APC 296.56"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.86","","","","","","","fee schedule","10.68","99.86","APC 308.91"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.56","","","","","","","fee schedule","10.68","99.86","APC"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","29.07","","","","","","","fee schedule","10.68","99.86","APC"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.78","","","","","","","fee schedule","10.68","99.86","APC"
"Obtaining screen pap smear","Q0091","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.63","","","","","","","fee schedule","10.68","99.86","APC"
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","7.33","19.47",""
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.19","","","","","","","fee schedule","7.33","19.47",""
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","18.19","","","","","","","fee schedule","7.33","19.47",""
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","18.19","","","","","","","fee schedule","7.33","19.47",""
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","7.33","19.47",""
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.42","","","","","","","fee schedule","7.33","19.47","APC"
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.1","","","","","","","fee schedule","7.33","19.47","APC"
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18.91","","","","","","","fee schedule","7.33","19.47","APC"
"Wet mounts/ w preparations","Q0111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.47","","","","","","","fee schedule","7.33","19.47","APC"
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","7.33","","","","","","","fee schedule","5.83","7.33",""
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5.83","","","","","","","fee schedule","5.83","7.33",""
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5.83","","","","","","","fee schedule","5.83","7.33",""
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5.83","","","","","","","fee schedule","5.83","7.33",""
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","7.33","","","","","","","fee schedule","5.83","7.33",""
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6.11","","","","","","","fee schedule","5.83","7.33","APC"
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","6","","","","","","","fee schedule","5.83","7.33","APC"
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.95","","","","","","","fee schedule","5.83","7.33","APC"
"Potassium hydroxide preps","Q0112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6.12","","","","","","","fee schedule","5.83","7.33","APC"
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","9.3","","","","","","","fee schedule","4.27","9.3",""
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4.27","","","","","","","fee schedule","4.27","9.3",""
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4.27","","","","","","","fee schedule","4.27","9.3",""
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4.27","","","","","","","fee schedule","4.27","9.3",""
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","9.3","","","","","","","fee schedule","4.27","9.3",""
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.47","","","","","","","fee schedule","4.27","9.3","APC"
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.4","","","","","","","fee schedule","4.27","9.3","APC"
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.36","","","","","","","fee schedule","4.27","9.3","APC"
"Pinworm examinations","Q0113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.48","","","","","","","fee schedule","4.27","9.3","APC"
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","12.29","","","","","","","fee schedule","9.74","12.29",""
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","9.74","","","","","","","fee schedule","9.74","12.29",""
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","9.74","","","","","","","fee schedule","9.74","12.29",""
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","9.74","","","","","","","fee schedule","9.74","12.29",""
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","12.29","","","","","","","fee schedule","9.74","12.29",""
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10.2","","","","","","","fee schedule","9.74","12.29","APC"
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","10.03","","","","","","","fee schedule","9.74","12.29","APC"
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9.93","","","","","","","fee schedule","9.74","12.29","APC"
"Fern test","Q0114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10.23","","","","","","","fee schedule","9.74","12.29","APC"
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","17.02","","","","","","","fee schedule","17.02","26.25",""
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","25","","","","","","","fee schedule","17.02","26.25",""
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25","","","","","","","fee schedule","17.02","26.25",""
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25","","","","","","","fee schedule","17.02","26.25",""
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","17.02","","","","","","","fee schedule","17.02","26.25",""
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.19","","","","","","","fee schedule","17.02","26.25","APC"
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.75","","","","","","","fee schedule","17.02","26.25","APC"
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.5","","","","","","","fee schedule","17.02","26.25","APC"
"Post-coital mucous exam","Q0115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.25","","","","","","","fee schedule","17.02","26.25","APC"
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.99","","","","","","","fee schedule","0.33","1.1",""
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.05","","","","","","","fee schedule","0.33","1.1",""
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.1","","","","","","","fee schedule","0.33","1.1",""
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.34","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.33","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.33","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, non-esrd","Q0138","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.34","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.99","","","","","","","fee schedule","0.33","1.1",""
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.05","","","","","","","fee schedule","0.33","1.1",""
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.1","","","","","","","fee schedule","0.33","1.1",""
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.34","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.33","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.33","","","","","","","fee schedule","0.33","1.1","APC"
"Ferumoxytol, esrd use","Q0139","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.34","","","","","","","fee schedule","0.33","1.1","APC"
"Inj, pemivibart, 4500 mg","Q0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","23020.02","","","","","","","fee schedule","23020.02","25626.06",""
"Inj, pemivibart, 4500 mg","Q0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","24612.6","","","","","","","fee schedule","23020.02","25626.06",""
"Inj, pemivibart, 4500 mg","Q0224","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","25626.06","","","","","","","fee schedule","23020.02","25626.06",""
"Tocilizumab for covid-19","Q0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.07","","","","","","","fee schedule","24.07","26.8",""
"Tocilizumab for covid-19","Q0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.74","","","","","","","fee schedule","24.07","26.8",""
"Tocilizumab for covid-19","Q0249","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.8","","","","","","","fee schedule","24.07","26.8",""
"Pwr module pt cable lvad rpl","Q0477","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","976.68","","","","","","","fee schedule","951.04","979.01","APC"
"Pwr module pt cable lvad rpl","Q0477","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","960.36","","","","","","","fee schedule","951.04","979.01","APC"
"Pwr module pt cable lvad rpl","Q0477","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","951.04","","","","","","","fee schedule","951.04","979.01","APC"
"Pwr module pt cable lvad rpl","Q0477","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","979.01","","","","","","","fee schedule","951.04","979.01","APC"
"Power adapter, combo vad","Q0478","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","231.36","","","","","","","fee schedule","225.29","231.91","APC"
"Power adapter, combo vad","Q0478","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","227.5","","","","","","","fee schedule","225.29","231.91","APC"
"Power adapter, combo vad","Q0478","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","225.29","","","","","","","fee schedule","225.29","231.91","APC"
"Power adapter, combo vad","Q0478","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","231.91","","","","","","","fee schedule","225.29","231.91","APC"
"Power module combo vad, rep","Q0479","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15117.26","","","","","","","fee schedule","14720.38","15153.34","APC"
"Power module combo vad, rep","Q0479","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","14864.7","","","","","","","fee schedule","14720.38","15153.34","APC"
"Power module combo vad, rep","Q0479","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14720.38","","","","","","","fee schedule","14720.38","15153.34","APC"
"Power module combo vad, rep","Q0479","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15153.34","","","","","","","fee schedule","14720.38","15153.34","APC"
"driver pneumatic vad, rep","Q0480","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","113384.91","","","","","","","fee schedule","110408.22","113655.52","APC"
"driver pneumatic vad, rep","Q0480","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","111490.65","","","","","","","fee schedule","110408.22","113655.52","APC"
"driver pneumatic vad, rep","Q0480","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","110408.22","","","","","","","fee schedule","110408.22","113655.52","APC"
"driver pneumatic vad, rep","Q0480","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","113655.52","","","","","","","fee schedule","110408.22","113655.52","APC"
"microprcsr cu elec vad, rep","Q0481","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18293.31","","","","","","","fee schedule","17813.06","18336.97","APC"
"microprcsr cu elec vad, rep","Q0481","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","17987.69","","","","","","","fee schedule","17813.06","18336.97","APC"
"microprcsr cu elec vad, rep","Q0481","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17813.06","","","","","","","fee schedule","17813.06","18336.97","APC"
"microprcsr cu elec vad, rep","Q0481","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18336.97","","","","","","","fee schedule","17813.06","18336.97","APC"
"microprcsr cu combo vad, rep","Q0482","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5729.8","","","","","","","fee schedule","5579.38","5743.48","APC"
"microprcsr cu combo vad, rep","Q0482","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5634.08","","","","","","","fee schedule","5579.38","5743.48","APC"
"microprcsr cu combo vad, rep","Q0482","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5579.38","","","","","","","fee schedule","5579.38","5743.48","APC"
"microprcsr cu combo vad, rep","Q0482","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5743.48","","","","","","","fee schedule","5579.38","5743.48","APC"
"monitor elec vad, rep","Q0483","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23604.28","","","","","","","fee schedule","22984.6","23660.62","APC"
"monitor elec vad, rep","Q0483","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","23209.94","","","","","","","fee schedule","22984.6","23660.62","APC"
"monitor elec vad, rep","Q0483","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22984.6","","","","","","","fee schedule","22984.6","23660.62","APC"
"monitor elec vad, rep","Q0483","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23660.62","","","","","","","fee schedule","22984.6","23660.62","APC"
"monitor elec or comb vad rep","Q0484","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4583.88","","","","","","","fee schedule","4463.54","4594.82","APC"
"monitor elec or comb vad rep","Q0484","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4507.3","","","","","","","fee schedule","4463.54","4594.82","APC"
"monitor elec or comb vad rep","Q0484","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4463.54","","","","","","","fee schedule","4463.54","4594.82","APC"
"monitor elec or comb vad rep","Q0484","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4594.82","","","","","","","fee schedule","4463.54","4594.82","APC"
"monitor cable elec vad, rep","Q0485","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","442.54","","","","","","","fee schedule","430.92","443.59","APC"
"monitor cable elec vad, rep","Q0485","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","435.14","","","","","","","fee schedule","430.92","443.59","APC"
"monitor cable elec vad, rep","Q0485","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","430.92","","","","","","","fee schedule","430.92","443.59","APC"
"monitor cable elec vad, rep","Q0485","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","443.59","","","","","","","fee schedule","430.92","443.59","APC"
"mon cable elec/pneum vad rep","Q0486","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","368.35","","","","","","","fee schedule","358.68","369.23","APC"
"mon cable elec/pneum vad rep","Q0486","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","362.2","","","","","","","fee schedule","358.68","369.23","APC"
"mon cable elec/pneum vad rep","Q0486","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","358.68","","","","","","","fee schedule","358.68","369.23","APC"
"mon cable elec/pneum vad rep","Q0486","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","369.23","","","","","","","fee schedule","358.68","369.23","APC"
"leads any type vad, rep only","Q0487","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","429.74","","","","","","","fee schedule","418.46","430.76","APC"
"leads any type vad, rep only","Q0487","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","422.56","","","","","","","fee schedule","418.46","430.76","APC"
"leads any type vad, rep only","Q0487","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","418.46","","","","","","","fee schedule","418.46","430.76","APC"
"leads any type vad, rep only","Q0487","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","430.76","","","","","","","fee schedule","418.46","430.76","APC"
"pwr pck base combo vad, rep","Q0489","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20463.61","","","","","","","fee schedule","19926.38","20512.45","APC"
"pwr pck base combo vad, rep","Q0489","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20121.74","","","","","","","fee schedule","19926.38","20512.45","APC"
"pwr pck base combo vad, rep","Q0489","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19926.38","","","","","","","fee schedule","19926.38","20512.45","APC"
"pwr pck base combo vad, rep","Q0489","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20512.45","","","","","","","fee schedule","19926.38","20512.45","APC"
"emr pwr source elec vad, rep","Q0490","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","885.17","","","","","","","fee schedule","861.93","887.28","APC"
"emr pwr source elec vad, rep","Q0490","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","870.38","","","","","","","fee schedule","861.93","887.28","APC"
"emr pwr source elec vad, rep","Q0490","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","861.93","","","","","","","fee schedule","861.93","887.28","APC"
"emr pwr source elec vad, rep","Q0490","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","887.28","","","","","","","fee schedule","861.93","887.28","APC"
"emr pwr source combo vad rep","Q0491","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1391.58","","","","","","","fee schedule","1355.05","1394.9","APC"
"emr pwr source combo vad rep","Q0491","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1368.33","","","","","","","fee schedule","1355.05","1394.9","APC"
"emr pwr source combo vad rep","Q0491","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1355.05","","","","","","","fee schedule","1355.05","1394.9","APC"
"emr pwr source combo vad rep","Q0491","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1394.9","","","","","","","fee schedule","1355.05","1394.9","APC"
"emr pwr cbl elec vad, rep","Q0492","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","112.09","","","","","","","fee schedule","109.15","112.36","APC"
"emr pwr cbl elec vad, rep","Q0492","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","110.22","","","","","","","fee schedule","109.15","112.36","APC"
"emr pwr cbl elec vad, rep","Q0492","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","109.15","","","","","","","fee schedule","109.15","112.36","APC"
"emr pwr cbl elec vad, rep","Q0492","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","112.36","","","","","","","fee schedule","109.15","112.36","APC"
"emr pwr cbl combo vad, rep","Q0493","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","319.25","","","","","","","fee schedule","310.87","320.01","APC"
"emr pwr cbl combo vad, rep","Q0493","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","313.91","","","","","","","fee schedule","310.87","320.01","APC"
"emr pwr cbl combo vad, rep","Q0493","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","310.87","","","","","","","fee schedule","310.87","320.01","APC"
"emr pwr cbl combo vad, rep","Q0493","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","320.01","","","","","","","fee schedule","310.87","320.01","APC"
"emr hd pmp elec/combo, rep","Q0494","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","270.15","","","","","","","fee schedule","263.06","270.8","APC"
"emr hd pmp elec/combo, rep","Q0494","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","265.64","","","","","","","fee schedule","263.06","270.8","APC"
"emr hd pmp elec/combo, rep","Q0494","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","263.06","","","","","","","fee schedule","263.06","270.8","APC"
"emr hd pmp elec/combo, rep","Q0494","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","270.8","","","","","","","fee schedule","263.06","270.8","APC"
"charger elec/combo vad, rep","Q0495","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5258.62","","","","","","","fee schedule","5120.56","5271.17","APC"
"charger elec/combo vad, rep","Q0495","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5170.76","","","","","","","fee schedule","5120.56","5271.17","APC"
"charger elec/combo vad, rep","Q0495","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5120.56","","","","","","","fee schedule","5120.56","5271.17","APC"
"charger elec/combo vad, rep","Q0495","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5271.17","","","","","","","fee schedule","5120.56","5271.17","APC"
"battery elec/combo vad, rep","Q0496","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1887.41","","","","","","","fee schedule","1837.86","1891.91","APC"
"battery elec/combo vad, rep","Q0496","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1855.87","","","","","","","fee schedule","1837.86","1891.91","APC"
"battery elec/combo vad, rep","Q0496","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1837.86","","","","","","","fee schedule","1837.86","1891.91","APC"
"battery elec/combo vad, rep","Q0496","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1891.91","","","","","","","fee schedule","1837.86","1891.91","APC"
"bat clps elec/comb vad, rep","Q0497","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","589.37","","","","","","","fee schedule","573.89","590.77","APC"
"bat clps elec/comb vad, rep","Q0497","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","579.52","","","","","","","fee schedule","573.89","590.77","APC"
"bat clps elec/comb vad, rep","Q0497","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","573.89","","","","","","","fee schedule","573.89","590.77","APC"
"bat clps elec/comb vad, rep","Q0497","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","590.77","","","","","","","fee schedule","573.89","590.77","APC"
"holster elec/combo vad, rep","Q0498","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","646.68","","","","","","","fee schedule","629.71","648.23","APC"
"holster elec/combo vad, rep","Q0498","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","635.88","","","","","","","fee schedule","629.71","648.23","APC"
"holster elec/combo vad, rep","Q0498","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","629.71","","","","","","","fee schedule","629.71","648.23","APC"
"holster elec/combo vad, rep","Q0498","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","648.23","","","","","","","fee schedule","629.71","648.23","APC"
"belt/vest elec/combo vad rep","Q0499","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","210.11","","","","","","","fee schedule","204.59","210.61","APC"
"belt/vest elec/combo vad rep","Q0499","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","206.6","","","","","","","fee schedule","204.59","210.61","APC"
"belt/vest elec/combo vad rep","Q0499","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","204.59","","","","","","","fee schedule","204.59","210.61","APC"
"belt/vest elec/combo vad rep","Q0499","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","210.61","","","","","","","fee schedule","204.59","210.61","APC"
"filters elec/combo vad, rep","Q0500","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38.45","","","","","","","fee schedule","37.44","38.55","APC"
"filters elec/combo vad, rep","Q0500","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37.81","","","","","","","fee schedule","37.44","38.55","APC"
"filters elec/combo vad, rep","Q0500","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37.44","","","","","","","fee schedule","37.44","38.55","APC"
"filters elec/combo vad, rep","Q0500","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38.55","","","","","","","fee schedule","37.44","38.55","APC"
"shwr cov elec/combo vad, rep","Q0501","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","642.9","","","","","","","fee schedule","626.02","644.44","APC"
"shwr cov elec/combo vad, rep","Q0501","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","632.16","","","","","","","fee schedule","626.02","644.44","APC"
"shwr cov elec/combo vad, rep","Q0501","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","626.02","","","","","","","fee schedule","626.02","644.44","APC"
"shwr cov elec/combo vad, rep","Q0501","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","644.44","","","","","","","fee schedule","626.02","644.44","APC"
"mobility cart pneum vad, rep","Q0502","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","818.51","","","","","","","fee schedule","797.02","820.46","APC"
"mobility cart pneum vad, rep","Q0502","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","804.83","","","","","","","fee schedule","797.02","820.46","APC"
"mobility cart pneum vad, rep","Q0502","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","797.02","","","","","","","fee schedule","797.02","820.46","APC"
"mobility cart pneum vad, rep","Q0502","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","820.46","","","","","","","fee schedule","797.02","820.46","APC"
"battery pneum vad replacemnt","Q0503","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1637.07","","","","","","","fee schedule","1594.1","1640.98","APC"
"battery pneum vad replacemnt","Q0503","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1609.73","","","","","","","fee schedule","1594.1","1640.98","APC"
"battery pneum vad replacemnt","Q0503","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1594.1","","","","","","","fee schedule","1594.1","1640.98","APC"
"battery pneum vad replacemnt","Q0503","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1640.98","","","","","","","fee schedule","1594.1","1640.98","APC"
"pwr adpt pneum vad, rep veh","Q0504","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","863.85","","","","","","","fee schedule","841.17","865.91","APC"
"pwr adpt pneum vad, rep veh","Q0504","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","849.42","","","","","","","fee schedule","841.17","865.91","APC"
"pwr adpt pneum vad, rep veh","Q0504","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","841.17","","","","","","","fee schedule","841.17","865.91","APC"
"pwr adpt pneum vad, rep veh","Q0504","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","865.91","","","","","","","fee schedule","841.17","865.91","APC"
"Lith-ion batt elec/pneum VAD","Q0506","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1075.3","","","","","","","fee schedule","1047.07","1077.87","APC"
"Lith-ion batt elec/pneum VAD","Q0506","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1057.34","","","","","","","fee schedule","1047.07","1077.87","APC"
"Lith-ion batt elec/pneum VAD","Q0506","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1047.07","","","","","","","fee schedule","1047.07","1077.87","APC"
"Lith-ion batt elec/pneum VAD","Q0506","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1077.87","","","","","","","fee schedule","1047.07","1077.87","APC"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1060.28","","","","","","","fee schedule","356.17","1235.59",""
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1133.63","","","","","","","fee schedule","356.17","1235.59",""
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1180.31","","","","","","","fee schedule","356.17","1235.59",""
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1109.15","","","","","","","fee schedule","356.17","1235.59","APC 277.30"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1186.19","","","","","","","fee schedule","356.17","1235.59","APC 296.56"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1235.59","","","","","","","fee schedule","356.17","1235.59","APC 308.91"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","365.78","","","","","","","fee schedule","356.17","1235.59","APC"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","359.67","","","","","","","fee schedule","356.17","1235.59","APC"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","356.17","","","","","","","fee schedule","356.17","1235.59","APC"
"Radiesse injection","Q2026","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","366.65","","","","","","","fee schedule","356.17","1235.59","APC"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","3.18","","","","","","","fee schedule","2.2","7.64",""
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","3.4","","","","","","","fee schedule","2.2","7.64",""
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3.54","","","","","","","fee schedule","2.2","7.64",""
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6.86","","","","","","","fee schedule","2.2","7.64","APC 277.30"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","7.34","","","","","","","fee schedule","2.2","7.64","APC 296.56"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","7.64","","","","","","","fee schedule","2.2","7.64","APC 308.91"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2.26","","","","","","","fee schedule","2.2","7.64","APC"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2.22","","","","","","","fee schedule","2.2","7.64","APC"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2.2","","","","","","","fee schedule","2.2","7.64","APC"
"Inj, sculptra, 0.5mg","Q2028","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2.27","","","","","","","fee schedule","2.2","7.64","APC"
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","559891.68",""
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","559891.68",""
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","559891.68",""
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","558558.6","","","","","","","fee schedule","0.03","559891.68","APC"
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","549227.08","","","","","","","fee schedule","0.03","559891.68","APC"
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","543894.77","","","","","","","fee schedule","0.03","559891.68","APC"
"Axicabtagene ciloleucel car+","Q2041","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","559891.68","","","","","","","fee schedule","0.03","559891.68","APC"
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","621312.51",""
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","621312.51",""
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","621312.51",""
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","619833.2","","","","","","","fee schedule","0.03","621312.51","APC"
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","609477.99","","","","","","","fee schedule","0.03","621312.51","APC"
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","603560.73","","","","","","","fee schedule","0.03","621312.51","APC"
"Tisagenlecleucel car-pos t","Q2042","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","621312.51","","","","","","","fee schedule","0.03","621312.51","APC"
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","177908.18","","","","","","","fee schedule","56377.77","198048.73",""
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","190216.3","","","","","","","fee schedule","56377.77","198048.73",""
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","198048.73","","","","","","","fee schedule","56377.77","198048.73",""
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57897.76","","","","","","","fee schedule","56377.77","198048.73","APC"
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","56930.49","","","","","","","fee schedule","56377.77","198048.73","APC"
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56377.77","","","","","","","fee schedule","56377.77","198048.73","APC"
"Sipuleucel-t auto cd54+","Q2043","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58035.94","","","","","","","fee schedule","56377.77","198048.73","APC"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1681.77","","","","","","","fee schedule","304.71","1872.16",""
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1798.12","","","","","","","fee schedule","304.71","1872.16",""
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1872.16","","","","","","","fee schedule","304.71","1872.16",""
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","948.9","","","","","","","fee schedule","304.71","1872.16","APC 277.30"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1014.81","","","","","","","fee schedule","304.71","1872.16","APC 296.56"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1057.07","","","","","","","fee schedule","304.71","1872.16","APC 308.91"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","312.93","","","","","","","fee schedule","304.71","1872.16","APC"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","307.7","","","","","","","fee schedule","304.71","1872.16","APC"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","304.71","","","","","","","fee schedule","304.71","1872.16","APC"
"Imported Lipodox inj","Q2049","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","313.68","","","","","","","fee schedule","304.71","1872.16","APC"
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","347.51","","","","","","","fee schedule","110.64","386.85",""
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","371.55","","","","","","","fee schedule","110.64","386.85",""
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","386.85","","","","","","","fee schedule","110.64","386.85",""
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","113.62","","","","","","","fee schedule","110.64","386.85","APC"
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","111.72","","","","","","","fee schedule","110.64","386.85","APC"
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","110.64","","","","","","","fee schedule","110.64","386.85","APC"
"Doxorubicin inj 10mg","Q2050","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","113.89","","","","","","","fee schedule","110.64","386.85","APC"
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","513769.84",""
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","513769.84",""
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","513769.84",""
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","512546.58","","","","","","","fee schedule","0.03","513769.84","APC"
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","503983.75","","","","","","","fee schedule","0.03","513769.84","APC"
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","499090.7","","","","","","","fee schedule","0.03","513769.84","APC"
"Brexucabtagene car pos t","Q2053","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","513769.84","","","","","","","fee schedule","0.03","513769.84","APC"
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","590665.09",""
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","590665.09",""
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","590665.09",""
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","589258.75","","","","","","","fee schedule","0.03","590665.09","APC"
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","579414.33","","","","","","","fee schedule","0.03","590665.09","APC"
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","573788.95","","","","","","","fee schedule","0.03","590665.09","APC"
"Lisocabtagene mara car pos t","Q2054","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","590665.09","","","","","","","fee schedule","0.03","590665.09","APC"
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","585183.83",""
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","585183.83",""
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","585183.83",""
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","583790.54","","","","","","","fee schedule","0.03","585183.83","APC"
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","574037.47","","","","","","","fee schedule","0.03","585183.83","APC"
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","568464.29","","","","","","","fee schedule","0.03","585183.83","APC"
"Idecabtagene vicleucel car","Q2055","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","585183.83","","","","","","","fee schedule","0.03","585183.83","APC"
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","594162.39",""
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","594162.39",""
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","594162.39",""
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","592747.72","","","","","","","fee schedule","0.03","594162.39","APC"
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","582845.01","","","","","","","fee schedule","0.03","594162.39","APC"
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","577186.32","","","","","","","fee schedule","0.03","594162.39","APC"
"Ciltacabtagene car-pos t","Q2056","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","594162.39","","","","","","","fee schedule","0.03","594162.39","APC"
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","809151",""
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","809151",""
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","809151",""
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","807224.45","","","","","","","fee schedule","0.03","809151","APC"
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","793738.6","","","","","","","fee schedule","0.03","809151","APC"
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","786032.4","","","","","","","fee schedule","0.03","809151","APC"
"Afamitresgene autoleucel","Q2057","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","809151","","","","","","","fee schedule","0.03","809151","APC"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.03","","","","","","","fee schedule","0.03","984569.34",""
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.03","","","","","","","fee schedule","0.03","984569.34",""
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","0.04","","","","","","","fee schedule","0.03","984569.34",""
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","883820.78","","","","","","","fee schedule","0.03","984569.34","APC 277.30"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","945206.96","","","","","","","fee schedule","0.03","984569.34","APC 296.56"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","984569.34","","","","","","","fee schedule","0.03","984569.34","APC 308.91"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","291466.88","","","","","","","fee schedule","0.03","984569.34","APC"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","286597.5","","","","","","","fee schedule","0.03","984569.34","APC"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","283815","","","","","","","fee schedule","0.03","984569.34","APC"
"Obecbtge autol up to 400 mil","Q2058","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","292162.5","","","","","","","fee schedule","0.03","984569.34","APC"
"Inj beta interferon im 1 mcg","Q3027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","182.75","","","","","","","fee schedule","182.75","203.44",""
"Inj beta interferon im 1 mcg","Q3027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","195.4","","","","","","","fee schedule","182.75","203.44",""
"Inj beta interferon im 1 mcg","Q3027","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","203.44","","","","","","","fee schedule","182.75","203.44",""
"Inj ustekinumab-stba, 1 mg","Q5099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","7.66","","","","","","","fee schedule","7.66","8.53",""
"Inj ustekinumab-stba, 1 mg","Q5099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","8.19","","","","","","","fee schedule","7.66","8.53",""
"Inj ustekinumab-stba, 1 mg","Q5099","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","8.53","","","","","","","fee schedule","7.66","8.53",""
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","10.08","","","","","","","fee schedule","10.08","26.23",""
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","10.78","","","","","","","fee schedule","10.08","26.23",""
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","11.22","","","","","","","fee schedule","10.08","26.23",""
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.17","","","","","","","fee schedule","10.08","26.23","APC"
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","25.73","","","","","","","fee schedule","10.08","26.23","APC"
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25.48","","","","","","","fee schedule","10.08","26.23","APC"
"Inj ustekinumab-kfce, 1 mg","Q5100","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26.23","","","","","","","fee schedule","10.08","26.23","APC"
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.18","","","","","","","fee schedule","0.47","1.31",""
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.26","","","","","","","fee schedule","0.47","1.31",""
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.31","","","","","","","fee schedule","0.47","1.31",""
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.48","","","","","","","fee schedule","0.47","1.31","APC"
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.47","","","","","","","fee schedule","0.47","1.31","APC"
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.47","","","","","","","fee schedule","0.47","1.31","APC"
"Inj filgrastim gcsf biosimil","Q5101","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.48","","","","","","","fee schedule","0.47","1.31","APC"
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","62.58","","","","","","","fee schedule","20.39","69.67",""
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","66.91","","","","","","","fee schedule","20.39","69.67",""
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","69.67","","","","","","","fee schedule","20.39","69.67",""
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20.94","","","","","","","fee schedule","20.39","69.67","APC"
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","20.59","","","","","","","fee schedule","20.39","69.67","APC"
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.39","","","","","","","fee schedule","20.39","69.67","APC"
"Injection, inflectra","Q5103","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20.99","","","","","","","fee schedule","20.39","69.67","APC"
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","79.66","","","","","","","fee schedule","27.54","88.68",""
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","85.17","","","","","","","fee schedule","27.54","88.68",""
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","88.68","","","","","","","fee schedule","27.54","88.68",""
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.28","","","","","","","fee schedule","27.54","88.68","APC"
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.81","","","","","","","fee schedule","27.54","88.68","APC"
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.54","","","","","","","fee schedule","27.54","88.68","APC"
"Injection, renflexis","Q5104","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.35","","","","","","","fee schedule","27.54","88.68","APC"
"Inj Retacrit esrd on dialysi","Q5105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2.42","","","","","","","fee schedule","2.42","2.69",""
"Inj Retacrit esrd on dialysi","Q5105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2.58","","","","","","","fee schedule","2.42","2.69",""
"Inj Retacrit esrd on dialysi","Q5105","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","2.69","","","","","","","fee schedule","2.42","2.69",""
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.07","","","","","","","fee schedule","8.01","26.8",""
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","25.74","","","","","","","fee schedule","8.01","26.8",""
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","26.8","","","","","","","fee schedule","8.01","26.8",""
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8.22","","","","","","","fee schedule","8.01","26.8","APC"
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.09","","","","","","","fee schedule","8.01","26.8","APC"
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.01","","","","","","","fee schedule","8.01","26.8","APC"
"Inj Retacrit non-esrd use","Q5106","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8.24","","","","","","","fee schedule","8.01","26.8","APC"
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.74","","","","","","","fee schedule","28.42","102.13",""
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","98.09","","","","","","","fee schedule","28.42","102.13",""
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","102.13","","","","","","","fee schedule","28.42","102.13",""
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.19","","","","","","","fee schedule","28.42","102.13","APC"
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.7","","","","","","","fee schedule","28.42","102.13","APC"
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.42","","","","","","","fee schedule","28.42","102.13","APC"
"Inj mvasi 10 mg","Q5107","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.26","","","","","","","fee schedule","28.42","102.13","APC"
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","329.8","","","","","","","fee schedule","101.11","367.13",""
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","352.61","","","","","","","fee schedule","101.11","367.13",""
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","367.13","","","","","","","fee schedule","101.11","367.13",""
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","103.84","","","","","","","fee schedule","101.11","367.13","APC"
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","102.1","","","","","","","fee schedule","101.11","367.13","APC"
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101.11","","","","","","","fee schedule","101.11","367.13","APC"
"Injection, fulphila","Q5108","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104.08","","","","","","","fee schedule","101.11","367.13","APC"
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","0.92","","","","","","","fee schedule","0.31","1.03",""
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","0.99","","","","","","","fee schedule","0.31","1.03",""
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.03","","","","","","","fee schedule","0.31","1.03",""
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.32","","","","","","","fee schedule","0.31","1.03","APC"
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.31","","","","","","","fee schedule","0.31","1.03","APC"
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.31","","","","","","","fee schedule","0.31","1.03","APC"
"Nivestym","Q5110","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.32","","","","","","","fee schedule","0.31","1.03","APC"
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","432.61","","","","","","","fee schedule","108.46","481.58",""
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","462.54","","","","","","","fee schedule","108.46","481.58",""
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","481.58","","","","","","","fee schedule","108.46","481.58",""
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","111.38","","","","","","","fee schedule","108.46","481.58","APC"
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","109.52","","","","","","","fee schedule","108.46","481.58","APC"
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","108.46","","","","","","","fee schedule","108.46","481.58","APC"
"Injection, udenyca 0.5 mg","Q5111","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","111.65","","","","","","","fee schedule","108.46","481.58","APC"
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","69.93","","","","","","","fee schedule","19.38","77.84",""
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","74.77","","","","","","","fee schedule","19.38","77.84",""
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","77.84","","","","","","","fee schedule","19.38","77.84",""
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19.9","","","","","","","fee schedule","19.38","77.84","APC"
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","19.57","","","","","","","fee schedule","19.38","77.84","APC"
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19.38","","","","","","","fee schedule","19.38","77.84","APC"
"Inj ontruzant 10 mg","Q5112","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19.95","","","","","","","fee schedule","19.38","77.84","APC"
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","246.42","","","","","","","fee schedule","70.76","274.31",""
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","263.47","","","","","","","fee schedule","70.76","274.31",""
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","274.31","","","","","","","fee schedule","70.76","274.31",""
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","72.66","","","","","","","fee schedule","70.76","274.31","APC"
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","71.45","","","","","","","fee schedule","70.76","274.31","APC"
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","70.76","","","","","","","fee schedule","70.76","274.31","APC"
"Inj herzuma 10 mg","Q5113","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","72.84","","","","","","","fee schedule","70.76","274.31","APC"
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","141.8","","","","","","","fee schedule","41.1","157.85",""
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","151.61","","","","","","","fee schedule","41.1","157.85",""
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","157.85","","","","","","","fee schedule","41.1","157.85",""
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.21","","","","","","","fee schedule","41.1","157.85","APC"
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.5","","","","","","","fee schedule","41.1","157.85","APC"
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.1","","","","","","","fee schedule","41.1","157.85","APC"
"Inj  ogivri 10 mg","Q5114","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.31","","","","","","","fee schedule","41.1","157.85","APC"
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","99.15","","","","","","","fee schedule","29.97","110.38",""
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","106.01","","","","","","","fee schedule","29.97","110.38",""
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","110.38","","","","","","","fee schedule","29.97","110.38",""
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30.77","","","","","","","fee schedule","29.97","110.38","APC"
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","30.26","","","","","","","fee schedule","29.97","110.38","APC"
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29.97","","","","","","","fee schedule","29.97","110.38","APC"
"Inj truxima 10 mg","Q5115","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30.85","","","","","","","fee schedule","29.97","110.38","APC"
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","91.01","","","","","","","fee schedule","28.55","101.31",""
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","97.31","","","","","","","fee schedule","28.55","101.31",""
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","101.31","","","","","","","fee schedule","28.55","101.31",""
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.32","","","","","","","fee schedule","28.55","101.31","APC"
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.83","","","","","","","fee schedule","28.55","101.31","APC"
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.55","","","","","","","fee schedule","28.55","101.31","APC"
"Inj., trazimera, 10 mg","Q5116","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.39","","","","","","","fee schedule","28.55","101.31","APC"
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","137.63","","","","","","","fee schedule","48.5","153.21",""
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","147.15","","","","","","","fee schedule","48.5","153.21",""
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","153.21","","","","","","","fee schedule","48.5","153.21",""
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49.81","","","","","","","fee schedule","48.5","153.21","APC"
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","48.97","","","","","","","fee schedule","48.5","153.21","APC"
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48.5","","","","","","","fee schedule","48.5","153.21","APC"
"Inj., kanjinti, 10 mg","Q5117","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49.92","","","","","","","fee schedule","48.5","153.21","APC"
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","76.1","","","","","","","fee schedule","26.28","84.71",""
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","81.36","","","","","","","fee schedule","26.28","84.71",""
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","84.71","","","","","","","fee schedule","26.28","84.71",""
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26.99","","","","","","","fee schedule","26.28","84.71","APC"
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","26.54","","","","","","","fee schedule","26.28","84.71","APC"
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26.28","","","","","","","fee schedule","26.28","84.71","APC"
"Inj., zirabev, 10 mg","Q5118","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.05","","","","","","","fee schedule","26.28","84.71","APC"
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84.27","","","","","","","fee schedule","28.4","93.81",""
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","90.1","","","","","","","fee schedule","28.4","93.81",""
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","93.81","","","","","","","fee schedule","28.4","93.81",""
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29.17","","","","","","","fee schedule","28.4","93.81","APC"
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.68","","","","","","","fee schedule","28.4","93.81","APC"
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.4","","","","","","","fee schedule","28.4","93.81","APC"
"Inj ruxience, 10 mg","Q5119","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29.24","","","","","","","fee schedule","28.4","93.81","APC"
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","89.01","","","","","","","fee schedule","30.93","99.08",""
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","95.17","","","","","","","fee schedule","30.93","99.08",""
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","99.08","","","","","","","fee schedule","30.93","99.08",""
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31.76","","","","","","","fee schedule","30.93","99.08","APC"
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","31.23","","","","","","","fee schedule","30.93","99.08","APC"
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30.93","","","","","","","fee schedule","30.93","99.08","APC"
"Inj pegfilgrastim-bmez 0.5mg","Q5120","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31.84","","","","","","","fee schedule","30.93","99.08","APC"
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","66.43","","","","","","","fee schedule","20.81","73.95",""
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","71.03","","","","","","","fee schedule","20.81","73.95",""
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","73.95","","","","","","","fee schedule","20.81","73.95",""
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21.37","","","","","","","fee schedule","20.81","73.95","APC"
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","21.02","","","","","","","fee schedule","20.81","73.95","APC"
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20.81","","","","","","","fee schedule","20.81","73.95","APC"
"Inj. avsola, 10 mg","Q5121","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21.43","","","","","","","fee schedule","20.81","73.95","APC"
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","419.89","","","","","","","fee schedule","133.78","467.42",""
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","448.94","","","","","","","fee schedule","133.78","467.42",""
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","467.42","","","","","","","fee schedule","133.78","467.42",""
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","137.39","","","","","","","fee schedule","133.78","467.42","APC"
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","135.09","","","","","","","fee schedule","133.78","467.42","APC"
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","133.78","","","","","","","fee schedule","133.78","467.42","APC"
"Inj, nyvepria","Q5122","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","137.72","","","","","","","fee schedule","133.78","467.42","APC"
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","95.15","","","","","","","fee schedule","27.04","105.92",""
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","101.73","","","","","","","fee schedule","27.04","105.92",""
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","105.92","","","","","","","fee schedule","27.04","105.92",""
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27.77","","","","","","","fee schedule","27.04","105.92","APC"
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","27.3","","","","","","","fee schedule","27.04","105.92","APC"
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27.04","","","","","","","fee schedule","27.04","105.92","APC"
"Inj. riabni, 10 mg","Q5123","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27.83","","","","","","","fee schedule","27.04","105.92","APC"
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","197.64","","","","","","","fee schedule","63.03","220.01",""
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","211.31","","","","","","","fee schedule","63.03","220.01",""
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","220.01","","","","","","","fee schedule","63.03","220.01",""
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","64.73","","","","","","","fee schedule","63.03","220.01","APC"
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","63.65","","","","","","","fee schedule","63.03","220.01","APC"
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","63.03","","","","","","","fee schedule","63.03","220.01","APC"
"Inj. byooviz, 0.1 mg","Q5124","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64.89","","","","","","","fee schedule","63.03","220.01","APC"
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.3","","","","","","","fee schedule","0.38","1.45",""
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.39","","","","","","","fee schedule","0.38","1.45",""
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.45","","","","","","","fee schedule","0.38","1.45",""
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.39","","","","","","","fee schedule","0.38","1.45","APC"
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.39","","","","","","","fee schedule","0.38","1.45","APC"
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.38","","","","","","","fee schedule","0.38","1.45","APC"
"Inj, releuko 1 mcg","Q5125","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.39","","","","","","","fee schedule","0.38","1.45","APC"
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","135.47","","","","","","","fee schedule","38.57","150.8",""
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","144.84","","","","","","","fee schedule","38.57","150.8",""
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","150.8","","","","","","","fee schedule","38.57","150.8",""
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39.61","","","","","","","fee schedule","38.57","150.8","APC"
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","38.95","","","","","","","fee schedule","38.57","150.8","APC"
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38.57","","","","","","","fee schedule","38.57","150.8","APC"
"Inj alymsys 10 mg","Q5126","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39.71","","","","","","","fee schedule","38.57","150.8","APC"
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","728.57","","","","","","","fee schedule","188.61","811.05",""
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","778.97","","","","","","","fee schedule","188.61","811.05",""
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","811.05","","","","","","","fee schedule","188.61","811.05",""
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","193.69","","","","","","","fee schedule","188.61","811.05","APC"
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","190.46","","","","","","","fee schedule","188.61","811.05","APC"
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","188.61","","","","","","","fee schedule","188.61","811.05","APC"
"Inj, stimufend, 0.5 mg","Q5127","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","194.15","","","","","","","fee schedule","188.61","811.05","APC"
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","275.1","","","","","","","fee schedule","87.88","306.25",""
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","294.13","","","","","","","fee schedule","87.88","306.25",""
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","306.25","","","","","","","fee schedule","87.88","306.25",""
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","90.25","","","","","","","fee schedule","87.88","306.25","APC"
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","88.74","","","","","","","fee schedule","87.88","306.25","APC"
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","87.88","","","","","","","fee schedule","87.88","306.25","APC"
"Inj, cimerli, 0.1 mg","Q5128","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","90.46","","","","","","","fee schedule","87.88","306.25","APC"
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","138.71","","","","","","","fee schedule","40.76","154.41",""
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","148.31","","","","","","","fee schedule","40.76","154.41",""
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","154.41","","","","","","","fee schedule","40.76","154.41",""
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41.86","","","","","","","fee schedule","40.76","154.41","APC"
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.16","","","","","","","fee schedule","40.76","154.41","APC"
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40.76","","","","","","","fee schedule","40.76","154.41","APC"
"Inj, vegzelma, 10 mg","Q5129","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41.96","","","","","","","fee schedule","40.76","154.41","APC"
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","474.49","","","","","","","fee schedule","140.72","528.2",""
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","507.31","","","","","","","fee schedule","140.72","528.2",""
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","528.2","","","","","","","fee schedule","140.72","528.2",""
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","144.52","","","","","","","fee schedule","140.72","528.2","APC"
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","142.1","","","","","","","fee schedule","140.72","528.2","APC"
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","140.72","","","","","","","fee schedule","140.72","528.2","APC"
"Inj, fylnetra, 0.5 mg","Q5130","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","144.86","","","","","","","fee schedule","140.72","528.2","APC"
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","18.41","","","","","","","fee schedule","5.65","20.5",""
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","19.69","","","","","","","fee schedule","5.65","20.5",""
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","20.5","","","","","","","fee schedule","5.65","20.5",""
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5.8","","","","","","","fee schedule","5.65","20.5","APC"
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","5.7","","","","","","","fee schedule","5.65","20.5","APC"
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5.65","","","","","","","fee schedule","5.65","20.5","APC"
"Inj, tofidence, 1 mg","Q5133","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5.81","","","","","","","fee schedule","5.65","20.5","APC"
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","14.91","","","","","","","fee schedule","4.5","16.6",""
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","15.95","","","","","","","fee schedule","4.5","16.6",""
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","16.6","","","","","","","fee schedule","4.5","16.6",""
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","4.62","","","","","","","fee schedule","4.5","16.6","APC"
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","4.55","","","","","","","fee schedule","4.5","16.6","APC"
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","4.5","","","","","","","fee schedule","4.5","16.6","APC"
"Inj, tyenne, 1 mg","Q5135","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","4.64","","","","","","","fee schedule","4.5","16.6","APC"
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","87.58","","","","","","","fee schedule","28.09","97.49",""
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","93.64","","","","","","","fee schedule","28.09","97.49",""
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","97.49","","","","","","","fee schedule","28.09","97.49",""
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28.85","","","","","","","fee schedule","28.09","97.49","APC"
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","28.36","","","","","","","fee schedule","28.09","97.49","APC"
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28.09","","","","","","","fee schedule","28.09","97.49","APC"
"Inj. denosumab-bbdz, 1 mg","Q5136","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28.91","","","","","","","fee schedule","28.09","97.49","APC"
"Inj adalimumab-fkjp, 1 mg","Q5140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","277.11","","","","","","","fee schedule","277.11","308.48",""
"Inj adalimumab-fkjp, 1 mg","Q5140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","296.28","","","","","","","fee schedule","277.11","308.48",""
"Inj adalimumab-fkjp, 1 mg","Q5140","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","308.48","","","","","","","fee schedule","277.11","308.48",""
"Inj adalimumab-aaty, 1 mg","Q5141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","138.55","","","","","","","fee schedule","138.55","154.24",""
"Inj adalimumab-aaty, 1 mg","Q5141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","148.14","","","","","","","fee schedule","138.55","154.24",""
"Inj adalimumab-aaty, 1 mg","Q5141","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","154.24","","","","","","","fee schedule","138.55","154.24",""
"Inj adalimumab-ryvk, 1 mg","Q5142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.84","","","","","","","fee schedule","33.84","37.67",""
"Inj adalimumab-ryvk, 1 mg","Q5142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","36.18","","","","","","","fee schedule","33.84","37.67",""
"Inj adalimumab-ryvk, 1 mg","Q5142","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","37.67","","","","","","","fee schedule","33.84","37.67",""
"Inj adalimumab-adbm, 1 mg","Q5143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","33.17","","","","","","","fee schedule","33.17","36.92",""
"Inj adalimumab-adbm, 1 mg","Q5143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.46","","","","","","","fee schedule","33.17","36.92",""
"Inj adalimumab-adbm, 1 mg","Q5143","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","36.92","","","","","","","fee schedule","33.17","36.92",""
"Inj, idacio, 1 mg","Q5144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","28.37","","","","","","","fee schedule","28.37","31.58",""
"Inj, idacio, 1 mg","Q5144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","30.33","","","","","","","fee schedule","28.37","31.58",""
"Inj, idacio, 1 mg","Q5144","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","31.58","","","","","","","fee schedule","28.37","31.58",""
"Inj, abrilada, 1 mg","Q5145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","84.68","","","","","","","fee schedule","84.68","94.27",""
"Inj, abrilada, 1 mg","Q5145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","90.54","","","","","","","fee schedule","84.68","94.27",""
"Inj, abrilada, 1 mg","Q5145","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","94.27","","","","","","","fee schedule","84.68","94.27",""
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","2763.67","","","","","","","fee schedule","876.55","3076.54",""
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","2954.87","","","","","","","fee schedule","876.55","3076.54",""
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","3076.54","","","","","","","fee schedule","876.55","3076.54",""
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","900.18","","","","","","","fee schedule","876.55","3076.54","APC"
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","885.14","","","","","","","fee schedule","876.55","3076.54","APC"
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","876.55","","","","","","","fee schedule","876.55","3076.54","APC"
"Inj, aflibercept-ayyh, 1 mg","Q5147","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","902.33","","","","","","","fee schedule","876.55","3076.54","APC"
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","1.75","","","","","","","fee schedule","0.56","1.95",""
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","1.87","","","","","","","fee schedule","0.56","1.95",""
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","1.95","","","","","","","fee schedule","0.56","1.95",""
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","0.58","","","","","","","fee schedule","0.56","1.95","APC"
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","0.57","","","","","","","fee schedule","0.56","1.95","APC"
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","0.56","","","","","","","fee schedule","0.56","1.95","APC"
"Inj, nyposi 1 mcg","Q5148","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","0.58","","","","","","","fee schedule","0.56","1.95","APC"
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","99.69","","","","","","","fee schedule","31.98","110.98",""
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","106.59","","","","","","","fee schedule","31.98","110.98",""
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","110.98","","","","","","","fee schedule","31.98","110.98",""
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32.84","","","","","","","fee schedule","31.98","110.98","APC"
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","32.29","","","","","","","fee schedule","31.98","110.98","APC"
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31.98","","","","","","","fee schedule","31.98","110.98","APC"
"Inj, eculizumab-aagh, 2 mg","Q5151","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32.92","","","","","","","fee schedule","31.98","110.98","APC"
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","131.94","","","","","","","fee schedule","41.12","146.87",""
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","141.07","","","","","","","fee schedule","41.12","146.87",""
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","146.87","","","","","","","fee schedule","41.12","146.87",""
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.23","","","","","","","fee schedule","41.12","146.87","APC"
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.52","","","","","","","fee schedule","41.12","146.87","APC"
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.12","","","","","","","fee schedule","41.12","146.87","APC"
"Inj, eculizumab-aeeb, 2 mg?","Q5152","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.33","","","","","","","fee schedule","41.12","146.87","APC"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","24.99","","","","","","","fee schedule","8.9","30.87",""
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","26.72","","","","","","","fee schedule","8.9","30.87",""
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","27.82","","","","","","","fee schedule","8.9","30.87",""
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","27.71","","","","","","","fee schedule","8.9","30.87","APC 277.30"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","29.64","","","","","","","fee schedule","8.9","30.87","APC 296.56"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","30.87","","","","","","","fee schedule","8.9","30.87","APC 308.91"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9.14","","","","","","","fee schedule","8.9","30.87","APC"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","8.99","","","","","","","fee schedule","8.9","30.87","APC"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8.9","","","","","","","fee schedule","8.9","30.87","APC"
"Visualization adjunct","Q9968","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9.16","","","","","","","fee schedule","8.9","30.87","APC"
"Non-HEU TC-99M add-on/dose","Q9969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","31.8","","","","","","","fee schedule","31.8","35.4",""
"Non-HEU TC-99M add-on/dose","Q9969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","34","","","","","","","fee schedule","31.8","35.4",""
"Non-HEU TC-99M add-on/dose","Q9969","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.4","","","","","","","fee schedule","31.8","35.4",""
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5935.72","","","","","","","fee schedule","1982.89","6878.75",""
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6346.37","","","","","","","fee schedule","1982.89","6878.75",""
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6607.69","","","","","","","fee schedule","1982.89","6878.75",""
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6174.87","","","","","","","fee schedule","1982.89","6878.75","APC 277.30"
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6603.74","","","","","","","fee schedule","1982.89","6878.75","APC 296.56"
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6878.75","","","","","","","fee schedule","1982.89","6878.75","APC 308.91"
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2036.35","","","","","","","fee schedule","1982.89","6878.75","APC"
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2002.33","","","","","","","fee schedule","1982.89","6878.75","APC"
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1982.89","","","","","","","fee schedule","1982.89","6878.75","APC"
"flutemetamol f18 diagnostic","Q9982","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2041.21","","","","","","","fee schedule","1982.89","6878.75","APC"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","4050.56","","","","","","","fee schedule","1616.36","5607.25",""
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","4330.78","","","","","","","fee schedule","1616.36","5607.25",""
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","4509.11","","","","","","","fee schedule","1616.36","5607.25",""
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","5033.47","","","","","","","fee schedule","1616.36","5607.25","APC 277.30"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","5383.08","","","","","","","fee schedule","1616.36","5607.25","APC 296.56"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","5607.25","","","","","","","fee schedule","1616.36","5607.25","APC 308.91"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","1659.94","","","","","","","fee schedule","1616.36","5607.25","APC"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","1632.21","","","","","","","fee schedule","1616.36","5607.25","APC"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","1616.36","","","","","","","fee schedule","1616.36","5607.25","APC"
"florbetaben f18 diagnostic","Q9983","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","1663.9","","","","","","","fee schedule","1616.36","5607.25","APC"
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6285.43","","","","","","","fee schedule","2056.75","6996.99",""
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6720.27","","","","","","","fee schedule","2056.75","6996.99",""
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6996.99","","","","","","","fee schedule","2056.75","6996.99",""
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2112.2","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2076.92","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2056.75","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorph xr 100 mg or less","Q9991","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2117.24","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","6285.43","","","","","","","fee schedule","2056.75","6996.99",""
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","6720.27","","","","","","","fee schedule","2056.75","6996.99",""
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","6996.99","","","","","","","fee schedule","2056.75","6996.99",""
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","2112.2","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","2076.92","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","2056.75","","","","","","","fee schedule","2056.75","6996.99","APC"
"Buprenorphine xr over 100 mg","Q9992","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","2117.24","","","","","","","fee schedule","2056.75","6996.99","APC"
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","152","","","","","","","fee schedule","41.16","169.21",""
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","162.52","","","","","","","fee schedule","41.16","169.21",""
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","169.21","","","","","","","fee schedule","41.16","169.21",""
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42.27","","","","","","","fee schedule","41.16","169.21","APC"
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","41.56","","","","","","","fee schedule","41.16","169.21","APC"
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41.16","","","","","","","fee schedule","41.16","169.21","APC"
"Ustekinumab-aekn inj","Q9998","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42.37","","","","","","","fee schedule","41.16","169.21","APC"
"Screening protoscopy","S0601","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Laser in situ keratomileusis (LASIK)","S0800","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Photorefractive keratectomy (PRK)","S0810","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Phototherapeutic keratectomy (PTK)","S0812","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"transplant sm. Intest, liver, allograft","S2053","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Transplant multivisceral organs","S2054","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"harvesting organs, cadaver donor","S2055","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Lobar lung transplantation","S2060","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Donor lobectomy, live donor","S2061","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Sim Panc/renal transplant","S2065","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Breast reconstruct, GAP","S2066","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Breast reconstruct, stacked DEIP or GAP","S2067","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Breast reconstruct, DEIP","S2068","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cystoerethroscopy","S2070","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Heller esophagomyotomy","S2079","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"LAUP","S2080","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"gastric band adjustment, percutaneous","S2083","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"percut occlusion tumor dest, yttrium-90","S2095","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Iselt cell transplant, allogeneic","S2102","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Adrenal tissue transplant to brain","S2103","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"arthroscopy, harvest cartilage","S2112","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Osteotomy, peracteabular, with internal fixation","S2115","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Arthroereisis, subtalar","S2117","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Minimally invasive direct co","S2205","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Minimally invasive direct co","S2206","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Minimally invasive direct co","S2207","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Minimally invasive direct co","S2208","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Minimally invasive direct co","S2209","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Myringotomy, laser-assisted","S2225","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Implant semi-imp hear","S2230","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Implant auditory brain imp","S2235","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Arthroscopy, shoulder, surgi","S2300","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Diskectomy, anterior, with d","S2350","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Diskectomy, anterior, with d","S2351","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Vertebroplast cerv 1st","S2360","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg congen hernia","S2400","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg urin trac obstr","S2401","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg cong cyst malf","S2402","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg pulmon sequest","S2403","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg myelomeningo","S2404","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg sacrococ teratoma","S2405","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Fetal surg noc","S2409","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Robotic surgical system","S2900","HCPCS","","","","","facility","outpatient","","","","","","Cigna","Ppo/Pos","5220","","","","","","","fee schedule","5220","5220",""
"Cardiac rehabilitation progr","S9472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","740","","","","","","","fee schedule","740","761",""
"Cardiac rehabilitation progr","S9472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","761","","","","","","","fee schedule","740","761",""
"Cardiac rehabilitation progr","S9472","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","743","","","","","","","fee schedule","740","761",""
"Pulmonary rehabilitation pro","S9473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Exchange","115","","","","","","","fee schedule","115","118",""
"Pulmonary rehabilitation pro","S9473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Hmo","118","","","","","","","fee schedule","115","118",""
"Pulmonary rehabilitation pro","S9473","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Ppo","117","","","","","","","fee schedule","115","118",""
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","43.1","","","","","","","fee schedule","35.92","43.1",""
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","35.92","","","","","","","fee schedule","35.92","43.1",""
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","35.92","","","","","","","fee schedule","35.92","43.1",""
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","35.92","","","","","","","fee schedule","35.92","43.1",""
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","43.1","","","","","","","fee schedule","35.92","43.1",""
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37.63","","","","","","","fee schedule","35.92","43.1","APC"
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","37","","","","","","","fee schedule","35.92","43.1","APC"
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36.64","","","","","","","fee schedule","35.92","43.1","APC"
"2019 nCoV diagnostic P","U0001","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37.72","","","","","","","fee schedule","35.92","43.1","APC"
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","61.57","","","","","","","fee schedule","51.31","61.57",""
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Exchange","51.31","","","","","","","fee schedule","51.31","61.57",""
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Hmo","51.31","","","","","","","fee schedule","51.31","61.57",""
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Ppo","51.31","","","","","","","fee schedule","51.31","61.57",""
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Options Ppo","61.57","","","","","","","fee schedule","51.31","61.57",""
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53.75","","","","","","","fee schedule","51.31","61.57","APC"
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","52.85","","","","","","","fee schedule","51.31","61.57","APC"
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52.34","","","","","","","fee schedule","51.31","61.57","APC"
"COVID-19 lab test non-CDC","U0002","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53.88","","","","","","","fee schedule","51.31","61.57","APC"
"Cntct lens hydrophil photoch","V2524","HCPCS","","","","","facility","outpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","195.12","","","","","","","fee schedule","190","195.58","APC"
"Cntct lens hydrophil photoch","V2524","HCPCS","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","191.86","","","","","","","fee schedule","190","195.58","APC"
"Cntct lens hydrophil photoch","V2524","HCPCS","","","","","facility","outpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","190","","","","","","","fee schedule","190","195.58","APC"
"Cntct lens hydrophil photoch","V2524","HCPCS","","","","","facility","outpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","195.58","","","","","","","fee schedule","190","195.58","APC"
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","653096.99","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","1038257.47","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","698495.71","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","1110447.04","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","915316.62","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","758943.26","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","655030.64","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","837185.99","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","1153491.75","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","625241.23","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","992998.87","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","746808.91","","","","","","","fee schedule","231109.63","1153491.75",""
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","503494.03","503494.03","503494.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","649183.98","446546.24","854779.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","231160.18","230513.38","232835.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","227441.28","227441.28","227441.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","227080.7","227080.7","227080.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","382885.12","382885.12","382885.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","705859.32","360283.01","940078.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","242087.34","","","","","","","fee schedule","231109.63","1153491.75","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","238042.92","","","","","","","fee schedule","231109.63","1153491.75","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","231109.63","","","","","","","fee schedule","231109.63","1153491.75","Transplants-Case Rate"
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","235731.82","","","","","","","fee schedule","231109.63","1153491.75","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","242665.11","","","","","","","fee schedule","231109.63","1153491.75","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System With Mcc","001","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","231109.63","","","","","","","fee schedule","231109.63","1153491.75","Psych-Case Rate"
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","264087.6","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","419831.86","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","282445.12","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","449022.58","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","370119.25","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","306887.81","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","264869.49","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","338526.19","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","466428.22","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","252823.79","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","401531","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","301981.14","","","","","","","fee schedule","94300.23","466428.22",""
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","92018.9","92018.9","92018.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","98779.49","","","","","","","fee schedule","94300.23","466428.22","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","97129.24","","","","","","","fee schedule","94300.23","466428.22","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","94300.23","","","","","","","fee schedule","94300.23","466428.22","Transplants-Case Rate"
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96186.23","","","","","","","fee schedule","94300.23","466428.22","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99015.24","","","","","","","fee schedule","94300.23","466428.22","MSDRG Base Rate"
"Heart Transplant Or Implant Of Heart Assist System Without Mcc","002","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","94300.23","","","","","","","fee schedule","94300.23","466428.22","Psych-Case Rate"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","494653.29","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","529038.11","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","693257.48","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","574820.87","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","496117.82","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","634081.62","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","473555.44","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","752093.74","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","565630.35","","","","","","","fee schedule","175387.09","752093.74",""
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","830662.74","830662.74","847729.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","231592.92","231592.92","231592.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","484213.48","484213.48","484213.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","699968.21","550603.38","973004.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","606550.45","167714.03","1743260.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8086.78","8086.78","8086.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","196254.01","174693.25","390529.27","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","519915.77","519915.77","519915.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","142725.77","99547.58","173576.81","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","440940.02","213244.58","831840.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","173934.03","171552.13","202095.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","231592.92","126075.45","366176.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","409522.66","409522.66","409522.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","179462.64","169990.81","344414.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","240332.28","240332.28","432638.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","402123.88","402123.88","402123.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","183717.98","","","","","","","fee schedule","175387.09","752093.74","MSDRG Base Rate"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","180648.7","","","","","","","fee schedule","175387.09","752093.74","MSDRG Base Rate"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","175387.09","","","","","","","fee schedule","175387.09","752093.74","Transplants-Case Rate"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","178894.83","","","","","","","fee schedule","175387.09","752093.74","MSDRG Base Rate"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","184156.44","","","","","","","fee schedule","175387.09","752093.74","MSDRG Base Rate"
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","003","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","175387.09","","","","","","","fee schedule","175387.09","752093.74","Psych-Case Rate"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","322806.88","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","345246.15","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","452414.43","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","375123.61","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","323762.62","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","413796.72","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","309038.59","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","490810.51","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","369125.96","","","","","","","fee schedule","114951.01","490810.51",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","58388.87","58388.87","58388.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","222255.07","132584.04","869997.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","460813.36","460813.36","460813.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","437366.28","437366.28","595821.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","363334.59","363334.59","363334.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","100249.47","100249.47","116164.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","161115.53","161115.53","260600.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","212231.04","212231.04","212231.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","109351.55","109351.55","109351.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","104100.19","24762.76","116942.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","120411.18","","","","","","","fee schedule","114951.01","490810.51","MSDRG Base Rate"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","118399.54","","","","","","","fee schedule","114951.01","490810.51","MSDRG Base Rate"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","114951.01","","","","","","","fee schedule","114951.01","490810.51","Transplants-Case Rate"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","117250.03","","","","","","","fee schedule","114951.01","490810.51","MSDRG Base Rate"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","120698.56","","","","","","","fee schedule","114951.01","490810.51","MSDRG Base Rate"
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","004","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","114951.01","","","","","","","fee schedule","114951.01","490810.51","Psych-Case Rate"
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","240286.2","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","381993.71","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","256989.21","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","408553.56","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","336761.55","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","279228.96","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","240997.63","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","308015.88","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","424390.49","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","230037.57","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","365342.26","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","274764.51","","","","","","","fee schedule","85929.59","424390.49",""
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","161998.26","161998.26","168637.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","154691.91","154691.91","161998.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","160529.34","160529.34","160529.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","90011.25","","","","","","","fee schedule","85929.59","424390.49","MSDRG Base Rate"
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","88507.48","","","","","","","fee schedule","85929.59","424390.49","MSDRG Base Rate"
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","85929.59","","","","","","","fee schedule","85929.59","424390.49","Transplants-Case Rate"
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","87648.18","","","","","","","fee schedule","85929.59","424390.49","MSDRG Base Rate"
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","90226.07","","","","","","","fee schedule","85929.59","424390.49","MSDRG Base Rate"
"Liver Transplant With Mcc Or Intestinal Transplant","005","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","85929.59","","","","","","","fee schedule","85929.59","424390.49","Psych-Case Rate"
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","108065.29","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","171796.21","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","115577.23","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","183741.13","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","151453.69","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","125579.23","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","108385.24","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","138525.74","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","190863.56","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","103456.11","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","164307.46","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","123571.41","","","","","","","fee schedule","39429.27","190863.56",""
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41302.16","","","","","","","fee schedule","39429.27","190863.56","MSDRG Base Rate"
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40612.15","","","","","","","fee schedule","39429.27","190863.56","MSDRG Base Rate"
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39429.27","","","","","","","fee schedule","39429.27","190863.56","Transplants-Case Rate"
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40217.86","","","","","","","fee schedule","39429.27","190863.56","MSDRG Base Rate"
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41400.73","","","","","","","fee schedule","39429.27","190863.56","MSDRG Base Rate"
"Liver Transplant Without Mcc","006","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39429.27","","","","","","","fee schedule","39429.27","190863.56","Psych-Case Rate"
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","301804.41","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","479791.96","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","322783.74","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","513151.68","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","422979.43","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","350717.32","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","302697.97","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","386874.27","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","533043.18","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","288931.91","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","458877.39","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","345109.88","","","","","","","fee schedule","107564.72","533043.18",""
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","112674.04","","","","","","","fee schedule","107564.72","533043.18","MSDRG Base Rate"
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","110791.66","","","","","","","fee schedule","107564.72","533043.18","MSDRG Base Rate"
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","107564.72","","","","","","","fee schedule","107564.72","533043.18","Transplants-Case Rate"
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","109716.01","","","","","","","fee schedule","107564.72","533043.18","MSDRG Base Rate"
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","112942.96","","","","","","","fee schedule","107564.72","533043.18","MSDRG Base Rate"
"Lung Transplant","007","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","107564.72","","","","","","","fee schedule","107564.72","533043.18","Psych-Case Rate"
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","130615.2","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","207644.83","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","139694.66","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","222082.28","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","183057.45","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","151783.78","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","131001.92","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","167431.82","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","230690.94","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","125044.23","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","198593.4","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","149356.99","","","","","","","fee schedule","47359.77","230690.94",""
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","79046.59","79046.59","79046.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20403.51","20403.51","20403.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","4684.46","4684.46","4684.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49609.36","","","","","","","fee schedule","47359.77","230690.94","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48780.56","","","","","","","fee schedule","47359.77","230690.94","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47359.77","","","","","","","fee schedule","47359.77","230690.94","Transplants-Case Rate"
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48306.97","","","","","","","fee schedule","47359.77","230690.94","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49727.76","","","","","","","fee schedule","47359.77","230690.94","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant","008","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47359.77","","","","","","","fee schedule","47359.77","230690.94","Psych-Case Rate"
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone marrow transplant","009","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","167229.69","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","265852.51","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","178854.32","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","284337.11","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","234372.71","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","194332.31","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","167724.81","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","214366.86","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","295358.99","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","160097.04","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","254263.75","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","191225.23","","","","","","","fee schedule","60236.59","295358.99",""
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63097.83","","","","","","","fee schedule","60236.59","295358.99","MSDRG Base Rate"
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","62043.69","","","","","","","fee schedule","60236.59","295358.99","MSDRG Base Rate"
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","60236.59","","","","","","","fee schedule","60236.59","295358.99","Transplants-Case Rate"
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61441.32","","","","","","","fee schedule","60236.59","295358.99","MSDRG Base Rate"
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63248.42","","","","","","","fee schedule","60236.59","295358.99","MSDRG Base Rate"
"Pancreas Transplant","010","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60236.59","","","","","","","fee schedule","60236.59","295358.99","Psych-Case Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","127107.8","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","135943.44","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","178141.81","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","147707.94","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","127484.13","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","162935.78","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","121686.43","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","193260.58","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","145346.31","","","","","","","fee schedule","46126.26","193260.58",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","160645.94","160645.94","160645.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","71428.08","71428.08","128956.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","220198.42","220198.42","220198.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","43499.99","43499.99","43499.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","43372.36","43372.36","43372.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","385454.16","385454.16","385454.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","42812.81","42812.81","42812.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","175160.46","175160.46","175160.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","44301.36","43736.1","52305.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","143795.34","143795.34","143795.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48317.26","","","","","","","fee schedule","46126.26","193260.58","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47510.05","","","","","","","fee schedule","46126.26","193260.58","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46126.26","","","","","","","fee schedule","46126.26","193260.58","Transplants-Case Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47048.79","","","","","","","fee schedule","46126.26","193260.58","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48432.57","","","","","","","fee schedule","46126.26","193260.58","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","011","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46126.26","","","","","","","fee schedule","46126.26","193260.58","Psych-Case Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","98253.88","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","105083.8","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","137702.99","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","114177.71","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","98544.78","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","125948.78","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","94063.18","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","149389.74","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","112352.18","","","","","","","fee schedule","35978.73","149389.74",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","148332.08","148332.08","148332.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","97574.33","97574.33","97574.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","132040.9","120888.75","161844.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","33370.66","33370.66","35439.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","32708.19","32096.67","34613.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","34142.69","34142.69","34142.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","83858.96","83858.96","84345","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","44817.78","44817.78","44817.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","108777","108777","108777","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","31719.71","31719.71","31719.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","106421.58","106421.58","133879.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37687.72","","","","","","","fee schedule","35978.73","149389.74","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37058.09","","","","","","","fee schedule","35978.73","149389.74","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35978.73","","","","","","","fee schedule","35978.73","149389.74","Transplants-Case Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36698.3","","","","","","","fee schedule","35978.73","149389.74","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37777.67","","","","","","","fee schedule","35978.73","149389.74","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","012","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35978.73","","","","","","","fee schedule","35978.73","149389.74","Psych-Case Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","67160.35","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","71828.87","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","94125.35","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","78044.91","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","67359.19","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","86090.89","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64295.84","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","102113.7","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","76797.09","","","","","","","fee schedule","25043.55","102113.7",""
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","64013.45","64013.45","64013.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24504.92","24504.92","24504.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","58176","58176","58176","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","67889.54","67889.54","67889.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","70619.85","70619.85","70619.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26233.12","","","","","","","fee schedule","25043.55","102113.7","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25794.86","","","","","","","fee schedule","25043.55","102113.7","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25043.55","","","","","","","fee schedule","25043.55","102113.7","Transplants-Case Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25544.42","","","","","","","fee schedule","25043.55","102113.7","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26295.73","","","","","","","fee schedule","25043.55","102113.7","MSDRG Base Rate"
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","013","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25043.55","","","","","","","fee schedule","25043.55","102113.7","Psych-Case Rate"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","280077.16","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","445251.18","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","299546.16","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","476209.29","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","392528.65","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","325468.77","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","280906.39","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","359022.74","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","494668.78","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","268131.37","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","425842.27","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","320265.02","","","","","","","fee schedule","99923.54","494668.78",""
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","89061.99","89061.99","89061.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","99392.31","99392.31","99392.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","104669.91","","","","","","","fee schedule","99923.54","494668.78","MSDRG Base Rate"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","102921.25","","","","","","","fee schedule","99923.54","494668.78","MSDRG Base Rate"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","99923.54","","","","","","","fee schedule","99923.54","494668.78","Transplants-Case Rate"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","101922.01","","","","","","","fee schedule","99923.54","494668.78","MSDRG Base Rate"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","104919.72","","","","","","","fee schedule","99923.54","494668.78","MSDRG Base Rate"
"Allogeneic Bone Marrow Transplant","014","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","99923.54","","","","","","","fee schedule","99923.54","494668.78","Psych-Case Rate"
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","138191.66","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","219689.46","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","147797.77","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","234964.36","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","193675.86","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","160588.14","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","138600.81","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","177143.86","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","244072.38","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","132297.54","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","210112.99","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","158020.58","","","","","","","fee schedule","50024.31","244072.38",""
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","85810.45","85810.45","85810.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","115241.26","105137.39","144825.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","70839.61","63739.89","109621.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","51490.81","51490.81","51490.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","49772.75","49772.75","49772.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5196.55","5196.55","5196.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","90110.37","90110.37","90110.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52400.46","","","","","","","fee schedule","50024.31","244072.38","MSDRG Base Rate"
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51525.04","","","","","","","fee schedule","50024.31","244072.38","MSDRG Base Rate"
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50024.31","","","","","","","fee schedule","50024.31","244072.38","Transplants-Case Rate"
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51024.8","","","","","","","fee schedule","50024.31","244072.38","MSDRG Base Rate"
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52525.53","","","","","","","fee schedule","50024.31","244072.38","MSDRG Base Rate"
"Autologous Bone Marrow Transplant With Cc/Mcc","016","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50024.31","","","","","","","fee schedule","50024.31","244072.38","Psych-Case Rate"
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","126599.75","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","201261.28","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","135400.08","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","215254.89","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","177429.78","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","147117.55","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","126974.58","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","162284.53","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","223598.9","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","121200.05","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","192488.12","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","144765.36","","","","","","","fee schedule","45947.59","223598.9",""
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48130.1","","","","","","","fee schedule","45947.59","223598.9","MSDRG Base Rate"
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47326.02","","","","","","","fee schedule","45947.59","223598.9","MSDRG Base Rate"
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","45947.59","","","","","","","fee schedule","45947.59","223598.9","Transplants-Case Rate"
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46866.54","","","","","","","fee schedule","45947.59","223598.9","MSDRG Base Rate"
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48244.97","","","","","","","fee schedule","45947.59","223598.9","MSDRG Base Rate"
"Autologous Bone Marrow Transplant Without Cc/Mcc","017","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45947.59","","","","","","","fee schedule","45947.59","223598.9","Psych-Case Rate"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","1006375.15","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","1076331.29","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","1410436.61","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","1169476.59","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","1009354.77","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","1290042.97","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","963451.45","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","1530139.34","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","1150778.44","","","","","","","fee schedule","355352.83","1530139.34",""
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","372232.09","","","","","","","fee schedule","355352.83","1530139.34","MSDRG Base Rate"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","366013.41","","","","","","","fee schedule","355352.83","1530139.34","MSDRG Base Rate"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","355352.83","","","","","","","fee schedule","355352.83","1530139.34","Transplants-Case Rate"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","362459.89","","","","","","","fee schedule","355352.83","1530139.34","MSDRG Base Rate"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","373120.47","","","","","","","fee schedule","355352.83","1530139.34","MSDRG Base Rate"
"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","018","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","355352.83","","","","","","","fee schedule","355352.83","1530139.34","Psych-Case Rate"
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","166271.85","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","264329.8","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","177829.91","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","282708.53","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","233030.31","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","193219.24","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","166764.14","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","213139.04","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","293667.27","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","159180.06","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","252807.42","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","190129.96","","","","","","","fee schedule","59899.74","293667.27",""
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62744.98","","","","","","","fee schedule","59899.74","293667.27","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","61696.73","","","","","","","fee schedule","59899.74","293667.27","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","59899.74","","","","","","","fee schedule","59899.74","293667.27","Transplants-Case Rate"
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61097.73","","","","","","","fee schedule","59899.74","293667.27","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62894.73","","","","","","","fee schedule","59899.74","293667.27","MSDRG Base Rate"
"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","019","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59899.74","","","","","","","fee schedule","59899.74","293667.27","Psych-Case Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","183382.38","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","196129.84","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","257010.75","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","213102.84","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","183925.33","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","235072.53","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","175560.8","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","278823.06","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","209695.65","","","","","","","fee schedule","65917.28","278823.06",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","418668.22","418668.22","465809.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","194752.75","194752.75","194752.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","364407.45","364407.45","364407.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","64761.08","64761.08","64761.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","42146.06","42146.06","97413.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","274595.52","274595.52","341795.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","64038.22","64038.22","181732.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","261789.96","261789.96","261789.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","34362.35","34362.35","34362.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","69048.35","","","","","","","fee schedule","65917.28","278823.06","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","67894.8","","","","","","","fee schedule","65917.28","278823.06","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","65917.28","","","","","","","fee schedule","65917.28","278823.06","Transplants-Case Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","67235.63","","","","","","","fee schedule","65917.28","278823.06","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","69213.14","","","","","","","fee schedule","65917.28","278823.06","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","020","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","65917.28","","","","","","","fee schedule","65917.28","278823.06","Psych-Case Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","123372.01","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","131947.97","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","172906.1","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","143366.69","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","123737.28","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","158146.98","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","118109.97","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","187580.51","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","141074.48","","","","","","","fee schedule","44812.44","187580.51",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","29131.63","27817.75","76729.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","129372.5","129372.5","129372.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","173109.51","173109.51","173109.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","46428.44","46428.44","65831.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","52313.14","26086.31","81789","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","117852","117852","117852","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","45538.82","45538.82","45538.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","28867.48","28867.48","28867.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6031.11","6031.11","6031.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46941.03","","","","","","","fee schedule","44812.44","187580.51","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46156.81","","","","","","","fee schedule","44812.44","187580.51","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","44812.44","","","","","","","fee schedule","44812.44","187580.51","Transplants-Case Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45708.69","","","","","","","fee schedule","44812.44","187580.51","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47053.06","","","","","","","fee schedule","44812.44","187580.51","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","021","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44812.44","","","","","","","fee schedule","44812.44","187580.51","Psych-Case Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","74049.31","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","79196.7","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","103780.24","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","86050.35","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","74268.55","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","94921.65","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","70890.97","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","112587.99","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","84674.53","","","","","","","fee schedule","27466.3","112587.99",""
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","29873.87","29873.87","29873.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16328.35","12272.16","16328.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","15291.19","15291.19","15291.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28770.95","","","","","","","fee schedule","27466.3","112587.99","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28290.29","","","","","","","fee schedule","27466.3","112587.99","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27466.3","","","","","","","fee schedule","27466.3","112587.99","Transplants-Case Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28015.63","","","","","","","fee schedule","27466.3","112587.99","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28839.62","","","","","","","fee schedule","27466.3","112587.99","MSDRG Base Rate"
"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","022","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27466.3","","","","","","","fee schedule","27466.3","112587.99","Psych-Case Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","133544.64","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","142827.73","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","187163.06","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","155187.98","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","133940.03","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","171186.98","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","127848.72","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","203047.45","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","152706.76","","","","","","","fee schedule","48390.01","203047.45",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","128289.53","128289.53","203491.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","136948.44","136948.44","136948.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","141832.03","141832.03","166582.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","27770.96","27770.96","27770.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","47576.65","45812.65","62149.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","45751.42","45067.01","47346.28","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","47236.81","47236.81","47236.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","44578.19","44578.19","44578.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","124747","124747","125247","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","46110.33","45097.23","48238.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","145030.39","145030.39","145030.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","107191.78","107191.78","107191.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50688.54","","","","","","","fee schedule","48390.01","203047.45","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","49841.71","","","","","","","fee schedule","48390.01","203047.45","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48390.01","","","","","","","fee schedule","48390.01","203047.45","Transplants-Case Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49357.81","","","","","","","fee schedule","48390.01","203047.45","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50809.51","","","","","","","fee schedule","48390.01","203047.45","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","023","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48390.01","","","","","","","fee schedule","48390.01","203047.45","Psych-Case Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","91166.83","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","97504.11","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","127770.48","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","105942.08","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","91436.75","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","116864.1","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","87278.4","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","138614.26","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","104248.22","","","","","","","fee schedule","33486.3","138614.26",""
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","119065.44","119065.44","119065.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","93490.5","93490.5","93490.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","29837.36","29837.36","29837.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","30909.38","30909.38","30909.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","83460","83460","83460","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","29337.35","29337.35","31981.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11291.36","11291.36","11291.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35076.9","","","","","","","fee schedule","33486.3","138614.26","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34490.89","","","","","","","fee schedule","33486.3","138614.26","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33486.3","","","","","","","fee schedule","33486.3","138614.26","Transplants-Case Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34156.03","","","","","","","fee schedule","33486.3","138614.26","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35160.62","","","","","","","fee schedule","33486.3","138614.26","MSDRG Base Rate"
"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","024","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33486.3","","","","","","","fee schedule","33486.3","138614.26","Psych-Case Rate"
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","105960.84","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","113326.5","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","148504.32","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","123133.73","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","106274.57","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","135828.12","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","101441.42","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","161107.77","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","121165.01","","","","","","","fee schedule","38689.16","161107.77",""
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","104744.91","104744.91","104744.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","106883.5","100409.49","118641.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","140067.96","113104.85","225527.95","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","37611.62","36009.91","81329.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","116340.98","80193.46","193474.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","36877.7","32495.7","37969.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","53312.31","53312.31","53312.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","97683","91422","191260.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","36450.23","35705.72","38342.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","36262.32","35046.94","38197.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","114406.94","111813.1","152589.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40526.9","","","","","","","fee schedule","38689.16","161107.77","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39849.83","","","","","","","fee schedule","38689.16","161107.77","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38689.16","","","","","","","fee schedule","38689.16","161107.77","Transplants-Case Rate"
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39462.94","","","","","","","fee schedule","38689.16","161107.77","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40623.62","","","","","","","fee schedule","38689.16","161107.77","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Mcc","025","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38689.16","","","","","","","fee schedule","38689.16","161107.77","Psych-Case Rate"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","72459.91","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","77496.81","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","101552.69","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","84203.35","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","72674.44","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","92884.24","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","69369.36","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","110171.39","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","82857.07","","","","","","","fee schedule","26907.33","110171.39",""
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","135282.37","135282.37","143141.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","30637.94","30637.94","30637.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","95170.54","95170.54","95170.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","70949.78","69184.37","73097.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","91219.69","73171.5","95792.29","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17581.2","17581.2","17581.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","60967.33","60967.33","60967.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24770.1","23836.82","26104.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22517.97","21266.56","76964.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","67862","67862","67862","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","70071.29","70071.29","70071.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3938.16","3938.16","3938.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28185.43","","","","","","","fee schedule","26907.33","110171.39","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27714.55","","","","","","","fee schedule","26907.33","110171.39","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26907.33","","","","","","","fee schedule","26907.33","110171.39","Transplants-Case Rate"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27445.48","","","","","","","fee schedule","26907.33","110171.39","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28252.7","","","","","","","fee schedule","26907.33","110171.39","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures With Cc","026","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26907.33","","","","","","","fee schedule","26907.33","110171.39","Psych-Case Rate"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","58796.18","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","62883.28","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","82402.96","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","68325.18","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","58970.26","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","75369.11","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","56288.42","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","89396.44","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","67232.76","","","","","","","fee schedule","22101.98","89396.44",""
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","50896.92","50896.92","50896.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","55142.99","55142.99","55142.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","71624.11","61092.01","78664.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","58477.95","58477.95","58477.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","20664.37","20664.37","21100.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","101411.53","101411.53","101411.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20410.95","20382.02","20961.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","53739.13","49957.34","55390","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20979.21","19485.73","21007.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22384.56","22384.56","22384.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","64353.01","64353.01","64353.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20368.11","19712.1","21512.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","85067.05","74773.62","101895.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","68342.27","68342.27","68342.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23151.82","","","","","","","fee schedule","22101.98","89396.44","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22765.04","","","","","","","fee schedule","22101.98","89396.44","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22101.98","","","","","","","fee schedule","22101.98","89396.44","Transplants-Case Rate"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22544.02","","","","","","","fee schedule","22101.98","89396.44","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23207.08","","","","","","","fee schedule","22101.98","89396.44","MSDRG Base Rate"
"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","027","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22101.98","","","","","","","fee schedule","22101.98","89396.44","Psych-Case Rate"
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","140023.43","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","149756.88","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","196243.09","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","162716.78","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","140438","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","179491.95","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","134051.18","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","212898.1","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","160115.19","","","","","","","fee schedule","50668.52","212898.1",""
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","629422.18","629422.18","629422.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","189105.87","189105.87","189105.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","71358.77","71358.77","71358.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","50445.55","50445.55","50445.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","205218","205218","205218","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","48749.1","48749.1","49726.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53075.27","","","","","","","fee schedule","50668.52","212898.1","MSDRG Base Rate"
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","52188.58","","","","","","","fee schedule","50668.52","212898.1","MSDRG Base Rate"
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50668.52","","","","","","","fee schedule","50668.52","212898.1","Transplants-Case Rate"
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51681.89","","","","","","","fee schedule","50668.52","212898.1","MSDRG Base Rate"
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53201.95","","","","","","","fee schedule","50668.52","212898.1","MSDRG Base Rate"
"Spinal Procedures With Mcc","028","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50668.52","","","","","","","fee schedule","50668.52","212898.1","Psych-Case Rate"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","79507.34","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","85034.13","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","111429.68","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","92392.95","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","79742.74","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","101918.14","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","76116.21","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","120886.63","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","90915.73","","","","","","","fee schedule","29385.82","120886.63",""
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","80908.47","80908.47","80908.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","105128.49","105128.49","105128.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","29858.5","29858.5","29858.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","26046.43","26046.43","26046.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","27336.45","27336.45","27336.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","73192","73192","73192","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","24102.82","24102.82","24102.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30781.65","","","","","","","fee schedule","29385.82","120886.63","MSDRG Base Rate"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30267.39","","","","","","","fee schedule","29385.82","120886.63","MSDRG Base Rate"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29385.82","","","","","","","fee schedule","29385.82","120886.63","Transplants-Case Rate"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29973.54","","","","","","","fee schedule","29385.82","120886.63","MSDRG Base Rate"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30855.11","","","","","","","fee schedule","29385.82","120886.63","MSDRG Base Rate"
"Spinal Procedures With Cc Or Spinal Neurostimulators","029","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29385.82","","","","","","","fee schedule","29385.82","120886.63","Psych-Case Rate"
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51159.14","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54715.36","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71699.62","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59450.41","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51310.6","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65579.4","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48977.11","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77784.72","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58499.88","","","","","","","fee schedule","19416.13","77784.72",""
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12917.92","12917.92","12917.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","56890.2","56890.2","59577.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18863.5","18863.5","18863.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","36809.27","20978.79","56890.2","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18042.01","18042.01","18042.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","21770.44","21770.44","59037","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","13627.43","13627.43","13627.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20338.4","","","","","","","fee schedule","19416.13","77784.72","MSDRG Base Rate"
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19998.61","","","","","","","fee schedule","19416.13","77784.72","MSDRG Base Rate"
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19416.13","","","","","","","fee schedule","19416.13","77784.72","Transplants-Case Rate"
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19804.45","","","","","","","fee schedule","19416.13","77784.72","MSDRG Base Rate"
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20386.94","","","","","","","fee schedule","19416.13","77784.72","MSDRG Base Rate"
"Spinal Procedures Without Cc/Mcc","030","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19416.13","","","","","","","fee schedule","19416.13","77784.72","Psych-Case Rate"
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","104418.05","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","111676.46","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","146342.09","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","121340.9","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","104727.21","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","133850.46","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","99964.44","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","158762.04","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","119400.84","","","","","","","fee schedule","38146.58","158762.04",""
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","53920.75","53920.75","53920.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","99611.03","99611.03","99611.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","85726.54","85726.54","85726.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","68423.39","68423.39","68423.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39958.54","","","","","","","fee schedule","38146.58","158762.04","MSDRG Base Rate"
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39290.98","","","","","","","fee schedule","38146.58","158762.04","MSDRG Base Rate"
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38146.58","","","","","","","fee schedule","38146.58","158762.04","Transplants-Case Rate"
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38909.51","","","","","","","fee schedule","38146.58","158762.04","MSDRG Base Rate"
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40053.91","","","","","","","fee schedule","38146.58","158762.04","MSDRG Base Rate"
"Ventricular Shunt Procedures With Mcc","031","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38146.58","","","","","","","fee schedule","38146.58","158762.04","Psych-Case Rate"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49662.96","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53115.18","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69602.72","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57711.74","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49809.99","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63661.49","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47544.74","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75509.85","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56789.02","","","","","","","fee schedule","18889.95","75509.85",""
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","66740.79","66740.79","66740.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","72090","72090","72090","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17328.09","17328.09","17328.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19787.22","","","","","","","fee schedule","18889.95","75509.85","MSDRG Base Rate"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19456.65","","","","","","","fee schedule","18889.95","75509.85","MSDRG Base Rate"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18889.95","","","","","","","fee schedule","18889.95","75509.85","Transplants-Case Rate"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19267.75","","","","","","","fee schedule","18889.95","75509.85","MSDRG Base Rate"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19834.45","","","","","","","fee schedule","18889.95","75509.85","MSDRG Base Rate"
"Ventricular Shunt Procedures With Cc","032","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18889.95","","","","","","","fee schedule","18889.95","75509.85","Psych-Case Rate"
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38753.88","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41447.78","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54313.64","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45034.66","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38868.62","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49677.47","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37100.96","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58923.2","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44314.62","","","","","","","fee schedule","15053.37","58923.2",""
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13952.41","13952.41","13952.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35027","35027","35027","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15768.41","","","","","","","fee schedule","15053.37","58923.2","MSDRG Base Rate"
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15504.97","","","","","","","fee schedule","15053.37","58923.2","MSDRG Base Rate"
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15053.37","","","","","","","fee schedule","15053.37","58923.2","Transplants-Case Rate"
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15354.44","","","","","","","fee schedule","15053.37","58923.2","MSDRG Base Rate"
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15806.04","","","","","","","fee schedule","15053.37","58923.2","MSDRG Base Rate"
"Ventricular Shunt Procedures Without Cc/Mcc","033","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15053.37","","","","","","","fee schedule","15053.37","58923.2","Psych-Case Rate"
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","90206.66","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","96477.2","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","126424.8","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","104826.3","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","90473.74","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","115633.29","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","86359.19","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","137154.38","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","103150.28","","","","","","","fee schedule","33148.63","137154.38",""
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33235.23","33235.23","33235.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34723.19","","","","","","","fee schedule","33148.63","137154.38","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34143.09","","","","","","","fee schedule","33148.63","137154.38","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33148.63","","","","","","","fee schedule","33148.63","137154.38","Transplants-Case Rate"
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33811.6","","","","","","","fee schedule","33148.63","137154.38","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34806.06","","","","","","","fee schedule","33148.63","137154.38","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Mcc","034","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33148.63","","","","","","","fee schedule","33148.63","137154.38","Psych-Case Rate"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","55710.6","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","59583.21","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","78078.51","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","64739.52","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","55875.55","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","71413.8","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","53334.45","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","84704.98","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","63704.43","","","","","","","fee schedule","21016.82","84704.98",""
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19930.05","19930.05","19930.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","6240","6240","6240","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19591.45","19591.45","19591.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","19089.22","19089.22","19089.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","53060.95","53060.95","53060.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22015.12","","","","","","","fee schedule","21016.82","84704.98","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21647.32","","","","","","","fee schedule","21016.82","84704.98","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21016.82","","","","","","","fee schedule","21016.82","84704.98","Transplants-Case Rate"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21437.16","","","","","","","fee schedule","21016.82","84704.98","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22067.66","","","","","","","fee schedule","21016.82","84704.98","MSDRG Base Rate"
"Carotid Artery Stent Procedures With Cc","035","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21016.82","","","","","","","fee schedule","21016.82","84704.98","Psych-Case Rate"
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45276.95","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48424.29","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63455.73","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52614.91","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45411.01","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58039.21","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43345.81","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68841.18","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51773.68","","","","","","","fee schedule","17347.45","68841.18",""
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","43809.26","43809.26","43809.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16018.94","15889.3","17525.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15837.09","15837.09","16062.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15609.89","15609.89","15609.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39744","39744","39744","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15384.49","15384.49","15384.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18171.45","","","","","","","fee schedule","17347.45","68841.18","MSDRG Base Rate"
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17867.87","","","","","","","fee schedule","17347.45","68841.18","MSDRG Base Rate"
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17347.45","","","","","","","fee schedule","17347.45","68841.18","Transplants-Case Rate"
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17694.4","","","","","","","fee schedule","17347.45","68841.18","MSDRG Base Rate"
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18214.82","","","","","","","fee schedule","17347.45","68841.18","MSDRG Base Rate"
"Carotid Artery Stent Procedures Without Cc/Mcc","036","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17347.45","","","","","","","fee schedule","17347.45","68841.18","Psych-Case Rate"
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","76722.39","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","82055.59","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","107526.57","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","89156.65","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","76949.55","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","98348.2","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","73450.04","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","116652.27","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","87731.17","","","","","","","fee schedule","28406.39","116652.27",""
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","127698.58","127698.58","127698.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25897.59","25756.47","27444.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","25902.41","25902.41","25902.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","85677","85677","85677","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29755.69","","","","","","","fee schedule","28406.39","116652.27","MSDRG Base Rate"
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29258.58","","","","","","","fee schedule","28406.39","116652.27","MSDRG Base Rate"
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28406.39","","","","","","","fee schedule","28406.39","116652.27","Transplants-Case Rate"
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28974.52","","","","","","","fee schedule","28406.39","116652.27","MSDRG Base Rate"
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29826.71","","","","","","","fee schedule","28406.39","116652.27","MSDRG Base Rate"
"Extracranial Procedures With Mcc","037","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28406.39","","","","","","","fee schedule","28406.39","116652.27","Psych-Case Rate"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37814.69","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40443.31","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52997.36","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43943.25","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37926.65","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48473.55","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36201.83","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57495.21","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43240.67","","","","","","","fee schedule","14723.07","57495.21",""
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14068.21","14068.21","14068.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13864.86","13864.86","13864.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12555.74","12555.74","12641.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","41568","41568","41568","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15422.42","","","","","","","fee schedule","14723.07","57495.21","MSDRG Base Rate"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15164.76","","","","","","","fee schedule","14723.07","57495.21","MSDRG Base Rate"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14723.07","","","","","","","fee schedule","14723.07","57495.21","Transplants-Case Rate"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15017.53","","","","","","","fee schedule","14723.07","57495.21","MSDRG Base Rate"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15459.22","","","","","","","fee schedule","14723.07","57495.21","MSDRG Base Rate"
"Extracranial Procedures With Cc","038","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14723.07","","","","","","","fee schedule","14723.07","57495.21","Psych-Case Rate"
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27395.03","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29299.34","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38394.18","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31834.89","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27476.14","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35116.89","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26226.58","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41652.67","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31325.9","","","","","","","fee schedule","11058.61","41652.67",""
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","35047.29","35047.29","35047.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10033.03","10033.03","10033.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","24960","24960","24960","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11107.96","11107.96","11107.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9767.73","9767.73","9767.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11583.89","","","","","","","fee schedule","11058.61","41652.67","MSDRG Base Rate"
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11390.37","","","","","","","fee schedule","11058.61","41652.67","MSDRG Base Rate"
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11058.61","","","","","","","fee schedule","11058.61","41652.67","Transplants-Case Rate"
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11279.78","","","","","","","fee schedule","11058.61","41652.67","MSDRG Base Rate"
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11611.54","","","","","","","fee schedule","11058.61","41652.67","MSDRG Base Rate"
"Extracranial Procedures Without Cc/Mcc","039","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11058.61","","","","","","","fee schedule","11058.61","41652.67","Psych-Case Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","89985.27","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","96240.41","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","126114.51","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","104569.02","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","90251.69","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","115349.49","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","86147.23","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","136817.76","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","102897.12","","","","","","","fee schedule","33070.76","136817.76",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","84287.57","84287.57","84287.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","73801.98","73801.98","73801.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","34038.87","32058.57","41162.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","31180.71","31180.71","31180.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","36822.89","36822.89","36822.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","55153.08","55153.08","55153.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","26063.76","26063.76","26063.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","30883.75","30741.66","32331.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","32943.96","32943.96","32943.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34641.62","","","","","","","fee schedule","33070.76","136817.76","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34062.88","","","","","","","fee schedule","33070.76","136817.76","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33070.76","","","","","","","fee schedule","33070.76","136817.76","Transplants-Case Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33732.18","","","","","","","fee schedule","33070.76","136817.76","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34724.3","","","","","","","fee schedule","33070.76","136817.76","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","040","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33070.76","","","","","","","fee schedule","33070.76","136817.76","Psych-Case Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51240.7","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54802.6","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71813.94","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59545.19","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51392.41","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65683.96","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49055.2","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77908.74","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58593.16","","","","","","","fee schedule","19444.82","77908.74",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","30304.13","30304.13","31735.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","50243.92","50243.92","50243.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","69674.57","69674.57","70724.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18194.21","18194.21","18194.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17656.28","17656.28","17656.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14780.53","14113.91","31735.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20368.45","","","","","","","fee schedule","19444.82","77908.74","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20028.16","","","","","","","fee schedule","19444.82","77908.74","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19444.82","","","","","","","fee schedule","19444.82","77908.74","Transplants-Case Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19833.72","","","","","","","fee schedule","19444.82","77908.74","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20417.06","","","","","","","fee schedule","19444.82","77908.74","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19444.82","","","","","","","fee schedule","19444.82","77908.74","Psych-Case Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40264.05","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43062.92","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56430.14","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46789.57","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40383.26","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51613.31","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38546.71","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61219.32","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46041.48","","","","","","","fee schedule","15584.48","61219.32",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9155.53","9155.53","9155.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","29187.72","29187.72","29187.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","45335.61","45335.61","45335.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","23927.04","18256.8","57535.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38086","38086","38086","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9501.02","9501.02","9501.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16324.74","","","","","","","fee schedule","15584.48","61219.32","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16052.01","","","","","","","fee schedule","15584.48","61219.32","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15584.48","","","","","","","fee schedule","15584.48","61219.32","Transplants-Case Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15896.17","","","","","","","fee schedule","15584.48","61219.32","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16363.7","","","","","","","fee schedule","15584.48","61219.32","MSDRG Base Rate"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","042","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15584.48","","","","","","","fee schedule","15584.48","61219.32","Psych-Case Rate"
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hyphema","043","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections","044","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological eye disorders","045","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w CC","046","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age >17 w/o CC","047","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders of the Eye Age 0-17","048","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures","049","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sialoadenectomy","050","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures Except Sialoadenectomy","051","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42212.35","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45146.65","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59160.68","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49053.63","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42337.33","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54110.78","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40411.91","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64181.6","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48269.33","","","","","","","fee schedule","16269.67","64181.6",""
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","45533.66","45533.66","45533.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13031.1","8903.76","35617.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","43682","43682","43682","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","11977.49","11977.49","11977.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12912.94","12912.94","12912.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3217.12","3217.12","3217.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17042.48","","","","","","","fee schedule","16269.67","64181.6","MSDRG Base Rate"
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16757.76","","","","","","","fee schedule","16269.67","64181.6","MSDRG Base Rate"
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16269.67","","","","","","","fee schedule","16269.67","64181.6","Transplants-Case Rate"
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16595.06","","","","","","","fee schedule","16269.67","64181.6","MSDRG Base Rate"
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17083.15","","","","","","","fee schedule","16269.67","64181.6","MSDRG Base Rate"
"Spinal Disorders And Injuries With Cc/Mcc","052","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16269.67","","","","","","","fee schedule","16269.67","64181.6","Psych-Case Rate"
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22820.26","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24406.56","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31982.63","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26518.69","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22887.82","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29252.62","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21846.93","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34696.97","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26094.7","","","","","","","fee schedule","9449.73","34696.97",""
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11123.94","11123.94","23754.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8558.82","6170.48","23754.37","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12088.93","11543.71","24650.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9898.59","","","","","","","fee schedule","9449.73","34696.97","MSDRG Base Rate"
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9733.22","","","","","","","fee schedule","9449.73","34696.97","MSDRG Base Rate"
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9449.73","","","","","","","fee schedule","9449.73","34696.97","Transplants-Case Rate"
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9638.72","","","","","","","fee schedule","9449.73","34696.97","MSDRG Base Rate"
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9922.22","","","","","","","fee schedule","9449.73","34696.97","MSDRG Base Rate"
"Spinal Disorders And Injuries Without Cc/Mcc","053","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9449.73","","","","","","","fee schedule","9449.73","34696.97","Psych-Case Rate"
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35584.4","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38057.98","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49871.61","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41351.51","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35689.76","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45614.61","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34066.67","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54104.17","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40690.36","","","","","","","fee schedule","13938.71","54104.17",""
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10230.4","10230.4","10230.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","24430.12","24430.12","24430.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2959.84","2959.84","2959.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11952.61","11909.49","13551.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13329.55","13329.55","13329.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","12534.81","12534.81","12534.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11274.97","11274.97","11274.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7961.29","7961.29","7961.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32913","32913","32913","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","14995.16","14995.16","14995.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11749.65","11035.97","12897.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14600.8","","","","","","","fee schedule","13938.71","54104.17","MSDRG Base Rate"
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14356.87","","","","","","","fee schedule","13938.71","54104.17","MSDRG Base Rate"
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13938.71","","","","","","","fee schedule","13938.71","54104.17","Transplants-Case Rate"
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14217.48","","","","","","","fee schedule","13938.71","54104.17","MSDRG Base Rate"
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14635.65","","","","","","","fee schedule","13938.71","54104.17","MSDRG Base Rate"
"Nervous System Neoplasms With Mcc","054","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13938.71","","","","","","","fee schedule","13938.71","54104.17","Psych-Case Rate"
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23761.78","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25413.53","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33302.18","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27612.81","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23832.13","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30459.53","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22748.3","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36128.51","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27171.32","","","","","","","fee schedule","9780.85","36128.51",""
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18443.49","8170.06","39652.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","18443.49","11198.79","39652.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9764.22","9764.22","9764.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11097.25","11097.25","20043.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7006.81","7006.81","7006.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","27171.32","27171.32","27171.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10245.44","","","","","","","fee schedule","9780.85","36128.51","MSDRG Base Rate"
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10074.28","","","","","","","fee schedule","9780.85","36128.51","MSDRG Base Rate"
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9780.85","","","","","","","fee schedule","9780.85","36128.51","Transplants-Case Rate"
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9976.47","","","","","","","fee schedule","9780.85","36128.51","MSDRG Base Rate"
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10269.89","","","","","","","fee schedule","9780.85","36128.51","MSDRG Base Rate"
"Nervous System Neoplasms Without Mcc","055","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9780.85","","","","","","","fee schedule","9780.85","36128.51","Psych-Case Rate"
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54139.85","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","57903.27","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","75877.09","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","62914.19","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54300.14","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69400.29","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","51830.68","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","82316.73","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","61908.29","","","","","","","fee schedule","20464.41","82316.73",""
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","40510.72","40510.72","40510.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12123.95","12123.95","12123.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","51478.14","51478.14","51478.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","75652.53","75652.53","76675.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24880.74","18739.33","67652.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","31534.97","19796.52","56730.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","19623.54","19623.54","19623.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","4977.65","4977.65","4977.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","51004","51004","51004","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","80266","80266","80266","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20298.77","20264.99","47724.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","147293.83","147293.83","147293.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21436.47","","","","","","","fee schedule","20464.41","82316.73","MSDRG Base Rate"
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21078.34","","","","","","","fee schedule","20464.41","82316.73","MSDRG Base Rate"
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20464.41","","","","","","","fee schedule","20464.41","82316.73","Transplants-Case Rate"
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20873.7","","","","","","","fee schedule","20464.41","82316.73","MSDRG Base Rate"
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21487.63","","","","","","","fee schedule","20464.41","82316.73","MSDRG Base Rate"
"Degenerative Nervous System Disorders With Mcc","056","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20464.41","","","","","","","fee schedule","20464.41","82316.73","Psych-Case Rate"
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30193.96","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32292.83","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42316.89","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35087.44","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30283.35","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38704.75","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28906.13","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45908.29","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34526.44","","","","","","","fee schedule","12042.96","45908.29",""
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","31899.34","31899.34","60512.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29817.17","29817.17","29817.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","31890.83","31890.83","31890.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","40576.9","28673.62","41792.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10709.07","10709.07","10709.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25959.4","10776.73","69046.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","97027.51","97027.51","97027.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","29188.85","2309.99","57240.08","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","26734.77","11019.42","64599.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","29303","29303","29303","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","34437","34123.79","34437","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","24131.9","9651.82","58747.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","132888.54","132888.54","132888.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10446.23","10446.23","10446.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","42435.35","42435.35","42435.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","34607.66","34607.66","34607.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12615","","","","","","","fee schedule","12042.96","45908.29","MSDRG Base Rate"
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12404.25","","","","","","","fee schedule","12042.96","45908.29","MSDRG Base Rate"
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12042.96","","","","","","","fee schedule","12042.96","45908.29","Transplants-Case Rate"
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12283.82","","","","","","","fee schedule","12042.96","45908.29","MSDRG Base Rate"
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12645.11","","","","","","","fee schedule","12042.96","45908.29","MSDRG Base Rate"
"Degenerative Nervous System Disorders Without Mcc","057","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12042.96","","","","","","","fee schedule","12042.96","45908.29","Psych-Case Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39839.9","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42609.29","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55835.69","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46296.68","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39957.85","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51069.6","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38140.65","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","60574.42","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45556.47","","","","","","","fee schedule","15435.31","60574.42",""
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","23537.1","23537.1","23537.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16413.91","16413.91","16413.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","18932.7","12163.09","38162.01","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39006.16","39006.16","39006.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","15741.01","9049.11","21637.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16168.49","","","","","","","fee schedule","15435.31","60574.42","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15898.37","","","","","","","fee schedule","15435.31","60574.42","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15435.31","","","","","","","fee schedule","15435.31","60574.42","Transplants-Case Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15744.02","","","","","","","fee schedule","15435.31","60574.42","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16207.08","","","","","","","fee schedule","15435.31","60574.42","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Mcc","058","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15435.31","","","","","","","fee schedule","15435.31","60574.42","Psych-Case Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28919.17","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30929.43","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","40530.28","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","33606.05","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29004.8","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37070.65","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27685.72","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","43970.05","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33068.74","","","","","","","fee schedule","11594.64","43970.05",""
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","41426.18","41426.18","41426.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","29845.13","29845.13","29845.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","24648.51","24648.51","24648.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","32327.32","29734.8","38321.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8755.29","8755.29","8755.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14749.9","9437.31","15446.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26744","26744","26744","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","30948.09","30948.09","31568","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","20661.96","20661.96","20661.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12145.39","","","","","","","fee schedule","11594.64","43970.05","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11942.48","","","","","","","fee schedule","11594.64","43970.05","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11594.64","","","","","","","fee schedule","11594.64","43970.05","Transplants-Case Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11826.53","","","","","","","fee schedule","11594.64","43970.05","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12174.37","","","","","","","fee schedule","11594.64","43970.05","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11594.64","","","","","","","fee schedule","11594.64","43970.05","Psych-Case Rate"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21435.94","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22926.02","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30042.51","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24910.02","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21499.41","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27478.11","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20521.66","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32592.19","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24511.75","","","","","","","fee schedule","8962.88","32592.19",""
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20158.09","20158.09","20158.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28807.22","27949.08","84110.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26200.76","26200.76","26200.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9437.31","9437.31","9437.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","23025","23025","23025","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","17716.33","17716.33","17716.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","29775.21","29775.21","29775.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9388.62","","","","","","","fee schedule","8962.88","32592.19","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9231.77","","","","","","","fee schedule","8962.88","32592.19","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8962.88","","","","","","","fee schedule","8962.88","32592.19","Transplants-Case Rate"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9142.14","","","","","","","fee schedule","8962.88","32592.19","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9411.02","","","","","","","fee schedule","8962.88","32592.19","MSDRG Base Rate"
"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","060","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8962.88","","","","","","","fee schedule","8962.88","32592.19","Psych-Case Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","64254.22","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","68720.72","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","90052.4","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","74667.78","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","64444.46","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","82365.61","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","61513.66","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","97695.08","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","73473.96","","","","","","","fee schedule","24021.5","97695.08",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21876.93","21876.93","21876.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20742.04","20742.04","20742.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17084.49","17084.49","17084.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","29510.94","29510.94","29510.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25162.52","","","","","","","fee schedule","24021.5","97695.08","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24742.14","","","","","","","fee schedule","24021.5","97695.08","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24021.5","","","","","","","fee schedule","24021.5","97695.08","Transplants-Case Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24501.93","","","","","","","fee schedule","24021.5","97695.08","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25222.58","","","","","","","fee schedule","24021.5","97695.08","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","061","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24021.5","","","","","","","fee schedule","24021.5","97695.08","Psych-Case Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40951.55","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43798.21","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57393.67","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47588.49","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41072.79","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52494.59","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39204.89","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62264.62","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46827.62","","","","","","","fee schedule","15826.26","62264.62",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","23108.82","23108.82","23108.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","51007.6","51007.6","51007.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15192.83","15192.83","15192.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","31550.81","31550.81","31550.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14086.01","13488.23","15051.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11269.29","11269.29","11269.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38597","38597","38597","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14248.56","14248.56","14248.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16578.01","","","","","","","fee schedule","15826.26","62264.62","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16301.05","","","","","","","fee schedule","15826.26","62264.62","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15826.26","","","","","","","fee schedule","15826.26","62264.62","Transplants-Case Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16142.79","","","","","","","fee schedule","15826.26","62264.62","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16617.57","","","","","","","fee schedule","15826.26","62264.62","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","062","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15826.26","","","","","","","fee schedule","15826.26","62264.62","Psych-Case Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32715.56","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34989.72","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45850.92","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38017.71","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32812.42","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41937.12","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31320.18","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49742.25","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37409.87","","","","","","","fee schedule","12929.77","49742.25",""
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7040.41","7040.41","7040.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13543.93","","","","","","","fee schedule","12929.77","49742.25","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13317.66","","","","","","","fee schedule","12929.77","49742.25","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12929.77","","","","","","","fee schedule","12929.77","49742.25","Transplants-Case Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13188.37","","","","","","","fee schedule","12929.77","49742.25","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13576.26","","","","","","","fee schedule","12929.77","49742.25","MSDRG Base Rate"
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","063","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12929.77","","","","","","","fee schedule","12929.77","49742.25","Psych-Case Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46866.36","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","50124.18","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65683.28","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54461.9","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","47005.11","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","60076.61","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44867.42","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","71257.77","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53591.14","","","","","","","fee schedule","17906.42","71257.77",""
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","108447.36","108447.36","206533.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","31043.71","16313.95","33712.82","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","37999.6","37999.6","37999.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","47539.89","39102.66","47991.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","42071.51","24974.65","62299.75","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16493.27","15939.27","25602.9","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","154925.66","154925.66","154925.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15289.27","14947.2","16666.12","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","111181.02","111181.02","111181.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","41599.34","40608.36","43171","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16036.2","15499.56","16924.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","32509.96","16313.95","33712.82","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","51886","51321","81094.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15982.64","15039.35","17619.63","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","32068.94","32068.94","32068.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10949","10949","10949","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","25860.67","25860.67","25860.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18756.97","","","","","","","fee schedule","17906.42","71257.77","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18443.61","","","","","","","fee schedule","17906.42","71257.77","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17906.42","","","","","","","fee schedule","17906.42","71257.77","Transplants-Case Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18264.55","","","","","","","fee schedule","17906.42","71257.77","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18801.74","","","","","","","fee schedule","17906.42","71257.77","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","064","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17906.42","","","","","","","fee schedule","17906.42","71257.77","Psych-Case Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23545.04","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25181.73","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32998.42","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27360.94","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23614.75","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30181.7","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22540.8","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35798.97","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26923.48","","","","","","","fee schedule","9704.63","35798.97",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","47263.07","47263.07","47263.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10074.99","10074.99","16313.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","18094.39","18094.39","18094.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","19507.96","19507.96","21943.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","30591.59","25478.64","31848.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8475.68","7264.54","9762.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8411.23","2800","9171.3","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8799.84","7715.96","9746.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10550.86","10074.99","16313.95","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21828","19007.74","32753.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26240","24419.98","26240","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8128.14","6345.05","8899.18","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10455.18","10455.18","10949","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","21043.49","21043.49","24465.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4067.55","4067.55","4067.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","17225.88","17225.88","17225.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","23113.59","23113.59","23113.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10165.6","","","","","","","fee schedule","9704.63","35798.97","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9995.77","","","","","","","fee schedule","9704.63","35798.97","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9704.63","","","","","","","fee schedule","9704.63","35798.97","Transplants-Case Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9898.72","","","","","","","fee schedule","9704.63","35798.97","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10189.86","","","","","","","fee schedule","9704.63","35798.97","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9704.63","","","","","","","fee schedule","9704.63","35798.97","Psych-Case Rate"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15949.94","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17058.67","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22353.87","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18534.92","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15997.17","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20445.77","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15269.65","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24251.03","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18238.58","","","","","","","fee schedule","7033.53","24251.03",""
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","21556.87","21556.87","21556.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20187.3","20187.3","21556.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","4961.3","4961.3","4961.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5838.88","5607.09","6213.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6181.08","6181.08","6181.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","12089.6","12013.5","14612","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10550.86","10550.86","21061.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5999.21","5999.21","21761.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","17851.06","17851.06","17851.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10949","10949","10949","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7367.62","","","","","","","fee schedule","7033.53","24251.03","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7244.54","","","","","","","fee schedule","7033.53","24251.03","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7033.53","","","","","","","fee schedule","7033.53","24251.03","Transplants-Case Rate"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7174.2","","","","","","","fee schedule","7033.53","24251.03","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7385.21","","","","","","","fee schedule","7033.53","24251.03","MSDRG Base Rate"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","066","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7033.53","","","","","","","fee schedule","7033.53","24251.03","Psych-Case Rate"
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34228.05","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36607.35","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","47970.68","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39775.33","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34329.39","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43875.94","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32768.17","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52041.92","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39139.39","","","","","","","fee schedule","13461.7","52041.92",""
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","44966.01","44966.01","44966.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14101.13","","","","","","","fee schedule","13461.7","52041.92","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13865.55","","","","","","","fee schedule","13461.7","52041.92","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13461.7","","","","","","","fee schedule","13461.7","52041.92","Transplants-Case Rate"
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13730.93","","","","","","","fee schedule","13461.7","52041.92","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14134.79","","","","","","","fee schedule","13461.7","52041.92","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction With Mcc","067","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13461.7","","","","","","","fee schedule","13461.7","52041.92","Psych-Case Rate"
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20144.84","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21545.17","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28233.03","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23409.68","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20204.49","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25823.09","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19285.63","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30629.15","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23035.4","","","","","","","fee schedule","8508.82","30629.15",""
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","3904.55","3904.55","7222.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8001.8","8001.8","8001.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19006","19006","19006","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","1531.54","1531.54","1531.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8912.99","","","","","","","fee schedule","8508.82","30629.15","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8764.08","","","","","","","fee schedule","8508.82","30629.15","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8508.82","","","","","","","fee schedule","8508.82","30629.15","Transplants-Case Rate"
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8679","","","","","","","fee schedule","8508.82","30629.15","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8934.26","","","","","","","fee schedule","8508.82","30629.15","MSDRG Base Rate"
"Precerebral Occlusion Without Infarction Without Mcc","068","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8508.82","","","","","","","fee schedule","8508.82","30629.15","Psych-Case Rate"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18616.03","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19910.09","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26090.41","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21633.1","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18671.15","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23863.35","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17822.03","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28304.68","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21287.22","","","","","","","fee schedule","7971.16","28304.68",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","28170.86","28170.86","28170.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18521.59","18521.59","19090.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25058.33","24708.33","25058.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7417.43","6633.7","7838.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17501.75","17501.75","17501.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2422.44","1898.25","7039.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7608.44","7608.44","7988.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7770.74","7770.74","9090.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15283.85","15283.85","17568","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6794.37","6175.36","7616.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8349.79","","","","","","","fee schedule","7971.16","28304.68","MSDRG Base Rate"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8210.29","","","","","","","fee schedule","7971.16","28304.68","MSDRG Base Rate"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7971.16","","","","","","","fee schedule","7971.16","28304.68","Transplants-Case Rate"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8130.58","","","","","","","fee schedule","7971.16","28304.68","MSDRG Base Rate"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8369.72","","","","","","","fee schedule","7971.16","28304.68","MSDRG Base Rate"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7971.16","","","","","","","fee schedule","7971.16","28304.68","Psych-Case Rate"
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38798.16","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41495.14","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54375.7","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45086.11","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38913.04","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49734.24","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37143.35","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58990.52","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44365.26","","","","","","","fee schedule","15068.95","58990.52",""
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","38794.37","38794.37","38794.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12927.08","12706.21","13936.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","36624.16","36624.16","36624.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15541.38","13841.35","15556.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15784.73","","","","","","","fee schedule","15068.95","58990.52","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15521.02","","","","","","","fee schedule","15068.95","58990.52","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15068.95","","","","","","","fee schedule","15068.95","58990.52","Transplants-Case Rate"
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15370.33","","","","","","","fee schedule","15068.95","58990.52","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15822.4","","","","","","","fee schedule","15068.95","58990.52","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Mcc","070","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15068.95","","","","","","","fee schedule","15068.95","58990.52","Psych-Case Rate"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23910.93","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25573.05","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33511.21","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27786.13","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23981.72","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30650.72","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22891.09","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36355.28","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27341.87","","","","","","","fee schedule","9833.3","36355.28",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8188.29","8188.29","8188.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1105.82","640.7","7786.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20455.42","20455.42","20455.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8503.72","8503.72","8503.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10300.38","","","","","","","fee schedule","9833.3","36355.28","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10128.3","","","","","","","fee schedule","9833.3","36355.28","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9833.3","","","","","","","fee schedule","9833.3","36355.28","Transplants-Case Rate"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10029.97","","","","","","","fee schedule","9833.3","36355.28","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10324.96","","","","","","","fee schedule","9833.3","36355.28","MSDRG Base Rate"
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9833.3","","","","","","","fee schedule","9833.3","36355.28","Psych-Case Rate"
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17623.24","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18848.29","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24699","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20479.41","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17675.42","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22590.72","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16871.58","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26795.19","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20151.97","","","","","","","fee schedule","7622.01","26795.19",""
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","31320.06","31320.06","31320.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18378.85","18378.85","18378.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","3886","3886","3886","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1244.9","1244.9","1244.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7984.06","","","","","","","fee schedule","7622.01","26795.19","MSDRG Base Rate"
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7850.67","","","","","","","fee schedule","7622.01","26795.19","MSDRG Base Rate"
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7622.01","","","","","","","fee schedule","7622.01","26795.19","Transplants-Case Rate"
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7774.45","","","","","","","fee schedule","7622.01","26795.19","MSDRG Base Rate"
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8003.11","","","","","","","fee schedule","7622.01","26795.19","MSDRG Base Rate"
"Other Cerebrovascular Disorders Without Cc/Mcc","072","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7622.01","","","","","","","fee schedule","7622.01","26795.19","Psych-Case Rate"
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37388.21","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39987.18","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52399.65","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43447.65","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37498.91","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47926.86","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35793.54","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56846.77","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42752.99","","","","","","","fee schedule","14573.08","56846.77",""
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","36938.29","36938.29","36938.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12536.86","12536.86","12809.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12343.68","12343.68","12343.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11377.64","11377.64","11377.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12231.87","12231.87","30246.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39875","39875","39875","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12309.35","12309.35","12309.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","28370.14","28370.14","28370.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15265.3","","","","","","","fee schedule","14573.08","56846.77","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15010.27","","","","","","","fee schedule","14573.08","56846.77","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14573.08","","","","","","","fee schedule","14573.08","56846.77","Transplants-Case Rate"
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14864.54","","","","","","","fee schedule","14573.08","56846.77","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15301.73","","","","","","","fee schedule","14573.08","56846.77","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders With Mcc","073","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14573.08","","","","","","","fee schedule","14573.08","56846.77","Psych-Case Rate"
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24022.79","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25692.69","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33667.99","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27916.13","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24093.92","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30794.12","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22998.18","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36525.37","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27469.79","","","","","","","fee schedule","9872.65","36525.37",""
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7788.63","7788.63","7788.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23750.42","23750.42","24912.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20956.25","8937.29","31088.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8564.29","8564.29","8623.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","15200.02","15200.02","15200.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8475.08","8049.09","10775.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10713.85","7788.63","11971.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21740.49","21740.49","21740.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9915.84","9107.34","24117.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","25539","25539","25539","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8544.27","8325.81","12628.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","27469.79","27409.66","27778.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12423.18","12423.18","12423.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10341.6","","","","","","","fee schedule","9872.65","36525.37","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10168.83","","","","","","","fee schedule","9872.65","36525.37","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9872.65","","","","","","","fee schedule","9872.65","36525.37","Transplants-Case Rate"
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10070.1","","","","","","","fee schedule","9872.65","36525.37","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10366.28","","","","","","","fee schedule","9872.65","36525.37","MSDRG Base Rate"
"Cranial And Peripheral Nerve Disorders Without Mcc","074","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9872.65","","","","","","","fee schedule","9872.65","36525.37","Psych-Case Rate"
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44687.34","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47793.69","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","62629.39","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51929.74","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44819.65","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57283.4","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42781.34","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","67944.7","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51099.46","","","","","","","fee schedule","17140.09","67944.7",""
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17954.24","","","","","","","fee schedule","17140.09","67944.7","MSDRG Base Rate"
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17654.29","","","","","","","fee schedule","17140.09","67944.7","MSDRG Base Rate"
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17140.09","","","","","","","fee schedule","17140.09","67944.7","Transplants-Case Rate"
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17482.89","","","","","","","fee schedule","17140.09","67944.7","MSDRG Base Rate"
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17997.09","","","","","","","fee schedule","17140.09","67944.7","MSDRG Base Rate"
"Viral Meningitis With Cc/Mcc","075","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17140.09","","","","","","","fee schedule","17140.09","67944.7","Psych-Case Rate"
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19231.29","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20568.11","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26952.68","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22348.07","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19288.22","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24652.02","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18411.04","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29240.14","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21990.75","","","","","","","fee schedule","8187.54","29240.14",""
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8576.45","","","","","","","fee schedule","8187.54","29240.14","MSDRG Base Rate"
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8433.17","","","","","","","fee schedule","8187.54","29240.14","MSDRG Base Rate"
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8187.54","","","","","","","fee schedule","8187.54","29240.14","Transplants-Case Rate"
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8351.29","","","","","","","fee schedule","8187.54","29240.14","MSDRG Base Rate"
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8596.92","","","","","","","fee schedule","8187.54","29240.14","MSDRG Base Rate"
"Viral Meningitis Without Cc/Mcc","076","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8187.54","","","","","","","fee schedule","8187.54","29240.14","Psych-Case Rate"
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46191.18","","","","","","","fee schedule","41204.68","46191.18",""
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41204.68","","","","","","","fee schedule","41204.68","46191.18",""
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11617.47","11617.47","11617.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Mcc","077","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29808.28","","","","","","","fee schedule","26590.37","29808.28",""
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26590.37","","","","","","","fee schedule","26590.37","29808.28",""
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy With Cc","078","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19917","","","","","","","fee schedule","17766.89","19917",""
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17766.89","","","","","","","fee schedule","17766.89","19917",""
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertensive Encephalopathy Without Cc/Mcc","079","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42182.05","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45114.25","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59118.22","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49018.42","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42306.94","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54071.94","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40382.91","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64135.54","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48234.69","","","","","","","fee schedule","16259.01","64135.54",""
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19548.94","19548.94","19548.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16820.7","16820.7","16820.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17130.82","17130.82","17130.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","18263.57","18263.57","18263.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","11579.95","11579.95","11579.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17031.31","","","","","","","fee schedule","16259.01","64135.54","MSDRG Base Rate"
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16746.78","","","","","","","fee schedule","16259.01","64135.54","MSDRG Base Rate"
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16259.01","","","","","","","fee schedule","16259.01","64135.54","Transplants-Case Rate"
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16584.19","","","","","","","fee schedule","16259.01","64135.54","MSDRG Base Rate"
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17071.96","","","","","","","fee schedule","16259.01","64135.54","MSDRG Base Rate"
"Nontraumatic Stupor And Coma With Mcc","080","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16259.01","","","","","","","fee schedule","16259.01","64135.54","Psych-Case Rate"
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20871.96","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22322.83","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29252.09","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24254.64","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20933.75","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26755.15","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19981.73","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31734.69","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23866.84","","","","","","","fee schedule","8764.54","31734.69",""
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8374","8374","8374","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9180.86","","","","","","","fee schedule","8764.54","31734.69","MSDRG Base Rate"
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9027.48","","","","","","","fee schedule","8764.54","31734.69","MSDRG Base Rate"
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8764.54","","","","","","","fee schedule","8764.54","31734.69","Transplants-Case Rate"
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8939.83","","","","","","","fee schedule","8764.54","31734.69","MSDRG Base Rate"
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9202.77","","","","","","","fee schedule","8764.54","31734.69","MSDRG Base Rate"
"Nontraumatic Stupor And Coma Without Mcc","081","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8764.54","","","","","","","fee schedule","8764.54","31734.69","Psych-Case Rate"
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","53265.91","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","56968.58","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","74652.27","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","61898.62","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","53423.61","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","68280.01","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","50994.02","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","80987.95","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","60908.95","","","","","","","fee schedule","20157.06","80987.95",""
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","231023.75","231023.75","231023.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1833.63","1833.63","1833.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8257.7","8257.7","8257.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","21583.32","21583.32","21583.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50062.3","50062.3","50062.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6549.22","6549.22","6549.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19179.35","19179.35","19179.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17375.37","17375.37","17375.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18262.92","17651.4","20432.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18999.57","18146.97","20207.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8647.72","8130.88","32641.05","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","50938","50938","50938","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","56842","56842","56842","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18813.34","17241.87","19895.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8569.31","8569.31","8569.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","47430.9","47430.9","47430.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21114.52","","","","","","","fee schedule","20157.06","80987.95","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20761.77","","","","","","","fee schedule","20157.06","80987.95","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20157.06","","","","","","","fee schedule","20157.06","80987.95","Transplants-Case Rate"
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20560.2","","","","","","","fee schedule","20157.06","80987.95","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21164.91","","","","","","","fee schedule","20157.06","80987.95","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Mcc","082","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20157.06","","","","","","","fee schedule","20157.06","80987.95","Psych-Case Rate"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32529.12","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34790.32","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45589.62","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37801.06","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32625.43","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41698.13","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31141.69","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49458.78","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37196.67","","","","","","","fee schedule","12864.21","49458.78",""
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11684.68","1225.2","12136.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","30024","30024","30024","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10993.67","10993.67","10993.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11376.13","11376.13","12693.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13475.26","","","","","","","fee schedule","12864.21","49458.78","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13250.14","","","","","","","fee schedule","12864.21","49458.78","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12864.21","","","","","","","fee schedule","12864.21","49458.78","Transplants-Case Rate"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13121.49","","","","","","","fee schedule","12864.21","49458.78","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13507.42","","","","","","","fee schedule","12864.21","49458.78","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12864.21","","","","","","","fee schedule","12864.21","49458.78","Psych-Case Rate"
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22274.92","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23823.32","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31218.34","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25884.98","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22340.87","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28553.57","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21324.85","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33867.82","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25471.11","","","","","","","fee schedule","9257.94","33867.82",""
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","16370.36","16370.36","16370.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8701.6","1614.13","8949.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8456.6","8456.6","8456.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","18028.65","18028.65","18028.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9697.69","","","","","","","fee schedule","9257.94","33867.82","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9535.68","","","","","","","fee schedule","9257.94","33867.82","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9257.94","","","","","","","fee schedule","9257.94","33867.82","Transplants-Case Rate"
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9443.1","","","","","","","fee schedule","9257.94","33867.82","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9720.84","","","","","","","fee schedule","9257.94","33867.82","MSDRG Base Rate"
"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","084","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9257.94","","","","","","","fee schedule","9257.94","33867.82","Psych-Case Rate"
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","52946.63","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","56627.11","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","74204.8","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","61527.6","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","53103.39","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","67870.74","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","50688.36","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","80502.5","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","60543.86","","","","","","","fee schedule","20044.77","80502.5",""
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","70511.61","70511.61","101014.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18632.17","18632.17","18632.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17212.43","17212.43","18326.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","44223.2","44223.2","44223.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24253.13","24253.13","24253.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20996.9","","","","","","","fee schedule","20044.77","80502.5","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20646.11","","","","","","","fee schedule","20044.77","80502.5","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20044.77","","","","","","","fee schedule","20044.77","80502.5","Transplants-Case Rate"
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20445.67","","","","","","","fee schedule","20044.77","80502.5","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21047.01","","","","","","","fee schedule","20044.77","80502.5","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Mcc","085","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20044.77","","","","","","","fee schedule","20044.77","80502.5","Psych-Case Rate"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30359.42","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32469.8","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42548.79","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35279.72","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30449.31","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38916.86","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29064.54","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46159.87","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34715.65","","","","","","","fee schedule","12101.15","46159.87",""
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","35510.14","35510.14","35510.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9467","8273.12","11090.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10048.81","10048.81","10048.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10570.41","10570.41","10570.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12675.95","","","","","","","fee schedule","12101.15","46159.87","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12464.18","","","","","","","fee schedule","12101.15","46159.87","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12101.15","","","","","","","fee schedule","12101.15","46159.87","Transplants-Case Rate"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12343.17","","","","","","","fee schedule","12101.15","46159.87","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12706.21","","","","","","","fee schedule","12101.15","46159.87","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12101.15","","","","","","","fee schedule","12101.15","46159.87","Psych-Case Rate"
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21317.08","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22798.9","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29875.93","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24771.91","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21380.2","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27325.75","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20407.87","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32411.48","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24375.84","","","","","","","fee schedule","8921.08","32411.48",""
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21628.82","21628.82","21628.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6946","6946","6946","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6453.23","6453.23","6453.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9344.83","","","","","","","fee schedule","8921.08","32411.48","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9188.71","","","","","","","fee schedule","8921.08","32411.48","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8921.08","","","","","","","fee schedule","8921.08","32411.48","Transplants-Case Rate"
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9099.5","","","","","","","fee schedule","8921.08","32411.48","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9367.13","","","","","","","fee schedule","8921.08","32411.48","MSDRG Base Rate"
"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","087","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8921.08","","","","","","","fee schedule","8921.08","32411.48","Psych-Case Rate"
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31503.7","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33693.62","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44152.49","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36609.45","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31596.97","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40383.67","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30160.01","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47899.68","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36024.12","","","","","","","fee schedule","12503.58","47899.68",""
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13097.5","","","","","","","fee schedule","12503.58","47899.68","MSDRG Base Rate"
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12878.69","","","","","","","fee schedule","12503.58","47899.68","MSDRG Base Rate"
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12503.58","","","","","","","fee schedule","12503.58","47899.68","Transplants-Case Rate"
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12753.65","","","","","","","fee schedule","12503.58","47899.68","MSDRG Base Rate"
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13128.76","","","","","","","fee schedule","12503.58","47899.68","MSDRG Base Rate"
"Concussion With Mcc","088","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12503.58","","","","","","","fee schedule","12503.58","47899.68","Psych-Case Rate"
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25602.87","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27382.61","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35882.47","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29752.29","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25678.68","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32819.58","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24510.86","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38927.79","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29276.59","","","","","","","fee schedule","10428.34","38927.79",""
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","42993.1","42993.1","42993.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","42251.1","21525.56","42251.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10923.69","","","","","","","fee schedule","10428.34","38927.79","MSDRG Base Rate"
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10741.19","","","","","","","fee schedule","10428.34","38927.79","MSDRG Base Rate"
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10428.34","","","","","","","fee schedule","10428.34","38927.79","Transplants-Case Rate"
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10636.91","","","","","","","fee schedule","10428.34","38927.79","MSDRG Base Rate"
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10949.76","","","","","","","fee schedule","10428.34","38927.79","MSDRG Base Rate"
"Concussion With Cc","089","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10428.34","","","","","","","fee schedule","10428.34","38927.79","Psych-Case Rate"
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19184.68","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20518.26","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26887.36","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22293.9","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19241.48","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24592.28","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18366.42","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29169.27","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21937.46","","","","","","","fee schedule","8171.14","29169.27",""
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","19156.37","19156.37","19156.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1910.99","1910.99","1910.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8559.27","","","","","","","fee schedule","8171.14","29169.27","MSDRG Base Rate"
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8416.27","","","","","","","fee schedule","8171.14","29169.27","MSDRG Base Rate"
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8171.14","","","","","","","fee schedule","8171.14","29169.27","Transplants-Case Rate"
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8334.56","","","","","","","fee schedule","8171.14","29169.27","MSDRG Base Rate"
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8579.7","","","","","","","fee schedule","8171.14","29169.27","MSDRG Base Rate"
"Concussion Without Cc/Mcc","090","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8171.14","","","","","","","fee schedule","8171.14","29169.27","Psych-Case Rate"
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40928.24","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43773.29","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57361","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47561.41","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41049.42","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52464.72","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39182.58","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62229.19","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46800.97","","","","","","","fee schedule","15818.06","62229.19",""
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","19632.62","19632.62","19632.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","33200.58","33200.58","78277.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57091.41","57091.41","57091.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","11509.92","11509.92","11509.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14538.55","14529.84","16214.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14777.16","10266.71","36263.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16566.15","16566.15","16566.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","81974.8","81974.8","81974.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","47030","47030","47030","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15272.64","14612.71","15610.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16569.42","","","","","","","fee schedule","15818.06","62229.19","MSDRG Base Rate"
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16292.6","","","","","","","fee schedule","15818.06","62229.19","MSDRG Base Rate"
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15818.06","","","","","","","fee schedule","15818.06","62229.19","Transplants-Case Rate"
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16134.42","","","","","","","fee schedule","15818.06","62229.19","MSDRG Base Rate"
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16608.96","","","","","","","fee schedule","15818.06","62229.19","MSDRG Base Rate"
"Other Disorders Of Nervous System With Mcc","091","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15818.06","","","","","","","fee schedule","15818.06","62229.19","Psych-Case Rate"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23841.02","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25498.28","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33413.23","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27704.89","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23911.6","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30561.1","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22824.15","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36248.98","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27261.93","","","","","","","fee schedule","9808.72","36248.98",""
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","20732.73","20732.73","20732.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","21865.58","21865.58","22164.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","30959.17","30959.17","33157.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9936.79","9936.79","9936.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","22824.15","22824.15","22824.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9193.12","8216.06","9204.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8920.59","8920.59","8920.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20732.73","16532.66","21711.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21264","21264","22746","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9252.33","9252.33","9578.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","21515.1","17156.54","21515.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10274.63","","","","","","","fee schedule","9808.72","36248.98","MSDRG Base Rate"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10102.98","","","","","","","fee schedule","9808.72","36248.98","MSDRG Base Rate"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9808.72","","","","","","","fee schedule","9808.72","36248.98","Transplants-Case Rate"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10004.89","","","","","","","fee schedule","9808.72","36248.98","MSDRG Base Rate"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10299.16","","","","","","","fee schedule","9808.72","36248.98","MSDRG Base Rate"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9808.72","","","","","","","fee schedule","9808.72","36248.98","Psych-Case Rate"
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18557.77","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19847.78","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26008.75","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21565.4","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18612.72","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23788.67","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17766.25","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28216.09","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21220.6","","","","","","","fee schedule","7950.67","28216.09",""
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","14606.99","14606.99","14606.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","12029.89","12029.89","12029.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24720.09","24720.09","24720.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","17927.61","17927.61","17927.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8328.33","","","","","","","fee schedule","7950.67","28216.09","MSDRG Base Rate"
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8189.19","","","","","","","fee schedule","7950.67","28216.09","MSDRG Base Rate"
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7950.67","","","","","","","fee schedule","7950.67","28216.09","Transplants-Case Rate"
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8109.68","","","","","","","fee schedule","7950.67","28216.09","MSDRG Base Rate"
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8348.2","","","","","","","fee schedule","7950.67","28216.09","MSDRG Base Rate"
"Other Disorders Of Nervous System Without Cc/Mcc","093","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7950.67","","","","","","","fee schedule","7950.67","28216.09","Psych-Case Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","82019.62","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","87721.05","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","114950.64","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","95312.39","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","82262.46","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","105138.56","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","78521.33","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","124706.42","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","93788.49","","","","","","","fee schedule","30269.35","124706.42",""
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","228254.2","228254.2","228254.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","61848.02","61848.02","61848.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","61848.02","61848.02","61848.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35016.31","35016.31","35016.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","35600.19","35600.19","35600.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","55437.73","55437.73","55437.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31707.14","","","","","","","fee schedule","30269.35","124706.42","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31177.43","","","","","","","fee schedule","30269.35","124706.42","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30269.35","","","","","","","fee schedule","30269.35","124706.42","Transplants-Case Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30874.74","","","","","","","fee schedule","30269.35","124706.42","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31782.82","","","","","","","fee schedule","30269.35","124706.42","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Mcc","094","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30269.35","","","","","","","fee schedule","30269.35","124706.42","Psych-Case Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","60108.26","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","64286.56","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","84241.83","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","69849.89","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","60286.22","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","77051.02","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","57544.53","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","91391.37","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","68733.1","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","34305.64","34305.64","34305.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","72761.27","72761.27","72761.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23635.18","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23240.32","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22563.42","","","","","","","fee schedule","22563.42","91391.37","Transplants-Case Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23014.69","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23691.59","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22563.42","","","","","","","fee schedule","22563.42","91391.37","Psych-Case Rate"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","60108.26","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","64286.56","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","84241.83","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","69849.89","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","60286.22","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","77051.02","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","57544.53","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","91391.37","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","68733.1","","","","","","","fee schedule","22563.42","91391.37",""
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","74772.71","74772.71","74772.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","52626","52626","52626","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23635.18","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23240.32","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22563.42","","","","","","","fee schedule","22563.42","91391.37","Transplants-Case Rate"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23014.69","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23691.59","","","","","","","fee schedule","22563.42","91391.37","MSDRG Base Rate"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","096","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22563.42","","","","","","","fee schedule","22563.42","91391.37","Psych-Case Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","84173","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","90024.12","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","117968.61","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","97814.77","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","84422.21","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","107898.91","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","80582.87","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","127980.52","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","96250.86","","","","","","","fee schedule","31026.67","127980.52",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","128723.71","128723.71","128723.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","41166.1","41166.1","41166.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","29653.9","29653.9","29653.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","30355.18","30355.18","30355.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32500.44","","","","","","","fee schedule","31026.67","127980.52","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31957.47","","","","","","","fee schedule","31026.67","127980.52","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31026.67","","","","","","","fee schedule","31026.67","127980.52","Transplants-Case Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31647.2","","","","","","","fee schedule","31026.67","127980.52","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32578","","","","","","","fee schedule","31026.67","127980.52","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","097","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31026.67","","","","","","","fee schedule","31026.67","127980.52","Psych-Case Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","53482.64","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","57200.38","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","74956.02","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","62150.48","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","53640.99","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","68557.84","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","51201.51","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","81317.49","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","61156.79","","","","","","","fee schedule","20233.28","81317.49",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","21090.81","19832","22023.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","51844.1","51844.1","51844.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","48399.25","48399.25","48399.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20768.7","19832","20768.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","61156.79","61156.79","65410.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","21552.42","21552.42","21552.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21194.36","","","","","","","fee schedule","20233.28","81317.49","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20840.28","","","","","","","fee schedule","20233.28","81317.49","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20233.28","","","","","","","fee schedule","20233.28","81317.49","Transplants-Case Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20637.95","","","","","","","fee schedule","20233.28","81317.49","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21244.94","","","","","","","fee schedule","20233.28","81317.49","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20233.28","","","","","","","fee schedule","20233.28","81317.49","Psych-Case Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31750.73","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33957.82","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44498.71","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36896.52","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31844.74","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40700.34","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30396.51","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48275.28","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36306.6","","","","","","","fee schedule","12590.46","48275.28",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","33118.27","33118.27","33118.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13188.51","","","","","","","fee schedule","12590.46","48275.28","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12968.17","","","","","","","fee schedule","12590.46","48275.28","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12590.46","","","","","","","fee schedule","12590.46","48275.28","Transplants-Case Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12842.27","","","","","","","fee schedule","12590.46","48275.28","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13219.98","","","","","","","fee schedule","12590.46","48275.28","MSDRG Base Rate"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","099","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12590.46","","","","","","","fee schedule","12590.46","48275.28","Psych-Case Rate"
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45137.12","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48274.74","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63259.76","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52452.42","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45270.76","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57859.96","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43211.94","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68628.57","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51613.78","","","","","","","fee schedule","17298.27","68628.57",""
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","31962.88","31962.88","31962.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","38972.19","38972.19","38972.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","47446.68","47446.68","47446.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16830.57","15521.09","19218.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16479.75","14938.92","36140.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15491.35","15491.35","24908.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","31012.13","31012.13","31012.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16004.51","15927.19","39760.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13372.84","13372.84","13372.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18119.94","","","","","","","fee schedule","17298.27","68628.57","MSDRG Base Rate"
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17817.22","","","","","","","fee schedule","17298.27","68628.57","MSDRG Base Rate"
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17298.27","","","","","","","fee schedule","17298.27","68628.57","Transplants-Case Rate"
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17644.24","","","","","","","fee schedule","17298.27","68628.57","MSDRG Base Rate"
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18163.18","","","","","","","fee schedule","17298.27","68628.57","MSDRG Base Rate"
"Seizures With Mcc","100","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17298.27","","","","","","","fee schedule","17298.27","68628.57","Psych-Case Rate"
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21035.09","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22497.31","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29480.72","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24444.21","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21097.37","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26964.27","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20137.91","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31982.73","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24053.39","","","","","","","fee schedule","8821.91","31982.73",""
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","17087.28","17087.28","17087.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8141.15","8141.15","8141.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24871.72","24871.72","25771.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20655.69","20655.69","20655.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7988.98","7667.56","8836.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","19514.6","19514.6","19514.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","3250.85","2528.87","7765.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8024.76","6951.58","8314.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19763.49","19763.49","19763.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7231.31","7049.68","8102.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24053.39","24053.39","24053.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9240.95","","","","","","","fee schedule","8821.91","31982.73","MSDRG Base Rate"
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9086.57","","","","","","","fee schedule","8821.91","31982.73","MSDRG Base Rate"
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8821.91","","","","","","","fee schedule","8821.91","31982.73","Transplants-Case Rate"
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8998.35","","","","","","","fee schedule","8821.91","31982.73","MSDRG Base Rate"
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9263.01","","","","","","","fee schedule","8821.91","31982.73","MSDRG Base Rate"
"Seizures Without Mcc","101","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8821.91","","","","","","","fee schedule","8821.91","31982.73","Psych-Case Rate"
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26122.57","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27938.43","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36610.84","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30356.21","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26199.92","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33485.77","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25008.4","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","39717.97","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29870.86","","","","","","","fee schedule","10611.11","39717.97",""
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36314.38","36314.38","36314.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","12723.09","12723.09","12723.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9146.35","9146.35","9146.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11115.14","","","","","","","fee schedule","10611.11","39717.97","MSDRG Base Rate"
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10929.44","","","","","","","fee schedule","10611.11","39717.97","MSDRG Base Rate"
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10611.11","","","","","","","fee schedule","10611.11","39717.97","Transplants-Case Rate"
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10823.33","","","","","","","fee schedule","10611.11","39717.97","MSDRG Base Rate"
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11141.67","","","","","","","fee schedule","10611.11","39717.97","MSDRG Base Rate"
"Headaches With Mcc","102","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10611.11","","","","","","","fee schedule","10611.11","39717.97","Psych-Case Rate"
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19489.97","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20844.78","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27315.23","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22648.68","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19547.68","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24983.63","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18658.69","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29633.45","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22286.56","","","","","","","fee schedule","8278.51","29633.45",""
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","40212.53","40212.53","40212.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","11641.31","11641.31","11641.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23927.44","8853.19","26627.41","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","19924.13","19924.13","19924.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18658.69","18658.69","18658.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6415.47","6415.47","6415.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17476","17160.32","18666","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8043.97","8043.97","8043.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7572.05","7572.05","7572.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","22049.94","22049.94","22049.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8671.74","","","","","","","fee schedule","8278.51","29633.45","MSDRG Base Rate"
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8526.87","","","","","","","fee schedule","8278.51","29633.45","MSDRG Base Rate"
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8278.51","","","","","","","fee schedule","8278.51","29633.45","Transplants-Case Rate"
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8444.08","","","","","","","fee schedule","8278.51","29633.45","MSDRG Base Rate"
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8692.44","","","","","","","fee schedule","8278.51","29633.45","MSDRG Base Rate"
"Headaches Without Mcc","103","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8278.51","","","","","","","fee schedule","8278.51","29633.45","Psych-Case Rate"
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","104","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","105","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass w PTCA","106","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","107","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures","108","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","109","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w CC","110","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Cardiovascular Procedures w/o CC","111","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","112","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54792.39","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","58601.17","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","76791.63","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","63672.49","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54954.61","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","70236.76","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","52455.39","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","83308.88","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","62654.46","","","","","","","fee schedule","20693.9","83308.88",""
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6516.66","6516.66","6516.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","68924.46","68924.46","68924.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17136.3","17136.3","17136.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9480.75","9480.75","9928.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","54016.78","54016.78","54016.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9838.51","9838.51","10303.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21676.86","","","","","","","fee schedule","20693.9","83308.88","MSDRG Base Rate"
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21314.72","","","","","","","fee schedule","20693.9","83308.88","MSDRG Base Rate"
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20693.9","","","","","","","fee schedule","20693.9","83308.88","Transplants-Case Rate"
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21107.78","","","","","","","fee schedule","20693.9","83308.88","MSDRG Base Rate"
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21728.6","","","","","","","fee schedule","20693.9","83308.88","MSDRG Base Rate"
"Orbital Procedures With Cc/Mcc","113","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20693.9","","","","","","","fee schedule","20693.9","83308.88","Psych-Case Rate"
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31531.67","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33723.53","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44191.69","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36641.95","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31625.02","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40419.52","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30186.78","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47942.2","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36056.1","","","","","","","fee schedule","12513.41","47942.2",""
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10091.27","10091.27","10091.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1315.44","1315.44","1315.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19636.31","19636.31","19636.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13107.8","","","","","","","fee schedule","12513.41","47942.2","MSDRG Base Rate"
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12888.81","","","","","","","fee schedule","12513.41","47942.2","MSDRG Base Rate"
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12513.41","","","","","","","fee schedule","12513.41","47942.2","Transplants-Case Rate"
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12763.68","","","","","","","fee schedule","12513.41","47942.2","MSDRG Base Rate"
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13139.08","","","","","","","fee schedule","12513.41","47942.2","MSDRG Base Rate"
"Orbital Procedures Without Cc/Mcc","114","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12513.41","","","","","","","fee schedule","12513.41","47942.2","Psych-Case Rate"
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35770.84","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38257.38","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50132.9","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41568.16","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35876.75","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45853.6","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34245.15","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54387.65","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40903.55","","","","","","","fee schedule","14004.28","54387.65",""
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1452.9","1452.9","1452.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8807.44","6738.25","13158.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","34210.2","34210.2","34210.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13079.26","12634.72","13876.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8410.22","6738.25","43173.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","33611","33611","33611","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","39453.22","39453.22","39453.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","4753.06","4753.06","4753.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9139.8","9139.8","9139.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14669.48","","","","","","","fee schedule","14004.28","54387.65","MSDRG Base Rate"
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14424.41","","","","","","","fee schedule","14004.28","54387.65","MSDRG Base Rate"
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14004.28","","","","","","","fee schedule","14004.28","54387.65","Transplants-Case Rate"
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14284.37","","","","","","","fee schedule","14004.28","54387.65","MSDRG Base Rate"
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14704.49","","","","","","","fee schedule","14004.28","54387.65","MSDRG Base Rate"
"Extraocular Procedures Except Orbit","115","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14004.28","","","","","","","fee schedule","14004.28","54387.65","Psych-Case Rate"
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42137.77","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45066.89","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59056.16","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48966.96","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42262.53","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54015.18","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40340.52","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64068.22","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48184.06","","","","","","","fee schedule","16243.44","64068.22",""
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","37228.13","37228.13","37228.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13918.4","13918.4","13918.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35998.79","35998.79","35998.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16372.09","16372.09","16372.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17015","","","","","","","fee schedule","16243.44","64068.22","MSDRG Base Rate"
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16730.74","","","","","","","fee schedule","16243.44","64068.22","MSDRG Base Rate"
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16243.44","","","","","","","fee schedule","16243.44","64068.22","Transplants-Case Rate"
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16568.31","","","","","","","fee schedule","16243.44","64068.22","MSDRG Base Rate"
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17055.61","","","","","","","fee schedule","16243.44","64068.22","MSDRG Base Rate"
"Intraocular Procedures With Cc/Mcc","116","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16243.44","","","","","","","fee schedule","16243.44","64068.22","Psych-Case Rate"
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25283.59","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27041.13","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35435","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29381.26","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25358.45","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32410.3","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24205.2","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38442.35","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28911.5","","","","","","","fee schedule","10316.05","38442.35",""
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10806.06","","","","","","","fee schedule","10316.05","38442.35","MSDRG Base Rate"
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10625.53","","","","","","","fee schedule","10316.05","38442.35","MSDRG Base Rate"
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10316.05","","","","","","","fee schedule","10316.05","38442.35","Transplants-Case Rate"
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10522.37","","","","","","","fee schedule","10316.05","38442.35","MSDRG Base Rate"
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10831.85","","","","","","","fee schedule","10316.05","38442.35","MSDRG Base Rate"
"Intraocular Procedures Without Cc/Mcc","117","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10316.05","","","","","","","fee schedule","10316.05","38442.35","Psych-Case Rate"
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement","118","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein ligation & stripping","119","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other circulatory system O.R. procedures","120","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27110.71","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28995.25","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37995.7","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31504.49","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27190.97","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34752.42","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25954.39","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41220.37","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31000.78","","","","","","","fee schedule","10958.62","41220.37",""
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","74520.5","74520.5","74520.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","15227.97","15227.97","15227.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8901.4","8901.4","8901.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10612.91","10612.91","10612.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22620.6","15947.04","33662.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","25536","25536","25536","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10346.21","10346.21","10346.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11479.15","","","","","","","fee schedule","10958.62","41220.37","MSDRG Base Rate"
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11287.38","","","","","","","fee schedule","10958.62","41220.37","MSDRG Base Rate"
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10958.62","","","","","","","fee schedule","10958.62","41220.37","Transplants-Case Rate"
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11177.79","","","","","","","fee schedule","10958.62","41220.37","MSDRG Base Rate"
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11506.55","","","","","","","fee schedule","10958.62","41220.37","MSDRG Base Rate"
"Acute Major Eye Infections With Cc/Mcc","121","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10958.62","","","","","","","fee schedule","10958.62","41220.37","Psych-Case Rate"
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18313.07","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19586.07","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25665.8","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21281.04","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18367.29","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23474.99","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17531.98","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27844.04","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20940.78","","","","","","","fee schedule","7864.61","27844.04",""
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8238.18","","","","","","","fee schedule","7864.61","27844.04","MSDRG Base Rate"
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8100.55","","","","","","","fee schedule","7864.61","27844.04","MSDRG Base Rate"
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7864.61","","","","","","","fee schedule","7864.61","27844.04","Transplants-Case Rate"
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8021.9","","","","","","","fee schedule","7864.61","27844.04","MSDRG Base Rate"
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8257.84","","","","","","","fee schedule","7864.61","27844.04","MSDRG Base Rate"
"Acute Major Eye Infections Without Cc/Mcc","122","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7864.61","","","","","","","fee schedule","7864.61","27844.04","Psych-Case Rate"
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18611.37","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19905.11","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26083.87","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21627.69","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18666.48","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23857.38","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17817.56","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28297.59","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21281.89","","","","","","","fee schedule","7969.52","28297.59",""
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","19238.19","19238.19","19238.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","14358","14358","14358","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","15201.97","15201.97","15201.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23888.87","21708.97","23918.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17634","12662.06","17634","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","37112.19","37112.19","37112.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7030.45","7030.45","7030.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19348.89","19348.89","19348.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8348.07","","","","","","","fee schedule","7969.52","28297.59","MSDRG Base Rate"
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8208.61","","","","","","","fee schedule","7969.52","28297.59","MSDRG Base Rate"
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7969.52","","","","","","","fee schedule","7969.52","28297.59","Transplants-Case Rate"
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8128.91","","","","","","","fee schedule","7969.52","28297.59","MSDRG Base Rate"
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8368","","","","","","","fee schedule","7969.52","28297.59","MSDRG Base Rate"
"Neurological Eye Disorders","123","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7969.52","","","","","","","fee schedule","7969.52","28297.59","Psych-Case Rate"
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30834.85","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32978.27","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43215.09","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35832.19","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30926.14","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39526.29","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29519.68","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46882.73","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35259.29","","","","","","","fee schedule","12268.35","46882.73",""
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","40486.84","40486.84","40486.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10968.81","10968.81","10968.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11199.56","11199.56","11199.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","33639","33639","33639","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10647.63","10647.63","10647.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12851.1","","","","","","","fee schedule","12268.35","46882.73","MSDRG Base Rate"
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12636.4","","","","","","","fee schedule","12268.35","46882.73","MSDRG Base Rate"
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12268.35","","","","","","","fee schedule","12268.35","46882.73","Transplants-Case Rate"
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12513.72","","","","","","","fee schedule","12268.35","46882.73","MSDRG Base Rate"
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12881.77","","","","","","","fee schedule","12268.35","46882.73","MSDRG Base Rate"
"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","124","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12268.35","","","","","","","fee schedule","12268.35","46882.73","Psych-Case Rate"
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17893.58","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19137.42","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25077.88","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20793.56","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17946.56","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22937.26","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17130.39","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27206.23","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20461.1","","","","","","","fee schedule","7717.08","27206.23",""
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17189.8","17189.8","17189.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23179.79","23179.79","23179.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6990.9","6990.9","7338.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7427.47","7101.29","7427.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6735.71","6735.71","6735.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17628","17628","18128","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","10970.31","10970.31","10970.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6772.83","6772.83","6875.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","17906.6","17906.6","17906.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8083.64","","","","","","","fee schedule","7717.08","27206.23","MSDRG Base Rate"
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7948.59","","","","","","","fee schedule","7717.08","27206.23","MSDRG Base Rate"
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7717.08","","","","","","","fee schedule","7717.08","27206.23","Transplants-Case Rate"
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7871.42","","","","","","","fee schedule","7717.08","27206.23","MSDRG Base Rate"
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8102.93","","","","","","","fee schedule","7717.08","27206.23","MSDRG Base Rate"
"Other Disorders Of The Eye Without Mcc","125","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7717.08","","","","","","","fee schedule","7717.08","27206.23","Psych-Case Rate"
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute & Subacute Endocarditis","126","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure & Shock","127","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis","128","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W Cc/Mcc Or Major Device","129","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head & Neck Procedures W/O Cc/Mcc","130","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W Cc/Mcc","131","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cranial/Facial Procedures W/O Cc/Mcc","132","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","133","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","134","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","50571.85","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54087.25","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","70876.54","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","58767.94","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","50721.58","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","64826.58","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48414.87","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","76891.78","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","57828.33","","","","","","","fee schedule","19209.59","76891.78",""
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","66212.23","66212.23","66212.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8234.85","7863.45","13660.67","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10975.58","10975.58","10975.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","21744.37","21744.37","21744.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20122.05","","","","","","","fee schedule","19209.59","76891.78","MSDRG Base Rate"
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19785.88","","","","","","","fee schedule","19209.59","76891.78","MSDRG Base Rate"
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19209.59","","","","","","","fee schedule","19209.59","76891.78","Transplants-Case Rate"
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19593.78","","","","","","","fee schedule","19209.59","76891.78","MSDRG Base Rate"
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20170.07","","","","","","","fee schedule","19209.59","76891.78","MSDRG Base Rate"
"Sinus And Mastoid Procedures With Cc/Mcc","135","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19209.59","","","","","","","fee schedule","19209.59","76891.78","Psych-Case Rate"
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23661.57","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25306.35","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33161.73","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27496.35","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23731.62","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30331.07","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22652.36","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35976.14","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27056.73","","","","","","","fee schedule","9745.61","35976.14",""
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","24365.89","24365.89","24365.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28939.88","28939.88","28939.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16541.3","16541.3","24365.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10208.53","","","","","","","fee schedule","9745.61","35976.14","MSDRG Base Rate"
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10037.98","","","","","","","fee schedule","9745.61","35976.14","MSDRG Base Rate"
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9745.61","","","","","","","fee schedule","9745.61","35976.14","Transplants-Case Rate"
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9940.52","","","","","","","fee schedule","9745.61","35976.14","MSDRG Base Rate"
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10232.89","","","","","","","fee schedule","9745.61","35976.14","MSDRG Base Rate"
"Sinus And Mastoid Procedures Without Cc/Mcc","136","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9745.61","","","","","","","fee schedule","9745.61","35976.14","Psych-Case Rate"
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34799.03","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37218.01","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48770.9","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40438.84","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34902.06","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44607.86","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33314.79","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52910.05","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39792.29","","","","","","","fee schedule","13662.5","52910.05",""
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17938.44","10306.66","18785.7","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36582.51","36582.51","36582.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11734.73","11734.73","11734.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17938.44","10306.66","18785.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12539.38","12539.38","12539.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10598.73","10598.73","18615.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14311.47","","","","","","","fee schedule","13662.5","52910.05","MSDRG Base Rate"
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14072.38","","","","","","","fee schedule","13662.5","52910.05","MSDRG Base Rate"
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13662.5","","","","","","","fee schedule","13662.5","52910.05","Transplants-Case Rate"
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13935.75","","","","","","","fee schedule","13662.5","52910.05","MSDRG Base Rate"
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14345.62","","","","","","","fee schedule","13662.5","52910.05","MSDRG Base Rate"
"Mouth Procedures With Cc/Mcc","137","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13662.5","","","","","","","fee schedule","13662.5","52910.05","Psych-Case Rate"
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20652.89","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22088.54","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28945.06","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24000.07","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20714.04","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26474.34","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19772.01","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31401.61","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23616.34","","","","","","","fee schedule","8687.5","31401.61",""
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","26467.54","26467.54","26467.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","25273.82","25273.82","25273.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15096.41","15096.41","15096.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9100.16","","","","","","","fee schedule","8687.5","31401.61","MSDRG Base Rate"
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8948.12","","","","","","","fee schedule","8687.5","31401.61","MSDRG Base Rate"
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8687.5","","","","","","","fee schedule","8687.5","31401.61","Transplants-Case Rate"
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8861.25","","","","","","","fee schedule","8687.5","31401.61","MSDRG Base Rate"
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9121.88","","","","","","","fee schedule","8687.5","31401.61","MSDRG Base Rate"
"Mouth Procedures Without Cc/Mcc","138","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8687.5","","","","","","","fee schedule","8687.5","31401.61","Psych-Case Rate"
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28797.99","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30799.82","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","40360.43","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","33465.23","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28883.25","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36915.3","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27569.7","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","43785.79","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32930.17","","","","","","","fee schedule","11552.02","43785.79",""
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10330.86","9864.92","15921.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9979.7","9979.7","9979.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9864.92","7043.29","15203.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10695.59","10695.59","10720.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3511.69","3511.69","3511.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12100.74","","","","","","","fee schedule","11552.02","43785.79","MSDRG Base Rate"
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11898.58","","","","","","","fee schedule","11552.02","43785.79","MSDRG Base Rate"
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11552.02","","","","","","","fee schedule","11552.02","43785.79","Transplants-Case Rate"
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11783.06","","","","","","","fee schedule","11552.02","43785.79","MSDRG Base Rate"
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12129.62","","","","","","","fee schedule","11552.02","43785.79","MSDRG Base Rate"
"Salivary Gland Procedures","139","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11552.02","","","","","","","fee schedule","11552.02","43785.79","Psych-Case Rate"
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","99402.82","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","106312.6","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","139313.23","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","115512.85","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","99697.12","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","127421.57","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","95163.11","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","151136.64","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","113665.98","","","","","","","fee schedule","36382.79","151136.64",""
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","96671.1","96671.1","96671.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9808.81","9808.81","15898.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10272.09","7675.81","15181.56","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","84780.11","84780.11","84780.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","16498.56","16498.56","16498.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38110.97","","","","","","","fee schedule","36382.79","151136.64","MSDRG Base Rate"
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37474.27","","","","","","","fee schedule","36382.79","151136.64","MSDRG Base Rate"
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36382.79","","","","","","","fee schedule","36382.79","151136.64","Transplants-Case Rate"
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37110.45","","","","","","","fee schedule","36382.79","151136.64","MSDRG Base Rate"
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38201.93","","","","","","","fee schedule","36382.79","151136.64","MSDRG Base Rate"
"Major Head And Neck Procedures With Mcc","140","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36382.79","","","","","","","fee schedule","36382.79","151136.64","Psych-Case Rate"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","50830.54","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54363.92","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71239.09","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59068.55","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","50981.03","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65158.18","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48662.52","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77285.1","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58124.13","","","","","","","fee schedule","19300.57","77285.1",""
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7623.07","7623.07","13264.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","41826.24","41826.24","41826.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","50847","50847","50847","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","67288.87","63669.58","68309.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","119574.28","119574.28","119574.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16235.56","16235.56","16235.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7279.26","5213.04","12666.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","47166","47166","47166","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17437.57","17437.57","17437.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17812.52","17418.13","17873.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","55721.35","55721.35","55721.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7069.47","7069.47","7069.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20217.35","","","","","","","fee schedule","19300.57","77285.1","MSDRG Base Rate"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19879.59","","","","","","","fee schedule","19300.57","77285.1","MSDRG Base Rate"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19300.57","","","","","","","fee schedule","19300.57","77285.1","Transplants-Case Rate"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19686.58","","","","","","","fee schedule","19300.57","77285.1","MSDRG Base Rate"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20265.6","","","","","","","fee schedule","19300.57","77285.1","MSDRG Base Rate"
"Major Head And Neck Procedures With Cc","141","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19300.57","","","","","","","fee schedule","19300.57","77285.1","Psych-Case Rate"
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37204.1","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39790.27","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52141.62","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43233.7","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37314.25","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47690.85","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35617.28","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56566.84","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42542.46","","","","","","","fee schedule","14508.34","56566.84",""
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","54280.23","54280.23","54280.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45494.58","45058.52","48140.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","13151.65","13151.65","13151.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13037.47","13037.47","13037.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","35081.82","35081.82","35081.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13184.64","1942.21","13531.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","24116.97","24116.97","24116.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","40607.29","40607.29","40607.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15197.49","","","","","","","fee schedule","14508.34","56566.84","MSDRG Base Rate"
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14943.59","","","","","","","fee schedule","14508.34","56566.84","MSDRG Base Rate"
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14508.34","","","","","","","fee schedule","14508.34","56566.84","Transplants-Case Rate"
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14798.51","","","","","","","fee schedule","14508.34","56566.84","MSDRG Base Rate"
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15233.76","","","","","","","fee schedule","14508.34","56566.84","MSDRG Base Rate"
"Major Head And Neck Procedures Without Cc/Mcc","142","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14508.34","","","","","","","fee schedule","14508.34","56566.84","Psych-Case Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","87314.51","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","93384.01","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","122371.45","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","101465.42","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","87573.03","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","111925.93","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","83590.39","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","132757.02","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","99843.14","","","","","","","fee schedule","32131.5","132757.02",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14322.47","13676.5","21642.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","89279.29","89279.29","89279.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","67566.25","67566.25","67566.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","30228.32","30228.32","30228.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13676.5","6818.82","14322.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","72489","72489","72489","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","25298.29","25298.29","25298.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","14862.94","14862.94","14862.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33657.75","","","","","","","fee schedule","32131.5","132757.02","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33095.44","","","","","","","fee schedule","32131.5","132757.02","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32131.5","","","","","","","fee schedule","32131.5","132757.02","Transplants-Case Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32774.13","","","","","","","fee schedule","32131.5","132757.02","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33738.08","","","","","","","fee schedule","32131.5","132757.02","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","143","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32131.5","","","","","","","fee schedule","32131.5","132757.02","Psych-Case Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40385.23","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43192.53","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56599.98","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46930.4","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40504.8","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51768.65","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38662.73","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61403.58","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46180.05","","","","","","","fee schedule","15627.1","61403.58",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","218681.78","218681.78","218681.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","58535.62","58535.62","58535.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9380.02","9380.02","9380.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","24689.27","24689.27","24689.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","55018.09","55018.09","55018.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14109.94","14109.94","14109.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38066","36370.85","38271.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12424.67","12424.67","12424.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","43037","43037","43037","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15056.14","15056.14","15056.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16369.39","","","","","","","fee schedule","15627.1","61403.58","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16095.91","","","","","","","fee schedule","15627.1","61403.58","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15627.1","","","","","","","fee schedule","15627.1","61403.58","Transplants-Case Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15939.64","","","","","","","fee schedule","15627.1","61403.58","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16408.46","","","","","","","fee schedule","15627.1","61403.58","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","144","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15627.1","","","","","","","fee schedule","15627.1","61403.58","Psych-Case Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28019.6","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29967.33","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39269.52","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32560.69","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28102.56","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35917.51","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26824.52","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42602.3","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32040.09","","","","","","","fee schedule","11278.27","42602.3",""
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","20356.6","20356.6","20356.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23749.37","23749.37","23749.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9779.15","9779.15","9779.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6979.97","6979.97","7309.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10857.84","10857.84","10857.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11813.99","","","","","","","fee schedule","11278.27","42602.3","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11616.62","","","","","","","fee schedule","11278.27","42602.3","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11278.27","","","","","","","fee schedule","11278.27","42602.3","Transplants-Case Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11503.84","","","","","","","fee schedule","11278.27","42602.3","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11842.18","","","","","","","fee schedule","11278.27","42602.3","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","145","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11278.27","","","","","","","fee schedule","11278.27","42602.3","Psych-Case Rate"
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49346.01","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52776.2","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69158.52","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57343.43","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49492.11","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63255.21","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47241.31","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75027.95","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56426.59","","","","","","","fee schedule","18778.48","75027.95",""
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","27184.29","27184.29","27184.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","66933.39","66933.39","68419.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18540.36","18540.36","18540.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","42796.43","42796.43","42796.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19670.46","","","","","","","fee schedule","18778.48","75027.95","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19341.83","","","","","","","fee schedule","18778.48","75027.95","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18778.48","","","","","","","fee schedule","18778.48","75027.95","Transplants-Case Rate"
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19154.05","","","","","","","fee schedule","18778.48","75027.95","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19717.4","","","","","","","fee schedule","18778.48","75027.95","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Mcc","146","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18778.48","","","","","","","fee schedule","18778.48","75027.95","Psych-Case Rate"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29632.31","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31692.14","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","41529.73","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","34434.76","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29720.04","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37984.79","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28368.44","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45054.33","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33884.2","","","","","","","fee schedule","11845.44","45054.33",""
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18505.13","18505.13","18505.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11063.8","11063.8","11063.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9840.79","9840.79","9840.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","27056.72","27056.72","27056.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9029.93","9029.93","9029.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12408.1","","","","","","","fee schedule","11845.44","45054.33","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12200.8","","","","","","","fee schedule","11845.44","45054.33","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11845.44","","","","","","","fee schedule","11845.44","45054.33","Transplants-Case Rate"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12082.35","","","","","","","fee schedule","11845.44","45054.33","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12437.71","","","","","","","fee schedule","11845.44","45054.33","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy With Cc","147","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11845.44","","","","","","","fee schedule","11845.44","45054.33","Psych-Case Rate"
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18576.42","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19867.72","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26034.88","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21587.06","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18631.42","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23812.57","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17784.1","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28244.44","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21241.92","","","","","","","fee schedule","7957.23","28244.44",""
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8335.2","","","","","","","fee schedule","7957.23","28244.44","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8195.95","","","","","","","fee schedule","7957.23","28244.44","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7957.23","","","","","","","fee schedule","7957.23","28244.44","Transplants-Case Rate"
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8116.37","","","","","","","fee schedule","7957.23","28244.44","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8355.09","","","","","","","fee schedule","7957.23","28244.44","MSDRG Base Rate"
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","148","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7957.23","","","","","","","fee schedule","7957.23","28244.44","Psych-Case Rate"
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17516.04","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18733.63","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24548.76","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20354.83","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17567.9","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22453.3","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16768.95","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26632.19","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20029.39","","","","","","","fee schedule","7584.31","26632.19",""
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21695.75","13228.44","22360.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","16621.23","16621.23","16621.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1554.41","1554.41","1554.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7195.4","7195.4","7195.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5512.33","5512.33","5512.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14359.17","14359.17","14359.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5742.57","5742.57","5742.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7944.56","","","","","","","fee schedule","7584.31","26632.19","MSDRG Base Rate"
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7811.84","","","","","","","fee schedule","7584.31","26632.19","MSDRG Base Rate"
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7584.31","","","","","","","fee schedule","7584.31","26632.19","Transplants-Case Rate"
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7736","","","","","","","fee schedule","7584.31","26632.19","MSDRG Base Rate"
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7963.53","","","","","","","fee schedule","7584.31","26632.19","MSDRG Base Rate"
"Dysequilibrium","149","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7584.31","","","","","","","fee schedule","7584.31","26632.19","Psych-Case Rate"
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31030.61","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33187.64","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43489.45","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36059.68","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31122.48","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39777.23","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29707.1","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47180.37","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35483.14","","","","","","","fee schedule","12337.2","47180.37",""
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10037.98","10037.98","10037.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12923.22","","","","","","","fee schedule","12337.2","47180.37","MSDRG Base Rate"
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12707.32","","","","","","","fee schedule","12337.2","47180.37","MSDRG Base Rate"
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12337.2","","","","","","","fee schedule","12337.2","47180.37","Transplants-Case Rate"
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12583.94","","","","","","","fee schedule","12337.2","47180.37","MSDRG Base Rate"
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12954.06","","","","","","","fee schedule","12337.2","47180.37","MSDRG Base Rate"
"Epistaxis With Mcc","150","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12337.2","","","","","","","fee schedule","12337.2","47180.37","Psych-Case Rate"
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17105.87","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18294.95","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23973.91","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19878.19","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17156.52","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21927.52","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16376.27","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26008.56","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19560.37","","","","","","","fee schedule","7440.06","26008.56",""
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7793.46","","","","","","","fee schedule","7440.06","26008.56","MSDRG Base Rate"
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7663.26","","","","","","","fee schedule","7440.06","26008.56","MSDRG Base Rate"
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7440.06","","","","","","","fee schedule","7440.06","26008.56","Transplants-Case Rate"
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7588.86","","","","","","","fee schedule","7440.06","26008.56","MSDRG Base Rate"
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7812.06","","","","","","","fee schedule","7440.06","26008.56","MSDRG Base Rate"
"Epistaxis Without Mcc","151","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7440.06","","","","","","","fee schedule","7440.06","26008.56","Psych-Case Rate"
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27551.17","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29466.34","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38613.02","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32016.34","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27632.74","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35317.04","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26376.06","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41890.07","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31504.45","","","","","","","fee schedule","11113.53","41890.07",""
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33844.28","33844.28","33844.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2643.13","2643.13","2643.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11641.42","","","","","","","fee schedule","11113.53","41890.07","MSDRG Base Rate"
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11446.94","","","","","","","fee schedule","11113.53","41890.07","MSDRG Base Rate"
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11113.53","","","","","","","fee schedule","11113.53","41890.07","Transplants-Case Rate"
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11335.8","","","","","","","fee schedule","11113.53","41890.07","MSDRG Base Rate"
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11669.21","","","","","","","fee schedule","11113.53","41890.07","MSDRG Base Rate"
"Otitis Media And Uri With Mcc","152","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11113.53","","","","","","","fee schedule","11113.53","41890.07","Psych-Case Rate"
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17203.75","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18399.64","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24111.09","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19991.93","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17254.69","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22052.99","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16469.98","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26157.38","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19672.29","","","","","","","fee schedule","7474.48","26157.38",""
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","15499.73","15499.73","19113.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20651.84","20651.84","22289.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17593.92","17593.92","17642.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","13703.88","13703.88","13703.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7086.14","6187.62","7204.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14625","14625","14895.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5448","5448","5448","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","9489.17","9489.17","11185.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7829.52","","","","","","","fee schedule","7474.48","26157.38","MSDRG Base Rate"
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7698.71","","","","","","","fee schedule","7474.48","26157.38","MSDRG Base Rate"
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7474.48","","","","","","","fee schedule","7474.48","26157.38","Transplants-Case Rate"
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7623.97","","","","","","","fee schedule","7474.48","26157.38","MSDRG Base Rate"
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7848.2","","","","","","","fee schedule","7474.48","26157.38","MSDRG Base Rate"
"Otitis Media And Uri Without Mcc","153","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7474.48","","","","","","","fee schedule","7474.48","26157.38","Psych-Case Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36437.37","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38970.24","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51067.04","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42342.71","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36545.25","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46708","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34883.25","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55401.06","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41665.71","","","","","","","fee schedule","14238.68","55401.06",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17540.14","17540.14","17540.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14597.86","14597.86","14597.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13595.33","13595.33","13595.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14609.92","14609.92","14609.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14915.02","","","","","","","fee schedule","14238.68","55401.06","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14665.84","","","","","","","fee schedule","14238.68","55401.06","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14238.68","","","","","","","fee schedule","14238.68","55401.06","Transplants-Case Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14523.45","","","","","","","fee schedule","14238.68","55401.06","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14950.61","","","","","","","fee schedule","14238.68","55401.06","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","154","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14238.68","","","","","","","fee schedule","14238.68","55401.06","Psych-Case Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21359.03","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22843.76","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29934.72","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24820.65","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21422.27","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27379.52","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20448.03","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32475.26","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24423.81","","","","","","","fee schedule","8935.84","32475.26",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17811.42","17811.42","17811.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18082.08","18082.08","18082.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7191.89","7191.89","7194.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","16741.8","16741.8","16741.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9360.29","","","","","","","fee schedule","8935.84","32475.26","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9203.92","","","","","","","fee schedule","8935.84","32475.26","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8935.84","","","","","","","fee schedule","8935.84","32475.26","Transplants-Case Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9114.56","","","","","","","fee schedule","8935.84","32475.26","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9382.63","","","","","","","fee schedule","8935.84","32475.26","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8935.84","","","","","","","fee schedule","8935.84","32475.26","Psych-Case Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16106.09","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17225.67","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22572.71","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18716.37","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16153.77","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20645.92","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15419.13","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24488.44","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18417.12","","","","","","","fee schedule","7088.44","24488.44",""
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","7856.58","7856.58","7856.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","12817.55","12817.55","12817.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7425.14","","","","","","","fee schedule","7088.44","24488.44","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7301.09","","","","","","","fee schedule","7088.44","24488.44","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7088.44","","","","","","","fee schedule","7088.44","24488.44","Transplants-Case Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7230.21","","","","","","","fee schedule","7088.44","24488.44","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7442.86","","","","","","","fee schedule","7088.44","24488.44","MSDRG Base Rate"
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","156","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7088.44","","","","","","","fee schedule","7088.44","24488.44","Psych-Case Rate"
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40010.02","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42791.24","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56074.12","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46494.38","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40128.48","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51287.68","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38303.52","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","60833.09","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45751","","","","","","","fee schedule","15495.14","60833.09",""
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21270.35","21270.35","21270.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12512.98","12512.98","15705.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14069.12","14069.12","14069.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16231.16","","","","","","","fee schedule","15495.14","60833.09","MSDRG Base Rate"
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15959.99","","","","","","","fee schedule","15495.14","60833.09","MSDRG Base Rate"
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15495.14","","","","","","","fee schedule","15495.14","60833.09","Transplants-Case Rate"
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15805.04","","","","","","","fee schedule","15495.14","60833.09","MSDRG Base Rate"
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16269.9","","","","","","","fee schedule","15495.14","60833.09","MSDRG Base Rate"
"Dental And Oral Diseases With Mcc","157","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15495.14","","","","","","","fee schedule","15495.14","60833.09","Psych-Case Rate"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21202.89","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22676.77","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29715.89","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24639.2","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21265.67","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27179.37","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20298.55","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32237.85","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24245.26","","","","","","","fee schedule","8880.92","32237.85",""
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","5511.47","5511.47","5511.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18434.89","18434.89","18434.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7721.13","7721.13","7721.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20649","20649","20649","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","6416.82","6416.82","6416.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","798.6","798.6","798.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9302.76","","","","","","","fee schedule","8880.92","32237.85","MSDRG Base Rate"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9147.35","","","","","","","fee schedule","8880.92","32237.85","MSDRG Base Rate"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8880.92","","","","","","","fee schedule","8880.92","32237.85","Transplants-Case Rate"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9058.54","","","","","","","fee schedule","8880.92","32237.85","MSDRG Base Rate"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9324.97","","","","","","","fee schedule","8880.92","32237.85","MSDRG Base Rate"
"Dental And Oral Diseases With Cc","158","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8880.92","","","","","","","fee schedule","8880.92","32237.85","Psych-Case Rate"
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16511.59","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17659.36","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23141.03","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19187.6","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16560.48","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21165.73","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15807.34","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25104.99","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18880.82","","","","","","","fee schedule","7231.06","25104.99",""
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","6390.92","6390.92","6390.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","13363.78","13363.78","13363.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","13477.13","13477.13","13477.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","11585.6","11585.6","11585.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7574.54","","","","","","","fee schedule","7231.06","25104.99","MSDRG Base Rate"
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7447.99","","","","","","","fee schedule","7231.06","25104.99","MSDRG Base Rate"
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7231.06","","","","","","","fee schedule","7231.06","25104.99","Transplants-Case Rate"
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7375.68","","","","","","","fee schedule","7231.06","25104.99","MSDRG Base Rate"
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7592.61","","","","","","","fee schedule","7231.06","25104.99","MSDRG Base Rate"
"Dental And Oral Diseases Without Cc/Mcc","159","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7231.06","","","","","","","fee schedule","7231.06","25104.99","Psych-Case Rate"
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","160","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w CC","161","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","162","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","104448.35","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","111708.87","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","146384.55","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","121376.11","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","104757.59","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","133889.29","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","99993.44","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","158808.1","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","119435.49","","","","","","","fee schedule","38157.24","158808.1",""
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","76698.69","76698.69","76698.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","65857.7","42473.14","107573.27","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","104900.78","104900.78","108955.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","171223.05","171223.05","171223.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12488.57","12488.57","12488.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","37339.38","37339.38","37654.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","78485.26","78485.26","79220.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","38032.22","36136.9","38684.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","62887.43","40557.54","175677.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","100688","94736","101188","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","33254.24","33217.97","37672.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","174439.6","174439.6","174439.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","65260.54","65260.54","65260.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","119539.6","119539.6","119539.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12401.99","12401.99","12401.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39969.71","","","","","","","fee schedule","38157.24","158808.1","MSDRG Base Rate"
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39301.96","","","","","","","fee schedule","38157.24","158808.1","MSDRG Base Rate"
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38157.24","","","","","","","fee schedule","38157.24","158808.1","Transplants-Case Rate"
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38920.38","","","","","","","fee schedule","38157.24","158808.1","MSDRG Base Rate"
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40065.1","","","","","","","fee schedule","38157.24","158808.1","MSDRG Base Rate"
"Major Chest Procedures With Mcc","163","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38157.24","","","","","","","fee schedule","38157.24","158808.1","Psych-Case Rate"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","58821.82","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","62910.7","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","82438.89","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","68354.97","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","58995.98","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","75401.98","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","56312.96","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","89435.42","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","67262.08","","","","","","","fee schedule","22111","89435.42",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","56242.37","56242.37","56242.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","77429.92","75067.01","78829.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","60321.08","60321.08","60321.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6530.89","6530.89","6530.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21208.54","21208.54","21891.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20067.65","19264","21561.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","19447.81","19447.81","19447.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","26997.96","26997.96","26997.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","55256","55256","55256","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","65122","65122","65122","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18909.97","18352.4","19380.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","64908.29","64908.29","64908.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12379.88","12379.88","12379.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23161.27","","","","","","","fee schedule","22111","89435.42","MSDRG Base Rate"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22774.33","","","","","","","fee schedule","22111","89435.42","MSDRG Base Rate"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22111","","","","","","","fee schedule","22111","89435.42","Transplants-Case Rate"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22553.22","","","","","","","fee schedule","22111","89435.42","MSDRG Base Rate"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23216.55","","","","","","","fee schedule","22111","89435.42","MSDRG Base Rate"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22111","","","","","","","fee schedule","22111","89435.42","Psych-Case Rate"
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44610.43","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47711.44","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","62521.6","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51840.36","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44742.51","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57184.81","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42707.72","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","67827.76","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51011.52","","","","","","","fee schedule","17113.04","67827.76",""
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","19624.06","19624.06","19624.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","42797.11","40866.9","72604.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","59950.83","59950.83","59950.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15391","15391","15391","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14484.09","14484.09","14484.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","48431.06","40866.9","76033.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","40422","40422","40422","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","50258.65","50258.65","50258.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","14205.94","14205.94","14205.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","47054.45","47054.45","47054.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","11299.18","11299.18","11299.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17925.91","","","","","","","fee schedule","17113.04","67827.76","MSDRG Base Rate"
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17626.43","","","","","","","fee schedule","17113.04","67827.76","MSDRG Base Rate"
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17113.04","","","","","","","fee schedule","17113.04","67827.76","Transplants-Case Rate"
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17455.3","","","","","","","fee schedule","17113.04","67827.76","MSDRG Base Rate"
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17968.69","","","","","","","fee schedule","17113.04","67827.76","MSDRG Base Rate"
"Major Chest Procedures Without Cc/Mcc","165","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17113.04","","","","","","","fee schedule","17113.04","67827.76","Psych-Case Rate"
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","87107.1","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","93162.17","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","122080.76","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","101224.39","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","87365","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","111660.05","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","83391.82","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","132441.66","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","99605.97","","","","","","","fee schedule","32058.55","132441.66",""
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","35636.6","35636.6","43392.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","120587.55","120587.55","120587.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","120587.55","120587.55","120587.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","30515.92","30515.92","30561.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","32345.28","30154.36","58472.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","53631.16","45441.61","84153.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","82637.66","82637.66","82637.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","28970.34","28970.34","28970.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","45029.57","45029.57","45029.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","14082.6","14082.6","14082.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33581.33","","","","","","","fee schedule","32058.55","132441.66","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33020.31","","","","","","","fee schedule","32058.55","132441.66","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32058.55","","","","","","","fee schedule","32058.55","132441.66","Transplants-Case Rate"
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32699.72","","","","","","","fee schedule","32058.55","132441.66","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33661.48","","","","","","","fee schedule","32058.55","132441.66","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Mcc","166","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32058.55","","","","","","","fee schedule","32058.55","132441.66","Psych-Case Rate"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42028.24","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44949.75","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58902.65","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48839.68","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42152.67","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53874.77","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40235.66","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63901.68","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48058.81","","","","","","","fee schedule","16204.92","63901.68",""
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","37458.74","37458.74","37458.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","81246.02","81246.02","108834.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17037.53","17037.53","17037.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","37056","37056","37056","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","62501.81","62501.81","65453.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","44764","44764","44764","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","88294.1","88294.1","88294.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16974.65","","","","","","","fee schedule","16204.92","63901.68","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16691.07","","","","","","","fee schedule","16204.92","63901.68","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16204.92","","","","","","","fee schedule","16204.92","63901.68","Transplants-Case Rate"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16529.02","","","","","","","fee schedule","16204.92","63901.68","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17015.17","","","","","","","fee schedule","16204.92","63901.68","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures With Cc","167","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16204.92","","","","","","","fee schedule","16204.92","63901.68","Psych-Case Rate"
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31843.95","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34057.52","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44629.36","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37004.84","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31938.23","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40819.83","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30485.75","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48417.02","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36413.19","","","","","","","fee schedule","12623.24","48417.02",""
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11583.87","11583.87","11583.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","27943.2","27943.2","27943.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13222.84","","","","","","","fee schedule","12623.24","48417.02","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13001.94","","","","","","","fee schedule","12623.24","48417.02","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12623.24","","","","","","","fee schedule","12623.24","48417.02","Transplants-Case Rate"
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12875.7","","","","","","","fee schedule","12623.24","48417.02","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13254.4","","","","","","","fee schedule","12623.24","48417.02","MSDRG Base Rate"
"Other Respiratory System O.R. Procedures Without Cc/Mcc","168","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12623.24","","","","","","","fee schedule","12623.24","48417.02","Psych-Case Rate"
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mouth Procedures w/o CC","169","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures w/o CC","171","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","69365","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","74186.77","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","97215.18","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","80606.86","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","69570.37","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","88916.97","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","66406.46","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","105465.76","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","79318.08","","","","","","","fee schedule","25818.89","105465.76",""
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27045.29","","","","","","","fee schedule","25818.89","105465.76","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26593.46","","","","","","","fee schedule","25818.89","105465.76","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25818.89","","","","","","","fee schedule","25818.89","105465.76","Transplants-Case Rate"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26335.27","","","","","","","fee schedule","25818.89","105465.76","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27109.83","","","","","","","fee schedule","25818.89","105465.76","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","173","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25818.89","","","","","","","fee schedule","25818.89","105465.76","Psych-Case Rate"
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"G.I. hemorrhage w CC","174","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32011.75","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34236.98","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44864.52","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37199.84","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32106.53","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41034.93","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30646.39","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48672.14","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36605.07","","","","","","","fee schedule","12682.25","48672.14",""
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10537.09","10537.09","10537.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","19582.82","11929.71","26001.94","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","31486.34","31486.34","31486.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","43004.28","38262.16","44131.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12076.95","11115.52","12845.47","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","17151.63","17151.63","17151.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11289.05","10255.54","12618.17","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10864.97","10864.97","12507.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19944.66","11929.71","44262.64","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","28166.36","28166.36","28223.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","47568","47568","47568","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11242.23","10933.6","11315.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","14924.33","14924.33","14924.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","20321.8","19405.25","25766.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8553.01","8553.01","8553.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8553.01","8553.01","8553.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13284.66","","","","","","","fee schedule","12682.25","48672.14","MSDRG Base Rate"
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13062.72","","","","","","","fee schedule","12682.25","48672.14","MSDRG Base Rate"
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12682.25","","","","","","","fee schedule","12682.25","48672.14","Transplants-Case Rate"
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12935.9","","","","","","","fee schedule","12682.25","48672.14","MSDRG Base Rate"
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13316.36","","","","","","","fee schedule","12682.25","48672.14","MSDRG Base Rate"
"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","175","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12682.25","","","","","","","fee schedule","12682.25","48672.14","Psych-Case Rate"
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18760.53","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20064.63","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26292.91","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21801.01","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18816.07","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24048.57","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17960.36","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28524.37","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21452.45","","","","","","","fee schedule","8021.98","28524.37",""
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","12380.51","12380.51","12380.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8444.3","8444.3","67444.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","16261.76","16261.76","16261.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17182.1","17182.1","19465.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24291.65","24291.65","24911.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7577.55","7577.55","7577.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18172.31","18172.31","18172.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6871.3","6238.22","6954.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6895.46","6895.46","6895.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8444.3","5222.68","25550.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14424.53","14424.53","14424.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7316.71","7316.71","7316.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","42904.9","42904.9","42904.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2580.94","2580.94","2580.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5419.77","5419.77","5419.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8403.02","","","","","","","fee schedule","8021.98","28524.37","MSDRG Base Rate"
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8262.64","","","","","","","fee schedule","8021.98","28524.37","MSDRG Base Rate"
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8021.98","","","","","","","fee schedule","8021.98","28524.37","Transplants-Case Rate"
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8182.42","","","","","","","fee schedule","8021.98","28524.37","MSDRG Base Rate"
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8423.08","","","","","","","fee schedule","8021.98","28524.37","MSDRG Base Rate"
"Pulmonary Embolism Without Mcc","176","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8021.98","","","","","","","fee schedule","8021.98","28524.37","Psych-Case Rate"
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36418.72","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38950.3","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51040.91","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42321.04","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36526.55","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46684.1","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34865.4","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55372.71","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41644.39","","","","","","","fee schedule","14232.13","55372.71",""
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","17068.91","17068.91","17068.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","36120.69","36120.69","36120.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","15400.21","15400.21","15400.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48198.32","29116.68","50627.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12905.51","11606","13716.22","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","34098.76","34098.76","34098.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12342.89","12078.55","14297.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","34309","19183.76","35490","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14153.94","12829.56","14297.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","45379.83","45379.83","45379.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","35086.54","35086.54","35086.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11717.09","7971.11","13068.81","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","54063.09","54063.09","54063.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14908.16","","","","","","","fee schedule","14232.13","55372.71","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14659.09","","","","","","","fee schedule","14232.13","55372.71","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14232.13","","","","","","","fee schedule","14232.13","55372.71","Transplants-Case Rate"
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14516.77","","","","","","","fee schedule","14232.13","55372.71","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14943.74","","","","","","","fee schedule","14232.13","55372.71","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Mcc","177","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14232.13","","","","","","","fee schedule","14232.13","55372.71","Psych-Case Rate"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22745.68","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24326.8","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31878.11","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26432.03","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22813.02","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29157.02","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21775.54","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34583.58","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26009.42","","","","","","","fee schedule","9423.5","34583.58",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","121725.55","121725.55","121725.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","21038.74","21038.74","21038.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7913.22","7913.22","9416.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8231.94","7945.6","8446.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9147.79","9147.79","9147.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","127827.3","127827.3","127827.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","20477.6","20477.6","20477.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","121725.55","121725.55","121725.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9871.12","","","","","","","fee schedule","9423.5","34583.58","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9706.2","","","","","","","fee schedule","9423.5","34583.58","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9423.5","","","","","","","fee schedule","9423.5","34583.58","Transplants-Case Rate"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9611.97","","","","","","","fee schedule","9423.5","34583.58","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9894.68","","","","","","","fee schedule","9423.5","34583.58","MSDRG Base Rate"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9423.5","","","","","","","fee schedule","9423.5","34583.58","Psych-Case Rate"
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17595.28","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18818.38","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24659.81","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20446.91","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17647.37","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22554.87","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16844.81","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26752.67","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20120","","","","","","","fee schedule","7612.17","26752.67",""
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","88668.99","88668.99","88668.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24106.23","24106.23","24106.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","57678.61","49533.24","57678.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","73039.96","73039.96","73039.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7973.75","","","","","","","fee schedule","7612.17","26752.67","MSDRG Base Rate"
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7840.54","","","","","","","fee schedule","7612.17","26752.67","MSDRG Base Rate"
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7612.17","","","","","","","fee schedule","7612.17","26752.67","Transplants-Case Rate"
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7764.41","","","","","","","fee schedule","7612.17","26752.67","MSDRG Base Rate"
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7992.78","","","","","","","fee schedule","7612.17","26752.67","MSDRG Base Rate"
"Respiratory Infections And Inflammations Without Cc/Mcc","179","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7612.17","","","","","","","fee schedule","7612.17","26752.67","Psych-Case Rate"
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41156.63","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44017.55","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57681.09","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47826.81","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41278.48","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52757.48","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39401.23","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62576.44","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47062.13","","","","","","","fee schedule","15898.39","62576.44",""
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","56956.39","56956.39","56956.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","39054.59","39054.59","39054.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15606.74","15596.88","15630.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","41997.88","41997.88","41997.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15361.45","15361.45","15361.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15226.92","15226.92","15226.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","63093.96","63093.96","63093.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14957.86","13320.97","15630.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","45329.19","45329.19","45329.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2860.11","2860.11","2860.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11809.03","11809.03","11809.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","47062.13","47062.13","47062.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16653.56","","","","","","","fee schedule","15898.39","62576.44","MSDRG Base Rate"
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16375.34","","","","","","","fee schedule","15898.39","62576.44","MSDRG Base Rate"
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15898.39","","","","","","","fee schedule","15898.39","62576.44","Transplants-Case Rate"
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16216.36","","","","","","","fee schedule","15898.39","62576.44","MSDRG Base Rate"
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16693.31","","","","","","","fee schedule","15898.39","62576.44","MSDRG Base Rate"
"Respiratory Neoplasms With Mcc","180","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15898.39","","","","","","","fee schedule","15898.39","62576.44","Psych-Case Rate"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24959.66","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26694.68","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34981","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29004.82","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25033.55","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31995.05","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23895.08","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37949.81","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28541.08","","","","","","","fee schedule","10202.13","37949.81",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","24118.78","24118.78","24118.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","37691.96","23200.4","102213.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","22493.53","22493.53","22493.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28604.45","28604.45","28604.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10207.13","10207.13","10207.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","35991.99","35991.99","66212.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9928.88","9928.88","9928.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","28259.94","28259.94","28259.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","84267.65","84267.65","111825.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10686.73","","","","","","","fee schedule","10202.13","37949.81","MSDRG Base Rate"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10508.19","","","","","","","fee schedule","10202.13","37949.81","MSDRG Base Rate"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10202.13","","","","","","","fee schedule","10202.13","37949.81","Transplants-Case Rate"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10406.17","","","","","","","fee schedule","10202.13","37949.81","MSDRG Base Rate"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10712.24","","","","","","","fee schedule","10202.13","37949.81","MSDRG Base Rate"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10202.13","","","","","","","fee schedule","10202.13","37949.81","Psych-Case Rate"
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17567.31","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18788.47","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24620.62","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20414.41","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17619.32","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22519.02","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16818.03","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26710.15","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20088.02","","","","","","","fee schedule","7602.34","26710.15",""
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","25862.33","18509.68","58749.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","25862.33","21469.44","146476.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","26838.26","23441.17","53079.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7963.45","","","","","","","fee schedule","7602.34","26710.15","MSDRG Base Rate"
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7830.41","","","","","","","fee schedule","7602.34","26710.15","MSDRG Base Rate"
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7602.34","","","","","","","fee schedule","7602.34","26710.15","Transplants-Case Rate"
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7754.39","","","","","","","fee schedule","7602.34","26710.15","MSDRG Base Rate"
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7982.46","","","","","","","fee schedule","7602.34","26710.15","MSDRG Base Rate"
"Respiratory Neoplasms Without Cc/Mcc","182","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7602.34","","","","","","","fee schedule","7602.34","26710.15","Psych-Case Rate"
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35654.32","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38132.76","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49969.59","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41432.75","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35759.88","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45704.23","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34133.6","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54210.48","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40770.31","","","","","","","fee schedule","13963.3","54210.48",""
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","1900.25","1900.25","1900.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","54120.37","44724.36","84141.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","11716.73","11716.73","11716.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3319.5","3319.5","3319.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12728.78","12728.78","13395.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","29637.79","29637.79","29637.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12888.43","11805.96","13654.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13919.82","13919.82","13919.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","56676.57","44723.09","88115.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12764.19","12607.7","13691.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","10192.17","10192.17","10192.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14626.56","","","","","","","fee schedule","13963.3","54210.48","MSDRG Base Rate"
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14382.2","","","","","","","fee schedule","13963.3","54210.48","MSDRG Base Rate"
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13963.3","","","","","","","fee schedule","13963.3","54210.48","Transplants-Case Rate"
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14242.57","","","","","","","fee schedule","13963.3","54210.48","MSDRG Base Rate"
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14661.46","","","","","","","fee schedule","13963.3","54210.48","MSDRG Base Rate"
"Major Chest Trauma With Mcc","183","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13963.3","","","","","","","fee schedule","13963.3","54210.48","Psych-Case Rate"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24798.85","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26522.69","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34755.63","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28817.96","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24872.27","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31788.92","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23741.14","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37705.32","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28357.2","","","","","","","fee schedule","10145.57","37705.32",""
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","28308.32","28308.32","28308.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20079.06","20079.06","20079.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","32838.01","32838.01","32838.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8625.48","8625.48","8625.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18277.54","18277.54","18277.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8292.21","2071.15","9465.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9218.12","9218.12","9218.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8559.21","8236.34","10008.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10627.48","","","","","","","fee schedule","10145.57","37705.32","MSDRG Base Rate"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10449.94","","","","","","","fee schedule","10145.57","37705.32","MSDRG Base Rate"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10145.57","","","","","","","fee schedule","10145.57","37705.32","Transplants-Case Rate"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10348.48","","","","","","","fee schedule","10145.57","37705.32","MSDRG Base Rate"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10652.85","","","","","","","fee schedule","10145.57","37705.32","MSDRG Base Rate"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10145.57","","","","","","","fee schedule","10145.57","37705.32","Psych-Case Rate"
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18329.38","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19603.51","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25688.66","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21299.99","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18383.65","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23495.9","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17547.6","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27868.84","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20959.44","","","","","","","fee schedule","7870.35","27868.84",""
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23620.61","23620.61","23620.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7233.25","7233.25","7233.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7903.19","7903.19","7903.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7305.16","7305.16","7305.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8244.19","","","","","","","fee schedule","7870.35","27868.84","MSDRG Base Rate"
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8106.46","","","","","","","fee schedule","7870.35","27868.84","MSDRG Base Rate"
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7870.35","","","","","","","fee schedule","7870.35","27868.84","Transplants-Case Rate"
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8027.76","","","","","","","fee schedule","7870.35","27868.84","MSDRG Base Rate"
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8263.87","","","","","","","fee schedule","7870.35","27868.84","MSDRG Base Rate"
"Major Chest Trauma Without Cc/Mcc","185","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7870.35","","","","","","","fee schedule","7870.35","27868.84","Psych-Case Rate"
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36320.84","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38845.61","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50903.73","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42207.3","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36428.38","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46558.63","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34771.69","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55223.89","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41532.47","","","","","","","fee schedule","14197.7","55223.89",""
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14217.17","14217.17","14217.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13201.82","13201.82","13201.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14872.09","","","","","","","fee schedule","14197.7","55223.89","MSDRG Base Rate"
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14623.63","","","","","","","fee schedule","14197.7","55223.89","MSDRG Base Rate"
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14197.7","","","","","","","fee schedule","14197.7","55223.89","Transplants-Case Rate"
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14481.65","","","","","","","fee schedule","14197.7","55223.89","MSDRG Base Rate"
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14907.58","","","","","","","fee schedule","14197.7","55223.89","MSDRG Base Rate"
"Pleural Effusion With Mcc","186","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14197.7","","","","","","","fee schedule","14197.7","55223.89","Psych-Case Rate"
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23050.98","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24653.32","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32305.98","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26786.81","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23119.22","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29548.37","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22067.81","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35047.77","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26358.53","","","","","","","fee schedule","9530.87","35047.77",""
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28924.93","28924.93","28924.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9983.59","","","","","","","fee schedule","9530.87","35047.77","MSDRG Base Rate"
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9816.8","","","","","","","fee schedule","9530.87","35047.77","MSDRG Base Rate"
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9530.87","","","","","","","fee schedule","9530.87","35047.77","Transplants-Case Rate"
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9721.49","","","","","","","fee schedule","9530.87","35047.77","MSDRG Base Rate"
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10007.41","","","","","","","fee schedule","9530.87","35047.77","MSDRG Base Rate"
"Pleural Effusion With Cc","187","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9530.87","","","","","","","fee schedule","9530.87","35047.77","Psych-Case Rate"
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16714.35","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17876.21","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23425.19","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19423.21","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16763.83","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21425.63","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16001.45","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25413.26","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19112.66","","","","","","","fee schedule","7302.36","25413.26",""
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22644.41","22644.41","22644.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7649.22","","","","","","","fee schedule","7302.36","25413.26","MSDRG Base Rate"
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7521.43","","","","","","","fee schedule","7302.36","25413.26","MSDRG Base Rate"
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7302.36","","","","","","","fee schedule","7302.36","25413.26","Transplants-Case Rate"
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7448.41","","","","","","","fee schedule","7302.36","25413.26","MSDRG Base Rate"
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7667.48","","","","","","","fee schedule","7302.36","25413.26","MSDRG Base Rate"
"Pleural Effusion Without Cc/Mcc","188","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7302.36","","","","","","","fee schedule","7302.36","25413.26","Psych-Case Rate"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28791","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30792.35","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","40350.63","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","33457.1","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28876.24","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36906.34","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27563.01","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","43775.16","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32922.17","","","","","","","fee schedule","11549.56","43775.16",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14876.52","14876.52","15579.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36098.22","21119.99","36904.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","29372.44","29372.44","29372.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11400.18","9844.13","11885.03","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","24884.16","24884.16","24884.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9684.22","8881.41","11234.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10607.43","10036.49","11601.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14876.52","8519.57","22066.57","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","31929","31929","31929","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9827.45","9226.96","11285.96","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","15437.9","15437.9","51587.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12098.16","","","","","","","fee schedule","11549.56","43775.16","MSDRG Base Rate"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11896.05","","","","","","","fee schedule","11549.56","43775.16","MSDRG Base Rate"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11549.56","","","","","","","fee schedule","11549.56","43775.16","Transplants-Case Rate"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11780.55","","","","","","","fee schedule","11549.56","43775.16","MSDRG Base Rate"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12127.04","","","","","","","fee schedule","11549.56","43775.16","MSDRG Base Rate"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11549.56","","","","","","","fee schedule","11549.56","43775.16","Psych-Case Rate"
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25814.95","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27609.42","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36179.7","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29998.73","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25891.38","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33091.43","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24713.89","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","39250.24","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29519.1","","","","","","","fee schedule","10502.92","39250.24",""
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","21111.16","10529.68","22108.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","32524.45","32524.45","35171.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10459.54","8860.18","10493.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8420.68","2277.01","9861.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10197.3","9372.43","10210.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10529.68","8633.24","22108.27","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22259.77","22259.77","22259.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","28091.9","28091.9","28091.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8948.5","972.31","10029.09","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","29125.01","29125.01","29125.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8959.03","8959.03","8959.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11001.81","","","","","","","fee schedule","10502.92","39250.24","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10818.01","","","","","","","fee schedule","10502.92","39250.24","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10502.92","","","","","","","fee schedule","10502.92","39250.24","Transplants-Case Rate"
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10712.98","","","","","","","fee schedule","10502.92","39250.24","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11028.07","","","","","","","fee schedule","10502.92","39250.24","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Mcc","190","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10502.92","","","","","","","fee schedule","10502.92","39250.24","Psych-Case Rate"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19646.12","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21011.78","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27534.07","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22830.13","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19704.28","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25183.78","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18808.17","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29870.86","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22465.11","","","","","","","fee schedule","8333.43","29870.86",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","26556.15","26556.15","26556.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6731.03","6731.03","7948.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2429.17","1770.37","6281.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8081.49","8081.49","8081.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11295.16","9721.04","14916.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7006.51","7006.51","7562.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","14780.9","14780.9","14780.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8729.27","","","","","","","fee schedule","8333.43","29870.86","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8583.43","","","","","","","fee schedule","8333.43","29870.86","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8333.43","","","","","","","fee schedule","8333.43","29870.86","Transplants-Case Rate"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8500.1","","","","","","","fee schedule","8333.43","29870.86","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8750.1","","","","","","","fee schedule","8333.43","29870.86","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8333.43","","","","","","","fee schedule","8333.43","29870.86","Psych-Case Rate"
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14961.81","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16001.85","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20969","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17386.64","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15006.11","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19179.11","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14323.66","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22748.63","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17108.66","","","","","","","fee schedule","6686.02","22748.63",""
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22353.88","13135.07","44344.63","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","13944.08","13944.08","13944.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5266.62","5266.62","5266.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22353.88","12542.66","44344.63","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","23197.43","13630.74","43942.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3460.66","3460.66","3460.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6519.4","6519.4","6519.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7003.61","","","","","","","fee schedule","6686.02","22748.63","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6886.6","","","","","","","fee schedule","6686.02","22748.63","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6686.02","","","","","","","fee schedule","6686.02","22748.63","Transplants-Case Rate"
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6819.74","","","","","","","fee schedule","6686.02","22748.63","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7020.32","","","","","","","fee schedule","6686.02","22748.63","MSDRG Base Rate"
"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","192","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6686.02","","","","","","","fee schedule","6686.02","22748.63","Psych-Case Rate"
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30632.09","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32761.42","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42930.93","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35596.58","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30722.79","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39266.39","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29325.58","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46574.45","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35027.45","","","","","","","fee schedule","12197.05","46574.45",""
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","25763.95","25763.95","25763.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","13289.22","13289.22","13289.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29444.01","29444.01","29444.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","41269.05","41269.05","41269.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","31412.85","31412.85","31412.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11178.43","9992.06","12060.43","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10313.82","9531.78","11095.86","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11504.09","10410.79","12252.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26037.27","8741.8","28932","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","34001","34001","34001","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10562.61","9932.98","11316.55","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12776.41","","","","","","","fee schedule","12197.05","46574.45","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12562.96","","","","","","","fee schedule","12197.05","46574.45","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12197.05","","","","","","","fee schedule","12197.05","46574.45","Transplants-Case Rate"
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12440.99","","","","","","","fee schedule","12197.05","46574.45","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12806.9","","","","","","","fee schedule","12197.05","46574.45","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Mcc","193","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12197.05","","","","","","","fee schedule","12197.05","46574.45","Psych-Case Rate"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18781.5","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20087.06","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26322.31","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21825.38","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18837.11","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24075.46","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17980.43","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28556.26","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21476.43","","","","","","","fee schedule","8029.35","28556.26",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","5666.78","5666.78","5666.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12103.81","8133.95","21707.45","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","16657.6","16657.6","16657.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8001.67","7223.39","12795.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18295.02","18295.02","18295.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2106.41","2106.41","2106.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6135.02","6135.02","6135.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12103.81","8133.95","20728.42","107","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18003","17694","18003","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6465.55","6465.55","8876.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8839.58","8440.89","21510.62","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4118.03","4118.03","4118.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8410.74","","","","","","","fee schedule","8029.35","28556.26","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8270.23","","","","","","","fee schedule","8029.35","28556.26","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8029.35","","","","","","","fee schedule","8029.35","28556.26","Transplants-Case Rate"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8189.94","","","","","","","fee schedule","8029.35","28556.26","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8430.82","","","","","","","fee schedule","8029.35","28556.26","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8029.35","","","","","","","fee schedule","8029.35","28556.26","Psych-Case Rate"
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14647.19","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15665.36","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20528.07","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17021.04","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14690.56","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18775.81","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14022.46","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22270.27","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16748.9","","","","","","","fee schedule","6575.37","22270.27",""
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","4756.74","4756.74","4756.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6887.7","","","","","","","fee schedule","6575.37","22270.27","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6772.63","","","","","","","fee schedule","6575.37","22270.27","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6575.37","","","","","","","fee schedule","6575.37","22270.27","Transplants-Case Rate"
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6706.88","","","","","","","fee schedule","6575.37","22270.27","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6904.14","","","","","","","fee schedule","6575.37","22270.27","MSDRG Base Rate"
"Simple Pneumonia And Pleurisy Without Cc/Mcc","195","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6575.37","","","","","","","fee schedule","6575.37","22270.27","Psych-Case Rate"
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","43981.2","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47038.46","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","61639.73","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51109.15","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44111.41","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","56378.21","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42105.32","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","66871.04","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","50291.99","","","","","","","fee schedule","16891.75","66871.04",""
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","20363.36","20363.36","20363.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14672.64","14119.27","26064.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14366.18","14366.18","14366.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20363.36","20363.36","20363.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","48614","48614","48614","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15084.91","15084.91","15084.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","20178.72","20178.72","20178.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","43965.16","43965.16","43965.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17694.11","","","","","","","fee schedule","16891.75","66871.04","MSDRG Base Rate"
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17398.5","","","","","","","fee schedule","16891.75","66871.04","MSDRG Base Rate"
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16891.75","","","","","","","fee schedule","16891.75","66871.04","Transplants-Case Rate"
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17229.58","","","","","","","fee schedule","16891.75","66871.04","MSDRG Base Rate"
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17736.34","","","","","","","fee schedule","16891.75","66871.04","MSDRG Base Rate"
"Interstitial Lung Disease With Mcc","196","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16891.75","","","","","","","fee schedule","16891.75","66871.04","Psych-Case Rate"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22118.78","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23656.32","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30999.5","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25703.53","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22184.26","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28353.41","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21175.37","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33630.41","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25292.57","","","","","","","fee schedule","9203.03","33630.41",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","59467.01","59467.01","59467.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12868.37","12287.99","29815.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9371.55","9371.55","9371.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","20938.16","20938.16","20938.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8538.56","8538.56","8538.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12287.99","9658.8","14345.89","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12751.68","12751.68","30940.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9640.17","","","","","","","fee schedule","9203.03","33630.41","MSDRG Base Rate"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9479.12","","","","","","","fee schedule","9203.03","33630.41","MSDRG Base Rate"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9203.03","","","","","","","fee schedule","9203.03","33630.41","Transplants-Case Rate"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9387.09","","","","","","","fee schedule","9203.03","33630.41","MSDRG Base Rate"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9663.18","","","","","","","fee schedule","9203.03","33630.41","MSDRG Base Rate"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9203.03","","","","","","","fee schedule","9203.03","33630.41","Psych-Case Rate"
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16691.04","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17851.29","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23392.52","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19396.13","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16740.46","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21395.76","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15979.14","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25377.83","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19086.01","","","","","","","fee schedule","7294.17","25377.83",""
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2310.6","2310.6","2310.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7041.85","5961.04","7374.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7041.85","6402.54","8380","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7640.64","","","","","","","fee schedule","7294.17","25377.83","MSDRG Base Rate"
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7513","","","","","","","fee schedule","7294.17","25377.83","MSDRG Base Rate"
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7294.17","","","","","","","fee schedule","7294.17","25377.83","Transplants-Case Rate"
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7440.05","","","","","","","fee schedule","7294.17","25377.83","MSDRG Base Rate"
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7658.88","","","","","","","fee schedule","7294.17","25377.83","MSDRG Base Rate"
"Interstitial Lung Disease Without Cc/Mcc","198","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7294.17","","","","","","","fee schedule","7294.17","25377.83","Psych-Case Rate"
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41112.35","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43970.19","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57619.03","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47775.36","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41234.07","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52700.72","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39358.84","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62509.12","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47011.5","","","","","","","fee schedule","15882.81","62509.12",""
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10886.88","10395.87","10886.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","52967.47","43517.4","55287.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4873.24","4873.24","4873.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14127.23","14127.23","14127.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","13315.15","13315.15","13315.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13527.4","13527.4","13527.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14019.92","14019.92","14019.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10395.87","6872.06","17436.28","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17751.86","17751.86","17751.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15075.82","15075.82","15753.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7468.21","7468.21","7468.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16637.24","","","","","","","fee schedule","15882.81","62509.12","MSDRG Base Rate"
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16359.29","","","","","","","fee schedule","15882.81","62509.12","MSDRG Base Rate"
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15882.81","","","","","","","fee schedule","15882.81","62509.12","Transplants-Case Rate"
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16200.47","","","","","","","fee schedule","15882.81","62509.12","MSDRG Base Rate"
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16676.95","","","","","","","fee schedule","15882.81","62509.12","MSDRG Base Rate"
"Pneumothorax With Mcc","199","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15882.81","","","","","","","fee schedule","15882.81","62509.12","Psych-Case Rate"
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25619.19","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27400.05","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35905.34","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29771.24","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25695.04","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32840.49","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24526.48","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38952.6","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29295.25","","","","","","","fee schedule","10434.08","38952.6",""
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","24248.5","24248.5","24248.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","34428.98","34428.98","34428.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9132.95","1985.73","9738.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22263","22263","22263","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19011.73","19011.73","19011.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9894.21","8830.57","14250.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10929.7","","","","","","","fee schedule","10434.08","38952.6","MSDRG Base Rate"
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10747.1","","","","","","","fee schedule","10434.08","38952.6","MSDRG Base Rate"
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10434.08","","","","","","","fee schedule","10434.08","38952.6","Transplants-Case Rate"
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10642.76","","","","","","","fee schedule","10434.08","38952.6","MSDRG Base Rate"
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10955.78","","","","","","","fee schedule","10434.08","38952.6","MSDRG Base Rate"
"Pneumothorax With Cc","200","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10434.08","","","","","","","fee schedule","10434.08","38952.6","Psych-Case Rate"
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16665.41","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17823.87","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23356.6","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19366.34","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16714.75","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21362.9","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15954.6","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25338.85","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19056.7","","","","","","","fee schedule","7285.15","25338.85",""
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","10264.36","10264.36","10264.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2550.87","2550.87","2550.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11754.82","7989.24","22670.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6058.18","6058.18","6058.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6016.98","6016.98","6016.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11224.66","7628.92","21647.86","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11648.23","7916.8","11648.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19056.7","19056.7","19056.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7631.19","","","","","","","fee schedule","7285.15","25338.85","MSDRG Base Rate"
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7503.7","","","","","","","fee schedule","7285.15","25338.85","MSDRG Base Rate"
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7285.15","","","","","","","fee schedule","7285.15","25338.85","Transplants-Case Rate"
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7430.85","","","","","","","fee schedule","7285.15","25338.85","MSDRG Base Rate"
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7649.41","","","","","","","fee schedule","7285.15","25338.85","MSDRG Base Rate"
"Pneumothorax Without Cc/Mcc","201","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7285.15","","","","","","","fee schedule","7285.15","25338.85","Psych-Case Rate"
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22633.82","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24207.16","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31721.33","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26302.04","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22700.83","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29013.63","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21668.44","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34413.5","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25881.51","","","","","","","fee schedule","9384.16","34413.5",""
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9025.18","9025.18","9025.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","21701.46","21701.46","21701.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19407.25","19407.25","24039.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7741.87","7741.87","7741.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","21668.44","21668.44","21668.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7826.96","7826.96","7826.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21224","21224","21224","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8203.95","8203.95","8203.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","8151.01","8151.01","8151.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9829.91","","","","","","","fee schedule","9384.16","34413.5","MSDRG Base Rate"
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9665.68","","","","","","","fee schedule","9384.16","34413.5","MSDRG Base Rate"
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9384.16","","","","","","","fee schedule","9384.16","34413.5","Transplants-Case Rate"
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9571.84","","","","","","","fee schedule","9384.16","34413.5","MSDRG Base Rate"
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9853.37","","","","","","","fee schedule","9384.16","34413.5","MSDRG Base Rate"
"Bronchitis And Asthma With Cc/Mcc","202","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9384.16","","","","","","","fee schedule","9384.16","34413.5","Psych-Case Rate"
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15614.35","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16699.75","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21883.54","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18144.94","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15660.58","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20015.58","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14948.37","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23740.78","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17854.83","","","","","","","fee schedule","6915.51","23740.78",""
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6165.57","6165.57","6165.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","2564.64","2564.64","2564.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6165.57","6165.57","6456.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","9622.58","9622.58","9622.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","13657.58","13657.58","13657.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7244","","","","","","","fee schedule","6915.51","23740.78","MSDRG Base Rate"
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7122.98","","","","","","","fee schedule","6915.51","23740.78","MSDRG Base Rate"
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6915.51","","","","","","","fee schedule","6915.51","23740.78","Transplants-Case Rate"
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7053.82","","","","","","","fee schedule","6915.51","23740.78","MSDRG Base Rate"
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7261.29","","","","","","","fee schedule","6915.51","23740.78","MSDRG Base Rate"
"Bronchitis And Asthma Without Cc/Mcc","203","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6915.51","","","","","","","fee schedule","6915.51","23740.78","Psych-Case Rate"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18816.46","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20124.45","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26371.3","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21866.01","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18872.17","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24120.27","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18013.9","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28609.41","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21516.4","","","","","","","fee schedule","8041.65","28609.41",""
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6919.54","6919.54","6919.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","5948.99","5948.99","5948.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5893.62","5893.62","5893.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12185.82","6919.54","12761.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6343.43","6343.43","6343.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8423.63","","","","","","","fee schedule","8041.65","28609.41","MSDRG Base Rate"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8282.9","","","","","","","fee schedule","8041.65","28609.41","MSDRG Base Rate"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8041.65","","","","","","","fee schedule","8041.65","28609.41","Transplants-Case Rate"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8202.48","","","","","","","fee schedule","8041.65","28609.41","MSDRG Base Rate"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8443.73","","","","","","","fee schedule","8041.65","28609.41","MSDRG Base Rate"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8041.65","","","","","","","fee schedule","8041.65","28609.41","Psych-Case Rate"
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42671.46","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45637.68","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59804.12","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49587.14","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42797.79","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54699.29","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40851.44","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64879.65","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48794.32","","","","","","","fee schedule","16431.13","64879.65",""
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57374.01","57374.01","57374.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15631.88","15631.88","15631.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","42118.71","42118.71","42118.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15679.24","15679.24","15679.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14686.6","14686.6","14708.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32048.25","32048.25","32048.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","32028.82","32028.82","32028.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16761.55","15281.75","32204.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17211.61","","","","","","","fee schedule","16431.13","64879.65","MSDRG Base Rate"
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16924.06","","","","","","","fee schedule","16431.13","64879.65","MSDRG Base Rate"
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16431.13","","","","","","","fee schedule","16431.13","64879.65","Transplants-Case Rate"
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16759.75","","","","","","","fee schedule","16431.13","64879.65","MSDRG Base Rate"
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17252.69","","","","","","","fee schedule","16431.13","64879.65","MSDRG Base Rate"
"Other Respiratory System Diagnoses With Mcc","205","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16431.13","","","","","","","fee schedule","16431.13","64879.65","Psych-Case Rate"
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21932.34","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23456.92","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30738.21","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25486.87","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21997.27","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28114.42","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20996.88","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33346.94","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25079.37","","","","","","","fee schedule","9137.46","33346.94",""
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","33608.43","33608.43","33608.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18819.74","18819.74","18819.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6927.5","6927.5","6927.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","20209.3","20209.3","20209.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","230.05","230.05","230.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15328.32","15328.32","32092.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8058.11","8058.11","8058.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9571.49","","","","","","","fee schedule","9137.46","33346.94","MSDRG Base Rate"
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9411.58","","","","","","","fee schedule","9137.46","33346.94","MSDRG Base Rate"
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9137.46","","","","","","","fee schedule","9137.46","33346.94","Transplants-Case Rate"
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9320.21","","","","","","","fee schedule","9137.46","33346.94","MSDRG Base Rate"
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9594.33","","","","","","","fee schedule","9137.46","33346.94","MSDRG Base Rate"
"Other Respiratory System Diagnoses Without Mcc","206","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9137.46","","","","","","","fee schedule","9137.46","33346.94","Psych-Case Rate"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","149960.68","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","160384.9","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","210170.17","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","174264.55","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","150404.68","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","192230.23","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","143564.59","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","228007.16","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","171478.32","","","","","","","fee schedule","54163.32","228007.16",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14804.57","7402.5","83939.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","236956.25","236956.25","236956.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","59634.55","59634.55","59634.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","32770.36","8603.02","83939.71","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","141274","141274","141274","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","159413.38","159413.38","159413.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","52907.11","52907.11","55871.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6997.54","6997.54","6997.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","18889.44","18889.44","18889.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","56736.08","","","","","","","fee schedule","54163.32","228007.16","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","55788.22","","","","","","","fee schedule","54163.32","228007.16","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","54163.32","","","","","","","fee schedule","54163.32","228007.16","Transplants-Case Rate"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","55246.59","","","","","","","fee schedule","54163.32","228007.16","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56871.49","","","","","","","fee schedule","54163.32","228007.16","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54163.32","","","","","","","fee schedule","54163.32","228007.16","Psych-Case Rate"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","64058.45","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","68511.35","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","89778.04","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","74440.29","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","64248.11","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","82114.66","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","61326.25","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","97397.44","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","73250.11","","","","","","","fee schedule","23952.65","97397.44",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6781.99","6781.99","6781.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","53837.93","53837.93","53837.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","64140.14","64140.14","112635.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","90959.19","90959.19","90959.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21940.62","21650.54","24652.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","60100.22","60100.22","60100.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","22326.08","21604.97","24281.18","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","22441.51","21609.78","24068.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","26027.55","24853.67","33639.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","21706.5","19182.54","22384.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25090.4","","","","","","","fee schedule","23952.65","97397.44","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24671.23","","","","","","","fee schedule","23952.65","97397.44","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23952.65","","","","","","","fee schedule","23952.65","97397.44","Transplants-Case Rate"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24431.7","","","","","","","fee schedule","23952.65","97397.44","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25150.28","","","","","","","fee schedule","23952.65","97397.44","MSDRG Base Rate"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23952.65","","","","","","","fee schedule","23952.65","97397.44","Psych-Case Rate"
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","263784.63","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","282121.09","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","369694.65","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","306535.74","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","264565.63","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","338137.83","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","252533.75","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","401070.36","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","301634.7","","","","","","","fee schedule","94193.68","401070.36",""
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","98436.77","98436.77","98436.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","98667.88","","","","","","","fee schedule","94193.68","401070.36","MSDRG Base Rate"
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","97019.49","","","","","","","fee schedule","94193.68","401070.36","MSDRG Base Rate"
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","94193.68","","","","","","","fee schedule","94193.68","401070.36","Transplants-Case Rate"
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","96077.55","","","","","","","fee schedule","94193.68","401070.36","MSDRG Base Rate"
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","98903.36","","","","","","","fee schedule","94193.68","401070.36","MSDRG Base Rate"
"Complex Aortic Arch Procedures","209","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","94193.68","","","","","","","fee schedule","94193.68","401070.36","Psych-Case Rate"
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w CC","210","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","211","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","253420.9","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","271036.94","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","355169.85","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","294492.38","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","254171.21","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","324852.86","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","242612.05","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","385312.86","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","289783.89","","","","","","","fee schedule","90548.89","385312.86",""
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","371195.36","371195.36","371195.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","83823.04","83823.04","83823.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","344412.33","344412.33","344412.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","90664.06","88476.89","91815.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","184831.56","184831.56","184831.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","86983.45","86983.45","86983.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","94849.96","","","","","","","fee schedule","90548.89","385312.86","MSDRG Base Rate"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","93265.36","","","","","","","fee schedule","90548.89","385312.86","MSDRG Base Rate"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","90548.89","","","","","","","fee schedule","90548.89","385312.86","Transplants-Case Rate"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","92359.87","","","","","","","fee schedule","90548.89","385312.86","MSDRG Base Rate"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","95076.33","","","","","","","fee schedule","90548.89","385312.86","MSDRG Base Rate"
"Concomitant Aortic And Mitral Valve Procedures","212","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","90548.89","","","","","","","fee schedule","90548.89","385312.86","Psych-Case Rate"
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","132999.3","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","142244.48","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","186398.77","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","154554.27","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","133393.08","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","170487.93","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","127326.65","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","202218.29","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","152083.18","","","","","","","fee schedule","48198.23","202218.29",""
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50487.65","","","","","","","fee schedule","48198.23","202218.29","MSDRG Base Rate"
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","49644.18","","","","","","","fee schedule","48198.23","202218.29","MSDRG Base Rate"
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48198.23","","","","","","","fee schedule","48198.23","202218.29","Transplants-Case Rate"
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49162.19","","","","","","","fee schedule","48198.23","202218.29","MSDRG Base Rate"
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50608.14","","","","","","","fee schedule","48198.23","202218.29","MSDRG Base Rate"
"Endovascular Abdominal Aorta With Iliac Branch Procedures","213","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48198.23","","","","","","","fee schedule","48198.23","202218.29","Psych-Case Rate"
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","214","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","232047.89","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","248178.23","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","325215.53","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","269655.47","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","232734.92","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","297455.42","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","222150.63","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","352816.34","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","265344.09","","","","","","","fee schedule","83032.29","352816.34",""
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","253205.13","253205.13","253205.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","88213.91","88213.91","88213.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","246218.12","246218.12","246218.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","111045.98","111045.98","111045.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","293469.58","293469.58","293469.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","86931.84","86931.84","87005.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","86976.32","","","","","","","fee schedule","83032.29","352816.34","MSDRG Base Rate"
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","85523.26","","","","","","","fee schedule","83032.29","352816.34","MSDRG Base Rate"
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","83032.29","","","","","","","fee schedule","83032.29","352816.34","Transplants-Case Rate"
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","84692.94","","","","","","","fee schedule","83032.29","352816.34","MSDRG Base Rate"
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","87183.9","","","","","","","fee schedule","83032.29","352816.34","MSDRG Base Rate"
"Other Heart Assist System Implant","215","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","83032.29","","","","","","","fee schedule","83032.29","352816.34","Psych-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","227988.15","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","243836.29","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","319525.81","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","264937.79","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","228663.17","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","292251.37","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","218264.05","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","346643.74","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","260701.84","","","","","","","fee schedule","81604.53","346643.74",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","316064.56","316064.56","316064.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","241985.79","241985.79","241985.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","357172.45","353430.69","434502.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","79730.71","55655.7","177486.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","78478.18","64140.26","108267.31","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","78413.89","76616.28","114614.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","105673.79","105673.79","105673.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","198364","198364","198364","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","77193.7","75818.8","83159.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","109661.48","109661.48","109661.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","85480.75","","","","","","","fee schedule","81604.53","346643.74","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","84052.67","","","","","","","fee schedule","81604.53","346643.74","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","81604.53","","","","","","","fee schedule","81604.53","346643.74","Transplants-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","83236.62","","","","","","","fee schedule","81604.53","346643.74","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","85684.76","","","","","","","fee schedule","81604.53","346643.74","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","216","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","81604.53","","","","","","","fee schedule","81604.53","346643.74","Psych-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","153237.37","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","163889.35","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","214762.45","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","178072.27","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","153691.06","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","196430.51","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","146701.52","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","232989.18","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","175225.17","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","154337.35","154337.35","154337.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","263337.52","263337.52","263337.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","52579.37","52579.37","52579.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","51727.92","51727.92","51727.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","32069.96","32069.96","32069.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","55535.94","55535.94","55535.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","231535.64","231535.64","231535.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57943.17","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","56975.15","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","55315.68","","","","","","","fee schedule","55315.68","232989.18","Transplants-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56421.99","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58081.46","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","217","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55315.68","","","","","","","fee schedule","55315.68","232989.18","Psych-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","153237.37","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","163889.35","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","214762.45","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","178072.27","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","153691.06","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","196430.51","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","146701.52","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","232989.18","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","175225.17","","","","","","","fee schedule","55315.68","232989.18",""
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","151790.76","151790.76","151790.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57943.17","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","56975.15","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","55315.68","","","","","","","fee schedule","55315.68","232989.18","Transplants-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56421.99","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58081.46","","","","","","","fee schedule","55315.68","232989.18","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","218","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55315.68","","","","","","","fee schedule","55315.68","232989.18","Psych-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","178942.78","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","191381.63","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","250788.63","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","207943.72","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","179472.58","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","229381.53","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","171310.55","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","272072.88","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","204619.02","","","","","","","fee schedule","64355.93","272072.88",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","235788.92","235788.92","574069","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","110664.93","110664.93","110664.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","174389.62","174389.62","311714.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","184401.22","167658.76","707631.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","256493.38","182682.48","352000.61","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","138914.78","138914.78","138914.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","64631.35","59150.96","77859.79","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","214022.02","214022.02","214022.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","62903.52","56000.78","87118.7","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","62208.17","56163.6","98962.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","105673.79","105673.79","105673.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","169866","167740.41","272888.48","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","173409.27","173409.27","213336.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","62021.9","56824.4","78255.41","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","246422.06","246422.06","246422.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","110162.68","110162.68","110162.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","198821.63","198821.63","198821.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","200672.06","200672.06","200672.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67412.84","","","","","","","fee schedule","64355.93","272072.88","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","66286.61","","","","","","","fee schedule","64355.93","272072.88","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","64355.93","","","","","","","fee schedule","64355.93","272072.88","Transplants-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65643.05","","","","","","","fee schedule","64355.93","272072.88","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67573.73","","","","","","","fee schedule","64355.93","272072.88","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","219","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64355.93","","","","","","","fee schedule","64355.93","272072.88","Psych-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","124280.9","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","132920.04","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","174179.91","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","144422.89","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","124648.87","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","159312.07","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","118980.1","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","188962.44","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","142113.79","","","","","","","fee schedule","45132.08","188962.44",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","110642.96","105825.66","151094.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14493.78","14493.78","14493.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","109464.82","109464.82","109464.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","124860.27","124568.74","127448.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","165887.35","159499.62","216208.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","43177.88","43177.88","46454.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","114572.29","114572.29","148481.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","42552.97","40684.85","43164.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","116280","108865","117082","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","43609.13","43609.13","43609.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14493.78","14493.78","14493.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","136650","135225.12","138639.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","137369.91","137369.91","137369.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47275.85","","","","","","","fee schedule","45132.08","188962.44","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46486.04","","","","","","","fee schedule","45132.08","188962.44","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","45132.08","","","","","","","fee schedule","45132.08","188962.44","Transplants-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46034.72","","","","","","","fee schedule","45132.08","188962.44","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47388.68","","","","","","","fee schedule","45132.08","188962.44","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","220","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45132.08","","","","","","","fee schedule","45132.08","188962.44","Psych-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","117461.86","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","125626.99","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","164623.01","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","136498.7","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","117809.63","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","150570.93","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","112451.9","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","178594.45","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","134316.29","","","","","","","fee schedule","42733.92","178594.45",""
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","109113.13","109113.13","109113.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","110187.14","110187.14","110187.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","149065.85","149065.85","149065.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","89633.82","89633.82","89633.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","41370.06","41370.06","41370.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","36950.92","36950.92","36950.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","118486","118486","118486","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","38526.63","38526.63","42067.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44763.78","","","","","","","fee schedule","42733.92","178594.45","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","44015.94","","","","","","","fee schedule","42733.92","178594.45","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","42733.92","","","","","","","fee schedule","42733.92","178594.45","Transplants-Case Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43588.6","","","","","","","fee schedule","42733.92","178594.45","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44870.62","","","","","","","fee schedule","42733.92","178594.45","MSDRG Base Rate"
"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","221","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42733.92","","","","","","","fee schedule","42733.92","178594.45","Psych-Case Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","228733.27","","","","","","","fee schedule","204040.73","228733.27",""
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","204040.73","","","","","","","fee schedule","204040.73","228733.27",""
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","222","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","155903.44","","","","","","","fee schedule","139073.14","155903.44",""
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","139073.14","","","","","","","fee schedule","139073.14","155903.44",""
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","223","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","211782.76","","","","","","","fee schedule","188920.09","211782.76",""
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","188920.09","","","","","","","fee schedule","188920.09","211782.76",""
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","224","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","151093.73","","","","","","","fee schedule","134782.65","151093.73",""
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","134782.65","","","","","","","fee schedule","134782.65","151093.73",""
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","225","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","191220.49","","","","","","","fee schedule","170577.58","191220.49",""
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","170577.58","","","","","","","fee schedule","170577.58","191220.49",""
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","226","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","149988.39","","","","","","","fee schedule","133796.63","149988.39",""
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","133796.63","","","","","","","fee schedule","133796.63","149988.39",""
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","227","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","115299.16","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","123313.95","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","161591.98","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","133985.49","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","115640.53","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","147798.63","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","110381.44","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","175306.17","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","131843.26","","","","","","","fee schedule","41973.32","175306.17",""
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","230477.08","230477.08","230477.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","45173.45","45173.45","45173.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","40424.59","39944.54","48021.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","40424.59","40424.59","40424.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19585.83","19585.83","19585.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","24863.64","24863.64","24863.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","44771.49","44771.49","55750.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43967.05","","","","","","","fee schedule","41973.32","175306.17","MSDRG Base Rate"
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","43232.52","","","","","","","fee schedule","41973.32","175306.17","MSDRG Base Rate"
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41973.32","","","","","","","fee schedule","41973.32","175306.17","Transplants-Case Rate"
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42812.79","","","","","","","fee schedule","41973.32","175306.17","MSDRG Base Rate"
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44071.99","","","","","","","fee schedule","41973.32","175306.17","MSDRG Base Rate"
"Other Cardiothoracic Procedures With Mcc","228","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41973.32","","","","","","","fee schedule","41973.32","175306.17","Psych-Case Rate"
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","73399.1","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","78501.29","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","102868.97","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","85294.76","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","73616.41","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","94088.16","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","70268.49","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","111599.38","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","83931.03","","","","","","","fee schedule","27237.63","111599.38",""
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","104281.36","104281.36","104281.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17483.76","17483.76","18309.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","95103.54","95103.54","95103.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25674.69","25674.69","25674.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25674.46","25674.46","26004.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","31842.36","31842.36","31842.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10722.49","10722.49","42178.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","69147","69147","69147","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","72536.72","72536.72","72536.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","28809.54","28809.54","28809.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28531.42","","","","","","","fee schedule","27237.63","111599.38","MSDRG Base Rate"
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28054.76","","","","","","","fee schedule","27237.63","111599.38","MSDRG Base Rate"
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27237.63","","","","","","","fee schedule","27237.63","111599.38","Transplants-Case Rate"
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27782.38","","","","","","","fee schedule","27237.63","111599.38","MSDRG Base Rate"
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28599.51","","","","","","","fee schedule","27237.63","111599.38","MSDRG Base Rate"
"Other Cardiothoracic Procedures Without Mcc","229","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27237.63","","","","","","","fee schedule","27237.63","111599.38","Psych-Case Rate"
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other cardiothoracic procedures w/o CC/MCC","230","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","196458.82","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","210115.26","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","275337.39","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","228298.55","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","197040.48","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","251834.83","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","188079.5","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","298705.08","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","224648.41","","","","","","","fee schedule","70516.09","298705.08",""
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","20976.65","20030.57","28331.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20976.65","15698.11","27053.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73865.6","","","","","","","fee schedule","70516.09","298705.08","MSDRG Base Rate"
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","72631.57","","","","","","","fee schedule","70516.09","298705.08","MSDRG Base Rate"
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","70516.09","","","","","","","fee schedule","70516.09","298705.08","Transplants-Case Rate"
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71926.41","","","","","","","fee schedule","70516.09","298705.08","MSDRG Base Rate"
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","74041.89","","","","","","","fee schedule","70516.09","298705.08","MSDRG Base Rate"
"Coronary Bypass With Ptca With Mcc","231","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70516.09","","","","","","","fee schedule","70516.09","298705.08","Psych-Case Rate"
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","141288.89","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","151110.31","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","198016.64","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","164187.33","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","141707.21","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","181114.11","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","135262.67","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","214822.17","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","161562.23","","","","","","","fee schedule","51113.56","214822.17",""
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53541.45","","","","","","","fee schedule","51113.56","214822.17","MSDRG Base Rate"
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","52646.97","","","","","","","fee schedule","51113.56","214822.17","MSDRG Base Rate"
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51113.56","","","","","","","fee schedule","51113.56","214822.17","Transplants-Case Rate"
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52135.83","","","","","","","fee schedule","51113.56","214822.17","MSDRG Base Rate"
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53669.24","","","","","","","fee schedule","51113.56","214822.17","MSDRG Base Rate"
"Coronary Bypass With Ptca Without Mcc","232","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51113.56","","","","","","","fee schedule","51113.56","214822.17","Psych-Case Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","178171.39","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","190556.61","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","249707.52","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","207047.31","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","178698.9","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","228392.7","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","170572.06","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","270900.02","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","203736.93","","","","","","","fee schedule","64084.64","270900.02",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","202124.16","202124.16","202124.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","208801.93","208801.93","208801.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","186804.14","186766.68","197248.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","276024.06","218892.89","308394.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","19239.27","19239.27","19239.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","63099.95","62231.3","64074.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","62830.57","62430.87","124208.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","62043.92","61906.56","63995.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","62375.96","62073.74","62830.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","127705.74","127705.74","127705.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","137004.3","137004.3","137004.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","67128.66","","","","","","","fee schedule","64084.64","270900.02","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","66007.18","","","","","","","fee schedule","64084.64","270900.02","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","64084.64","","","","","","","fee schedule","64084.64","270900.02","Transplants-Case Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65366.33","","","","","","","fee schedule","64084.64","270900.02","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67288.87","","","","","","","fee schedule","64084.64","270900.02","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","233","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","64084.64","","","","","","","fee schedule","64084.64","270900.02","Psych-Case Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","127308.22","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","136157.8","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","178422.71","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","147940.84","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","127685.15","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","163192.7","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","121878.3","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","193565.31","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","145575.49","","","","","","","fee schedule","46196.75","193565.31",""
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","159364.6","159364.6","159364.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","130002.73","130002.73","130002.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","122064.03","122064.03","122064.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","121082.43","121082.43","121082.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","173216.43","172945.84","199382.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","43486.07","43486.07","43486.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","128440.06","128440.06","128440.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","43835.22","41887.22","57099","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","42478.24","41976.19","42500.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","116298","116298","116798","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7796.36","7796.36","7796.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","4795.02","4795.02","4795.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","151180.01","151180.01","151180.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48391.1","","","","","","","fee schedule","46196.75","193565.31","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47582.65","","","","","","","fee schedule","46196.75","193565.31","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46196.75","","","","","","","fee schedule","46196.75","193565.31","Transplants-Case Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47120.68","","","","","","","fee schedule","46196.75","193565.31","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48506.59","","","","","","","fee schedule","46196.75","193565.31","MSDRG Base Rate"
"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","234","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46196.75","","","","","","","fee schedule","46196.75","193565.31","Psych-Case Rate"
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","136767.72","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","146274.86","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","191680.21","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","158933.43","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","137172.66","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","175318.56","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","130934.33","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","207947.97","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","156392.32","","","","","","","fee schedule","49523.53","207947.97",""
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","131717.01","131717.01","139128.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","94824.22","94824.22","94824.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","131482.45","131482.45","131482.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","140253.67","138064.62","185288.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","175490.38","147041.89","248154.79","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","13806.47","13806.47","13806.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","47965.39","42149.21","49382.8","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","27120.3","27120.3","27120.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","47766.14","46839.68","49036.68","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","129044.46","127575.2","129179","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","47360.52","46483.42","47831.23","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","198112","198112","198112","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","151134.5","148856.78","151808","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","47049.08","44577.95","48190.28","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51875.9","","","","","","","fee schedule","49523.53","207947.97","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51009.24","","","","","","","fee schedule","49523.53","207947.97","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","49523.53","","","","","","","fee schedule","49523.53","207947.97","Transplants-Case Rate"
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50514","","","","","","","fee schedule","49523.53","207947.97","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51999.71","","","","","","","fee schedule","49523.53","207947.97","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization With Mcc","235","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49523.53","","","","","","","fee schedule","49523.53","207947.97","Psych-Case Rate"
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","97619.98","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","104405.84","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","136814.59","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","113441.08","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","97909.01","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","125136.21","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","93456.32","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","148425.94","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","111627.33","","","","","","","fee schedule","35755.79","148425.94",""
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","131189.03","131189.03","131189.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","98275.08","95275.08","99248.5","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","128786.86","122351.03","129232.64","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","16295.5","16295.5","16295.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","33608.76","32714.41","35037.01","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","87324.58","87324.58","87324.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","32552.6","28353.91","34071.6","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","53245.27","53245.27","53245.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","89775","85671.1","90275","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33132.12","32534.32","34585.68","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","138406","138406","138406","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","106037.82","101138.84","106089","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","32256.36","30866.98","34911.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","119237.89","119237.89","119237.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37454.19","","","","","","","fee schedule","35755.79","148425.94","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36828.46","","","","","","","fee schedule","35755.79","148425.94","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35755.79","","","","","","","fee schedule","35755.79","148425.94","Transplants-Case Rate"
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36470.91","","","","","","","fee schedule","35755.79","148425.94","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37543.58","","","","","","","fee schedule","35755.79","148425.94","MSDRG Base Rate"
"Coronary Bypass Without Cardiac Catheterization Without Mcc","236","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35755.79","","","","","","","fee schedule","35755.79","148425.94","Psych-Case Rate"
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w MCC","237","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major cardiovasc procedures w/o MCC","238","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","114700.22","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","122673.37","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","160752.57","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","133289.48","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","115039.82","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","147030.87","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","109808.05","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","174395.52","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","131158.38","","","","","","","fee schedule","41762.68","174395.52",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","38377.01","38377.01","40663.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","635231.92","635231.92","635231.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","40621.15","40621.15","58516.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","41577.01","41577.01","41577.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","43306.05","29089.48","94975.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","51471.17","51471.17","51471.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43746.41","","","","","","","fee schedule","41762.68","174395.52","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","43015.56","","","","","","","fee schedule","41762.68","174395.52","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41762.68","","","","","","","fee schedule","41762.68","174395.52","Transplants-Case Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42597.93","","","","","","","fee schedule","41762.68","174395.52","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43850.81","","","","","","","fee schedule","41762.68","174395.52","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","239","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41762.68","","","","","","","fee schedule","41762.68","174395.52","Psych-Case Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","66430.9","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","71048.71","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","93103.03","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","77197.24","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","66627.59","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","85155.84","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","63597.51","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","101004.62","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","75962.97","","","","","","","fee schedule","24787.01","101004.62",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22895.36","22895.36","22895.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","69598.67","69598.67","69598.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","23547.66","23547.66","23547.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","22446.25","22446.25","23095.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","24576.01","24576.01","24576.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10932.56","10932.56","16331.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","73623.97","73623.97","73623.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25964.39","","","","","","","fee schedule","24787.01","101004.62","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25530.62","","","","","","","fee schedule","24787.01","101004.62","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24787.01","","","","","","","fee schedule","24787.01","101004.62","Transplants-Case Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25282.75","","","","","","","fee schedule","24787.01","101004.62","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26026.36","","","","","","","fee schedule","24787.01","101004.62","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24787.01","","","","","","","fee schedule","24787.01","101004.62","Psych-Case Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32263.44","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34506.17","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45217.27","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37492.32","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32358.97","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41357.57","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30887.35","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49054.83","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36892.88","","","","","","","fee schedule","12770.77","49054.83",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12857.78","12857.78","29137.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11479.5","11479.5","11479.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12857.78","8834.57","13465.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13973.19","13973.19","30236.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13377.38","","","","","","","fee schedule","12770.77","49054.83","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13153.89","","","","","","","fee schedule","12770.77","49054.83","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12770.77","","","","","","","fee schedule","12770.77","49054.83","Transplants-Case Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13026.19","","","","","","","fee schedule","12770.77","49054.83","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13409.31","","","","","","","fee schedule","12770.77","49054.83","MSDRG Base Rate"
"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","241","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12770.77","","","","","","","fee schedule","12770.77","49054.83","Psych-Case Rate"
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","74408.2","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","79580.54","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","104283.23","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","86467.41","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","74628.51","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","95381.71","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","71234.56","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","113133.68","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","85084.93","","","","","","","fee schedule","27592.52","113133.68",""
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","19465.09","19465.09","19465.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","70547.51","70547.51","70547.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","27940.1","27516.74","29116.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","26683.6","23183.82","28549.88","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","27031.89","27031.89","29987","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13427.57","13427.57","13427.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","74471","74471","74471","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","27830.23","26587.04","27928.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","28809.54","28809.54","28809.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28903.16","","","","","","","fee schedule","27592.52","113133.68","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28420.3","","","","","","","fee schedule","27592.52","113133.68","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27592.52","","","","","","","fee schedule","27592.52","113133.68","Transplants-Case Rate"
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28144.37","","","","","","","fee schedule","27592.52","113133.68","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28972.15","","","","","","","fee schedule","27592.52","113133.68","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Mcc","242","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27592.52","","","","","","","fee schedule","27592.52","113133.68","Psych-Case Rate"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49660.62","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53112.68","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69599.46","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57709.03","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49807.66","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63658.51","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47542.51","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75506.31","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56786.35","","","","","","","fee schedule","18889.13","75506.31",""
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","70555.44","70555.44","70555.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","70555.44","70555.44","70555.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8412.66","8412.66","8412.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18941.79","18785.71","19761.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17973.75","17470.14","18364.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18420.48","18177.47","18440.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13151.65","8033.23","20384.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","45768.62","45768.62","45768.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","54979","54979","54979","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17946.86","17563.55","25386.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8336.37","8336.37","8336.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","56786.35","56786.35","56786.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19786.36","","","","","","","fee schedule","18889.13","75506.31","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19455.8","","","","","","","fee schedule","18889.13","75506.31","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18889.13","","","","","","","fee schedule","18889.13","75506.31","Transplants-Case Rate"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19266.91","","","","","","","fee schedule","18889.13","75506.31","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19833.59","","","","","","","fee schedule","18889.13","75506.31","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant With Cc","243","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18889.13","","","","","","","fee schedule","18889.13","75506.31","Psych-Case Rate"
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42123.79","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45051.94","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59036.57","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48950.72","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42248.51","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53997.26","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40327.13","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64046.96","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48168.07","","","","","","","fee schedule","16238.52","64046.96",""
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7862.67","7862.67","7862.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15322.37","15322.37","15322.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","41107.19","41107.19","41107.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15431.27","15431.27","15431.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14359.64","14359.64","14359.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7508.04","6563.77","11983.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39622","39622","39622","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15416.43","14740.23","24974.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11875.19","11875.19","11875.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","46051.15","46051.15","46051.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17009.85","","","","","","","fee schedule","16238.52","64046.96","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16725.68","","","","","","","fee schedule","16238.52","64046.96","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16238.52","","","","","","","fee schedule","16238.52","64046.96","Transplants-Case Rate"
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16563.29","","","","","","","fee schedule","16238.52","64046.96","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17050.45","","","","","","","fee schedule","16238.52","64046.96","MSDRG Base Rate"
"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","244","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16238.52","","","","","","","fee schedule","16238.52","64046.96","Psych-Case Rate"
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","106326.73","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","113717.82","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","149017.11","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","123558.92","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","106641.54","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","136297.14","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","101791.71","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","161664.08","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","121583.4","","","","","","","fee schedule","38817.84","161664.08",""
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12269.28","8989.78","12848.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8989.78","8584.33","12848.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","37259.68","37259.68","37259.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12732.27","12732.27","12732.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40661.69","","","","","","","fee schedule","38817.84","161664.08","MSDRG Base Rate"
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39982.38","","","","","","","fee schedule","38817.84","161664.08","MSDRG Base Rate"
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38817.84","","","","","","","fee schedule","38817.84","161664.08","Transplants-Case Rate"
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39594.2","","","","","","","fee schedule","38817.84","161664.08","MSDRG Base Rate"
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40758.73","","","","","","","fee schedule","38817.84","161664.08","MSDRG Base Rate"
"Aicd Generator Procedures","245","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38817.84","","","","","","","fee schedule","38817.84","161664.08","Psych-Case Rate"
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","89484.58","","","","","","","fee schedule","79824.41","89484.58",""
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","79824.41","","","","","","","fee schedule","79824.41","89484.58",""
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","246","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57044.4","","","","","","","fee schedule","50886.27","57044.4",""
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","50886.27","","","","","","","fee schedule","50886.27","57044.4",""
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","247","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","89914.77","","","","","","","fee schedule","80208.16","89914.77",""
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","80208.16","","","","","","","fee schedule","80208.16","89914.77",""
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","248","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54272.1","","","","","","","fee schedule","48413.24","54272.1",""
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48413.24","","","","","","","fee schedule","48413.24","54272.1",""
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","249","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","50863.16","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54398.81","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71284.82","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59106.47","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51013.76","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65200.01","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48693.76","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77334.71","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58161.44","","","","","","","fee schedule","19312.04","77334.71",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","50410.97","50410.97","50410.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","20035.08","20035.08","20035.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","26157.61","26157.61","26157.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17980.9","17980.9","19908.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16128.28","16128.28","16128.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","50775","50775","50775","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18779.4","18779.4","18779.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","59977.28","59977.28","59977.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20229.36","","","","","","","fee schedule","19312.04","77334.71","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19891.4","","","","","","","fee schedule","19312.04","77334.71","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19312.04","","","","","","","fee schedule","19312.04","77334.71","Transplants-Case Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19698.28","","","","","","","fee schedule","19312.04","77334.71","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20277.64","","","","","","","fee schedule","19312.04","77334.71","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","250","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19312.04","","","","","","","fee schedule","19312.04","77334.71","Psych-Case Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34829.32","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37250.41","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48813.36","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40474.05","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34932.44","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44646.69","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33343.79","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52956.11","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39826.93","","","","","","","fee schedule","13673.16","52956.11",""
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6753.63","6753.63","6753.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12634.46","12634.46","12634.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13870.09","13870.09","13870.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16416.75","16416.75","16416.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10926.06","10926.06","10926.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","1174.8","1174.8","1174.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14322.64","","","","","","","fee schedule","13673.16","52956.11","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14083.35","","","","","","","fee schedule","13673.16","52956.11","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13673.16","","","","","","","fee schedule","13673.16","52956.11","Transplants-Case Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13946.62","","","","","","","fee schedule","13673.16","52956.11","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14356.82","","","","","","","fee schedule","13673.16","52956.11","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","251","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13673.16","","","","","","","fee schedule","13673.16","52956.11","Psych-Case Rate"
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","81294.83","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","86945.88","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","113934.85","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","94470.14","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","81535.52","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","104209.47","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","77827.46","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","123604.42","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","92959.71","","","","","","","fee schedule","30014.45","123604.42",""
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","16293.81","16293.81","46160.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","101337.97","101337.97","101337.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","90733.18","90733.18","90733.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","29431.83","27878.49","51579.4","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","28598.45","27087.26","32829.82","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","27628.54","27054.4","28736.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9080.18","8670.65","46160.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","75310","75310","75310","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","88503","88503","88503","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","27692.14","23744.07","29495.02","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","198767.42","198767.42","198767.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","131401.67","131401.67","131401.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","61854.18","61854.18","61854.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31440.14","","","","","","","fee schedule","30014.45","123604.42","MSDRG Base Rate"
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30914.88","","","","","","","fee schedule","30014.45","123604.42","MSDRG Base Rate"
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30014.45","","","","","","","fee schedule","30014.45","123604.42","Transplants-Case Rate"
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30614.74","","","","","","","fee schedule","30014.45","123604.42","MSDRG Base Rate"
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31515.17","","","","","","","fee schedule","30014.45","123604.42","MSDRG Base Rate"
"Other Vascular Procedures With Mcc","252","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30014.45","","","","","","","fee schedule","30014.45","123604.42","Psych-Case Rate"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","60490.46","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","64695.33","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","84777.49","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","70294.04","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","60669.55","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","77540.95","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","57910.43","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","91972.49","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","69170.14","","","","","","","fee schedule","22697.83","91972.49",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","44146.53","44146.53","44146.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11879.35","7755.53","24630.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","79957.41","79957.41","79957.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","22251.04","22217.52","23361.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20289.07","19536.94","21696.34","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","55077.53","55077.53","55077.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","21691.95","21691.95","22248.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12440.43","12440.43","12440.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","21074.52","20550.3","21931.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","25560.11","25560.11","25560.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23775.98","","","","","","","fee schedule","22697.83","91972.49","MSDRG Base Rate"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23378.76","","","","","","","fee schedule","22697.83","91972.49","MSDRG Base Rate"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22697.83","","","","","","","fee schedule","22697.83","91972.49","Transplants-Case Rate"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23151.79","","","","","","","fee schedule","22697.83","91972.49","MSDRG Base Rate"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23832.72","","","","","","","fee schedule","22697.83","91972.49","MSDRG Base Rate"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22697.83","","","","","","","fee schedule","22697.83","91972.49","Psych-Case Rate"
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41522.52","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44408.87","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58193.89","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48252","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41645.46","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53226.51","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39751.51","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63132.76","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47480.52","","","","","","","fee schedule","16027.06","63132.76",""
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10405.94","10405.94","10405.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50666.35","50666.35","50666.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16107.06","16107.06","16107.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14966.81","14180.85","15044.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15014.2","15014.2","15219.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13872.19","10405.94","36667.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15678.41","15678.41","15678.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","45370.69","45370.69","45370.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10798.61","10798.61","10798.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16788.35","","","","","","","fee schedule","16027.06","63132.76","MSDRG Base Rate"
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16507.87","","","","","","","fee schedule","16027.06","63132.76","MSDRG Base Rate"
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16027.06","","","","","","","fee schedule","16027.06","63132.76","Transplants-Case Rate"
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16347.6","","","","","","","fee schedule","16027.06","63132.76","MSDRG Base Rate"
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16828.41","","","","","","","fee schedule","16027.06","63132.76","MSDRG Base Rate"
"Other Vascular Procedures Without Cc/Mcc","254","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16027.06","","","","","","","fee schedule","16027.06","63132.76","Psych-Case Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","62862.91","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","67232.7","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","88102.48","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","73050.99","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","63049.03","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","80582.13","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","60181.69","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","95579.67","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","71883.01","","","","","","","fee schedule","23532.19","95579.67",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24649.97","","","","","","","fee schedule","23532.19","95579.67","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24238.16","","","","","","","fee schedule","23532.19","95579.67","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23532.19","","","","","","","fee schedule","23532.19","95579.67","Transplants-Case Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24002.83","","","","","","","fee schedule","23532.19","95579.67","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24708.8","","","","","","","fee schedule","23532.19","95579.67","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","255","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23532.19","","","","","","","fee schedule","23532.19","95579.67","Psych-Case Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39569.56","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42320.16","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55456.81","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45982.53","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39686.71","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50723.06","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37881.85","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","60163.39","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45247.34","","","","","","","fee schedule","15340.23","60163.39",""
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16068.89","","","","","","","fee schedule","15340.23","60163.39","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15800.44","","","","","","","fee schedule","15340.23","60163.39","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15340.23","","","","","","","fee schedule","15340.23","60163.39","Transplants-Case Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15647.03","","","","","","","fee schedule","15340.23","60163.39","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16107.24","","","","","","","fee schedule","15340.23","60163.39","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","256","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15340.23","","","","","","","fee schedule","15340.23","60163.39","Psych-Case Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25453.72","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27223.09","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35673.44","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29578.96","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25529.08","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32628.38","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24368.07","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38701.01","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29106.04","","","","","","","fee schedule","10375.88","38701.01",""
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10868.73","","","","","","","fee schedule","10375.88","38701.01","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10687.16","","","","","","","fee schedule","10375.88","38701.01","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10375.88","","","","","","","fee schedule","10375.88","38701.01","Transplants-Case Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10583.4","","","","","","","fee schedule","10375.88","38701.01","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10894.67","","","","","","","fee schedule","10375.88","38701.01","MSDRG Base Rate"
"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","257","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10375.88","","","","","","","fee schedule","10375.88","38701.01","Psych-Case Rate"
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","73226.64","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","78316.84","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","102627.27","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","85094.35","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","73443.45","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","93867.1","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","70103.39","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","111337.17","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","83733.82","","","","","","","fee schedule","27176.98","111337.17",""
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","23010.9","23010.9","23010.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28467.89","","","","","","","fee schedule","27176.98","111337.17","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27992.29","","","","","","","fee schedule","27176.98","111337.17","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27176.98","","","","","","","fee schedule","27176.98","111337.17","Transplants-Case Rate"
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27720.52","","","","","","","fee schedule","27176.98","111337.17","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28535.83","","","","","","","fee schedule","27176.98","111337.17","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement With Mcc","258","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27176.98","","","","","","","fee schedule","27176.98","111337.17","Psych-Case Rate"
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","47125.04","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","50400.84","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","66045.83","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54762.51","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","47264.57","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","60408.22","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","45115.07","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","71651.09","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53886.94","","","","","","","fee schedule","17997.4","71651.09",""
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14428.35","14428.35","14428.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18852.28","","","","","","","fee schedule","17997.4","71651.09","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18537.32","","","","","","","fee schedule","17997.4","71651.09","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17997.4","","","","","","","fee schedule","17997.4","71651.09","Transplants-Case Rate"
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18357.35","","","","","","","fee schedule","17997.4","71651.09","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18897.27","","","","","","","fee schedule","17997.4","71651.09","MSDRG Base Rate"
"Cardiac Pacemaker Device Replacement Without Mcc","259","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17997.4","","","","","","","fee schedule","17997.4","71651.09","Psych-Case Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75806.5","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","81076.04","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","106242.95","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","88092.33","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","76030.95","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","97174.15","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","72573.22","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","115259.72","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","86683.87","","","","","","","fee schedule","28084.28","115259.72",""
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","21091.01","21091.01","21091.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","29232.83","29232.83","29232.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","73270.75","73270.75","73270.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10886.03","10886.03","10886.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22798.96","22798.96","38663.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","118602.2","118602.2","118602.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12844.45","12844.45","12844.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29418.28","","","","","","","fee schedule","28084.28","115259.72","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28926.81","","","","","","","fee schedule","28084.28","115259.72","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28084.28","","","","","","","fee schedule","28084.28","115259.72","Transplants-Case Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28645.97","","","","","","","fee schedule","28084.28","115259.72","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29488.49","","","","","","","fee schedule","28084.28","115259.72","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Mcc","260","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28084.28","","","","","","","fee schedule","28084.28","115259.72","Psych-Case Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44058.1","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47120.71","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","61747.51","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51198.52","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44188.55","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","56476.8","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42178.95","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","66987.98","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","50379.93","","","","","","","fee schedule","16918.8","66987.98",""
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","41261.68","41261.68","41261.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","21298.21","21298.21","21298.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16366.89","16366.89","16366.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","1838.6","1838.6","1838.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17722.44","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17426.36","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16918.8","","","","","","","fee schedule","16918.8","66987.98","Transplants-Case Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17257.18","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17764.74","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement With Cc","261","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16918.8","","","","","","","fee schedule","16918.8","66987.98","Psych-Case Rate"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37984.82","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40625.26","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53235.79","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44140.95","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38097.28","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48691.63","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36364.7","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57753.88","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43435.21","","","","","","","fee schedule","14782.9","57753.88",""
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15485.09","","","","","","","fee schedule","14782.9","57753.88","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15226.39","","","","","","","fee schedule","14782.9","57753.88","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14782.9","","","","","","","fee schedule","14782.9","57753.88","Transplants-Case Rate"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15078.56","","","","","","","fee schedule","14782.9","57753.88","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15522.04","","","","","","","fee schedule","14782.9","57753.88","MSDRG Base Rate"
"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","262","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14782.9","","","","","","","fee schedule","14782.9","57753.88","Psych-Case Rate"
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","71252.71","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","76205.7","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","99860.8","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","82800.51","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","71463.67","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","91336.77","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","68213.65","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","108335.91","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","81476.65","","","","","","","fee schedule","26482.77","108335.91",""
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12621.8","10558.38","17696.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","62976.34","62976.34","62976.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12621.8","10558.38","63798.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13098.1","13098.1","13716.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27740.7","","","","","","","fee schedule","26482.77","108335.91","MSDRG Base Rate"
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27277.25","","","","","","","fee schedule","26482.77","108335.91","MSDRG Base Rate"
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26482.77","","","","","","","fee schedule","26482.77","108335.91","Transplants-Case Rate"
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27012.43","","","","","","","fee schedule","26482.77","108335.91","MSDRG Base Rate"
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27806.91","","","","","","","fee schedule","26482.77","108335.91","MSDRG Base Rate"
"Vein Ligation And Stripping","263","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26482.77","","","","","","","fee schedule","26482.77","108335.91","Psych-Case Rate"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","77852.68","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","83264.46","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","109110.68","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","90470.13","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","78083.18","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","99797.08","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","74532.13","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","118370.82","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","89023.65","","","","","","","fee schedule","28803.9","118370.82",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","83013.52","83013.52","83013.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","80520.73","80520.73","80520.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","27729.7","27169.34","74174.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","28945.26","27819.12","58448.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","43599.33","43599.33","43599.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","90172","90172","90172","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","30086.8","30086.8","30086.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30172.09","","","","","","","fee schedule","28803.9","118370.82","MSDRG Base Rate"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29668.02","","","","","","","fee schedule","28803.9","118370.82","MSDRG Base Rate"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28803.9","","","","","","","fee schedule","28803.9","118370.82","Transplants-Case Rate"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29379.98","","","","","","","fee schedule","28803.9","118370.82","MSDRG Base Rate"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30244.1","","","","","","","fee schedule","28803.9","118370.82","MSDRG Base Rate"
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28803.9","","","","","","","fee schedule","28803.9","118370.82","Psych-Case Rate"
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","84322.15","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","90183.64","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","118177.65","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","97988.09","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","84571.81","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","108090.11","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","80725.66","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","128207.3","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","96421.41","","","","","","","fee schedule","31079.12","128207.3",""
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","30556.66","30556.66","30556.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32555.38","","","","","","","fee schedule","31079.12","128207.3","MSDRG Base Rate"
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32011.49","","","","","","","fee schedule","31079.12","128207.3","MSDRG Base Rate"
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31079.12","","","","","","","fee schedule","31079.12","128207.3","Transplants-Case Rate"
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31700.7","","","","","","","fee schedule","31079.12","128207.3","MSDRG Base Rate"
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32633.08","","","","","","","fee schedule","31079.12","128207.3","MSDRG Base Rate"
"Aicd Lead Procedures","265","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31079.12","","","","","","","fee schedule","31079.12","128207.3","Psych-Case Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","142822.36","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","152750.37","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","200165.8","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","165969.33","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","143245.22","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","183079.82","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","136730.73","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","217153.73","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","163315.73","","","","","","","fee schedule","51652.86","217153.73",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","74341.33","74341.33","74341.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","186025.87","122493.71","316553.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","48991.98","5379.36","51074.4","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","103372.05","103372.05","103372.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","49119.52","47701.82","50506.88","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","108447.08","108447.08","108447.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","49294.41","47916.14","55685.64","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","108285.2","108285.2","108285.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","48360.84","46860.99","62933.05","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","112996.85","112996.85","112996.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54106.37","","","","","","","fee schedule","51652.86","217153.73","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","53202.45","","","","","","","fee schedule","51652.86","217153.73","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51652.86","","","","","","","fee schedule","51652.86","217153.73","Transplants-Case Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52685.92","","","","","","","fee schedule","51652.86","217153.73","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54235.5","","","","","","","fee schedule","51652.86","217153.73","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","266","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51652.86","","","","","","","fee schedule","51652.86","217153.73","Psych-Case Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","110950.44","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","118662.94","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","155497.25","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","128931.99","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","111278.94","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","142224.14","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","106218.21","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","168694.19","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","126870.56","","","","","","","fee schedule","40443.94","168694.19",""
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","93271.4","93271.4","93271.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","110413.64","110413.64","115795.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","113778.36","113378.36","113778.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","39438.49","38163.04","41628.8","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","157039.74","157039.74","157039.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","38864.37","22553.72","39830.09","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","38634.3","38130.28","40366.33","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","102785","96640.45","103285","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","155568.09","155568.09","155568.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","122833","122833","122833","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","38283.52","37152.01","39390.78","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","121130.33","121130.33","121130.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","115435.51","115435.51","115435.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42365.03","","","","","","","fee schedule","40443.94","168694.19","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41657.26","","","","","","","fee schedule","40443.94","168694.19","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40443.94","","","","","","","fee schedule","40443.94","168694.19","Transplants-Case Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41252.82","","","","","","","fee schedule","40443.94","168694.19","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42466.14","","","","","","","fee schedule","40443.94","168694.19","MSDRG Base Rate"
"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","267","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40443.94","","","","","","","fee schedule","40443.94","168694.19","Psych-Case Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","160289.46","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","171431.66","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","224645.97","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","186267.29","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","160764.03","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","205470.38","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","153452.83","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","243711.51","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","183289.16","","","","","","","fee schedule","57795.81","243711.51",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","177038.81","177038.81","177038.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","55234.82","55234.82","66769.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","53222.1","52784.55","245879.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","82748.21","82748.21","82748.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","56444.97","56444.97","56444.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","55332.26","55332.26","66473.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","168980.57","168980.57","168980.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60541.11","","","","","","","fee schedule","57795.81","243711.51","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","59529.68","","","","","","","fee schedule","57795.81","243711.51","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","57795.81","","","","","","","fee schedule","57795.81","243711.51","Transplants-Case Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","58951.73","","","","","","","fee schedule","57795.81","243711.51","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60685.6","","","","","","","fee schedule","57795.81","243711.51","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","268","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57795.81","","","","","","","fee schedule","57795.81","243711.51","Psych-Case Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","98421.68","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","105263.26","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","137938.16","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","114372.7","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","98713.08","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","126163.88","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","94223.82","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","149644.87","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","112544.06","","","","","","","fee schedule","36037.74","149644.87",""
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","42261.17","42261.17","42261.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","92970.84","92970.84","92970.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","128408.96","128408.96","131362.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","93765.82","93765.82","93765.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","35118.15","34058.66","36078.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","34580.22","33847.99","36144.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33993.48","32980.76","35947.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","91342","91342","91342","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","105565.85","105565.85","105565.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","33988.77","33988.77","33988.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37749.53","","","","","","","fee schedule","36037.74","149644.87","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37118.87","","","","","","","fee schedule","36037.74","149644.87","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36037.74","","","","","","","fee schedule","36037.74","149644.87","Transplants-Case Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36758.49","","","","","","","fee schedule","36037.74","149644.87","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37839.63","","","","","","","fee schedule","36037.74","149644.87","MSDRG Base Rate"
"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","269","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36037.74","","","","","","","fee schedule","36037.74","149644.87","Psych-Case Rate"
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","122964.17","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","131511.78","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","172334.51","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","142892.76","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","123328.24","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","157624.19","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","117719.53","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","186960.41","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","140608.12","","","","","","","fee schedule","44669","186960.41",""
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","117898.92","117898.92","160557.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","119505.5","119505.5","119505.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","160760.43","127918.34","181623.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","16541.53","16541.53","16541.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","41882.83","29431.83","85866.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","126010.86","126010.86","126010.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","41342.14","40391.82","73556.55","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","41059.55","40764.57","138273.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","42261.17","42261.17","42261.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","144963.23","144963.23","144963.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","13378.09","13378.09","13378.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","41662.19","41240.5","105105.69","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","297824.36","297824.36","297824.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","33292.66","33292.66","33292.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","155593.32","155593.32","155593.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46790.78","","","","","","","fee schedule","44669","186960.41","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46009.07","","","","","","","fee schedule","44669","186960.41","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","44669","","","","","","","fee schedule","44669","186960.41","Transplants-Case Rate"
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","45562.38","","","","","","","fee schedule","44669","186960.41","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46902.45","","","","","","","fee schedule","44669","186960.41","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Mcc","270","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44669","","","","","","","fee schedule","44669","186960.41","Psych-Case Rate"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","82879.57","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","88640.78","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","116155.87","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","96311.72","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83124.96","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","106240.91","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79344.61","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126013.93","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","94771.84","","","","","","","fee schedule","30571.79","126013.93",""
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","187841.47","187841.47","187841.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","42261.17","42261.17","42261.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","107875.16","107875.16","107875.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","22832.73","22832.73","22832.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","31284.38","29725.44","43044.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","79746.58","79746.58","79746.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","28671.47","27538.77","30992.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","28767.19","27971.22","29303.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","78079","78079","78079","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","44257.24","44257.24","44257.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","84388","84388","84388","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","28045.33","27967.87","28358.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","101011.88","101011.88","101011.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10513.81","10513.81","10513.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32023.95","","","","","","","fee schedule","30571.79","126013.93","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31488.94","","","","","","","fee schedule","30571.79","126013.93","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30571.79","","","","","","","fee schedule","30571.79","126013.93","Transplants-Case Rate"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31183.23","","","","","","","fee schedule","30571.79","126013.93","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32100.38","","","","","","","fee schedule","30571.79","126013.93","MSDRG Base Rate"
"Other Major Cardiovascular Procedures With Cc","271","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30571.79","","","","","","","fee schedule","30571.79","126013.93","Psych-Case Rate"
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","59497.67","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","63633.53","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","83386.09","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","69140.35","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","59673.82","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","76268.32","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","56959.98","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","90463","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","68034.9","","","","","","","fee schedule","22348.68","90463",""
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","71933.2","71933.2","71933.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","59800.08","59800.08","59800.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","78066.4","78066.4","78066.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8117.29","8117.29","8117.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21064.82","21064.82","21064.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","44257.24","44257.24","44257.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","50268.99","50268.99","50268.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20526.49","20526.49","21571.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23410.24","","","","","","","fee schedule","22348.68","90463","MSDRG Base Rate"
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23019.14","","","","","","","fee schedule","22348.68","90463","MSDRG Base Rate"
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22348.68","","","","","","","fee schedule","22348.68","90463","Transplants-Case Rate"
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22795.65","","","","","","","fee schedule","22348.68","90463","MSDRG Base Rate"
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23466.11","","","","","","","fee schedule","22348.68","90463","MSDRG Base Rate"
"Other Major Cardiovascular Procedures Without Cc/Mcc","272","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22348.68","","","","","","","fee schedule","22348.68","90463","Psych-Case Rate"
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","96144.78","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","102828.09","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","134747.08","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","111726.79","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","96429.44","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","123245.19","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","92044.03","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","146182.97","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","109940.45","","","","","","","fee schedule","35236.98","146182.97",""
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","96595.32","96595.32","96595.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","121244","121244","196216.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","31442.26","8656.71","32990.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","31972.37","31888.55","37523.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","39129.75","31972.37","72758.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","31116","31116","31116","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","36867.7","31972.37","38529.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36910.74","","","","","","","fee schedule","35236.98","146182.97","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36294.09","","","","","","","fee schedule","35236.98","146182.97","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35236.98","","","","","","","fee schedule","35236.98","146182.97","Transplants-Case Rate"
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35941.72","","","","","","","fee schedule","35236.98","146182.97","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36998.83","","","","","","","fee schedule","35236.98","146182.97","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures With Mcc","273","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35236.98","","","","","","","fee schedule","35236.98","146182.97","Psych-Case Rate"
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","76713.07","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","82045.62","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","107513.51","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","89145.82","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","76940.2","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","98336.25","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","73441.12","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","116638.1","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","87720.51","","","","","","","fee schedule","28403.11","116638.1",""
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","74344.63","74344.63","74344.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","76117.09","62884.48","108476.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","74588.78","74588.78","76102.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","93094.55","82671.02","97746.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25790.63","25754.9","33348.5","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","132194.83","132194.83","132194.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25790.63","25754.9","28039.39","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","68475.54","66954.24","70304.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","25790.41","25754.9","30560.56","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","101181.69","101181.69","101181.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","84929","84929","84929","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","25790.63","25790.41","25840.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","79994.35","79994.35","79994.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29752.26","","","","","","","fee schedule","28403.11","116638.1","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29255.2","","","","","","","fee schedule","28403.11","116638.1","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28403.11","","","","","","","fee schedule","28403.11","116638.1","Transplants-Case Rate"
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28971.17","","","","","","","fee schedule","28403.11","116638.1","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29823.27","","","","","","","fee schedule","28403.11","116638.1","MSDRG Base Rate"
"Percutaneous And Other Intracardiac Procedures Without Mcc","274","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28403.11","","","","","","","fee schedule","28403.11","116638.1","Psych-Case Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","166173.97","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","177725.22","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","232893.12","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","193105.49","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","166665.97","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","213013.57","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","159086.35","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","252658.59","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","190018.03","","","","","","","fee schedule","59865.31","252658.59",""
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","249652.72","249652.72","249652.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","287446.06","287446.06","287446.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","57657.49","57657.49","57657.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","56522.9","56522.9","56523.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","57974.19","57974.19","57974.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","196586.43","196586.43","197286.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","59460.38","59460.38","59460.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","177212.74","177212.74","177212.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","62708.91","","","","","","","fee schedule","59865.31","252658.59","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","61661.27","","","","","","","fee schedule","59865.31","252658.59","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","59865.31","","","","","","","fee schedule","59865.31","252658.59","Transplants-Case Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61062.62","","","","","","","fee schedule","59865.31","252658.59","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","62858.58","","","","","","","fee schedule","59865.31","252658.59","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","275","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59865.31","","","","","","","fee schedule","59865.31","252658.59","Psych-Case Rate"
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","139983.81","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","149714.51","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","196187.57","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","162670.74","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","140398.27","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","179441.17","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","134013.25","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","212837.86","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","160069.88","","","","","","","fee schedule","50654.58","212837.86",""
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","142563.64","142563.64","142563.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","141125.17","141125.17","238007.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12744.93","12744.93","12744.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","51820.34","51820.34","52191.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","51303.56","51303.56","51303.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","50963.18","50963.18","50963.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","135989","135989","135989","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","53757","50495.89","72082.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","53060.67","","","","","","","fee schedule","50654.58","212837.86","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","52174.22","","","","","","","fee schedule","50654.58","212837.86","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50654.58","","","","","","","fee schedule","50654.58","212837.86","Transplants-Case Rate"
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51667.67","","","","","","","fee schedule","50654.58","212837.86","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","53187.31","","","","","","","fee schedule","50654.58","212837.86","MSDRG Base Rate"
"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","276","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50654.58","","","","","","","fee schedule","50654.58","212837.86","Psych-Case Rate"
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","107634.14","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","115116.11","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","150849.45","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","125078.22","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","107952.82","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","137973.07","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","103043.35","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","163651.93","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","123078.41","","","","","","","fee schedule","39277.64","163651.93",""
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","69631.46","69631.46","69631.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","172370.22","145692.86","181058.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","36907.96","34000.45","39032.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","113050.72","113050.72","113050.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","38194.84","38017.34","38357.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","100485.19","98357.41","100513.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","39473.3","39473.3","39473.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","36965.42","36965.42","36965.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41143.33","","","","","","","fee schedule","39277.64","163651.93","MSDRG Base Rate"
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40455.97","","","","","","","fee schedule","39277.64","163651.93","MSDRG Base Rate"
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39277.64","","","","","","","fee schedule","39277.64","163651.93","Transplants-Case Rate"
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40063.19","","","","","","","fee schedule","39277.64","163651.93","MSDRG Base Rate"
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41241.52","","","","","","","fee schedule","39277.64","163651.93","MSDRG Base Rate"
"Cardiac Defibrillator Implant Without Mcc","277","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39277.64","","","","","","","fee schedule","39277.64","163651.93","Psych-Case Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","129720.29","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","138737.54","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","181803.22","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","150743.83","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","130104.36","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","166284.66","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","124187.49","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","197232.73","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","148333.66","","","","","","","fee schedule","47045.04","197232.73",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","156698.35","156698.35","156698.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","83925","83925","83925","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","40975.83","40975.83","40975.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49279.68","","","","","","","fee schedule","47045.04","197232.73","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48456.39","","","","","","","fee schedule","47045.04","197232.73","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47045.04","","","","","","","fee schedule","47045.04","197232.73","Transplants-Case Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47985.94","","","","","","","fee schedule","47045.04","197232.73","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49397.29","","","","","","","fee schedule","47045.04","197232.73","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","278","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47045.04","","","","","","","fee schedule","47045.04","197232.73","Psych-Case Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","84047.15","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","89889.52","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","117792.24","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","97668.52","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","84295.99","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","107737.59","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","80462.39","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","127789.18","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","96106.95","","","","","","","fee schedule","30982.41","127789.18",""
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4489.29","4489.29","4489.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25594.92","25594.92","25594.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","30855.75","30855.75","31135.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32454.07","","","","","","","fee schedule","30982.41","127789.18","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31911.88","","","","","","","fee schedule","30982.41","127789.18","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30982.41","","","","","","","fee schedule","30982.41","127789.18","Transplants-Case Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31602.06","","","","","","","fee schedule","30982.41","127789.18","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32531.53","","","","","","","fee schedule","30982.41","127789.18","MSDRG Base Rate"
"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","279","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30982.41","","","","","","","fee schedule","30982.41","127789.18","Psych-Case Rate"
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37383.55","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39982.19","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52393.11","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43442.24","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37494.23","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47920.88","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35789.08","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56839.68","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42747.66","","","","","","","fee schedule","14571.44","56839.68",""
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","24750.17","24750.17","24750.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14506.73","4448.5","15191.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","31356.14","31356.14","31356.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","35077.43","25024.79","39227.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48953.11","25738.09","51407.01","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13766.5","12470.95","14755.52","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","36621.28","36621.28","97710.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12916.34","11014.57","14725.54","70","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13294.6","12398.45","14639.01","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14506.73","8896.56","34735.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","34718","31528","35839.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","32936.5","32936.5","32936.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13163.54","12482.82","14753.76","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","43741.67","43741.67","100153.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","15054.15","9668.33","15054.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15263.58","","","","","","","fee schedule","14571.44","56839.68","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15008.58","","","","","","","fee schedule","14571.44","56839.68","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14571.44","","","","","","","fee schedule","14571.44","56839.68","Transplants-Case Rate"
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14862.87","","","","","","","fee schedule","14571.44","56839.68","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15300.01","","","","","","","fee schedule","14571.44","56839.68","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Mcc","280","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14571.44","","","","","","","fee schedule","14571.44","56839.68","Psych-Case Rate"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21419.63","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22908.57","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30019.64","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24891.07","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21483.04","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27457.19","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20506.04","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32567.39","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24493.1","","","","","","","fee schedule","8957.15","32567.39",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","98780.39","98780.39","98780.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","23188.68","12519.64","23188.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","19988.38","18725.59","21965.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25428.95","22811.85","28869.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8794.2","7688","8838.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","20506.04","20506.04","37975.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7774.87","6585.11","8684.89","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6952.39","6952.39","6952.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13110.97","13110.97","23188.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19738","15374.43","20238","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","22365.04","22365.04","22365.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8158.87","6824.91","9236.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","42569.71","18213.58","60506.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9382.61","","","","","","","fee schedule","8957.15","32567.39","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9225.86","","","","","","","fee schedule","8957.15","32567.39","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8957.15","","","","","","","fee schedule","8957.15","32567.39","Transplants-Case Rate"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9136.29","","","","","","","fee schedule","8957.15","32567.39","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9405.01","","","","","","","fee schedule","8957.15","32567.39","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8957.15","","","","","","","fee schedule","8957.15","32567.39","Psych-Case Rate"
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16851.85","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18023.27","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23617.89","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19582.99","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16901.74","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21601.89","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16133.08","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25622.33","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19269.89","","","","","","","fee schedule","7350.72","25622.33",""
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8715.53","6011.62","14162.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","8396.58","8396.58","8396.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","16536.19","9965.21","20875.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7187.87","7187.87","7187.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","11573.72","11573.72","11573.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6170.82","2138.51","7078.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5544.98","5544.98","5544.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8715.53","4357.76","14162.73","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6343","6343","6640.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8636.51","6238.47","31016.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2015.15","2015.15","2015.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","15984.65","15984.65","15984.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7699.88","","","","","","","fee schedule","7350.72","25622.33","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7571.24","","","","","","","fee schedule","7350.72","25622.33","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7350.72","","","","","","","fee schedule","7350.72","25622.33","Transplants-Case Rate"
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7497.73","","","","","","","fee schedule","7350.72","25622.33","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7718.26","","","","","","","fee schedule","7350.72","25622.33","MSDRG Base Rate"
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","282","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7350.72","","","","","","","fee schedule","7350.72","25622.33","Psych-Case Rate"
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46162.54","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49371.44","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","64696.89","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","53644.03","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46299.22","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59174.42","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44193.63","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","70187.67","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","52786.34","","","","","","","fee schedule","17658.9","70187.67",""
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","196150.11","196150.11","196150.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","24938.57","24938.57","24938.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","59314.96","59314.96","59314.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15722.38","15704.48","74322.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15690.47","15478.79","31215.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15546.26","15523.56","16871.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5379.95","5379.95","5379.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","50451","50451","50451","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17317.75","16573.27","17833.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18497.7","","","","","","","fee schedule","17658.9","70187.67","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18188.67","","","","","","","fee schedule","17658.9","70187.67","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17658.9","","","","","","","fee schedule","17658.9","70187.67","Transplants-Case Rate"
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18012.08","","","","","","","fee schedule","17658.9","70187.67","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18541.84","","","","","","","fee schedule","17658.9","70187.67","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Mcc","283","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17658.9","","","","","","","fee schedule","17658.9","70187.67","Psych-Case Rate"
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16131.72","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17253.09","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22608.64","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18746.16","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16179.48","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20678.78","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15443.67","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24527.41","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18446.44","","","","","","","fee schedule","7097.46","24527.41",""
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20797.28","20797.28","20797.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22225.8","22225.8","22225.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7041.52","7041.52","7041.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12269.28","12269.28","12848.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7434.59","","","","","","","fee schedule","7097.46","24527.41","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7310.38","","","","","","","fee schedule","7097.46","24527.41","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7097.46","","","","","","","fee schedule","7097.46","24527.41","Transplants-Case Rate"
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7239.41","","","","","","","fee schedule","7097.46","24527.41","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7452.33","","","","","","","fee schedule","7097.46","24527.41","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired With Cc","284","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7097.46","","","","","","","fee schedule","7097.46","24527.41","Psych-Case Rate"
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","13957.36","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","14927.58","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","19561.27","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16219.41","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","13998.69","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","17891.54","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","13362.06","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","21221.42","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","15960.09","","","","","","","fee schedule","6332.77","21221.42",""
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6633.58","","","","","","","fee schedule","6332.77","21221.42","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6522.75","","","","","","","fee schedule","6332.77","21221.42","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6332.77","","","","","","","fee schedule","6332.77","21221.42","Transplants-Case Rate"
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6459.43","","","","","","","fee schedule","6332.77","21221.42","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6649.41","","","","","","","fee schedule","6332.77","21221.42","MSDRG Base Rate"
"Acute Myocardial Infarction, Expired Without Cc/Mcc","285","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6332.77","","","","","","","fee schedule","6332.77","21221.42","Psych-Case Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51569.3","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","55154.04","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","72274.47","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59927.05","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51721.99","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","66105.19","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49369.78","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","78408.36","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58968.91","","","","","","","fee schedule","19560.38","78408.36",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","79807.27","46968.67","221604.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","49456.19","49456.19","49456.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","52108.79","48988.68","52883.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","69302.68","66849.78","69318.34","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18538.84","17488.88","19436.88","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","49380.94","49380.94","49380.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17481.35","16759.64","18926.58","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18976.63","17567.97","38643.14","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","48093","45494","48593","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","52725.44","52725.44","52725.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17942.3","17100.49","36102.6","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","432551.94","432551.94","432551.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","322238.23","322238.23","322238.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20489.5","","","","","","","fee schedule","19560.38","78408.36","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20147.19","","","","","","","fee schedule","19560.38","78408.36","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19560.38","","","","","","","fee schedule","19560.38","78408.36","Transplants-Case Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19951.59","","","","","","","fee schedule","19560.38","78408.36","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20538.4","","","","","","","fee schedule","19560.38","78408.36","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","286","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19560.38","","","","","","","fee schedule","19560.38","78408.36","Psych-Case Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24938.68","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26672.24","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34951.61","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28980.45","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25012.52","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31968.17","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23875","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37917.92","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28517.09","","","","","","","fee schedule","10194.75","37917.92",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","42592.85","42338.83","47092.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","28245.94","28245.94","33119.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23375.58","23375.58","25542.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33778.31","32499.21","34128.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9187.85","8577.99","9854.25","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17724.21","17724.21","17724.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8296.74","1519.84","9236.43","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9185.52","8813.12","9948.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22397","21897","26323.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26779.4","26779.4","26779.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9351.67","9043.55","10207.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","21396.14","21396.14","21396.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10679","","","","","","","fee schedule","10194.75","37917.92","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10500.59","","","","","","","fee schedule","10194.75","37917.92","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10194.75","","","","","","","fee schedule","10194.75","37917.92","Transplants-Case Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10398.64","","","","","","","fee schedule","10194.75","37917.92","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10704.49","","","","","","","fee schedule","10194.75","37917.92","MSDRG Base Rate"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","287","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10194.75","","","","","","","fee schedule","10194.75","37917.92","Psych-Case Rate"
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","63067.99","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","67452.04","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","88389.9","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","73289.31","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","63254.72","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","80845.02","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","60378.03","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","95891.49","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","72117.52","","","","","","","fee schedule","23604.32","95891.49",""
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","85197.85","85197.85","85197.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","38367.38","38367.38","38367.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","38244.53","38244.53","38244.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","22686.76","22686.76","22686.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24725.53","","","","","","","fee schedule","23604.32","95891.49","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24312.45","","","","","","","fee schedule","23604.32","95891.49","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23604.32","","","","","","","fee schedule","23604.32","95891.49","Transplants-Case Rate"
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24076.41","","","","","","","fee schedule","23604.32","95891.49","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24784.54","","","","","","","fee schedule","23604.32","95891.49","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Mcc","288","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23604.32","","","","","","","fee schedule","23604.32","95891.49","Psych-Case Rate"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39779.3","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42544.48","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55750.77","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46226.27","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39897.08","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50991.93","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38082.65","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","60482.29","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45487.18","","","","","","","fee schedule","15414","60482.29",""
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12667.91","12667.91","12667.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","43183.47","43183.47","43183.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16146.16","","","","","","","fee schedule","15414","60482.29","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15876.42","","","","","","","fee schedule","15414","60482.29","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15414","","","","","","","fee schedule","15414","60482.29","Transplants-Case Rate"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15722.28","","","","","","","fee schedule","15414","60482.29","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16184.7","","","","","","","fee schedule","15414","60482.29","MSDRG Base Rate"
"Acute And Subacute Endocarditis With Cc","289","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15414","","","","","","","fee schedule","15414","60482.29","Psych-Case Rate"
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21666.66","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23172.77","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30365.86","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25178.14","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21730.81","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27773.86","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20742.54","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32942.99","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24775.58","","","","","","","fee schedule","9044.02","32942.99",""
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9473.61","","","","","","","fee schedule","9044.02","32942.99","MSDRG Base Rate"
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9315.34","","","","","","","fee schedule","9044.02","32942.99","MSDRG Base Rate"
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9044.02","","","","","","","fee schedule","9044.02","32942.99","Transplants-Case Rate"
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9224.9","","","","","","","fee schedule","9044.02","32942.99","MSDRG Base Rate"
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9496.22","","","","","","","fee schedule","9044.02","32942.99","MSDRG Base Rate"
"Acute And Subacute Endocarditis Without Cc/Mcc","290","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9044.02","","","","","","","fee schedule","9044.02","32942.99","Psych-Case Rate"
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29918.96","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31998.72","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","41931.48","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","34767.87","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30007.54","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38352.24","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28642.86","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45490.17","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34211.99","","","","","","","fee schedule","11946.25","45490.17",""
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","27513.13","27513.13","27513.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29155.76","21086.32","29155.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","29547.68","20645.33","31183.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36648.36","20851.56","40865.03","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10998.85","10018.85","12293.38","68","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","29111.39","23272.35","29111.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10209.32","2083.54","12106.83","100","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26822","25768.36","28649","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10846.35","9401.42","11677.17","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","30014.21","30014.21","32213.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10456.29","9243.36","11980.19","75","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","33407.45","33407.45","34771.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","116189.99","116189.99","116189.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12513.7","","","","","","","fee schedule","11946.25","45490.17","MSDRG Base Rate"
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12304.64","","","","","","","fee schedule","11946.25","45490.17","MSDRG Base Rate"
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11946.25","","","","","","","fee schedule","11946.25","45490.17","Transplants-Case Rate"
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12185.18","","","","","","","fee schedule","11946.25","45490.17","MSDRG Base Rate"
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12543.56","","","","","","","fee schedule","11946.25","45490.17","MSDRG Base Rate"
"Heart Failure And Shock With Mcc","291","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11946.25","","","","","","","fee schedule","11946.25","45490.17","Psych-Case Rate"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19785.95","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21161.33","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27730.04","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22992.62","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19844.53","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25363.03","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18942.04","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30083.47","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22625","","","","","","","fee schedule","8382.6","30083.47",""
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","26971.92","26971.92","26971.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6371.42","6371.42","6371.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17.37","17.37","17.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14230.09","14230.09","14230.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","9451.59","9451.59","9451.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7908.78","7908.78","7908.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8780.77","","","","","","","fee schedule","8382.6","30083.47","MSDRG Base Rate"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8634.08","","","","","","","fee schedule","8382.6","30083.47","MSDRG Base Rate"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8382.6","","","","","","","fee schedule","8382.6","30083.47","Transplants-Case Rate"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8550.25","","","","","","","fee schedule","8382.6","30083.47","MSDRG Base Rate"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8801.73","","","","","","","fee schedule","8382.6","30083.47","MSDRG Base Rate"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8382.6","","","","","","","fee schedule","8382.6","30083.47","Psych-Case Rate"
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","13190.63","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","14107.55","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","18486.69","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","15328.41","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","13229.68","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","16908.68","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","12628.03","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","20055.64","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","15083.33","","","","","","","fee schedule","6063.12","20055.64",""
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6351.12","","","","","","","fee schedule","6063.12","20055.64","MSDRG Base Rate"
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6245.01","","","","","","","fee schedule","6063.12","20055.64","MSDRG Base Rate"
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6063.12","","","","","","","fee schedule","6063.12","20055.64","Transplants-Case Rate"
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6184.38","","","","","","","fee schedule","6063.12","20055.64","MSDRG Base Rate"
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6366.28","","","","","","","fee schedule","6063.12","20055.64","MSDRG Base Rate"
"Heart Failure And Shock Without Cc/Mcc","293","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6063.12","","","","","","","fee schedule","6063.12","20055.64","Psych-Case Rate"
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36682.28","","","","","","","fee schedule","32722.31","36682.28",""
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32722.31","","","","","","","fee schedule","32722.31","36682.28",""
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis With Cc/Mcc","294","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23594.49","","","","","","","fee schedule","21047.38","23594.49",""
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21047.38","","","","","","","fee schedule","21047.38","23594.49",""
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Deep Vein Thrombophlebitis Without Cc/Mcc","295","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36400.08","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38930.36","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51014.78","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42299.38","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36507.85","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46660.2","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34847.55","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55344.36","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41623.07","","","","","","","fee schedule","14225.57","55344.36",""
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12129.25","12129.25","12129.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13540.03","13540.03","13540.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14901.28","","","","","","","fee schedule","14225.57","55344.36","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14652.34","","","","","","","fee schedule","14225.57","55344.36","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14225.57","","","","","","","fee schedule","14225.57","55344.36","Transplants-Case Rate"
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14510.08","","","","","","","fee schedule","14225.57","55344.36","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14936.85","","","","","","","fee schedule","14225.57","55344.36","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Mcc","296","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14225.57","","","","","","","fee schedule","14225.57","55344.36","Psych-Case Rate"
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14775.37","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15802.45","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20707.71","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17169.99","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14819.12","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18940.12","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14145.17","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22465.16","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16895.47","","","","","","","fee schedule","6620.45","22465.16",""
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2424.31","2424.31","2424.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6934.92","","","","","","","fee schedule","6620.45","22465.16","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6819.06","","","","","","","fee schedule","6620.45","22465.16","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6620.45","","","","","","","fee schedule","6620.45","22465.16","Transplants-Case Rate"
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6752.86","","","","","","","fee schedule","6620.45","22465.16","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6951.47","","","","","","","fee schedule","6620.45","22465.16","MSDRG Base Rate"
"Cardiac Arrest, Unexplained With Cc","297","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6620.45","","","","","","","fee schedule","6620.45","22465.16","Psych-Case Rate"
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","10606.11","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","11343.37","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","14864.48","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","12325.02","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","10637.51","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","13595.66","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","10153.74","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","16126.01","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","12127.96","","","","","","","fee schedule","5154.18","16126.01",""
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5399","","","","","","","fee schedule","5154.18","16126.01","MSDRG Base Rate"
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","5308.81","","","","","","","fee schedule","5154.18","16126.01","MSDRG Base Rate"
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","5154.18","","","","","","","fee schedule","5154.18","16126.01","Transplants-Case Rate"
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5257.26","","","","","","","fee schedule","5154.18","16126.01","MSDRG Base Rate"
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5411.89","","","","","","","fee schedule","5154.18","16126.01","MSDRG Base Rate"
"Cardiac Arrest, Unexplained Without Cc/Mcc","298","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5154.18","","","","","","","fee schedule","5154.18","16126.01","Psych-Case Rate"
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38050.07","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40695.05","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53327.25","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44216.78","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38162.73","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48775.28","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36427.17","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57853.09","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43509.82","","","","","","","fee schedule","14805.85","57853.09",""
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48839.53","43299.94","50661.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13447.88","12914.55","25303.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12351.8","10463.86","14611.08","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11854.91","11854.91","13064.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35461.15","35461.15","35461.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","31591.25","31591.25","31591.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13045.07","12519.71","14557.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","40357.42","40357.42","40357.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15509.13","","","","","","","fee schedule","14805.85","57853.09","MSDRG Base Rate"
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15250.03","","","","","","","fee schedule","14805.85","57853.09","MSDRG Base Rate"
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14805.85","","","","","","","fee schedule","14805.85","57853.09","Transplants-Case Rate"
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15101.97","","","","","","","fee schedule","14805.85","57853.09","MSDRG Base Rate"
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15546.14","","","","","","","fee schedule","14805.85","57853.09","MSDRG Base Rate"
"Peripheral Vascular Disorders With Mcc","299","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14805.85","","","","","","","fee schedule","14805.85","57853.09","Psych-Case Rate"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24878.09","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26607.44","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34866.69","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28910.04","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24951.75","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31890.5","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23816.99","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37825.8","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28447.81","","","","","","","fee schedule","10173.44","37825.8",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","31780.12","29394.41","33433.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8776.44","8386.2","10015.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","23886.16","23886.16","23886.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8312.46","1464.3","8703.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8951.7","8951.7","9789.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","23402.28","23402.28","23402.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8666.73","8401.02","9603.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","27766.01","27766.01","27766.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","15305.18","15305.18","15305.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10656.68","","","","","","","fee schedule","10173.44","37825.8","MSDRG Base Rate"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10478.64","","","","","","","fee schedule","10173.44","37825.8","MSDRG Base Rate"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10173.44","","","","","","","fee schedule","10173.44","37825.8","Transplants-Case Rate"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10376.91","","","","","","","fee schedule","10173.44","37825.8","MSDRG Base Rate"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10682.11","","","","","","","fee schedule","10173.44","37825.8","MSDRG Base Rate"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10173.44","","","","","","","fee schedule","10173.44","37825.8","Psych-Case Rate"
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16772.61","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17938.52","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23506.84","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19490.92","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16822.27","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21500.32","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16057.23","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25501.85","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19179.29","","","","","","","fee schedule","7322.85","25501.85",""
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","28924.91","28924.91","28924.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22342.97","22342.97","22342.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17200.11","17200.11","17200.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6555.15","6555.15","6555.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6201.41","6201.41","6201.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","13783.7","13783.7","13783.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5710.37","5710.37","5710.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7670.69","","","","","","","fee schedule","7322.85","25501.85","MSDRG Base Rate"
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7542.54","","","","","","","fee schedule","7322.85","25501.85","MSDRG Base Rate"
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7322.85","","","","","","","fee schedule","7322.85","25501.85","Transplants-Case Rate"
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7469.31","","","","","","","fee schedule","7322.85","25501.85","MSDRG Base Rate"
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7688.99","","","","","","","fee schedule","7322.85","25501.85","MSDRG Base Rate"
"Peripheral Vascular Disorders Without Cc/Mcc","301","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7322.85","","","","","","","fee schedule","7322.85","25501.85","Psych-Case Rate"
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27886.76","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29825.26","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39083.35","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32406.32","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27969.33","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35747.23","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26697.34","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42400.32","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31888.19","","","","","","","fee schedule","11231.55","42400.32",""
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","37476.32","36433.39","62648.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2154.98","2154.98","2154.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10540.29","10540.29","10540.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","10263.42","10263.42","10263.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11081.2","11081.2","11081.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11765.05","","","","","","","fee schedule","11231.55","42400.32","MSDRG Base Rate"
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11568.5","","","","","","","fee schedule","11231.55","42400.32","MSDRG Base Rate"
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11231.55","","","","","","","fee schedule","11231.55","42400.32","Transplants-Case Rate"
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11456.18","","","","","","","fee schedule","11231.55","42400.32","MSDRG Base Rate"
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11793.13","","","","","","","fee schedule","11231.55","42400.32","MSDRG Base Rate"
"Atherosclerosis With Mcc","302","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11231.55","","","","","","","fee schedule","11231.55","42400.32","Psych-Case Rate"
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15688.93","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16779.51","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21988.06","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18231.6","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15735.38","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20111.18","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15019.77","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23854.17","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17940.11","","","","","","","fee schedule","6941.74","23854.17",""
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","16172.55","16172.55","16172.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","13397.31","13397.31","13397.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17859.95","17859.95","20708.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7141.74","7141.74","7141.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","4315.99","1471.29","5967.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6033.82","6033.82","6033.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14163","14163","14163","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","14151.17","14151.17","14151.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","578.9","578.9","578.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7271.47","","","","","","","fee schedule","6941.74","23854.17","MSDRG Base Rate"
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7149.99","","","","","","","fee schedule","6941.74","23854.17","MSDRG Base Rate"
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6941.74","","","","","","","fee schedule","6941.74","23854.17","Transplants-Case Rate"
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7080.57","","","","","","","fee schedule","6941.74","23854.17","MSDRG Base Rate"
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7288.83","","","","","","","fee schedule","6941.74","23854.17","MSDRG Base Rate"
"Atherosclerosis Without Mcc","303","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6941.74","","","","","","","fee schedule","6941.74","23854.17","Psych-Case Rate"
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27732.95","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29660.75","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38867.78","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32227.58","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27815.06","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35550.06","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26550.09","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42166.46","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31712.31","","","","","","","fee schedule","11177.46","42166.46",""
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","30479.66","30479.66","112254.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25614.54","25614.54","25614.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50828.86","50828.86","50828.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10650.86","9450.46","10885.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10727.01","10727.01","10727.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10668.86","10668.86","10668.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","39948.9","30479.66","52883.87","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","25747.09","25747.09","25747.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9890.35","9890.35","9890.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","33123.77","33123.77","33123.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","31307.25","31307.25","31307.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","21022.66","21022.66","21022.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11708.39","","","","","","","fee schedule","11177.46","42166.46","MSDRG Base Rate"
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11512.78","","","","","","","fee schedule","11177.46","42166.46","MSDRG Base Rate"
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11177.46","","","","","","","fee schedule","11177.46","42166.46","Transplants-Case Rate"
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11401.01","","","","","","","fee schedule","11177.46","42166.46","MSDRG Base Rate"
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11736.33","","","","","","","fee schedule","11177.46","42166.46","MSDRG Base Rate"
"Hypertension With Mcc","304","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11177.46","","","","","","","fee schedule","11177.46","42166.46","Psych-Case Rate"
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17597.61","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18820.87","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24663.08","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20449.62","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17649.71","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22557.86","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16847.04","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26756.21","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20122.66","","","","","","","fee schedule","7612.99","26756.21",""
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8870.8","8870.8","8870.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","24079.21","16011.62","54062.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","12584.11","12584.11","12584.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17440.98","17440.98","18046.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22461.17","22461.17","22461.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6624.15","6624.15","7815.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","11558.04","11558.04","11558.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","4949.24","2760.92","7285.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16011.62","15289.47","22993.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6523.5","6523.5","6523.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","23860.87","15866.43","56102.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7974.61","","","","","","","fee schedule","7612.99","26756.21","MSDRG Base Rate"
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7841.38","","","","","","","fee schedule","7612.99","26756.21","MSDRG Base Rate"
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7612.99","","","","","","","fee schedule","7612.99","26756.21","Transplants-Case Rate"
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7765.25","","","","","","","fee schedule","7612.99","26756.21","MSDRG Base Rate"
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7993.64","","","","","","","fee schedule","7612.99","26756.21","MSDRG Base Rate"
"Hypertension Without Mcc","305","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7612.99","","","","","","","fee schedule","7612.99","26756.21","Psych-Case Rate"
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36724.02","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39276.82","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51468.78","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42675.82","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36832.75","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47075.45","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35157.67","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55836.9","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41993.49","","","","","","","fee schedule","14339.5","55836.9",""
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45147.07","45147.07","45147.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13537.98","13537.98","13537.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10987.23","10987.23","10987.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","43227.56","43227.56","43227.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13224.66","13224.66","13224.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13567.22","13567.22","13567.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15020.63","","","","","","","fee schedule","14339.5","55836.9","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14769.68","","","","","","","fee schedule","14339.5","55836.9","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14339.5","","","","","","","fee schedule","14339.5","55836.9","Transplants-Case Rate"
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14626.29","","","","","","","fee schedule","14339.5","55836.9","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15056.48","","","","","","","fee schedule","14339.5","55836.9","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders With Mcc","306","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14339.5","","","","","","","fee schedule","14339.5","55836.9","Psych-Case Rate"
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21282.13","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22761.51","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29826.94","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24731.28","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21345.14","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27280.94","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20374.41","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32358.33","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24335.87","","","","","","","fee schedule","8908.79","32358.33",""
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8467.63","8467.63","8467.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8462.06","8444.1","8970","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9331.96","","","","","","","fee schedule","8908.79","32358.33","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9176.05","","","","","","","fee schedule","8908.79","32358.33","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8908.79","","","","","","","fee schedule","8908.79","32358.33","Transplants-Case Rate"
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9086.97","","","","","","","fee schedule","8908.79","32358.33","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9354.23","","","","","","","fee schedule","8908.79","32358.33","MSDRG Base Rate"
"Cardiac Congenital And Valvular Disorders Without Mcc","307","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8908.79","","","","","","","fee schedule","8908.79","32358.33","Psych-Case Rate"
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28059.22","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30009.7","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39325.05","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32606.73","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28142.3","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35968.3","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26862.44","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42662.54","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32085.4","","","","","","","fee schedule","11292.2","42662.54",""
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","23706.06","23706.06","23706.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17429.08","14718.24","49697.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","25661.55","25661.55","25661.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20496.95","19850.89","28774.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19985.56","11142.44","21332.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10464.98","9072.57","11620.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9408.31","8626.27","10979.09","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9465.45","9233.46","9471.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17429.08","14718.24","31834.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","25469.3","23170.1","26478","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","29547","29547","29547","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10546.83","9870.24","11196.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","18086.78","18086.78","18086.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5715.52","5715.52","5715.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11828.58","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11630.97","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11292.2","","","","","","","fee schedule","11292.2","42662.54","Transplants-Case Rate"
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11518.04","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11856.81","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Mcc","308","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11292.2","","","","","","","fee schedule","11292.2","42662.54","Psych-Case Rate"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17145.49","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18337.32","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24029.43","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19924.23","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17196.25","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21978.3","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16414.2","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26068.79","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19605.67","","","","","","","fee schedule","7453.99","26068.79",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","8420.7","8420.7","22811.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","51553.42","51553.42","53988.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","13579.8","13579.8","13579.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","14837.3","14134.82","17668.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21918.52","16336.53","22691.39","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6667.61","6155.17","6917.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","16144.52","16144.52","16144.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","4847.09","773.73","6020.15","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6428.01","5827.51","7484.67","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","35782.8","35782.8","35782.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15731","13283.33","16231","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","23698","23698","23698","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","14888.15","14888.15","14888.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6748.82","5727.31","7355.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19173.75","19173.75","19173.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","35458.34","35458.34","66169.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","21341.9","21341.9","21341.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","16741.72","16741.72","16741.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7808.05","","","","","","","fee schedule","7453.99","26068.79","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7677.61","","","","","","","fee schedule","7453.99","26068.79","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7453.99","","","","","","","fee schedule","7453.99","26068.79","Transplants-Case Rate"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7603.07","","","","","","","fee schedule","7453.99","26068.79","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7826.69","","","","","","","fee schedule","7453.99","26068.79","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7453.99","","","","","","","fee schedule","7453.99","26068.79","Psych-Case Rate"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","13192.96","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","14110.04","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","18489.96","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","15331.12","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","13232.02","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","16911.67","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","12630.26","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","20059.19","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","15086","","","","","","","fee schedule","6063.94","20059.19",""
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","12555.28","12555.28","12555.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17738.44","17738.44","17738.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","10697.19","10620.81","13071.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","15329.63","13027.56","17522.98","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6569.61","6569.61","6569.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","12483","12483","12483","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1156.55","1156.55","1248.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5012.8","4841.52","5218.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17738.44","17738.44","17738.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","10527.13","10527.13","10527.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5245.78","5067.93","5977.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","55446.75","55446.75","55446.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6351.98","","","","","","","fee schedule","6063.94","20059.19","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6245.86","","","","","","","fee schedule","6063.94","20059.19","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6063.94","","","","","","","fee schedule","6063.94","20059.19","Transplants-Case Rate"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6185.22","","","","","","","fee schedule","6063.94","20059.19","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6367.14","","","","","","","fee schedule","6063.94","20059.19","MSDRG Base Rate"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","310","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6063.94","","","","","","","fee schedule","6063.94","20059.19","Psych-Case Rate"
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16357.78","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17494.86","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22925.46","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19008.86","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16406.21","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20968.56","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15660.09","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24871.12","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18704.93","","","","","","","fee schedule","7176.96","24871.12",""
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","805.49","805.49","805.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7517.87","","","","","","","fee schedule","7176.96","24871.12","MSDRG Base Rate"
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7392.27","","","","","","","fee schedule","7176.96","24871.12","MSDRG Base Rate"
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7176.96","","","","","","","fee schedule","7176.96","24871.12","Transplants-Case Rate"
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7320.5","","","","","","","fee schedule","7176.96","24871.12","MSDRG Base Rate"
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7535.81","","","","","","","fee schedule","7176.96","24871.12","MSDRG Base Rate"
"Angina Pectoris","311","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7176.96","","","","","","","fee schedule","7176.96","24871.12","Psych-Case Rate"
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20312.64","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21724.63","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28468.2","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23604.67","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20372.78","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26038.18","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19446.27","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30884.27","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23227.27","","","","","","","fee schedule","8567.83","30884.27",""
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23875.34","23875.34","27288.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7365.29","6067.37","8389.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6307.24","2046.62","7252.87","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17410","15023.5","19044.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6841.79","6536.8","12935.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6864.1","6123.09","8450.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","40866.89","40866.89","40866.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8974.8","","","","","","","fee schedule","8567.83","30884.27","MSDRG Base Rate"
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8824.86","","","","","","","fee schedule","8567.83","30884.27","MSDRG Base Rate"
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8567.83","","","","","","","fee schedule","8567.83","30884.27","Transplants-Case Rate"
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8739.19","","","","","","","fee schedule","8567.83","30884.27","MSDRG Base Rate"
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8996.22","","","","","","","fee schedule","8567.83","30884.27","MSDRG Base Rate"
"Syncope And Collapse","312","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8567.83","","","","","","","fee schedule","8567.83","30884.27","Psych-Case Rate"
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16779.6","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17946","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23516.64","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19499.04","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16829.28","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21509.28","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16063.92","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25512.48","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19187.28","","","","","","","fee schedule","7325.31","25512.48",""
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","12746.52","12746.52","12746.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","24305.08","20737.06","32832.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","15120.12","15120.12","15120.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","16236.27","14492.12","17049.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19896.98","18485.2","21992.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7083.16","6253.76","7095.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","15916.67","15916.67","15916.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2759.53","1679.95","5810.39","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6382.61","5712.85","7076.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20737.06","15958.55","32832.42","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15161","15161","15161","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","18404","18404","18404","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5470.52","614.2","5916.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","16874.75","16874.75","16874.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","32534.71","16560.76","59870.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8264.87","8264.87","8264.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","13513.53","13513.53","13513.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7673.26","","","","","","","fee schedule","7325.31","25512.48","MSDRG Base Rate"
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7545.07","","","","","","","fee schedule","7325.31","25512.48","MSDRG Base Rate"
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7325.31","","","","","","","fee schedule","7325.31","25512.48","Transplants-Case Rate"
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7471.82","","","","","","","fee schedule","7325.31","25512.48","MSDRG Base Rate"
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7691.58","","","","","","","fee schedule","7325.31","25512.48","MSDRG Base Rate"
"Chest Pain","313","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7325.31","","","","","","","fee schedule","7325.31","25512.48","Psych-Case Rate"
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48595.59","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51973.61","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68106.8","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56471.39","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48739.46","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62293.26","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46522.9","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73886.98","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55568.49","","","","","","","fee schedule","18514.57","73886.98",""
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","30982.02","18689.26","195597.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","48119.96","48119.96","48119.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","47275.03","47275.03","65306.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","67445.47","65695.47","74926.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7225.34","7225.34","7225.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18373.17","16610.1","22566.45","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16420.91","4884.99","18647.37","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","15906.75","15906.75","15906.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17136.83","16392.88","18484.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","18689.26","15411.9","33091.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","47278","47278","47278","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","55560","55560","55560","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18133.75","17119.42","94351.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","55851.02","55851.02","55851.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3805.28","3805.28","3805.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7790.81","7790.81","7790.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19394.01","","","","","","","fee schedule","18514.57","73886.98","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19070.01","","","","","","","fee schedule","18514.57","73886.98","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18514.57","","","","","","","fee schedule","18514.57","73886.98","Transplants-Case Rate"
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18884.86","","","","","","","fee schedule","18514.57","73886.98","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19440.3","","","","","","","fee schedule","18514.57","73886.98","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Mcc","314","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18514.57","","","","","","","fee schedule","18514.57","73886.98","Psych-Case Rate"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22449.71","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24010.25","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31463.3","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26088.09","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22516.17","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28777.62","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21492.19","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34133.57","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25670.98","","","","","","","fee schedule","9319.41","34133.57",""
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","62539.77","62539.77","99659.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","33466.78","17846.35","33466.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18398.41","18398.41","18398.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25913.15","13889.41","30138.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4087.58","4087.58","4087.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9126.72","9126.72","9138.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","36161.8","36161.8","36161.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8608.34","8608.34","8999.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8650.54","8650.54","9080.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","33466.78","13370.14","35047.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21127","20627","21149","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8663.38","7634.12","9610.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19856.86","19856.86","19856.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","17832.39","17832.39","17832.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24957.25","24957.25","24957.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9762.08","","","","","","","fee schedule","9319.41","34133.57","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9598.99","","","","","","","fee schedule","9319.41","34133.57","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9319.41","","","","","","","fee schedule","9319.41","34133.57","Transplants-Case Rate"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9505.8","","","","","","","fee schedule","9319.41","34133.57","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9785.38","","","","","","","fee schedule","9319.41","34133.57","MSDRG Base Rate"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9319.41","","","","","","","fee schedule","9319.41","34133.57","Psych-Case Rate"
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15896.34","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17001.34","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22278.75","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18472.63","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15943.41","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20377.06","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15218.33","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24169.53","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18177.28","","","","","","","fee schedule","7014.68","24169.53",""
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4685.74","4685.74","4685.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12559.93","12559.93","12559.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17591.67","17591.67","17591.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18400.97","18400.97","18400.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","34722.91","34722.91","34722.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","23043","23043","23043","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13649.5","13649.5","13649.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7347.88","","","","","","","fee schedule","7014.68","24169.53","MSDRG Base Rate"
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7225.12","","","","","","","fee schedule","7014.68","24169.53","MSDRG Base Rate"
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7014.68","","","","","","","fee schedule","7014.68","24169.53","Transplants-Case Rate"
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7154.97","","","","","","","fee schedule","7014.68","24169.53","MSDRG Base Rate"
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7365.41","","","","","","","fee schedule","7014.68","24169.53","MSDRG Base Rate"
"Other Circulatory System Diagnoses Without Cc/Mcc","316","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7014.68","","","","","","","fee schedule","7014.68","24169.53","Psych-Case Rate"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","155828.88","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","166661.01","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","218394.46","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","181083.79","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","156290.25","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","199752.5","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","149182.5","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","236929.44","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","178188.54","","","","","","","fee schedule","56227.08","236929.44",""
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15826.17","15826.17","15826.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","49901.62","49901.62","55517.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","49972.23","49901.62","55517.63","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","50070.87","49972","56510.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","132123.07","132123.07","132123.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14563.55","14563.55","14563.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","142869.87","142869.87","142869.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","50070.87","49972","55517.63","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","141816.24","141816.24","141816.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","29263.17","29263.17","79424.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","79925.11","79925.11","79925.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58897.87","","","","","","","fee schedule","56227.08","236929.44","MSDRG Base Rate"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","57913.89","","","","","","","fee schedule","56227.08","236929.44","MSDRG Base Rate"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","56227.08","","","","","","","fee schedule","56227.08","236929.44","Transplants-Case Rate"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57351.62","","","","","","","fee schedule","56227.08","236929.44","MSDRG Base Rate"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59038.43","","","","","","","fee schedule","56227.08","236929.44","MSDRG Base Rate"
"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","317","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56227.08","","","","","","","fee schedule","56227.08","236929.44","Psych-Case Rate"
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","56449.37","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","60373.34","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","79113.9","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","65598.02","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","56616.5","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","72360.8","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54041.7","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","85828.23","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","64549.21","","","","","","","fee schedule","21276.64","85828.23",""
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","21965.57","21965.57","21965.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22287.28","","","","","","","fee schedule","21276.64","85828.23","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21914.94","","","","","","","fee schedule","21276.64","85828.23","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21276.64","","","","","","","fee schedule","21276.64","85828.23","Transplants-Case Rate"
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21702.17","","","","","","","fee schedule","21276.64","85828.23","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22340.47","","","","","","","fee schedule","21276.64","85828.23","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy Without Intraluminal Device","318","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21276.64","","","","","","","fee schedule","21276.64","85828.23","Psych-Case Rate"
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","104007.88","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","111237.78","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","145767.24","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","120864.26","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","104315.82","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","133324.67","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","99571.76","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","158138.4","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","118931.82","","","","","","","fee schedule","38002.33","158138.4",""
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","137578.1","137578.1","137578.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","36131.39","35823.31","96432.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","36318.82","35593.51","36965.29","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","37519.34","37519.34","37519.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","96437","96437","96437","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","34206.09","34206.09","34206.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39807.44","","","","","","","fee schedule","38002.33","158138.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39142.4","","","","","","","fee schedule","38002.33","158138.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38002.33","","","","","","","fee schedule","38002.33","158138.4","Transplants-Case Rate"
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38762.38","","","","","","","fee schedule","38002.33","158138.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39902.45","","","","","","","fee schedule","38002.33","158138.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures With Mcc","319","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38002.33","","","","","","","fee schedule","38002.33","158138.4","Psych-Case Rate"
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","56055.52","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","59952.1","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","78561.91","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","65140.33","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","56221.48","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","71855.93","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","53664.65","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","85229.4","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","64098.84","","","","","","","fee schedule","21138.13","85229.4",""
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17913.98","17913.98","17913.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19081.15","13137.92","20864.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17913.98","17913.98","18760.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","19134.83","19134.83","19134.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","19468.02","19468.02","19468.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22142.19","","","","","","","fee schedule","21138.13","85229.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21772.27","","","","","","","fee schedule","21138.13","85229.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21138.13","","","","","","","fee schedule","21138.13","85229.4","Transplants-Case Rate"
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21560.89","","","","","","","fee schedule","21138.13","85229.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22195.04","","","","","","","fee schedule","21138.13","85229.4","MSDRG Base Rate"
"Other Endovascular Cardiac Valve Procedures Without Mcc","320","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21138.13","","","","","","","fee schedule","21138.13","85229.4","Psych-Case Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","63408.24","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","67815.94","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","88866.77","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","73684.71","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","63595.98","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","81281.18","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","60703.77","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","96408.83","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","72506.6","","","","","","","fee schedule","23723.98","96408.83",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","160642.68","160642.68","160642.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7067.43","7067.43","8137.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","24216.25","21896.78","38668.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","57378.7","57378.7","57378.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","66530.43","66530.43","66530.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","85212.74","80769.06","89158.93","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","8385.3","8385.3","8385.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24281.66","22942.76","24633.26","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","71085.49","71085.49","71085.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","22307.57","2573.56","24049.31","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","23213","22491.51","24017.86","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","23824.88","21896.78","25360.02","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","61325.52","58514","62499","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","69744","69744","73448","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","23627.38","22662.72","27596.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","72506.6","71772.99","165331.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","25891.68","25891.68","26317.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6614.74","6614.74","6614.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24850.87","","","","","","","fee schedule","23723.98","96408.83","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24435.7","","","","","","","fee schedule","23723.98","96408.83","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23723.98","","","","","","","fee schedule","23723.98","96408.83","Transplants-Case Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24198.46","","","","","","","fee schedule","23723.98","96408.83","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24910.18","","","","","","","fee schedule","23723.98","96408.83","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","321","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23723.98","","","","","","","fee schedule","23723.98","96408.83","Psych-Case Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41086.72","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43942.78","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57583.11","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47745.57","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41208.36","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52667.86","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39334.29","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62470.14","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46982.19","","","","","","","fee schedule","15873.8","62470.14",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","67545.24","62539.92","110174.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","16816.27","14610.33","40494.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","40426.57","40426.57","40426.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","41175.58","38960.48","43238.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","54791.32","53662.33","56662.33","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15327.52","14940.42","15904.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","38019.96","36903.39","69817.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14916.26","1662.59","15840.07","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39219","36349","39719","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14372.39","14077.41","15440.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15300.4","15300.4","17337.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","57991","57991","57991","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","43091.87","43032.11","46672","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15197.21","13923.21","16114.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","46921.6","44421.6","46982.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","23796.32","23796.32","23796.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5138.7","5138.7","5138.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","46982.19","46982.19","46982.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16627.81","","","","","","","fee schedule","15873.8","62470.14","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16350.01","","","","","","","fee schedule","15873.8","62470.14","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15873.8","","","","","","","fee schedule","15873.8","62470.14","Transplants-Case Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16191.28","","","","","","","fee schedule","15873.8","62470.14","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16667.49","","","","","","","fee schedule","15873.8","62470.14","MSDRG Base Rate"
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","322","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15873.8","","","","","","","fee schedule","15873.8","62470.14","Psych-Case Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","100850.06","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","107860.45","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","141341.54","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","117194.65","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","101148.65","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","129276.75","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","96548.62","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","153337.09","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","115320.88","","","","","","","fee schedule","36891.77","153337.09",""
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","34750.25","34750.25","34750.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","96939.68","96939.68","96939.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","110691.84","110691.84","110691.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","36248.18","34168.82","36379.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","77188.32","77188.32","77188.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","35455.41","33748.76","47425.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","35392.83","35392.83","35392.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","34750.25","34750.25","34750.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","93261","93261","93261","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","107917.14","107917.14","107917.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","34770.76","34770.76","35855.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","28716.67","28716.67","28716.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38644.13","","","","","","","fee schedule","36891.77","153337.09","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37998.52","","","","","","","fee schedule","36891.77","153337.09","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36891.77","","","","","","","fee schedule","36891.77","153337.09","Transplants-Case Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37629.61","","","","","","","fee schedule","36891.77","153337.09","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38736.36","","","","","","","fee schedule","36891.77","153337.09","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","323","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36891.77","","","","","","","fee schedule","36891.77","153337.09","Psych-Case Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","73434.06","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","78538.68","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","102917.96","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","85335.38","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","73651.47","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","94132.97","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","70301.96","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","111652.53","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","83971","","","","","","","fee schedule","27249.92","111652.53",""
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22127.61","22127.61","22127.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","95290.66","95290.66","95290.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25821.29","25821.29","26625.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","70774.23","70774.23","70774.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24737.55","24718.73","26433.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","26577.93","26577.93","26577.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","27291.24","27291.24","27291.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","18867.71","18867.71","18867.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28544.29","","","","","","","fee schedule","27249.92","111652.53","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28067.42","","","","","","","fee schedule","27249.92","111652.53","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27249.92","","","","","","","fee schedule","27249.92","111652.53","Transplants-Case Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27794.92","","","","","","","fee schedule","27249.92","111652.53","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28612.42","","","","","","","fee schedule","27249.92","111652.53","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","324","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27249.92","","","","","","","fee schedule","27249.92","111652.53","Psych-Case Rate"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","74818.37","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80019.22","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","104858.08","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","86944.05","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75039.89","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","95907.49","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","71627.23","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","113757.31","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","85553.95","","","","","","","fee schedule","27736.77","113757.31",""
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24386.58","24386.58","24386.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","32658.12","32658.12","32658.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","63958.3","63958.3","63958.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29054.27","","","","","","","fee schedule","27736.77","113757.31","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28568.87","","","","","","","fee schedule","27736.77","113757.31","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27736.77","","","","","","","fee schedule","27736.77","113757.31","Transplants-Case Rate"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28291.51","","","","","","","fee schedule","27736.77","113757.31","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29123.61","","","","","","","fee schedule","27736.77","113757.31","MSDRG Base Rate"
"Coronary Intravascular Lithotripsy Without Intraluminal Device","325","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27736.77","","","","","","","fee schedule","27736.77","113757.31","Psych-Case Rate"
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","116231.36","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","124310.95","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","162898.46","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","135068.77","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","116575.49","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","148993.59","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","111273.88","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","176723.53","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","132909.22","","","","","","","fee schedule","42301.16","176723.53",""
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","80267.09","80267.09","80267.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","39034.2","39034.2","39034.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","42987.22","41456.69","89758.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","668879.91","668879.91","668879.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","40540.24","39995.98","95520.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","139530.92","139530.92","139530.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","42512.49","42512.49","42512.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","126861.24","126861.24","126861.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","41364.38","41364.38","41364.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","44310.47","","","","","","","fee schedule","42301.16","176723.53","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","43570.19","","","","","","","fee schedule","42301.16","176723.53","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","42301.16","","","","","","","fee schedule","42301.16","176723.53","Transplants-Case Rate"
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","43147.18","","","","","","","fee schedule","42301.16","176723.53","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44416.22","","","","","","","fee schedule","42301.16","176723.53","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Mcc","326","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42301.16","","","","","","","fee schedule","42301.16","176723.53","Psych-Case Rate"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","56962.08","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","60921.69","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","79832.46","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","66193.82","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","57130.73","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","73018.03","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54532.55","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","86607.78","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","65135.49","","","","","","","fee schedule","21456.95","86607.78",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","73270.35","57368.29","75695.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","20867.6","20867.6","20867.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","91860.67","91860.67","91860.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19439.42","19033.94","19969.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","52059","52059","52059","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","25052.63","25052.63","25052.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20163.94","20163.94","20163.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","59488","59488","59488","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","19683.22","19683.22","21166.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","81272.77","81272.77","81272.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22476.16","","","","","","","fee schedule","21456.95","86607.78","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22100.66","","","","","","","fee schedule","21456.95","86607.78","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21456.95","","","","","","","fee schedule","21456.95","86607.78","Transplants-Case Rate"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21886.09","","","","","","","fee schedule","21456.95","86607.78","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22529.8","","","","","","","fee schedule","21456.95","86607.78","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21456.95","","","","","","","fee schedule","21456.95","86607.78","Psych-Case Rate"
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37341.6","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39937.33","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52334.32","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43393.49","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37452.16","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47867.11","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35748.92","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56775.9","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42699.69","","","","","","","fee schedule","14556.69","56775.9",""
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","131369.75","131369.75","131369.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","37683.06","37683.06","37683.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12416.32","12416.32","12416.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13449.01","13449.01","13449.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","34983","34983","34983","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13171.04","13171.04","13171.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15248.13","","","","","","","fee schedule","14556.69","56775.9","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14993.39","","","","","","","fee schedule","14556.69","56775.9","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14556.69","","","","","","","fee schedule","14556.69","56775.9","Transplants-Case Rate"
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14847.82","","","","","","","fee schedule","14556.69","56775.9","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15284.52","","","","","","","fee schedule","14556.69","56775.9","MSDRG Base Rate"
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","328","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14556.69","","","","","","","fee schedule","14556.69","56775.9","Psych-Case Rate"
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","107121.43","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","114567.76","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","150130.88","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","124482.41","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","107438.59","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","137315.84","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","102552.51","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","162872.38","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","122492.13","","","","","","","fee schedule","39097.32","162872.38",""
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","94059.34","88735.53","228038.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","82101.38","82101.38","82101.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","37382.75","37339.63","62142.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","36828.9","35996.97","39637.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","36168.05","36168.05","85597.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","24455.93","24455.93","39402.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","100916","100916","100916","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","152902.56","152902.56","152902.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","37341.45","27255.56","38795.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","119090.93","119090.93","119090.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40954.44","","","","","","","fee schedule","39097.32","162872.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40270.24","","","","","","","fee schedule","39097.32","162872.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39097.32","","","","","","","fee schedule","39097.32","162872.38","Transplants-Case Rate"
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39879.27","","","","","","","fee schedule","39097.32","162872.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41052.19","","","","","","","fee schedule","39097.32","162872.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Mcc","329","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39097.32","","","","","","","fee schedule","39097.32","162872.38","Psych-Case Rate"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","55866.75","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","59750.21","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","78297.35","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","64920.97","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","56032.15","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","71613.95","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","53483.93","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","84942.38","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","63882.98","","","","","","","fee schedule","21071.74","84942.38",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","144210.92","144210.92","144210.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","23352.92","23352.92","23352.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","44269.44","44269.44","44269.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","56490.07","56490.07","56490.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","72628.72","50752.1","106540.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6330.96","6330.96","6330.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19191.02","19191.02","19191.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19149.1","17976.04","20362.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18773.83","18773.83","18773.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","37625.11","37625.11","39402.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","51395","47209.12","51895","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","79794","79794","79794","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","57911","57911","57911","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20799.12","20799.12","20799.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","61302.56","61302.56","61302.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22072.65","","","","","","","fee schedule","21071.74","84942.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21703.89","","","","","","","fee schedule","21071.74","84942.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21071.74","","","","","","","fee schedule","21071.74","84942.38","Transplants-Case Rate"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21493.17","","","","","","","fee schedule","21071.74","84942.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22125.33","","","","","","","fee schedule","21071.74","84942.38","MSDRG Base Rate"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21071.74","","","","","","","fee schedule","21071.74","84942.38","Psych-Case Rate"
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39219.98","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41946.28","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54966.88","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45576.3","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39336.1","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50274.95","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37547.18","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59631.88","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44847.6","","","","","","","fee schedule","15217.29","59631.88",""
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","45485.31","45485.31","45485.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","40219.63","40219.63","40219.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","51707.67","51707.67","51707.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","32117.86","32117.86","32117.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13385.01","13385.01","13385.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","1421.41","1421.41","1421.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32436","32436","32436","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14337.53","14337.53","14337.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14057.82","14057.82","15727.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15940.11","","","","","","","fee schedule","15217.29","59631.88","MSDRG Base Rate"
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15673.81","","","","","","","fee schedule","15217.29","59631.88","MSDRG Base Rate"
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15217.29","","","","","","","fee schedule","15217.29","59631.88","Transplants-Case Rate"
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15521.64","","","","","","","fee schedule","15217.29","59631.88","MSDRG Base Rate"
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15978.15","","","","","","","fee schedule","15217.29","59631.88","MSDRG Base Rate"
"Major Small And Large Bowel Procedures Without Cc/Mcc","331","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15217.29","","","","","","","fee schedule","15217.29","59631.88","Psych-Case Rate"
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","84380.41","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","90245.95","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","118259.3","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","98055.8","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","84630.24","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","108164.79","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","80781.44","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","128295.88","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","96488.03","","","","","","","fee schedule","31099.61","128295.88",""
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","76151","76151","76151","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32576.84","","","","","","","fee schedule","31099.61","128295.88","MSDRG Base Rate"
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32032.6","","","","","","","fee schedule","31099.61","128295.88","MSDRG Base Rate"
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31099.61","","","","","","","fee schedule","31099.61","128295.88","Transplants-Case Rate"
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31721.6","","","","","","","fee schedule","31099.61","128295.88","MSDRG Base Rate"
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32654.59","","","","","","","fee schedule","31099.61","128295.88","MSDRG Base Rate"
"Rectal Resection With Mcc","332","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31099.61","","","","","","","fee schedule","31099.61","128295.88","Psych-Case Rate"
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54584.97","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","58379.34","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","76500.94","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","63431.46","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54746.58","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69970.88","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","52256.82","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","82993.51","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","62417.29","","","","","","","fee schedule","20620.95","82993.51",""
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21600.45","","","","","","","fee schedule","20620.95","82993.51","MSDRG Base Rate"
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21239.58","","","","","","","fee schedule","20620.95","82993.51","MSDRG Base Rate"
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20620.95","","","","","","","fee schedule","20620.95","82993.51","Transplants-Case Rate"
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21033.37","","","","","","","fee schedule","20620.95","82993.51","MSDRG Base Rate"
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21652","","","","","","","fee schedule","20620.95","82993.51","MSDRG Base Rate"
"Rectal Resection With Cc","333","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20620.95","","","","","","","fee schedule","20620.95","82993.51","Psych-Case Rate"
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38171.26","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40824.66","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53497.09","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44357.61","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38284.27","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48930.62","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36543.19","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58037.35","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43648.4","","","","","","","fee schedule","14848.47","58037.35",""
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15553.77","","","","","","","fee schedule","14848.47","58037.35","MSDRG Base Rate"
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15293.92","","","","","","","fee schedule","14848.47","58037.35","MSDRG Base Rate"
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14848.47","","","","","","","fee schedule","14848.47","58037.35","Transplants-Case Rate"
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15145.44","","","","","","","fee schedule","14848.47","58037.35","MSDRG Base Rate"
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15590.89","","","","","","","fee schedule","14848.47","58037.35","MSDRG Base Rate"
"Rectal Resection Without Cc/Mcc","334","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14848.47","","","","","","","fee schedule","14848.47","58037.35","Psych-Case Rate"
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","83219.82","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","89004.68","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","116632.74","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","96707.11","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83466.22","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","106677.07","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79670.35","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126531.27","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","95160.91","","","","","","","fee schedule","30691.45","126531.27",""
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","106840.06","106840.06","106840.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","24947.2","24947.2","24947.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","120546","120546","120546","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32149.29","","","","","","","fee schedule","30691.45","126531.27","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31612.19","","","","","","","fee schedule","30691.45","126531.27","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30691.45","","","","","","","fee schedule","30691.45","126531.27","Transplants-Case Rate"
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31305.28","","","","","","","fee schedule","30691.45","126531.27","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32226.02","","","","","","","fee schedule","30691.45","126531.27","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Mcc","335","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30691.45","","","","","","","fee schedule","30691.45","126531.27","Psych-Case Rate"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49143.25","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52559.35","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68874.36","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57107.81","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49288.75","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62995.3","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47047.21","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","74719.68","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56194.75","","","","","","","fee schedule","18707.17","74719.68",""
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","55606.53","55606.53","55606.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18323.11","18323.11","18323.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17858.93","17858.93","17858.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16059.42","16059.42","16059.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17496.71","17496.71","17496.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17153.71","17153.71","17153.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17809.21","17809.21","17809.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19595.76","","","","","","","fee schedule","18707.17","74719.68","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19268.39","","","","","","","fee schedule","18707.17","74719.68","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18707.17","","","","","","","fee schedule","18707.17","74719.68","Transplants-Case Rate"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19081.31","","","","","","","fee schedule","18707.17","74719.68","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19642.53","","","","","","","fee schedule","18707.17","74719.68","MSDRG Base Rate"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18707.17","","","","","","","fee schedule","18707.17","74719.68","Psych-Case Rate"
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35773.18","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38259.88","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50136.17","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41570.87","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35879.09","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45856.59","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34247.39","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54391.19","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40906.22","","","","","","","fee schedule","14005.1","54391.19",""
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","32327.13","32327.13","32327.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12856.67","12856.67","12856.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","33701","33701","33701","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13885.48","13885.48","13885.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","39612.82","39612.82","39612.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14670.34","","","","","","","fee schedule","14005.1","54391.19","MSDRG Base Rate"
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14425.25","","","","","","","fee schedule","14005.1","54391.19","MSDRG Base Rate"
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14005.1","","","","","","","fee schedule","14005.1","54391.19","Transplants-Case Rate"
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14285.2","","","","","","","fee schedule","14005.1","54391.19","MSDRG Base Rate"
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14705.36","","","","","","","fee schedule","14005.1","54391.19","MSDRG Base Rate"
"Peritoneal Adhesiolysis Without Cc/Mcc","337","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14005.1","","","","","","","fee schedule","14005.1","54391.19","Psych-Case Rate"
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","79360.28","","","","","","","fee schedule","70793.07","79360.28",""
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","70793.07","","","","","","","fee schedule","70793.07","79360.28",""
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Mcc","338","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48646.82","","","","","","","fee schedule","43395.23","48646.82",""
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43395.23","","","","","","","fee schedule","43395.23","48646.82",""
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis With Cc","339","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35845.81","","","","","","","fee schedule","31976.14","35845.81",""
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31976.14","","","","","","","fee schedule","31976.14","35845.81",""
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","340","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","67485.37","","","","","","","fee schedule","60200.09","67485.37",""
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","60200.09","","","","","","","fee schedule","60200.09","67485.37",""
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Mcc","341","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43412.9","","","","","","","fee schedule","38726.33","43412.9",""
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38726.33","","","","","","","fee schedule","38726.33","43412.9",""
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis With Cc","342","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32643.32","","","","","","","fee schedule","29119.36","32643.32",""
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29119.36","","","","","","","fee schedule","29119.36","32643.32",""
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","343","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","60192.15","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","64376.29","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","84359.41","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","69947.39","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","60370.37","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","77158.57","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","57624.85","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","91518.94","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","68829.04","","","","","","","fee schedule","22592.93","91518.94",""
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18207.08","18207.08","18207.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20947.33","20947.33","20947.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10957.03","10957.03","10957.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23666.09","","","","","","","fee schedule","22592.93","91518.94","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23270.72","","","","","","","fee schedule","22592.93","91518.94","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22592.93","","","","","","","fee schedule","22592.93","91518.94","Transplants-Case Rate"
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23044.79","","","","","","","fee schedule","22592.93","91518.94","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23722.58","","","","","","","fee schedule","22592.93","91518.94","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Mcc","344","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22592.93","","","","","","","fee schedule","22592.93","91518.94","Psych-Case Rate"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35067.03","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37504.65","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49146.51","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40750.29","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35170.86","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44951.41","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33571.36","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53317.54","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40098.75","","","","","","","fee schedule","13756.76","53317.54",""
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10253.41","10253.41","10253.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12674.51","12674.51","12674.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","32157.38","32157.38","32157.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","26433.8","26433.8","26433.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14410.21","","","","","","","fee schedule","13756.76","53317.54","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14169.46","","","","","","","fee schedule","13756.76","53317.54","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13756.76","","","","","","","fee schedule","13756.76","53317.54","Transplants-Case Rate"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14031.9","","","","","","","fee schedule","13756.76","53317.54","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14444.6","","","","","","","fee schedule","13756.76","53317.54","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13756.76","","","","","","","fee schedule","13756.76","53317.54","Psych-Case Rate"
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27644.39","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29566.04","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38743.66","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32124.67","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27726.24","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35436.54","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26465.31","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42031.81","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31611.04","","","","","","","fee schedule","11146.31","42031.81",""
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36118.66","36118.66","36118.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14807.66","14807.66","14807.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","24802.49","23683.87","127861.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26292.42","26292.42","26292.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8340.75","8340.75","8340.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11675.76","","","","","","","fee schedule","11146.31","42031.81","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11480.7","","","","","","","fee schedule","11146.31","42031.81","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11146.31","","","","","","","fee schedule","11146.31","42031.81","Transplants-Case Rate"
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11369.24","","","","","","","fee schedule","11146.31","42031.81","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11703.63","","","","","","","fee schedule","11146.31","42031.81","MSDRG Base Rate"
"Minor Small And Large Bowel Procedures Without Cc/Mcc","346","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11146.31","","","","","","","fee schedule","11146.31","42031.81","Psych-Case Rate"
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","53498.96","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","57217.83","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","74978.89","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","62169.44","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","53657.35","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","68578.75","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","51217.13","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","81342.29","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","61175.44","","","","","","","fee schedule","20239.02","81342.29",""
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3245.2","3245.2","3245.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10693.71","10693.71","11198.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13913.91","10693.71","14571.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3543.96","3543.96","3543.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21200.37","","","","","","","fee schedule","20239.02","81342.29","MSDRG Base Rate"
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20846.19","","","","","","","fee schedule","20239.02","81342.29","MSDRG Base Rate"
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20239.02","","","","","","","fee schedule","20239.02","81342.29","Transplants-Case Rate"
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20643.8","","","","","","","fee schedule","20239.02","81342.29","MSDRG Base Rate"
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21250.97","","","","","","","fee schedule","20239.02","81342.29","MSDRG Base Rate"
"Anal And Stomal Procedures With Mcc","347","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20239.02","","","","","","","fee schedule","20239.02","81342.29","Psych-Case Rate"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30501.58","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32621.84","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42748.03","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35444.92","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30591.89","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39099.09","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29200.64","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46376.02","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34878.21","","","","","","","fee schedule","12151.15","46376.02",""
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7674.95","7674.95","7674.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11871.78","11871.78","11871.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12728.33","","","","","","","fee schedule","12151.15","46376.02","MSDRG Base Rate"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12515.68","","","","","","","fee schedule","12151.15","46376.02","MSDRG Base Rate"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12151.15","","","","","","","fee schedule","12151.15","46376.02","Transplants-Case Rate"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12394.17","","","","","","","fee schedule","12151.15","46376.02","MSDRG Base Rate"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12758.71","","","","","","","fee schedule","12151.15","46376.02","MSDRG Base Rate"
"Anal And Stomal Procedures With Cc","348","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12151.15","","","","","","","fee schedule","12151.15","46376.02","Psych-Case Rate"
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20289.33","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21699.71","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28435.54","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23577.59","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20349.4","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26008.3","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19423.96","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30848.84","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23200.62","","","","","","","fee schedule","8559.64","30848.84",""
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12994.48","12994.48","12994.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","27763.43","27763.43","27763.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8966.22","","","","","","","fee schedule","8559.64","30848.84","MSDRG Base Rate"
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8816.43","","","","","","","fee schedule","8559.64","30848.84","MSDRG Base Rate"
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8559.64","","","","","","","fee schedule","8559.64","30848.84","Transplants-Case Rate"
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8730.83","","","","","","","fee schedule","8559.64","30848.84","MSDRG Base Rate"
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8987.62","","","","","","","fee schedule","8559.64","30848.84","MSDRG Base Rate"
"Anal And Stomal Procedures Without Cc/Mcc","349","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8559.64","","","","","","","fee schedule","8559.64","30848.84","Psych-Case Rate"
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","58073.73","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","62110.61","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","81390.44","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","67485.64","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","58245.67","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","74443.02","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","55596.78","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","88297.98","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","66406.64","","","","","","","fee schedule","21847.9","88297.98",""
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22885.68","","","","","","","fee schedule","21847.9","88297.98","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22503.34","","","","","","","fee schedule","21847.9","88297.98","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21847.9","","","","","","","fee schedule","21847.9","88297.98","Transplants-Case Rate"
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22284.86","","","","","","","fee schedule","21847.9","88297.98","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22940.3","","","","","","","fee schedule","21847.9","88297.98","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Mcc","350","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21847.9","","","","","","","fee schedule","21847.9","88297.98","Psych-Case Rate"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35528.47","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37998.16","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49793.22","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41286.51","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35633.66","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45542.91","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34013.12","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54019.13","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40626.4","","","","","","","fee schedule","13919.04","54019.13",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12696.63","8041.98","13296.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12487.66","12487.66","12487.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2580.03","2580.03","2580.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12976.68","12976.68","12976.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8041.98","7679.28","27617.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8345.45","8345.45","13175.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14580.19","","","","","","","fee schedule","13919.04","54019.13","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14336.61","","","","","","","fee schedule","13919.04","54019.13","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13919.04","","","","","","","fee schedule","13919.04","54019.13","Transplants-Case Rate"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14197.42","","","","","","","fee schedule","13919.04","54019.13","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14614.99","","","","","","","fee schedule","13919.04","54019.13","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13919.04","","","","","","","fee schedule","13919.04","54019.13","Psych-Case Rate"
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27215.58","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29107.42","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38142.68","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31626.36","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27296.16","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34886.86","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26054.79","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41379.83","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31120.7","","","","","","","fee schedule","10995.51","41379.83",""
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23669.09","23669.09","23669.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11517.8","","","","","","","fee schedule","10995.51","41379.83","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11325.38","","","","","","","fee schedule","10995.51","41379.83","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10995.51","","","","","","","fee schedule","10995.51","41379.83","Transplants-Case Rate"
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11215.42","","","","","","","fee schedule","10995.51","41379.83","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11545.29","","","","","","","fee schedule","10995.51","41379.83","MSDRG Base Rate"
"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","352","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10995.51","","","","","","","fee schedule","10995.51","41379.83","Psych-Case Rate"
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","67631.11","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","72332.35","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","94785.12","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","78591.96","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","67831.35","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","86694.35","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64746.52","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","102829.47","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","77335.4","","","","","","","fee schedule","25209.11","102829.47",""
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","62414.24","62414.24","62414.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","91858.63","91858.63","91858.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","23074.35","23074.35","23074.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","39869.82","39869.82","39869.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26406.54","","","","","","","fee schedule","25209.11","102829.47","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25965.38","","","","","","","fee schedule","25209.11","102829.47","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25209.11","","","","","","","fee schedule","25209.11","102829.47","Transplants-Case Rate"
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25713.29","","","","","","","fee schedule","25209.11","102829.47","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26469.57","","","","","","","fee schedule","25209.11","102829.47","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Mcc","353","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25209.11","","","","","","","fee schedule","25209.11","102829.47","Psych-Case Rate"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39208.33","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41933.82","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54950.55","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45562.76","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39324.42","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50260.02","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37536.03","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59614.16","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44834.28","","","","","","","fee schedule","15213.2","59614.16",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14395.39","14395.39","14395.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32452.58","32452.58","32452.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14628.35","14628.35","14628.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15935.83","","","","","","","fee schedule","15213.2","59614.16","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15669.6","","","","","","","fee schedule","15213.2","59614.16","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15213.2","","","","","","","fee schedule","15213.2","59614.16","Transplants-Case Rate"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15517.46","","","","","","","fee schedule","15213.2","59614.16","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15973.86","","","","","","","fee schedule","15213.2","59614.16","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15213.2","","","","","","","fee schedule","15213.2","59614.16","Psych-Case Rate"
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31345.23","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33524.13","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43930.39","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36425.29","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31438.03","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40180.53","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30008.3","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47658.73","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35842.91","","","","","","","fee schedule","12447.85","47658.73",""
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","39398.59","39398.59","39398.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11785.43","11785.43","11785.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11758.47","11758.47","11758.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","29263.04","29263.04","29263.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13039.12","","","","","","","fee schedule","12447.85","47658.73","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12821.29","","","","","","","fee schedule","12447.85","47658.73","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12447.85","","","","","","","fee schedule","12447.85","47658.73","Transplants-Case Rate"
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12696.81","","","","","","","fee schedule","12447.85","47658.73","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13070.24","","","","","","","fee schedule","12447.85","47658.73","MSDRG Base Rate"
"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","355","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12447.85","","","","","","","fee schedule","12447.85","47658.73","Psych-Case Rate"
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","102374.2","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","109490.54","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","143477.63","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","118965.81","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","102677.31","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","131230.51","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","98007.76","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","155654.48","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","117063.73","","","","","","","fee schedule","37427.79","155654.48",""
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","133597.46","133597.46","133597.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24296.66","24296.66","24296.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","33716.49","33408.77","36107.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33709.72","33709.72","33709.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","93647","93647","95944","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","34780.44","33379.85","131564.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","39205.61","","","","","","","fee schedule","37427.79","155654.48","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38550.62","","","","","","","fee schedule","37427.79","155654.48","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37427.79","","","","","","","fee schedule","37427.79","155654.48","Transplants-Case Rate"
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","38176.35","","","","","","","fee schedule","37427.79","155654.48","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39299.18","","","","","","","fee schedule","37427.79","155654.48","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Mcc","356","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37427.79","","","","","","","fee schedule","37427.79","155654.48","Psych-Case Rate"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54195.78","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","57963.09","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","75955.48","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","62979.19","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54356.24","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69471.99","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","51884.23","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","82401.77","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","61972.25","","","","","","","fee schedule","20484.08","82401.77",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","39137.88","39137.88","39137.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19715.74","19715.74","19715.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20582.33","20582.33","20582.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","49190","49190","49190","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18370.63","18370.63","18370.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","58405.62","58405.62","58405.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21457.07","","","","","","","fee schedule","20484.08","82401.77","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21098.6","","","","","","","fee schedule","20484.08","82401.77","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20484.08","","","","","","","fee schedule","20484.08","82401.77","Transplants-Case Rate"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20893.76","","","","","","","fee schedule","20484.08","82401.77","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21508.28","","","","","","","fee schedule","20484.08","82401.77","MSDRG Base Rate"
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20484.08","","","","","","","fee schedule","20484.08","82401.77","Psych-Case Rate"
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32578.06","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34842.66","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45658.21","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37857.93","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32674.51","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41760.86","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31188.55","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49533.19","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37252.64","","","","","","","fee schedule","12881.42","49533.19",""
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","42440.38","42440.38","42440.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","29399","29399","29399","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13493.29","","","","","","","fee schedule","12881.42","49533.19","MSDRG Base Rate"
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13267.86","","","","","","","fee schedule","12881.42","49533.19","MSDRG Base Rate"
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12881.42","","","","","","","fee schedule","12881.42","49533.19","Transplants-Case Rate"
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13139.05","","","","","","","fee schedule","12881.42","49533.19","MSDRG Base Rate"
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13525.49","","","","","","","fee schedule","12881.42","49533.19","MSDRG Base Rate"
"Other Digestive System O.R. Procedures Without Cc/Mcc","358","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12881.42","","","","","","","fee schedule","12881.42","49533.19","Psych-Case Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","80136.57","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","85707.11","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","112311.55","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","93124.17","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","80373.84","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","102724.74","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","76718.6","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","121843.35","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","91635.25","","","","","","","fee schedule","29607.11","121843.35",""
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","27455.09","27455.09","27455.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31013.45","","","","","","","fee schedule","29607.11","121843.35","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30495.32","","","","","","","fee schedule","29607.11","121843.35","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29607.11","","","","","","","fee schedule","29607.11","121843.35","Transplants-Case Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30199.25","","","","","","","fee schedule","29607.11","121843.35","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31087.47","","","","","","","fee schedule","29607.11","121843.35","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","359","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29607.11","","","","","","","fee schedule","29607.11","121843.35","Psych-Case Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","56265.26","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","60176.43","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","78855.87","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","65384.07","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","56431.85","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","72124.8","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","53865.45","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","85548.31","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","64338.68","","","","","","","fee schedule","21211.89","85548.31",""
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","47433.06","47433.06","47433.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","75539.37","75539.37","75539.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22219.45","","","","","","","fee schedule","21211.89","85548.31","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21848.25","","","","","","","fee schedule","21211.89","85548.31","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21211.89","","","","","","","fee schedule","21211.89","85548.31","Transplants-Case Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21636.13","","","","","","","fee schedule","21211.89","85548.31","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22272.48","","","","","","","fee schedule","21211.89","85548.31","MSDRG Base Rate"
"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","360","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21211.89","","","","","","","fee schedule","21211.89","85548.31","Psych-Case Rate"
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopy & Incisional Tubal Interruption","361","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endoscopic Tubal Interruption","362","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization & Radio-Implant, for Malignancy","363","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization Except for Malignancy","364","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures","365","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, female reproductive system w CC","366","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System w/o CC","367","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37099.23","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39678.11","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51994.64","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43111.84","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37209.07","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47556.42","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35516.88","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56407.38","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42422.54","","","","","","","fee schedule","14471.45","56407.38",""
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","51952.73","51952.73","51952.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14320.16","13350.97","14957.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","3382.22","3382.22","3382.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13274.44","13274.44","13274.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15158.84","","","","","","","fee schedule","14471.45","56407.38","MSDRG Base Rate"
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14905.59","","","","","","","fee schedule","14471.45","56407.38","MSDRG Base Rate"
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14471.45","","","","","","","fee schedule","14471.45","56407.38","Transplants-Case Rate"
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14760.88","","","","","","","fee schedule","14471.45","56407.38","MSDRG Base Rate"
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15195.02","","","","","","","fee schedule","14471.45","56407.38","MSDRG Base Rate"
"Major Esophageal Disorders With Mcc","368","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14471.45","","","","","","","fee schedule","14471.45","56407.38","Psych-Case Rate"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23309.66","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24929.99","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32668.53","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27087.42","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23378.67","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29879.97","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22315.46","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35441.09","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26654.33","","","","","","","fee schedule","9621.85","35441.09",""
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28293.84","28293.84","28293.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","60683.14","60683.14","60683.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7794.8","7794.8","7794.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8079.99","8079.99","8079.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","17513.65","17513.65","17513.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10078.89","","","","","","","fee schedule","9621.85","35441.09","MSDRG Base Rate"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9910.51","","","","","","","fee schedule","9621.85","35441.09","MSDRG Base Rate"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9621.85","","","","","","","fee schedule","9621.85","35441.09","Transplants-Case Rate"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9814.29","","","","","","","fee schedule","9621.85","35441.09","MSDRG Base Rate"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10102.94","","","","","","","fee schedule","9621.85","35441.09","MSDRG Base Rate"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9621.85","","","","","","","fee schedule","9621.85","35441.09","Psych-Case Rate"
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16332.14","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17467.44","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22889.53","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18979.07","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16380.5","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20935.7","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15635.55","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24832.15","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18675.62","","","","","","","fee schedule","7167.95","24832.15",""
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7508.43","","","","","","","fee schedule","7167.95","24832.15","MSDRG Base Rate"
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7382.99","","","","","","","fee schedule","7167.95","24832.15","MSDRG Base Rate"
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7167.95","","","","","","","fee schedule","7167.95","24832.15","Transplants-Case Rate"
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7311.31","","","","","","","fee schedule","7167.95","24832.15","MSDRG Base Rate"
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7526.35","","","","","","","fee schedule","7167.95","24832.15","MSDRG Base Rate"
"Major Esophageal Disorders Without Cc/Mcc","370","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7167.95","","","","","","","fee schedule","7167.95","24832.15","Psych-Case Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41322.1","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44194.52","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57912.99","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48019.09","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41444.44","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52969.59","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39559.63","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62828.03","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47251.34","","","","","","","fee schedule","15956.58","62828.03",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","37197.44","37197.44","37197.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","54745.61","54745.61","54745.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16421.62","16421.62","16421.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15228.55","15228.55","15228.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19106.66","19106.66","19106.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35936","35936","35936","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16457.09","16457.09","16457.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16714.52","","","","","","","fee schedule","15956.58","62828.03","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16435.28","","","","","","","fee schedule","15956.58","62828.03","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15956.58","","","","","","","fee schedule","15956.58","62828.03","Transplants-Case Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16275.71","","","","","","","fee schedule","15956.58","62828.03","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16754.41","","","","","","","fee schedule","15956.58","62828.03","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","371","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15956.58","","","","","","","fee schedule","15956.58","62828.03","Psych-Case Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23794.41","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25448.43","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33347.9","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27650.72","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23864.85","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30501.35","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22779.53","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36178.11","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27208.63","","","","","","","fee schedule","9792.32","36178.11",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18244.92","18244.92","18244.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","22323.32","22323.32","22323.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8084.32","8084.32","8084.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7576.63","7576.63","7576.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9457.98","9457.98","9457.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7743.62","7743.62","7743.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22416","22416","22598","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26557","26557","26557","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","26694.9","26694.9","26694.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10257.46","","","","","","","fee schedule","9792.32","36178.11","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10086.09","","","","","","","fee schedule","9792.32","36178.11","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9792.32","","","","","","","fee schedule","9792.32","36178.11","Transplants-Case Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9988.17","","","","","","","fee schedule","9792.32","36178.11","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10281.94","","","","","","","fee schedule","9792.32","36178.11","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9792.32","","","","","","","fee schedule","9792.32","36178.11","Psych-Case Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16952.06","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18130.45","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23758.34","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19699.45","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17002.25","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21730.35","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16229.02","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25774.69","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19384.48","","","","","","","fee schedule","7385.96","25774.69",""
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9473.55","9473.55","9473.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7736.79","","","","","","","fee schedule","7385.96","25774.69","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7607.54","","","","","","","fee schedule","7385.96","25774.69","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7385.96","","","","","","","fee schedule","7385.96","25774.69","Transplants-Case Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7533.68","","","","","","","fee schedule","7385.96","25774.69","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7755.26","","","","","","","fee schedule","7385.96","25774.69","MSDRG Base Rate"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","373","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7385.96","","","","","","","fee schedule","7385.96","25774.69","Psych-Case Rate"
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49842.4","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53307.1","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69854.22","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57920.27","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49989.97","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63891.52","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47716.54","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75782.7","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56994.22","","","","","","","fee schedule","18953.06","75782.7",""
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18073.86","18073.86","18073.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16919.44","15960.25","21677.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17842.49","17842.49","17842.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","46955","46955","46955","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","3338.18","3338.18","3338.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19853.33","","","","","","","fee schedule","18953.06","75782.7","MSDRG Base Rate"
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19521.65","","","","","","","fee schedule","18953.06","75782.7","MSDRG Base Rate"
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18953.06","","","","","","","fee schedule","18953.06","75782.7","Transplants-Case Rate"
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19332.12","","","","","","","fee schedule","18953.06","75782.7","MSDRG Base Rate"
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19900.71","","","","","","","fee schedule","18953.06","75782.7","MSDRG Base Rate"
"Digestive Malignancy With Mcc","374","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18953.06","","","","","","","fee schedule","18953.06","75782.7","Psych-Case Rate"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28189.73","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30149.28","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39507.96","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32758.39","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28273.19","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36135.59","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26987.39","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42860.97","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32234.63","","","","","","","fee schedule","11338.1","42860.97",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36731.66","36731.66","38481.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","69927.14","69927.14","69927.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9969.58","9969.58","11157.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26255.11","26255.11","26255.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11876.66","","","","","","","fee schedule","11338.1","42860.97","MSDRG Base Rate"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11678.24","","","","","","","fee schedule","11338.1","42860.97","MSDRG Base Rate"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11338.1","","","","","","","fee schedule","11338.1","42860.97","Transplants-Case Rate"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11564.86","","","","","","","fee schedule","11338.1","42860.97","MSDRG Base Rate"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11905","","","","","","","fee schedule","11338.1","42860.97","MSDRG Base Rate"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11338.1","","","","","","","fee schedule","11338.1","42860.97","Psych-Case Rate"
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21540.81","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23038.18","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30189.49","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25031.89","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21604.59","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27612.54","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20622.06","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32751.65","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24631.67","","","","","","","fee schedule","8999.77","32751.65",""
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9427.26","","","","","","","fee schedule","8999.77","32751.65","MSDRG Base Rate"
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9269.76","","","","","","","fee schedule","8999.77","32751.65","MSDRG Base Rate"
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8999.77","","","","","","","fee schedule","8999.77","32751.65","Transplants-Case Rate"
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9179.77","","","","","","","fee schedule","8999.77","32751.65","MSDRG Base Rate"
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9449.76","","","","","","","fee schedule","8999.77","32751.65","MSDRG Base Rate"
"Digestive Malignancy Without Cc/Mcc","376","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8999.77","","","","","","","fee schedule","8999.77","32751.65","Psych-Case Rate"
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42601.54","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45562.9","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59706.14","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49505.9","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42727.67","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54609.67","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40784.51","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64773.35","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48714.37","","","","","","","fee schedule","16406.54","64773.35",""
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","56944.21","47619.05","56944.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23483.73","23483.73","23483.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5432.26","5432.26","5432.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14497.02","1565.36","16154.05","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14276.61","13564.2","16629.51","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15178.42","14444.66","16483.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15513.21","14668.7","16191.89","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","42906.59","42906.59","42906.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17185.85","","","","","","","fee schedule","16406.54","64773.35","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16898.74","","","","","","","fee schedule","16406.54","64773.35","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16406.54","","","","","","","fee schedule","16406.54","64773.35","Transplants-Case Rate"
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16734.67","","","","","","","fee schedule","16406.54","64773.35","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17226.87","","","","","","","fee schedule","16406.54","64773.35","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Mcc","377","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16406.54","","","","","","","fee schedule","16406.54","64773.35","Psych-Case Rate"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22855.21","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24443.95","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32031.62","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26559.32","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22922.88","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29297.43","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21880.4","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34750.12","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26134.67","","","","","","","fee schedule","9462.02","34750.12",""
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","19072.39","19072.39","19072.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","29827.4","29103.48","30527.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9365.78","8215.06","9638.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","8885.56","8885.56","8885.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7614.91","1921.26","8394.99","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8497.56","7750.61","8944.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20265","20265","20265","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7818.8","7330.57","9352.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9911.47","","","","","","","fee schedule","9462.02","34750.12","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9745.88","","","","","","","fee schedule","9462.02","34750.12","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9462.02","","","","","","","fee schedule","9462.02","34750.12","Transplants-Case Rate"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9651.26","","","","","","","fee schedule","9462.02","34750.12","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9935.12","","","","","","","fee schedule","9462.02","34750.12","MSDRG Base Rate"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9462.02","","","","","","","fee schedule","9462.02","34750.12","Psych-Case Rate"
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14691.47","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15712.72","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20590.12","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17072.49","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14734.97","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18832.57","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14064.85","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22337.59","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16799.53","","","","","","","fee schedule","6590.94","22337.59",""
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6780.64","6780.64","6780.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5499.95","5499.95","5499.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","4951.2","4951.2","4951.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6904.01","","","","","","","fee schedule","6590.94","22337.59","MSDRG Base Rate"
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6788.67","","","","","","","fee schedule","6590.94","22337.59","MSDRG Base Rate"
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6590.94","","","","","","","fee schedule","6590.94","22337.59","Transplants-Case Rate"
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6722.76","","","","","","","fee schedule","6590.94","22337.59","MSDRG Base Rate"
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6920.49","","","","","","","fee schedule","6590.94","22337.59","MSDRG Base Rate"
"Gastrointestinal Hemorrhage Without Cc/Mcc","379","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6590.94","","","","","","","fee schedule","6590.94","22337.59","Psych-Case Rate"
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45729.07","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48907.84","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","64089.38","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","53140.3","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45864.46","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58618.76","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43778.64","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","69528.59","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","52290.67","","","","","","","fee schedule","17506.45","69528.59",""
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","61454.14","61454.14","61454.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15627.12","15627.12","16159.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16399.97","16399.97","17744.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16654.63","16654.63","16654.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10098.51","10098.51","19221.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15484.73","15484.73","15484.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","76499.24","76499.24","76499.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","19046.9","19046.9","19046.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18338.01","","","","","","","fee schedule","17506.45","69528.59","MSDRG Base Rate"
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18031.64","","","","","","","fee schedule","17506.45","69528.59","MSDRG Base Rate"
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17506.45","","","","","","","fee schedule","17506.45","69528.59","Transplants-Case Rate"
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17856.58","","","","","","","fee schedule","17506.45","69528.59","MSDRG Base Rate"
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18381.77","","","","","","","fee schedule","17506.45","69528.59","MSDRG Base Rate"
"Complicated Peptic Ulcer With Mcc","380","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17506.45","","","","","","","fee schedule","17506.45","69528.59","Psych-Case Rate"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25250.97","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27006.24","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35389.28","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29343.35","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25325.73","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32368.48","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24173.97","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38392.74","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28874.19","","","","","","","fee schedule","10304.58","38392.74",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8558.82","8172.8","21766.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","13998.09","13998.09","13998.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8815.76","8815.76","8815.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8096.06","8096.06","8096.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16166.82","16166.82","16166.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9749.26","9749.26","9749.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10794.05","","","","","","","fee schedule","10304.58","38392.74","MSDRG Base Rate"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10613.72","","","","","","","fee schedule","10304.58","38392.74","MSDRG Base Rate"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10304.58","","","","","","","fee schedule","10304.58","38392.74","Transplants-Case Rate"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10510.67","","","","","","","fee schedule","10304.58","38392.74","MSDRG Base Rate"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10819.81","","","","","","","fee schedule","10304.58","38392.74","MSDRG Base Rate"
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10304.58","","","","","","","fee schedule","10304.58","38392.74","Psych-Case Rate"
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18657.98","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19954.96","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26149.2","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21681.85","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18713.22","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23917.12","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17862.19","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28368.46","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21335.19","","","","","","","fee schedule","7985.91","28368.46",""
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","13712.47","13712.47","13712.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8365.24","","","","","","","fee schedule","7985.91","28368.46","MSDRG Base Rate"
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8225.49","","","","","","","fee schedule","7985.91","28368.46","MSDRG Base Rate"
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7985.91","","","","","","","fee schedule","7985.91","28368.46","Transplants-Case Rate"
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8145.63","","","","","","","fee schedule","7985.91","28368.46","MSDRG Base Rate"
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8385.21","","","","","","","fee schedule","7985.91","28368.46","MSDRG Base Rate"
"Complicated Peptic Ulcer Without Cc/Mcc","382","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7985.91","","","","","","","fee schedule","7985.91","28368.46","Psych-Case Rate"
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32177.21","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34413.95","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45096.42","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37392.12","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32272.48","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41247.03","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30804.8","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48923.72","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36794.27","","","","","","","fee schedule","12740.45","48923.72",""
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9568.4","9136.85","13226.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9136.85","6084.6","13226.13","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9929.47","9929.47","9929.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2292.11","2292.11","2292.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3730.16","3730.16","3730.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13345.62","","","","","","","fee schedule","12740.45","48923.72","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13122.66","","","","","","","fee schedule","12740.45","48923.72","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12740.45","","","","","","","fee schedule","12740.45","48923.72","Transplants-Case Rate"
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12995.26","","","","","","","fee schedule","12740.45","48923.72","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13377.47","","","","","","","fee schedule","12740.45","48923.72","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer With Mcc","383","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12740.45","","","","","","","fee schedule","12740.45","48923.72","Psych-Case Rate"
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19921.11","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21305.89","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27919.48","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23149.69","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19980.1","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25536.3","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19071.44","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30288.98","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22779.57","","","","","","","fee schedule","8430.14","30288.98",""
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8887.31","8887.31","8887.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5892.24","5892.24","5892.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8486.48","8486.48","19198.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8830.57","","","","","","","fee schedule","8430.14","30288.98","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8683.04","","","","","","","fee schedule","8430.14","30288.98","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8430.14","","","","","","","fee schedule","8430.14","30288.98","Transplants-Case Rate"
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8598.74","","","","","","","fee schedule","8430.14","30288.98","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8851.65","","","","","","","fee schedule","8430.14","30288.98","MSDRG Base Rate"
"Uncomplicated Peptic Ulcer Without Mcc","384","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8430.14","","","","","","","fee schedule","8430.14","30288.98","Psych-Case Rate"
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36875.5","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39438.83","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51681.08","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42851.85","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36984.68","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47269.63","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35302.7","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56067.22","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42166.71","","","","","","","fee schedule","14392.77","56067.22",""
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","17663.62","17663.62","17663.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14639.03","14639.03","14639.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11075.23","5856.21","11075.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15076.43","","","","","","","fee schedule","14392.77","56067.22","MSDRG Base Rate"
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14824.55","","","","","","","fee schedule","14392.77","56067.22","MSDRG Base Rate"
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14392.77","","","","","","","fee schedule","14392.77","56067.22","Transplants-Case Rate"
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14680.63","","","","","","","fee schedule","14392.77","56067.22","MSDRG Base Rate"
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15112.41","","","","","","","fee schedule","14392.77","56067.22","MSDRG Base Rate"
"Inflammatory Bowel Disease With Mcc","385","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14392.77","","","","","","","fee schedule","14392.77","56067.22","Psych-Case Rate"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22752.67","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24334.28","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31887.91","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26440.16","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22820.04","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29165.99","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21782.23","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34594.21","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26017.42","","","","","","","fee schedule","9425.96","34594.21",""
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","29852.37","29852.37","29852.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2607.35","2607.35","2607.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8639.68","8639.68","8639.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","854.48","854.48","854.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9873.69","","","","","","","fee schedule","9425.96","34594.21","MSDRG Base Rate"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9708.74","","","","","","","fee schedule","9425.96","34594.21","MSDRG Base Rate"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9425.96","","","","","","","fee schedule","9425.96","34594.21","Transplants-Case Rate"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9614.48","","","","","","","fee schedule","9425.96","34594.21","MSDRG Base Rate"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9897.26","","","","","","","fee schedule","9425.96","34594.21","MSDRG Base Rate"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9425.96","","","","","","","fee schedule","9425.96","34594.21","Psych-Case Rate"
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15877.7","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16981.4","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22252.62","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18450.97","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15924.71","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20353.16","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15200.48","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24141.18","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18155.96","","","","","","","fee schedule","7008.12","24141.18",""
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","16021.62","16021.62","16021.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7341.01","","","","","","","fee schedule","7008.12","24141.18","MSDRG Base Rate"
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7218.36","","","","","","","fee schedule","7008.12","24141.18","MSDRG Base Rate"
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7008.12","","","","","","","fee schedule","7008.12","24141.18","Transplants-Case Rate"
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7148.28","","","","","","","fee schedule","7008.12","24141.18","MSDRG Base Rate"
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7358.53","","","","","","","fee schedule","7008.12","24141.18","MSDRG Base Rate"
"Inflammatory Bowel Disease Without Cc/Mcc","387","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7008.12","","","","","","","fee schedule","7008.12","24141.18","Psych-Case Rate"
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34416.82","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36809.24","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48235.24","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39994.7","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34518.72","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44117.92","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32948.88","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52328.93","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39355.24","","","","","","","fee schedule","13528.09","52328.93",""
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12999.46","12999.46","12999.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12559.35","12559.35","12559.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1964.55","1964.55","1964.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","31530.05","31530.05","31530.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32274","32274","32274","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13590.25","13590.25","13590.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11841.4","11841.4","11841.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12881.58","12881.58","12881.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","39171.37","39171.37","39171.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","27176.29","27176.29","27176.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14170.67","","","","","","","fee schedule","13528.09","52328.93","MSDRG Base Rate"
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13933.93","","","","","","","fee schedule","13528.09","52328.93","MSDRG Base Rate"
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13528.09","","","","","","","fee schedule","13528.09","52328.93","Transplants-Case Rate"
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13798.65","","","","","","","fee schedule","13528.09","52328.93","MSDRG Base Rate"
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14204.49","","","","","","","fee schedule","13528.09","52328.93","MSDRG Base Rate"
"Gastrointestinal Obstruction With Mcc","388","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13528.09","","","","","","","fee schedule","13528.09","52328.93","Psych-Case Rate"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18406.29","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19685.77","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25796.45","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21389.36","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18460.79","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23594.49","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17621.23","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27985.77","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21047.38","","","","","","","fee schedule","7897.4","27985.77",""
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","14329.4","14329.4","14329.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18716.1","18716.1","18716.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23906.92","23906.92","23906.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7807.3","7807.3","7807.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17884.5","17884.5","17884.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","3002.54","3002.54","3002.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12413.16","7093.65","12999.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6619.33","6619.33","6813.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","12639.44","12639.44","12639.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6125","6125","6125","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8272.53","","","","","","","fee schedule","7897.4","27985.77","MSDRG Base Rate"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8134.32","","","","","","","fee schedule","7897.4","27985.77","MSDRG Base Rate"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7897.4","","","","","","","fee schedule","7897.4","27985.77","Transplants-Case Rate"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8055.35","","","","","","","fee schedule","7897.4","27985.77","MSDRG Base Rate"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8292.27","","","","","","","fee schedule","7897.4","27985.77","MSDRG Base Rate"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7897.4","","","","","","","fee schedule","7897.4","27985.77","Psych-Case Rate"
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","12677.92","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","13559.2","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","17768.13","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","14732.61","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","12715.46","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","16251.46","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","12137.18","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","19276.1","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","14497.06","","","","","","","fee schedule","5882.8","19276.1",""
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","13132.11","13132.11","13132.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17037.54","17037.54","17037.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5902.27","5902.27","5902.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","5048.91","5048.91","5048.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","4895.91","4895.91","4895.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","4649.38","4649.38","4649.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5636.07","5636.07","5902.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","11444","11444","11444","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5345.7","5002.65","5950.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","7309.14","7309.14","7309.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5848.76","5848.76","5848.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6162.23","","","","","","","fee schedule","5882.8","19276.1","MSDRG Base Rate"
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6059.28","","","","","","","fee schedule","5882.8","19276.1","MSDRG Base Rate"
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","5882.8","","","","","","","fee schedule","5882.8","19276.1","Transplants-Case Rate"
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6000.46","","","","","","","fee schedule","5882.8","19276.1","MSDRG Base Rate"
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6176.94","","","","","","","fee schedule","5882.8","19276.1","MSDRG Base Rate"
"Gastrointestinal Obstruction Without Cc/Mcc","390","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5882.8","","","","","","","fee schedule","5882.8","19276.1","Psych-Case Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29557.73","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31612.38","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","41425.21","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","34348.1","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29645.24","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37889.19","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28297.04","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","44940.94","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33798.93","","","","","","","fee schedule","11819.21","44940.94",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12645.35","12645.35","12645.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","28680.17","28680.17","28680.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","30698.27","30698.27","30698.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","40229.26","40229.26","40229.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10188.1","9464.86","12866.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9262.89","534.56","11978.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11872.53","11872.53","11872.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12645.35","12075.03","23919.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","27710","27710","27710","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10847.28","10112.66","11323.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","34230.64","34230.64","34230.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","14004.46","14004.46","14004.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","27940.75","27940.75","27940.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12380.62","","","","","","","fee schedule","11819.21","44940.94","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12173.79","","","","","","","fee schedule","11819.21","44940.94","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11819.21","","","","","","","fee schedule","11819.21","44940.94","Transplants-Case Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12055.59","","","","","","","fee schedule","11819.21","44940.94","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12410.17","","","","","","","fee schedule","11819.21","44940.94","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","391","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11819.21","","","","","","","fee schedule","11819.21","44940.94","Psych-Case Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18168.58","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19431.53","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25463.3","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21113.13","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18222.37","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23289.77","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17393.66","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27624.35","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20775.56","","","","","","","fee schedule","7813.8","27624.35",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","1002.82","1002.82","1002.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6863.43","6863.43","6863.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","16461","16461","16461","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22771.67","20524.94","23938.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","14570.23","14570.23","14570.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2088.41","2088.41","2088.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6858.24","5970.34","7543.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","16909.27","16909.27","17368.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2247.9","762.31","6663.47","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6757.44","6111.25","7463.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7187.6","6863.43","7187.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17116","14150.92","17131","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","20114","20114","20114","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5948.75","5365.68","6777.8","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","20237.08","10588.59","20794.21","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7122.42","7122.42","7122.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2130.18","2130.18","2130.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8184.96","","","","","","","fee schedule","7813.8","27624.35","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8048.21","","","","","","","fee schedule","7813.8","27624.35","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7813.8","","","","","","","fee schedule","7813.8","27624.35","Transplants-Case Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7970.08","","","","","","","fee schedule","7813.8","27624.35","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8204.49","","","","","","","fee schedule","7813.8","27624.35","MSDRG Base Rate"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","392","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7813.8","","","","","","","fee schedule","7813.8","27624.35","Psych-Case Rate"
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37271.69","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39862.55","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52236.34","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43312.24","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37382.04","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47777.49","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35681.98","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56669.6","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42619.75","","","","","","","fee schedule","14532.1","56669.6",""
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12075.03","12075.03","12075.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","39576.74","38943.15","39576.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50512.96","50512.96","50512.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13129.38","13129.38","13129.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14617.91","14617.91","37291.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12890.48","12890.48","13195.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","36355","36355","36355","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14214.84","14214.84","14214.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","42948.36","42948.36","42948.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15222.37","","","","","","","fee schedule","14532.1","56669.6","MSDRG Base Rate"
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14968.06","","","","","","","fee schedule","14532.1","56669.6","MSDRG Base Rate"
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14532.1","","","","","","","fee schedule","14532.1","56669.6","Transplants-Case Rate"
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14822.74","","","","","","","fee schedule","14532.1","56669.6","MSDRG Base Rate"
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15258.71","","","","","","","fee schedule","14532.1","56669.6","MSDRG Base Rate"
"Other Digestive System Diagnoses With Mcc","393","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14532.1","","","","","","","fee schedule","14532.1","56669.6","Psych-Case Rate"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21806.49","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23322.32","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30561.83","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25340.63","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21871.05","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27953.1","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20876.4","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33155.59","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24935.47","","","","","","","fee schedule","9093.2","33155.59",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","7329.67","7329.67","7329.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","12552.56","12552.56","12552.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25275.58","17417.91","29005.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6631.72","6631.72","8970.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1769.2","1769.2","8829.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8740.52","8740.52","8740.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20666","17673.44","20666","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8685.4","8685.4","8685.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5894.09","5894.09","6978.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9525.13","","","","","","","fee schedule","9093.2","33155.59","MSDRG Base Rate"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9366","","","","","","","fee schedule","9093.2","33155.59","MSDRG Base Rate"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9093.2","","","","","","","fee schedule","9093.2","33155.59","Transplants-Case Rate"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9275.06","","","","","","","fee schedule","9093.2","33155.59","MSDRG Base Rate"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9547.86","","","","","","","fee schedule","9093.2","33155.59","MSDRG Base Rate"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9093.2","","","","","","","fee schedule","9093.2","33155.59","Psych-Case Rate"
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15124.95","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16176.33","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21197.64","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17576.22","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15169.73","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19388.23","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14479.84","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22996.67","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17295.2","","","","","","","fee schedule","6743.39","22996.67",""
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","25457.33","25457.33","25457.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7674.95","7674.95","7674.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19931.41","19931.41","19931.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1395.88","1395.88","1395.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","3949.41","3949.41","3949.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","16745","16745","16745","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7063.7","","","","","","","fee schedule","6743.39","22996.67","MSDRG Base Rate"
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6945.69","","","","","","","fee schedule","6743.39","22996.67","MSDRG Base Rate"
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6743.39","","","","","","","fee schedule","6743.39","22996.67","Transplants-Case Rate"
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6878.26","","","","","","","fee schedule","6743.39","22996.67","MSDRG Base Rate"
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7080.56","","","","","","","fee schedule","6743.39","22996.67","MSDRG Base Rate"
"Other Digestive System Diagnoses Without Cc/Mcc","395","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6743.39","","","","","","","fee schedule","6743.39","22996.67","Psych-Case Rate"
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Age 0-17","396","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","55813.14","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","59692.88","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","78222.22","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","64858.68","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","55978.39","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","71545.24","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","53432.61","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","84860.89","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","63821.69","","","","","","","fee schedule","21052.89","84860.89",""
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","9317.21","9317.21","9317.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22052.9","","","","","","","fee schedule","21052.89","84860.89","MSDRG Base Rate"
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21684.48","","","","","","","fee schedule","21052.89","84860.89","MSDRG Base Rate"
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21052.89","","","","","","","fee schedule","21052.89","84860.89","Transplants-Case Rate"
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21473.95","","","","","","","fee schedule","21052.89","84860.89","MSDRG Base Rate"
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22105.53","","","","","","","fee schedule","21052.89","84860.89","MSDRG Base Rate"
"Appendix Procedures With Mcc","397","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21052.89","","","","","","","fee schedule","21052.89","84860.89","Psych-Case Rate"
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35274.45","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37726.48","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49437.2","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40991.32","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35378.89","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45217.29","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33769.93","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53632.9","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40335.93","","","","","","","fee schedule","13829.7","53632.9",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","42104.23","42104.23","42104.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32725","32725","32725","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13108.09","13108.09","13108.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14486.61","","","","","","","fee schedule","13829.7","53632.9","MSDRG Base Rate"
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14244.59","","","","","","","fee schedule","13829.7","53632.9","MSDRG Base Rate"
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13829.7","","","","","","","fee schedule","13829.7","53632.9","Transplants-Case Rate"
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14106.29","","","","","","","fee schedule","13829.7","53632.9","MSDRG Base Rate"
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14521.19","","","","","","","fee schedule","13829.7","53632.9","MSDRG Base Rate"
"Appendix Procedures With Cc","398","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13829.7","","","","","","","fee schedule","13829.7","53632.9","Psych-Case Rate"
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26677.23","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28531.65","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37388.19","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31000.77","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26756.22","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34196.77","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25539.4","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40561.3","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30505.11","","","","","","","fee schedule","10806.18","40561.3",""
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","37848.14","37848.14","37848.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9163.98","9163.98","9163.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22374.35","22374.35","22374.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","32672.24","32672.24","32672.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11319.47","","","","","","","fee schedule","10806.18","40561.3","MSDRG Base Rate"
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11130.37","","","","","","","fee schedule","10806.18","40561.3","MSDRG Base Rate"
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10806.18","","","","","","","fee schedule","10806.18","40561.3","Transplants-Case Rate"
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11022.3","","","","","","","fee schedule","10806.18","40561.3","MSDRG Base Rate"
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11346.49","","","","","","","fee schedule","10806.18","40561.3","MSDRG Base Rate"
"Appendix Procedures Without Cc/Mcc","399","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10806.18","","","","","","","fee schedule","10806.18","40561.3","Psych-Case Rate"
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","400","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w other O.R. proc w CC","401","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","93697.75","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","100210.96","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","131317.57","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","108883.18","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","93975.17","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","120108.42","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","89701.38","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","142462.4","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","107142.3","","","","","","","fee schedule","34376.4","142462.4",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","87418.11","87418.11","87418.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","93163.87","93163.87","93163.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","116677.45","113135","122526.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","32173.27","32173.27","32959.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","32578.16","32578.16","32578.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","85932.87","85932.87","85932.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","118215.29","118215.29","118215.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36009.28","","","","","","","fee schedule","34376.4","142462.4","MSDRG Base Rate"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35407.69","","","","","","","fee schedule","34376.4","142462.4","MSDRG Base Rate"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34376.4","","","","","","","fee schedule","34376.4","142462.4","Transplants-Case Rate"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35063.93","","","","","","","fee schedule","34376.4","142462.4","MSDRG Base Rate"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36095.22","","","","","","","fee schedule","34376.4","142462.4","MSDRG Base Rate"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34376.4","","","","","","","fee schedule","34376.4","142462.4","Psych-Case Rate"
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & non-acute leukemia w CC","403","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma & Non-Acute Leukemia w/o CC","404","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","127490","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","136352.21","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","178677.47","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","148152.08","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","127867.47","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","163425.72","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","122052.33","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","193841.7","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","145783.35","","","","","","","fee schedule","46260.68","193841.7",""
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","58313.25","58313.25","58313.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","96778.26","96778.26","96778.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","47592.08","47592.08","124564.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","44555.16","44555.16","139149.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","30521.17","30521.17","30521.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","119181","119181","119181","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","167417.85","167417.85","167417.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4677.19","4677.19","4677.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48458.06","","","","","","","fee schedule","46260.68","193841.7","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47648.5","","","","","","","fee schedule","46260.68","193841.7","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46260.68","","","","","","","fee schedule","46260.68","193841.7","Transplants-Case Rate"
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47185.89","","","","","","","fee schedule","46260.68","193841.7","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48573.71","","","","","","","fee schedule","46260.68","193841.7","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Mcc","405","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46260.68","","","","","","","fee schedule","46260.68","193841.7","Psych-Case Rate"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","67589.16","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","72287.49","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","94726.33","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","78543.22","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","67789.27","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","86640.57","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64706.36","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","102765.69","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","77287.43","","","","","","","fee schedule","25194.35","102765.69",""
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","69311.88","69311.88","69311.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","87956.28","87106.28","146633.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24333.37","24333.37","24333.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","90256.62","90256.62","156479.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","21996.56","21036.67","25540.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","61654","57223","63674","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","23710.01","23710.01","23710.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","74828","74828","74828","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","22733.19","22733.19","24710.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","77287.43","77287.43","77287.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26391.08","","","","","","","fee schedule","25194.35","102765.69","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25950.18","","","","","","","fee schedule","25194.35","102765.69","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25194.35","","","","","","","fee schedule","25194.35","102765.69","Transplants-Case Rate"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25698.24","","","","","","","fee schedule","25194.35","102765.69","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26454.07","","","","","","","fee schedule","25194.35","102765.69","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures With Cc","406","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25194.35","","","","","","","fee schedule","25194.35","102765.69","Psych-Case Rate"
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51727.78","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","55323.53","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","72496.58","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","60111.21","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51880.93","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","66308.33","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49521.5","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","78649.31","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","59150.12","","","","","","","fee schedule","19616.12","78649.31",""
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","44799.55","44799.55","44799.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","63698.1","63698.1","63698.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","47651.83","47651.83","47651.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","63681.27","63681.27","63681.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18038.51","18038.51","18112.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","43887","43887","43887","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17177.95","17177.95","17177.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","52322","52322","52322","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","56916.93","56916.93","56916.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20547.89","","","","","","","fee schedule","19616.12","78649.31","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20204.6","","","","","","","fee schedule","19616.12","78649.31","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19616.12","","","","","","","fee schedule","19616.12","78649.31","Transplants-Case Rate"
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20008.44","","","","","","","fee schedule","19616.12","78649.31","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20596.93","","","","","","","fee schedule","19616.12","78649.31","MSDRG Base Rate"
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","407","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19616.12","","","","","","","fee schedule","19616.12","78649.31","Psych-Case Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","83096.31","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","88872.58","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","116459.63","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","96563.58","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83342.33","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","106518.73","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79552.1","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126343.47","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","95019.67","","","","","","","fee schedule","30648.01","126343.47",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","29265.33","29265.33","29265.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32103.79","","","","","","","fee schedule","30648.01","126343.47","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31567.45","","","","","","","fee schedule","30648.01","126343.47","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30648.01","","","","","","","fee schedule","30648.01","126343.47","Transplants-Case Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31260.97","","","","","","","fee schedule","30648.01","126343.47","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32180.41","","","","","","","fee schedule","30648.01","126343.47","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","408","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30648.01","","","","","","","fee schedule","30648.01","126343.47","Psych-Case Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","50741.98","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54269.2","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71114.97","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","58965.64","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","50892.21","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65044.66","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48577.74","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77150.45","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58022.87","","","","","","","fee schedule","19269.42","77150.45",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20184.72","","","","","","","fee schedule","19269.42","77150.45","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19847.5","","","","","","","fee schedule","19269.42","77150.45","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19269.42","","","","","","","fee schedule","19269.42","77150.45","Transplants-Case Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19654.81","","","","","","","fee schedule","19269.42","77150.45","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20232.89","","","","","","","fee schedule","19269.42","77150.45","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","409","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19269.42","","","","","","","fee schedule","19269.42","77150.45","Psych-Case Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37001.35","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39573.42","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51857.46","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42998.09","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37110.9","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47430.95","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35423.17","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56258.56","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42310.62","","","","","","","fee schedule","14437.03","56258.56",""
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15122.79","","","","","","","fee schedule","14437.03","56258.56","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14870.14","","","","","","","fee schedule","14437.03","56258.56","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14437.03","","","","","","","fee schedule","14437.03","56258.56","Transplants-Case Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14725.77","","","","","","","fee schedule","14437.03","56258.56","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15158.88","","","","","","","fee schedule","14437.03","56258.56","MSDRG Base Rate"
"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","410","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14437.03","","","","","","","fee schedule","14437.03","56258.56","Psych-Case Rate"
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","76983.41","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","82334.75","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","107892.38","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","89459.97","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","77211.33","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","98682.78","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","73699.93","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","117049.13","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","88029.64","","","","","","","fee schedule","28498.18","117049.13",""
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29851.84","","","","","","","fee schedule","28498.18","117049.13","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29353.13","","","","","","","fee schedule","28498.18","117049.13","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28498.18","","","","","","","fee schedule","28498.18","117049.13","Transplants-Case Rate"
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29068.14","","","","","","","fee schedule","28498.18","117049.13","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29923.09","","","","","","","fee schedule","28498.18","117049.13","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Mcc","411","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28498.18","","","","","","","fee schedule","28498.18","117049.13","Psych-Case Rate"
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48998.76","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52404.81","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68671.86","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56939.91","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49143.84","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62810.09","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46908.88","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","74499.99","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56029.52","","","","","","","fee schedule","18656.36","74499.99",""
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16791.7","16791.7","16791.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19542.54","","","","","","","fee schedule","18656.36","74499.99","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19216.05","","","","","","","fee schedule","18656.36","74499.99","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18656.36","","","","","","","fee schedule","18656.36","74499.99","Transplants-Case Rate"
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19029.49","","","","","","","fee schedule","18656.36","74499.99","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19589.18","","","","","","","fee schedule","18656.36","74499.99","MSDRG Base Rate"
"Cholecystectomy With C.D.E. With Cc","412","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18656.36","","","","","","","fee schedule","18656.36","74499.99","Psych-Case Rate"
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38697.95","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41387.96","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54235.25","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44969.66","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38812.53","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49605.78","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37047.42","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58838.16","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44250.66","","","","","","","fee schedule","15033.7","58838.16",""
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","52005.2","52005.2","52005.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","83119.26","83119.26","83119.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15747.8","","","","","","","fee schedule","15033.7","58838.16","MSDRG Base Rate"
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15484.71","","","","","","","fee schedule","15033.7","58838.16","MSDRG Base Rate"
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15033.7","","","","","","","fee schedule","15033.7","58838.16","Transplants-Case Rate"
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15334.37","","","","","","","fee schedule","15033.7","58838.16","MSDRG Base Rate"
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15785.39","","","","","","","fee schedule","15033.7","58838.16","MSDRG Base Rate"
"Cholecystectomy With C.D.E. Without Cc/Mcc","413","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15033.7","","","","","","","fee schedule","15033.7","58838.16","Psych-Case Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","83026.39","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","88797.81","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","116361.64","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","96482.33","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83272.21","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","106429.11","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79485.17","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126237.17","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","94939.73","","","","","","","fee schedule","30623.42","126237.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","1703.02","1703.02","1703.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24960.95","24960.95","24960.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","109171.05","109171.05","109171.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32078.03","","","","","","","fee schedule","30623.42","126237.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31542.12","","","","","","","fee schedule","30623.42","126237.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30623.42","","","","","","","fee schedule","30623.42","126237.17","Transplants-Case Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31235.89","","","","","","","fee schedule","30623.42","126237.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32154.59","","","","","","","fee schedule","30623.42","126237.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","414","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30623.42","","","","","","","fee schedule","30623.42","126237.17","Psych-Case Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48164.44","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51512.5","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","67502.56","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","55970.37","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48307.05","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","61740.6","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46110.14","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73231.45","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55075.49","","","","","","","fee schedule","18362.94","73231.45",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","45019.58","45019.58","45019.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","43026.6","43026.6","43026.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19235.18","","","","","","","fee schedule","18362.94","73231.45","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18913.83","","","","","","","fee schedule","18362.94","73231.45","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18362.94","","","","","","","fee schedule","18362.94","73231.45","Transplants-Case Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18730.2","","","","","","","fee schedule","18362.94","73231.45","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19281.09","","","","","","","fee schedule","18362.94","73231.45","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18362.94","","","","","","","fee schedule","18362.94","73231.45","Psych-Case Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31771.71","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33980.25","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44528.1","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36920.89","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31865.77","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40727.22","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30416.59","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48307.17","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36330.58","","","","","","","fee schedule","12597.83","48307.17",""
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13196.23","","","","","","","fee schedule","12597.83","48307.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12975.76","","","","","","","fee schedule","12597.83","48307.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12597.83","","","","","","","fee schedule","12597.83","48307.17","Transplants-Case Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12849.79","","","","","","","fee schedule","12597.83","48307.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13227.72","","","","","","","fee schedule","12597.83","48307.17","MSDRG Base Rate"
"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","416","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12597.83","","","","","","","fee schedule","12597.83","48307.17","Psych-Case Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","55615.05","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","59481.02","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","77944.6","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","64628.48","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","55779.71","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","71291.31","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","53242.97","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","84559.7","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","63595.17","","","","","","","fee schedule","20983.22","84559.7",""
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","56795.97","56795.97","56795.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","56439.39","56439.39","56439.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21596","21596","21596","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","44786.73","44786.73","44786.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","38439.56","38439.56","38439.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21979.92","","","","","","","fee schedule","20983.22","84559.7","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21612.72","","","","","","","fee schedule","20983.22","84559.7","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20983.22","","","","","","","fee schedule","20983.22","84559.7","Transplants-Case Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21402.88","","","","","","","fee schedule","20983.22","84559.7","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22032.38","","","","","","","fee schedule","20983.22","84559.7","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","417","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20983.22","","","","","","","fee schedule","20983.22","84559.7","Psych-Case Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39422.74","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42163.13","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55251.04","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45811.91","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39539.46","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50534.86","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37741.29","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59940.15","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45079.45","","","","","","","fee schedule","15288.6","59940.15",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","18377.38","18377.38","18377.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","36726.51","36513.97","36920.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45305.59","43770.47","51939.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13249.53","13249.53","13249.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","37000.56","37000.56","37000.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13147.92","13147.92","14637.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35912","35912","35912","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","57105","57105","57105","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16014.81","","","","","","","fee schedule","15288.6","59940.15","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15747.26","","","","","","","fee schedule","15288.6","59940.15","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15288.6","","","","","","","fee schedule","15288.6","59940.15","Transplants-Case Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15594.37","","","","","","","fee schedule","15288.6","59940.15","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16053.03","","","","","","","fee schedule","15288.6","59940.15","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15288.6","","","","","","","fee schedule","15288.6","59940.15","Psych-Case Rate"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31829.97","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34042.57","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44609.76","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36988.6","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31924.21","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40801.91","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30472.36","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48395.76","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36397.2","","","","","","","fee schedule","12618.32","48395.76",""
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","31106.83","31106.83","31106.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","30911.68","30911.68","30911.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","40565.91","35246.59","40965.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12029.7","12029.7","12029.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","50474.51","50474.51","50474.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","24691.82","24691.82","24691.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10750.1","10750.1","10750.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11780.04","11780.04","11780.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26938.2","26938.2","29486","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","33931.21","33931.21","33931.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13217.69","","","","","","","fee schedule","12618.32","48395.76","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12996.87","","","","","","","fee schedule","12618.32","48395.76","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12618.32","","","","","","","fee schedule","12618.32","48395.76","Transplants-Case Rate"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12870.69","","","","","","","fee schedule","12618.32","48395.76","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13249.24","","","","","","","fee schedule","12618.32","48395.76","MSDRG Base Rate"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","419","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12618.32","","","","","","","fee schedule","12618.32","48395.76","Psych-Case Rate"
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","79402.47","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","84921.97","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","111282.7","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","92271.08","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","79637.56","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","101783.71","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","76015.81","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","120727.18","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","90795.81","","","","","","","fee schedule","29348.94","120727.18",""
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","299467.95","299467.95","299467.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2416.52","2416.52","2416.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6976.64","6661.98","11385.64","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","29750.76","29750.76","29750.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6976.64","6661.98","11385.64","63","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","76284","76284","76284","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6913.38","6913.38","11282.4","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30743.01","","","","","","","fee schedule","29348.94","120727.18","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30229.41","","","","","","","fee schedule","29348.94","120727.18","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29348.94","","","","","","","fee schedule","29348.94","120727.18","Transplants-Case Rate"
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","29935.92","","","","","","","fee schedule","29348.94","120727.18","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30816.39","","","","","","","fee schedule","29348.94","120727.18","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Mcc","420","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29348.94","","","","","","","fee schedule","29348.94","120727.18","Psych-Case Rate"
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40492.44","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43307.19","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56750.23","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47054.98","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40612.33","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51906.08","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38765.36","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61566.58","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46302.64","","","","","","","fee schedule","15664.8","61566.58",""
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2268.94","2268.94","2268.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","36884.82","36884.82","36884.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14671.25","14671.25","14671.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15184.44","10487.96","48792.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10883.73","10883.73","10883.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16408.88","","","","","","","fee schedule","15664.8","61566.58","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16134.74","","","","","","","fee schedule","15664.8","61566.58","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15664.8","","","","","","","fee schedule","15664.8","61566.58","Transplants-Case Rate"
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15978.1","","","","","","","fee schedule","15664.8","61566.58","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16448.04","","","","","","","fee schedule","15664.8","61566.58","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures With Cc","421","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15664.8","","","","","","","fee schedule","15664.8","61566.58","Psych-Case Rate"
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32615.35","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34882.54","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45710.47","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37901.26","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32711.91","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41808.66","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31224.24","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49589.88","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37295.28","","","","","","","fee schedule","12894.53","49589.88",""
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10188.67","10188.67","10188.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","46020.14","46020.14","46020.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12955.82","12955.82","12955.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7328.18","7328.18","10188.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12674.13","12674.13","12674.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10573.15","10573.15","10573.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13507.02","","","","","","","fee schedule","12894.53","49589.88","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13281.37","","","","","","","fee schedule","12894.53","49589.88","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12894.53","","","","","","","fee schedule","12894.53","49589.88","Transplants-Case Rate"
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13152.42","","","","","","","fee schedule","12894.53","49589.88","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13539.26","","","","","","","fee schedule","12894.53","49589.88","MSDRG Base Rate"
"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","422","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12894.53","","","","","","","fee schedule","12894.53","49589.88","Psych-Case Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","96785.67","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","103513.53","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","135645.29","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","112471.55","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","97072.22","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","124066.72","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","92657.58","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","147157.4","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","110673.3","","","","","","","fee schedule","35462.37","147157.4",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","166939.48","166939.48","166939.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","3645.4","3645.4","3645.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","58920.89","58920.89","58920.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13804.31","13804.31","13804.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37146.83","","","","","","","fee schedule","35462.37","147157.4","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36526.24","","","","","","","fee schedule","35462.37","147157.4","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35462.37","","","","","","","fee schedule","35462.37","147157.4","Transplants-Case Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36171.62","","","","","","","fee schedule","35462.37","147157.4","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37235.49","","","","","","","fee schedule","35462.37","147157.4","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","423","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35462.37","","","","","","","fee schedule","35462.37","147157.4","Psych-Case Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","50989.01","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54533.41","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71461.19","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59252.71","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51139.97","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65361.32","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48814.24","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77526.05","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58305.35","","","","","","","fee schedule","19356.3","77526.05",""
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12935.48","12935.48","12935.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","51020.34","51020.34","51020.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17971.35","17971.35","17971.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13546.44","13546.44","13546.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20718.17","20718.17","20718.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20275.72","","","","","","","fee schedule","19356.3","77526.05","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19936.99","","","","","","","fee schedule","19356.3","77526.05","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19356.3","","","","","","","fee schedule","19356.3","77526.05","Transplants-Case Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19743.43","","","","","","","fee schedule","19356.3","77526.05","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20324.12","","","","","","","fee schedule","19356.3","77526.05","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","424","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19356.3","","","","","","","fee schedule","19356.3","77526.05","Psych-Case Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34964.49","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37394.98","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49002.8","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40631.12","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35068.01","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44819.96","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33473.19","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53161.63","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39981.49","","","","","","","fee schedule","13720.69","53161.63",""
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","25228.93","25228.93","25228.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10896.59","8415.98","62634.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12423.69","12423.69","12423.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14372.42","","","","","","","fee schedule","13720.69","53161.63","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14132.31","","","","","","","fee schedule","13720.69","53161.63","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13720.69","","","","","","","fee schedule","13720.69","53161.63","Transplants-Case Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13995.1","","","","","","","fee schedule","13720.69","53161.63","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14406.72","","","","","","","fee schedule","13720.69","53161.63","MSDRG Base Rate"
"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","425","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13720.69","","","","","","","fee schedule","13720.69","53161.63","Psych-Case Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","256849.07","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","274703.41","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","359974.43","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","298476.14","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","257609.53","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","329247.33","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","245893.99","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","390525.2","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","293703.96","","","","","","","fee schedule","91754.53","390525.2",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","328623.69","328623.69","328623.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","30902.16","30902.16","30902.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","85715.95","85715.95","85715.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","84946.88","84946.88","90685.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","83954.27","83954.27","83954.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","30902.16","29508.43","30902.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","64237.87","64237.87","64237.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","14248.4","14248.4","14248.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","96112.87","","","","","","","fee schedule","91754.53","390525.2","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","94507.17","","","","","","","fee schedule","91754.53","390525.2","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","91754.53","","","","","","","fee schedule","91754.53","390525.2","Transplants-Case Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","93589.62","","","","","","","fee schedule","91754.53","390525.2","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","96342.26","","","","","","","fee schedule","91754.53","390525.2","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","426","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","91754.53","","","","","","","fee schedule","91754.53","390525.2","Psych-Case Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","168229.47","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","179923.61","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","235773.91","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","195494.13","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","168727.56","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","215648.46","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","161054.18","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","255783.87","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","192368.47","","","","","","","fee schedule","60588.21","255783.87",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","106985.37","106985.37","106985.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","132121.56","132121.56","132121.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","158513.48","158513.48","158513.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","89307.82","89307.82","89307.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","174422.49","131191.27","222449.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","16741.94","16741.94","16741.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","58807.19","57304.23","59528.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","112366.54","112366.54","112366.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","57419.65","57085.52","59083.08","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","153584.22","145914","156440.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","60056.42","57384.09","72855.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9910.97","9910.97","10379.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","126800.79","126800.79","126800.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","57969.4","55999.79","64090.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63466.15","","","","","","","fee schedule","60588.21","255783.87","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","62405.86","","","","","","","fee schedule","60588.21","255783.87","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","60588.21","","","","","","","fee schedule","60588.21","255783.87","Transplants-Case Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61799.97","","","","","","","fee schedule","60588.21","255783.87","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63617.62","","","","","","","fee schedule","60588.21","255783.87","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60588.21","","","","","","","fee schedule","60588.21","255783.87","Psych-Case Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","131020.71","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","140128.35","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","183625.76","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","152255","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","131408.63","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","167951.63","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","125432.44","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","199209.95","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","149820.68","","","","","","","fee schedule","47502.38","199209.95",""
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","172169.3","172169.3","172169.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","45923.96","45923.96","45923.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","121864.29","121864.29","121864.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","46596.25","44324.18","46987.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","120367","120367","120367","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","49758.74","","","","","","","fee schedule","47502.38","199209.95","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48927.45","","","","","","","fee schedule","47502.38","199209.95","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47502.38","","","","","","","fee schedule","47502.38","199209.95","Transplants-Case Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","48452.43","","","","","","","fee schedule","47502.38","199209.95","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49877.5","","","","","","","fee schedule","47502.38","199209.95","MSDRG Base Rate"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","428","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47502.38","","","","","","","fee schedule","47502.38","199209.95","Psych-Case Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","209968.73","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","224564.28","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","294271.56","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","243997.99","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","210590.39","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","269152.79","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","201013.19","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","319246.17","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","240096.83","","","","","","","fee schedule","75267.34","319246.17",""
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","67586.01","67586.01","67586.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","68976.86","68976.86","68976.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","78842.54","","","","","","","fee schedule","75267.34","319246.17","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","77525.36","","","","","","","fee schedule","75267.34","319246.17","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","75267.34","","","","","","","fee schedule","75267.34","319246.17","Transplants-Case Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","76772.69","","","","","","","fee schedule","75267.34","319246.17","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","79030.71","","","","","","","fee schedule","75267.34","319246.17","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","429","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","75267.34","","","","","","","fee schedule","75267.34","319246.17","Psych-Case Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","134402.27","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","143744.97","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","188365.02","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","156184.6","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","134800.2","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","172286.35","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","128669.77","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","204351.42","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","153687.45","","","","","","","fee schedule","48691.63","204351.42",""
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","170980.59","170980.59","170980.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","43611.43","43611.43","45073","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","112438","112438","112438","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51004.48","","","","","","","fee schedule","48691.63","204351.42","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50152.38","","","","","","","fee schedule","48691.63","204351.42","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48691.63","","","","","","","fee schedule","48691.63","204351.42","Transplants-Case Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49665.46","","","","","","","fee schedule","48691.63","204351.42","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51126.21","","","","","","","fee schedule","48691.63","204351.42","MSDRG Base Rate"
"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","430","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48691.63","","","","","","","fee schedule","48691.63","204351.42","Psych-Case Rate"
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Childhood Mental Disorders","431","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45868.9","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49057.39","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","64285.35","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","53302.79","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46004.71","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58798.01","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43912.51","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","69741.2","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","52450.56","","","","","","","fee schedule","17555.63","69741.2",""
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48053.64","48053.64","49271.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17310.93","17310.93","33089.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15197.78","14992.87","17049.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16934.24","16934.24","16934.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12886.56","12886.56","12886.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","41284.74","41284.74","41284.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","50547","50547","50547","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15963.23","15709.72","17348.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18389.52","","","","","","","fee schedule","17555.63","69741.2","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18082.3","","","","","","","fee schedule","17555.63","69741.2","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17555.63","","","","","","","fee schedule","17555.63","69741.2","Transplants-Case Rate"
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17906.74","","","","","","","fee schedule","17555.63","69741.2","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18433.41","","","","","","","fee schedule","17555.63","69741.2","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Mcc","432","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17555.63","","","","","","","fee schedule","17555.63","69741.2","Psych-Case Rate"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24614.74","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26325.79","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34497.6","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28604.01","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24687.62","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31552.92","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23564.88","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37425.39","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28146.67","","","","","","","fee schedule","10080.83","37425.39",""
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25567.15","25567.15","25567.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33505.07","33505.07","33505.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9224.57","9224.57","9224.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22485","22485","23485","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8510.12","8510.12","8510.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10559.67","","","","","","","fee schedule","10080.83","37425.39","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10383.25","","","","","","","fee schedule","10080.83","37425.39","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10080.83","","","","","","","fee schedule","10080.83","37425.39","Transplants-Case Rate"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10282.45","","","","","","","fee schedule","10080.83","37425.39","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10584.87","","","","","","","fee schedule","10080.83","37425.39","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10080.83","","","","","","","fee schedule","10080.83","37425.39","Psych-Case Rate"
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16604.81","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17759.06","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23271.68","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19295.93","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16653.98","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21285.23","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15896.59","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25246.73","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18987.41","","","","","","","fee schedule","7263.84","25246.73",""
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7608.87","","","","","","","fee schedule","7263.84","25246.73","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7481.76","","","","","","","fee schedule","7263.84","25246.73","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7263.84","","","","","","","fee schedule","7263.84","25246.73","Transplants-Case Rate"
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7409.12","","","","","","","fee schedule","7263.84","25246.73","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7627.03","","","","","","","fee schedule","7263.84","25246.73","MSDRG Base Rate"
"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","434","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7263.84","","","","","","","fee schedule","7263.84","25246.73","Psych-Case Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42804.29","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45779.75","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59990.3","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49741.51","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42931.03","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54869.58","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40978.61","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","65081.63","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48946.22","","","","","","","fee schedule","16477.85","65081.63",""
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","74893.15","74893.15","74893.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25160.8","25160.8","25160.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","54416.87","54416.87","56087.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16228.35","14758.35","16238.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24239.74","24239.74","24239.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16031.23","16031.23","16031.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14338.7","14338.7","14489.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","47321","47321","47321","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17260.55","","","","","","","fee schedule","16477.85","65081.63","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16972.19","","","","","","","fee schedule","16477.85","65081.63","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16477.85","","","","","","","fee schedule","16477.85","65081.63","Transplants-Case Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16807.41","","","","","","","fee schedule","16477.85","65081.63","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17301.74","","","","","","","fee schedule","16477.85","65081.63","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","435","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16477.85","","","","","","","fee schedule","16477.85","65081.63","Psych-Case Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26360.29","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28192.67","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36943.99","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30632.45","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26438.33","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33790.48","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25235.97","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40079.4","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30142.68","","","","","","","fee schedule","10694.71","40079.4",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","32710.84","32710.84","32710.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10531.71","10531.71","10531.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8592.52","8592.52","8592.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9742.53","9742.53","9742.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11202.71","","","","","","","fee schedule","10694.71","40079.4","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11015.55","","","","","","","fee schedule","10694.71","40079.4","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10694.71","","","","","","","fee schedule","10694.71","40079.4","Transplants-Case Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10908.6","","","","","","","fee schedule","10694.71","40079.4","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11229.45","","","","","","","fee schedule","10694.71","40079.4","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10694.71","","","","","","","fee schedule","10694.71","40079.4","Psych-Case Rate"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19886.16","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21268.5","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27870.48","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23109.07","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19945.03","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25491.48","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19037.98","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30235.83","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22739.59","","","","","","","fee schedule","8417.85","30235.83",""
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8817.7","","","","","","","fee schedule","8417.85","30235.83","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8670.39","","","","","","","fee schedule","8417.85","30235.83","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8417.85","","","","","","","fee schedule","8417.85","30235.83","Transplants-Case Rate"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8586.21","","","","","","","fee schedule","8417.85","30235.83","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8838.74","","","","","","","fee schedule","8417.85","30235.83","MSDRG Base Rate"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","437","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8417.85","","","","","","","fee schedule","8417.85","30235.83","Psych-Case Rate"
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37991.81","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40632.74","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53245.59","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44149.08","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38104.29","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48700.59","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36371.39","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57764.51","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43443.2","","","","","","","fee schedule","14785.36","57764.51",""
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","20409.97","20409.97","20409.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","32190.48","32190.48","32190.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45963.11","45963.11","45963.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14560.79","14560.79","14560.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","34962.9","13724.95","93903.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15487.66","","","","","","","fee schedule","14785.36","57764.51","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15228.92","","","","","","","fee schedule","14785.36","57764.51","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14785.36","","","","","","","fee schedule","14785.36","57764.51","Transplants-Case Rate"
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15081.07","","","","","","","fee schedule","14785.36","57764.51","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15524.63","","","","","","","fee schedule","14785.36","57764.51","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Mcc","438","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14785.36","","","","","","","fee schedule","14785.36","57764.51","Psych-Case Rate"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19604.17","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20966.91","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27475.27","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22781.38","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19662.21","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25130.01","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18768.01","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29807.08","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22417.14","","","","","","","fee schedule","8318.67","29807.08",""
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","32917.2","32917.2","32917.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20557.92","20557.92","20557.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23872.21","13314.6","26940.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6868.65","6868.65","7274.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18556.42","18556.42","18556.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6999.36","6999.36","6999.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8090.29","8090.29","8090.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18386","17223.55","18886","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6719.32","6719.32","6719.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","22309.29","22309.29","22309.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","16812.85","16812.85","16812.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8713.81","","","","","","","fee schedule","8318.67","29807.08","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8568.23","","","","","","","fee schedule","8318.67","29807.08","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8318.67","","","","","","","fee schedule","8318.67","29807.08","Transplants-Case Rate"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8485.04","","","","","","","fee schedule","8318.67","29807.08","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8734.6","","","","","","","fee schedule","8318.67","29807.08","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8318.67","","","","","","","fee schedule","8318.67","29807.08","Psych-Case Rate"
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14481.73","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15488.4","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20296.17","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16828.75","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14524.6","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18563.7","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","13864.06","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22018.69","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16559.69","","","","","","","fee schedule","6517.18","22018.69",""
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","385106.35","385106.35","385106.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18344.74","18344.74","18344.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","114268.18","114268.18","119665.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","13505","13143","13505","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","3761.49","3761.49","3761.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","14051.11","14051.11","14051.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","16648.37","16648.37","16648.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6826.75","","","","","","","fee schedule","6517.18","22018.69","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6712.7","","","","","","","fee schedule","6517.18","22018.69","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6517.18","","","","","","","fee schedule","6517.18","22018.69","Transplants-Case Rate"
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6647.52","","","","","","","fee schedule","6517.18","22018.69","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6843.04","","","","","","","fee schedule","6517.18","22018.69","MSDRG Base Rate"
"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","440","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6517.18","","","","","","","fee schedule","6517.18","22018.69","Psych-Case Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41825.48","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44732.9","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58618.49","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48604.07","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41949.32","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53614.87","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40041.55","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63593.4","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47826.96","","","","","","","fee schedule","16133.61","63593.4",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","40102.57","40102.57","40102.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","30082.46","30082.46","30082.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","58855.44","58855.44","58855.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","1627.53","1575.34","16746.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","42176.71","42176.71","42176.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15179.71","15179.71","15179.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","24000.41","24000.41","24000.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26163.1","26163.1","26163.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16899.96","","","","","","","fee schedule","16133.61","63593.4","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16617.62","","","","","","","fee schedule","16133.61","63593.4","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16133.61","","","","","","","fee schedule","16133.61","63593.4","Transplants-Case Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16456.28","","","","","","","fee schedule","16133.61","63593.4","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16940.29","","","","","","","fee schedule","16133.61","63593.4","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","441","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16133.61","","","","","","","fee schedule","16133.61","63593.4","Psych-Case Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22496.32","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24060.1","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31528.63","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26142.25","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22562.92","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28837.37","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21536.81","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34204.44","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25724.28","","","","","","","fee schedule","9335.8","34204.44",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28613.81","28613.81","28613.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","19431.35","19431.35","19431.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9186.43","9186.43","9186.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","21556.89","21556.89","21556.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","708.72","708.72","708.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8118.77","8118.77","8118.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12630.44","12630.44","12630.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19860","19860","19860","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","32617","32617","32617","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","19943.2","19943.2","19943.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7666.26","7616.15","8939.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9779.25","","","","","","","fee schedule","9335.8","34204.44","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9615.87","","","","","","","fee schedule","9335.8","34204.44","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9335.8","","","","","","","fee schedule","9335.8","34204.44","Transplants-Case Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9522.52","","","","","","","fee schedule","9335.8","34204.44","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9802.59","","","","","","","fee schedule","9335.8","34204.44","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9335.8","","","","","","","fee schedule","9335.8","34204.44","Psych-Case Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16306.51","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17440.02","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22853.6","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18949.28","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16354.79","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20902.84","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15611.01","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24793.17","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18646.31","","","","","","","fee schedule","7158.93","24793.17",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15667.9","15667.9","15667.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15667.9","12600.15","50368.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7498.98","","","","","","","fee schedule","7158.93","24793.17","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7373.7","","","","","","","fee schedule","7158.93","24793.17","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7158.93","","","","","","","fee schedule","7158.93","24793.17","Transplants-Case Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7302.11","","","","","","","fee schedule","7158.93","24793.17","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7516.88","","","","","","","fee schedule","7158.93","24793.17","MSDRG Base Rate"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","443","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7158.93","","","","","","","fee schedule","7158.93","24793.17","Psych-Case Rate"
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38940.32","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41647.18","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54574.94","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45251.31","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39055.62","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49916.47","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37279.45","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59206.67","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44527.81","","","","","","","fee schedule","15118.94","59206.67",""
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","20532.73","20532.73","20532.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48011.33","48011.33","52753.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14061.27","14061.27","14728.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","37580.65","37580.65","37580.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14065.9","12482.07","14857.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14210.81","14210.81","14210.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22085.28","22085.28","22085.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35483","35483","35483","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","38374.64","38374.64","38374.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15837.09","","","","","","","fee schedule","15118.94","59206.67","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15572.51","","","","","","","fee schedule","15118.94","59206.67","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15118.94","","","","","","","fee schedule","15118.94","59206.67","Transplants-Case Rate"
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15421.32","","","","","","","fee schedule","15118.94","59206.67","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15874.89","","","","","","","fee schedule","15118.94","59206.67","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Mcc","444","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15118.94","","","","","","","fee schedule","15118.94","59206.67","Psych-Case Rate"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25504.99","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27277.92","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35745.29","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29638.54","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25580.51","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32694.11","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24417.16","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38778.97","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29164.67","","","","","","","fee schedule","10393.91","38778.97",""
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25208.65","25208.65","25208.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33965.46","33965.46","33965.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","15135.51","15135.51","15135.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8579.91","8579.91","8816.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","25885.35","25885.35","25885.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","23808","23272.47","24028","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9725.37","9082.06","11001.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","16625.72","16625.72","16625.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3328.24","3328.24","3328.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10887.62","","","","","","","fee schedule","10393.91","38778.97","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10705.73","","","","","","","fee schedule","10393.91","38778.97","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10393.91","","","","","","","fee schedule","10393.91","38778.97","Transplants-Case Rate"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10601.79","","","","","","","fee schedule","10393.91","38778.97","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10913.61","","","","","","","fee schedule","10393.91","38778.97","MSDRG Base Rate"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10393.91","","","","","","","fee schedule","10393.91","38778.97","Psych-Case Rate"
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19280.23","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20620.45","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27021.27","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22404.94","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19337.31","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24714.76","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18457.89","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29314.55","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22046.72","","","","","","","fee schedule","8204.75","29314.55",""
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17788.56","17788.56","17788.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7040.21","7040.21","7040.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11450.44","11450.44","11450.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17503","17503","17503","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8594.48","","","","","","","fee schedule","8204.75","29314.55","MSDRG Base Rate"
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8450.89","","","","","","","fee schedule","8204.75","29314.55","MSDRG Base Rate"
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8204.75","","","","","","","fee schedule","8204.75","29314.55","Transplants-Case Rate"
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8368.84","","","","","","","fee schedule","8204.75","29314.55","MSDRG Base Rate"
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8614.99","","","","","","","fee schedule","8204.75","29314.55","MSDRG Base Rate"
"Disorders Of The Biliary Tract Without Cc/Mcc","446","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8204.75","","","","","","","fee schedule","8204.75","29314.55","Psych-Case Rate"
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","155714.69","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","166538.88","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","218234.42","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","180951.09","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","156175.72","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","199606.12","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","149073.18","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","236755.81","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","178057.96","","","","","","","fee schedule","56186.92","236755.81",""
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","311305.56","311305.56","311305.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","55500.24","55500.24","55500.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","53383.93","53383.93","53383.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","34242.32","34242.32","34242.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","58855.8","","","","","","","fee schedule","56186.92","236755.81","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","57872.53","","","","","","","fee schedule","56186.92","236755.81","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","56186.92","","","","","","","fee schedule","56186.92","236755.81","Transplants-Case Rate"
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57310.66","","","","","","","fee schedule","56186.92","236755.81","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58996.27","","","","","","","fee schedule","56186.92","236755.81","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","447","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56186.92","","","","","","","fee schedule","56186.92","236755.81","Psych-Case Rate"
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","98831.84","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","105701.94","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","138513.01","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","114849.35","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","99124.46","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","126689.66","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","94616.49","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","150268.51","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","113013.08","","","","","","","fee schedule","36181.99","150268.51",""
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","94760.68","94760.68","94760.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","127591.14","116898.61","127791.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","33428.41","33159.38","36467.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","33400.23","32417.17","33888.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33142.6","33142.6","33421.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","89647","89647","89647","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","143161","143161","143161","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","34472.11","33336.69","34907.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","108821.19","108821.19","108821.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","108455.06","108455.06","108455.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37900.63","","","","","","","fee schedule","36181.99","150268.51","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37267.45","","","","","","","fee schedule","36181.99","150268.51","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36181.99","","","","","","","fee schedule","36181.99","150268.51","Transplants-Case Rate"
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36905.63","","","","","","","fee schedule","36181.99","150268.51","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37991.09","","","","","","","fee schedule","36181.99","150268.51","MSDRG Base Rate"
"Multiple Level Spinal Fusion Except Cervical Without Mcc","448","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36181.99","","","","","","","fee schedule","36181.99","150268.51","Psych-Case Rate"
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning & toxic Effects of Drugs Age >17 w CC","449","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","124206.33","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","132840.28","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","174075.4","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","144336.23","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","124574.07","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","159216.47","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","118908.71","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","188849.05","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","142028.51","","","","","","","fee schedule","45105.85","188849.05",""
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","42077.34","42077.34","42077.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","41137.09","41137.09","41137.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","112562","112562","112562","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","47248.38","","","","","","","fee schedule","45105.85","188849.05","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46459.03","","","","","","","fee schedule","45105.85","188849.05","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","45105.85","","","","","","","fee schedule","45105.85","188849.05","Transplants-Case Rate"
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","46007.97","","","","","","","fee schedule","45105.85","188849.05","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","47361.14","","","","","","","fee schedule","45105.85","188849.05","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","450","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","45105.85","","","","","","","fee schedule","45105.85","188849.05","Psych-Case Rate"
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75284.47","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80517.72","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","105511.32","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","87485.69","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75507.37","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","96504.97","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","72073.45","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","114465.99","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","86086.93","","","","","","","fee schedule","27900.69","114465.99",""
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","63072.73","63072.73","63072.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","73402.31","71210.22","73752.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","96650.43","96300.43","96650.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25490.41","25490.41","25490.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","80334.84","80334.84","80334.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25991.77","25381.83","27502.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","25753.23","25432.47","27758.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","73784.73","73784.73","73784.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","24499.21","24499.21","24499.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29225.97","","","","","","","fee schedule","27900.69","114465.99","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28737.71","","","","","","","fee schedule","27900.69","114465.99","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27900.69","","","","","","","fee schedule","27900.69","114465.99","Transplants-Case Rate"
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28458.7","","","","","","","fee schedule","27900.69","114465.99","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29295.72","","","","","","","fee schedule","27900.69","114465.99","MSDRG Base Rate"
"Single Level Spinal Fusion Except Cervical Without Mcc","451","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27900.69","","","","","","","fee schedule","27900.69","114465.99","Psych-Case Rate"
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications of treatment w CC","452","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","264725.46","","","","","","","fee schedule","236147.45","264725.46",""
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","236147.45","","","","","","","fee schedule","236147.45","264725.46",""
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Mcc","453","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","182718.35","","","","","","","fee schedule","162993.28","182718.35",""
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","162993.28","","","","","","","fee schedule","162993.28","182718.35",""
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion With Cc","454","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","137587.69","","","","","","","fee schedule","122734.63","137587.69",""
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","122734.63","","","","","","","fee schedule","122734.63","137587.69",""
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","455","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","195841.24","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","209454.75","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","274471.85","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","227580.88","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","196421.07","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","251043.17","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","187488.26","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","297766.08","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","223942.21","","","","","","","fee schedule","70298.89","297766.08",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","320668.95","320668.95","320668.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","66531.24","66531.24","66531.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","73638.09","","","","","","","fee schedule","70298.89","297766.08","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","72407.86","","","","","","","fee schedule","70298.89","297766.08","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","70298.89","","","","","","","fee schedule","70298.89","297766.08","Transplants-Case Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","71704.87","","","","","","","fee schedule","70298.89","297766.08","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","73813.83","","","","","","","fee schedule","70298.89","297766.08","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","456","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","70298.89","","","","","","","fee schedule","70298.89","297766.08","Psych-Case Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","138970.05","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","148630.27","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","194766.77","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","161492.67","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","139381.5","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","178141.65","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","133042.72","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","211296.49","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","158910.65","","","","","","","fee schedule","50298.06","211296.49",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","48417.28","48417.28","48417.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","49040.02","49040.02","49040.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","147405.31","147405.31","147405.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52687.22","","","","","","","fee schedule","50298.06","211296.49","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51807","","","","","","","fee schedule","50298.06","211296.49","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50298.06","","","","","","","fee schedule","50298.06","211296.49","Transplants-Case Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51304.02","","","","","","","fee schedule","50298.06","211296.49","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52812.96","","","","","","","fee schedule","50298.06","211296.49","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","457","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50298.06","","","","","","","fee schedule","50298.06","211296.49","Psych-Case Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","97242.44","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","104002.06","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","136285.46","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","113002.35","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","97530.35","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","124652.25","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","93094.88","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","147851.91","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","111195.62","","","","","","","fee schedule","35623.02","147851.91",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","135235.44","135235.44","135235.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37315.11","","","","","","","fee schedule","35623.02","147851.91","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36691.71","","","","","","","fee schedule","35623.02","147851.91","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35623.02","","","","","","","fee schedule","35623.02","147851.91","Transplants-Case Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36335.48","","","","","","","fee schedule","35623.02","147851.91","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37404.17","","","","","","","fee schedule","35623.02","147851.91","MSDRG Base Rate"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","458","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35623.02","","","","","","","fee schedule","35623.02","147851.91","Psych-Case Rate"
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","198133.33","","","","","","","fee schedule","176744.16","198133.33",""
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","176744.16","","","","","","","fee schedule","176744.16","198133.33",""
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical With Mcc","459","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","109276.1","","","","","","","fee schedule","97479.38","109276.1",""
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","97479.38","","","","","","","fee schedule","97479.38","109276.1",""
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Fusion Except Cervical Without Mcc","460","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","128713.52","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","137660.78","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","180392.23","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","149573.89","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","129094.6","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","164994.1","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","123223.65","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","195701.98","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","147182.43","","","","","","","fee schedule","46690.97","195701.98",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7547.73","7547.73","7547.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15734.36","15734.36","15734.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48908.79","","","","","","","fee schedule","46690.97","195701.98","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48091.7","","","","","","","fee schedule","46690.97","195701.98","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46690.97","","","","","","","fee schedule","46690.97","195701.98","Transplants-Case Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47624.79","","","","","","","fee schedule","46690.97","195701.98","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49025.52","","","","","","","fee schedule","46690.97","195701.98","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","461","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46690.97","","","","","","","fee schedule","46690.97","195701.98","Psych-Case Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","61991.3","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","66300.5","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","86880.92","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","72038.12","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","62174.84","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","79464.84","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","59347.26","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","94254.44","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","70886.34","","","","","","","fee schedule","23225.66","94254.44",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24328.88","","","","","","","fee schedule","23225.66","94254.44","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23922.43","","","","","","","fee schedule","23225.66","94254.44","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23225.66","","","","","","","fee schedule","23225.66","94254.44","Transplants-Case Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23690.17","","","","","","","fee schedule","23225.66","94254.44","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24386.94","","","","","","","fee schedule","23225.66","94254.44","MSDRG Base Rate"
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","462","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23225.66","","","","","","","fee schedule","23225.66","94254.44","Psych-Case Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","132826.85","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","142060.04","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","186157.07","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","154353.86","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","133220.11","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","170266.86","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","127161.54","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","201956.08","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","151885.98","","","","","","","fee schedule","48137.58","201956.08",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","366951.7","366951.7","366951.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10992.36","10992.36","20040.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","141855.08","141855.08","141855.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","43714.74","43714.74","43714.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10496.59","7336.82","11937.15","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","116860.17","116860.17","116860.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","45693.89","45693.89","45784.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","50424.12","","","","","","","fee schedule","48137.58","201956.08","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","49581.71","","","","","","","fee schedule","48137.58","201956.08","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","48137.58","","","","","","","fee schedule","48137.58","201956.08","Transplants-Case Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","49100.33","","","","","","","fee schedule","48137.58","201956.08","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50544.46","","","","","","","fee schedule","48137.58","201956.08","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","463","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48137.58","","","","","","","fee schedule","48137.58","201956.08","Psych-Case Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","72588.08","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","77633.9","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","101732.33","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","84352.31","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","72803","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","93048.55","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","69492.07","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","110366.28","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","83003.64","","","","","","","fee schedule","26952.41","110366.28",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","92347.2","92347.2","92347.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7638.05","7638.05","7638.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","23534.78","23534.78","23534.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","27084.16","27084.16","27084.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","68383","68383","68383","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","26100.04","26100.04","26100.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","129313.48","129313.48","129313.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","158821.94","158821.94","158821.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28232.65","","","","","","","fee schedule","26952.41","110366.28","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27760.98","","","","","","","fee schedule","26952.41","110366.28","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26952.41","","","","","","","fee schedule","26952.41","110366.28","Transplants-Case Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27491.46","","","","","","","fee schedule","26952.41","110366.28","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28300.03","","","","","","","fee schedule","26952.41","110366.28","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","464","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26952.41","","","","","","","fee schedule","26952.41","110366.28","Psych-Case Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42501.33","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45455.72","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59565.69","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49389.44","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42627.16","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54481.21","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40688.57","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64620.99","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48599.78","","","","","","","fee schedule","16371.3","64620.99",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","54372.92","54372.92","54372.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","38734.13","38734.13","38734.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19207.53","19207.53","19207.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17148.94","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16862.44","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16371.3","","","","","","","fee schedule","16371.3","64620.99","Transplants-Case Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16698.73","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17189.87","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","465","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16371.3","","","","","","","fee schedule","16371.3","64620.99","Psych-Case Rate"
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","121311.85","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","129744.6","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","170018.77","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","140972.64","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","121671.02","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","155506.12","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","116137.68","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","184448.14","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","138718.7","","","","","","","fee schedule","44087.9","184448.14",""
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22070.6","22070.6","22070.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12539.79","8405.12","21075.19","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8722.3","8722.3","8722.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46182.08","","","","","","","fee schedule","44087.9","184448.14","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","45410.54","","","","","","","fee schedule","44087.9","184448.14","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","44087.9","","","","","","","fee schedule","44087.9","184448.14","Transplants-Case Rate"
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44969.66","","","","","","","fee schedule","44087.9","184448.14","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46292.3","","","","","","","fee schedule","44087.9","184448.14","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Mcc","466","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44087.9","","","","","","","fee schedule","44087.9","184448.14","Psych-Case Rate"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","82187.41","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","87900.51","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","115185.81","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","95507.38","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","82430.75","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","105353.65","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","78681.97","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","124961.54","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","93980.36","","","","","","","fee schedule","30328.36","124961.54",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31768.96","","","","","","","fee schedule","30328.36","124961.54","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31238.21","","","","","","","fee schedule","30328.36","124961.54","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30328.36","","","","","","","fee schedule","30328.36","124961.54","Transplants-Case Rate"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30934.93","","","","","","","fee schedule","30328.36","124961.54","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31844.78","","","","","","","fee schedule","30328.36","124961.54","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30328.36","","","","","","","fee schedule","30328.36","124961.54","Psych-Case Rate"
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","64042.14","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","68493.9","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","89755.18","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","74421.34","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","64231.75","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","82093.75","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","61310.63","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","97372.63","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","73231.45","","","","","","","fee schedule","23946.91","97372.63",""
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11733.72","11733.72","11733.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5694.56","5694.56","5694.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25084.39","","","","","","","fee schedule","23946.91","97372.63","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24665.32","","","","","","","fee schedule","23946.91","97372.63","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23946.91","","","","","","","fee schedule","23946.91","97372.63","Transplants-Case Rate"
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24425.85","","","","","","","fee schedule","23946.91","97372.63","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25144.26","","","","","","","fee schedule","23946.91","97372.63","MSDRG Base Rate"
"Revision Of Hip Or Knee Replacement Without Cc/Mcc","468","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23946.91","","","","","","","fee schedule","23946.91","97372.63","Psych-Case Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","70688.73","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","75602.51","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","99070.38","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","82145.12","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","70898.02","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","90613.82","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","67673.73","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","107478.41","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","80831.75","","","","","","","fee schedule","26284.43","107478.41",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12757.06","7433.22","25420.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12757.06","7097.96","24273.81","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7713.72","7713.72","7713.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2729.35","2729.35","2729.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27532.94","","","","","","","fee schedule","26284.43","107478.41","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27072.96","","","","","","","fee schedule","26284.43","107478.41","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26284.43","","","","","","","fee schedule","26284.43","107478.41","Transplants-Case Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26810.12","","","","","","","fee schedule","26284.43","107478.41","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27598.65","","","","","","","fee schedule","26284.43","107478.41","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","469","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26284.43","","","","","","","fee schedule","26284.43","107478.41","Psych-Case Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44953.01","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48077.83","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63001.73","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52238.47","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45086.11","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57623.96","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43035.69","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68348.64","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51403.26","","","","","","","fee schedule","17233.52","68348.64",""
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","13585.85","13585.85","13585.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8703.74","8703.74","8703.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18052.11","","","","","","","fee schedule","17233.52","68348.64","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17750.53","","","","","","","fee schedule","17233.52","68348.64","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17233.52","","","","","","","fee schedule","17233.52","68348.64","Transplants-Case Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17578.19","","","","","","","fee schedule","17233.52","68348.64","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18095.2","","","","","","","fee schedule","17233.52","68348.64","MSDRG Base Rate"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","470","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17233.52","","","","","","","fee schedule","17233.52","68348.64","Psych-Case Rate"
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","112532.85","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","120355.35","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","157715","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","130770.85","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","112866.03","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","144252.58","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","107733.13","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","171100.16","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","128680.03","","","","","","","fee schedule","41000.45","171100.16",""
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","115406.31","115406.31","115406.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","40076.09","40076.09","40076.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","40272.58","40272.58","40272.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","38134.93","38134.93","38134.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","121671.93","121671.93","121671.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42947.97","","","","","","","fee schedule","41000.45","171100.16","MSDRG Base Rate"
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","42230.46","","","","","","","fee schedule","41000.45","171100.16","MSDRG Base Rate"
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41000.45","","","","","","","fee schedule","41000.45","171100.16","Transplants-Case Rate"
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41820.46","","","","","","","fee schedule","41000.45","171100.16","MSDRG Base Rate"
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43050.47","","","","","","","fee schedule","41000.45","171100.16","MSDRG Base Rate"
"Cervical Spinal Fusion With Mcc","471","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41000.45","","","","","","","fee schedule","41000.45","171100.16","Psych-Case Rate"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","68658.86","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","73431.54","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","96225.52","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","79786.28","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","68862.14","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","88011.79","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","65730.44","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","104392.11","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","78510.62","","","","","","","fee schedule","25570.55","104392.11",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","65238.1","65238.1","65238.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","90737.41","90737.41","90737.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24273.47","24273.47","25543.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24010.76","23575.59","24686.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","59548","59048","62104","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","23025.46","23025.46","23025.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","24895.03","24895.03","24895.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","61613.09","61613.09","61613.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26785.15","","","","","","","fee schedule","25570.55","104392.11","MSDRG Base Rate"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26337.67","","","","","","","fee schedule","25570.55","104392.11","MSDRG Base Rate"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25570.55","","","","","","","fee schedule","25570.55","104392.11","Transplants-Case Rate"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26081.96","","","","","","","fee schedule","25570.55","104392.11","MSDRG Base Rate"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26849.08","","","","","","","fee schedule","25570.55","104392.11","MSDRG Base Rate"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25570.55","","","","","","","fee schedule","25570.55","104392.11","Psych-Case Rate"
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","56894.5","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","60849.4","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","79737.74","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","66115.29","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","57062.95","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","72931.4","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54467.84","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","86505.02","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","65058.2","","","","","","","fee schedule","21433.18","86505.02",""
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","20353.34","20353.34","20353.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","21099.29","21099.29","21099.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20235.26","20235.26","20235.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","50912.98","50912.98","50912.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","19522.2","19522.2","19522.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22451.26","","","","","","","fee schedule","21433.18","86505.02","MSDRG Base Rate"
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22076.18","","","","","","","fee schedule","21433.18","86505.02","MSDRG Base Rate"
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21433.18","","","","","","","fee schedule","21433.18","86505.02","Transplants-Case Rate"
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21861.84","","","","","","","fee schedule","21433.18","86505.02","MSDRG Base Rate"
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22504.84","","","","","","","fee schedule","21433.18","86505.02","MSDRG Base Rate"
"Cervical Spinal Fusion Without Cc/Mcc","473","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21433.18","","","","","","","fee schedule","21433.18","86505.02","Psych-Case Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","100046.03","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","107000.53","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","140214.7","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","116260.32","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","100342.24","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","128246.09","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","95778.89","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","152114.62","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","114401.49","","","","","","","fee schedule","36609","152114.62",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","215327.76","215327.76","215327.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","30146.78","30146.78","30146.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","37528.66","37528.66","37528.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","35619.31","35619.31","35619.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","74770.67","74770.67","74770.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","38347.93","","","","","","","fee schedule","36609","152114.62","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37707.27","","","","","","","fee schedule","36609","152114.62","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36609","","","","","","","fee schedule","36609","152114.62","Transplants-Case Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","37341.18","","","","","","","fee schedule","36609","152114.62","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38439.45","","","","","","","fee schedule","36609","152114.62","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","474","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36609","","","","","","","fee schedule","36609","152114.62","Psych-Case Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","53035.19","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","56721.82","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","74328.91","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","61630.51","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","53192.21","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","67984.26","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","50773.14","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","80637.15","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","60645.13","","","","","","","fee schedule","20075.92","80637.15",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","65671.48","65671.48","65671.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18682.31","18682.31","18682.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14968.39","14968.39","14968.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21029.53","","","","","","","fee schedule","20075.92","80637.15","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20678.2","","","","","","","fee schedule","20075.92","80637.15","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20075.92","","","","","","","fee schedule","20075.92","80637.15","Transplants-Case Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20477.44","","","","","","","fee schedule","20075.92","80637.15","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21079.72","","","","","","","fee schedule","20075.92","80637.15","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","475","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20075.92","","","","","","","fee schedule","20075.92","80637.15","Psych-Case Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27504.56","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29416.49","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38547.69","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31962.18","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27585.99","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35257.29","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26331.44","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41819.21","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31451.15","","","","","","","fee schedule","11097.14","41819.21",""
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11624.25","","","","","","","fee schedule","11097.14","41819.21","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11430.05","","","","","","","fee schedule","11097.14","41819.21","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11097.14","","","","","","","fee schedule","11097.14","41819.21","Transplants-Case Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11319.08","","","","","","","fee schedule","11097.14","41819.21","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11652","","","","","","","fee schedule","11097.14","41819.21","MSDRG Base Rate"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","476","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11097.14","","","","","","","fee schedule","11097.14","41819.21","Psych-Case Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","80509.45","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","86105.91","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","112834.15","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","93557.48","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","80747.82","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","103202.72","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","77075.58","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","122410.3","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","92061.64","","","","","","","fee schedule","29738.25","122410.3",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","26934.28","26934.28","26934.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16147.08","16147.08","16147.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","27888.2","27888.2","27888.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31150.82","","","","","","","fee schedule","29738.25","122410.3","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30630.4","","","","","","","fee schedule","29738.25","122410.3","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29738.25","","","","","","","fee schedule","29738.25","122410.3","Transplants-Case Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30333.02","","","","","","","fee schedule","29738.25","122410.3","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31225.16","","","","","","","fee schedule","29738.25","122410.3","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","477","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29738.25","","","","","","","fee schedule","29738.25","122410.3","Psych-Case Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","57311.66","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","61295.56","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","80322.39","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","66600.05","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","57481.34","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","73466.14","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54867.21","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","87139.29","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","65535.22","","","","","","","fee schedule","21579.89","87139.29",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","72942.61","72942.61","72942.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","42018.91","42018.91","42018.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18741.15","18741.15","18741.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18572.16","18572.16","18572.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18435.41","18435.41","18435.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22604.93","","","","","","","fee schedule","21579.89","87139.29","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22227.29","","","","","","","fee schedule","21579.89","87139.29","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21579.89","","","","","","","fee schedule","21579.89","87139.29","Transplants-Case Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22011.49","","","","","","","fee schedule","21579.89","87139.29","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22658.88","","","","","","","fee schedule","21579.89","87139.29","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21579.89","","","","","","","fee schedule","21579.89","87139.29","Psych-Case Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","43321.66","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","46333.08","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","60715.39","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","50342.73","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","43449.93","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","55532.78","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","41473.92","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","65868.26","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","49537.83","","","","","","","fee schedule","16659.8","65868.26",""
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17451.14","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17159.59","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16659.8","","","","","","","fee schedule","16659.8","65868.26","Transplants-Case Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16993","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17492.79","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","479","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16659.8","","","","","","","fee schedule","16659.8","65868.26","Psych-Case Rate"
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","67871.15","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","72589.08","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","95121.54","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","78870.91","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","68072.1","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","87002.05","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64976.33","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","103194.44","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","77609.88","","","","","","","fee schedule","25293.53","103194.44",""
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","174035.13","174035.13","174035.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","23732.01","23472.31","24637.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","23294.67","23294.67","25074.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","23875.15","22753.48","72309.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","85424.84","85424.84","85424.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","76274.84","76274.84","76274.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26494.97","","","","","","","fee schedule","25293.53","103194.44","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26052.34","","","","","","","fee schedule","25293.53","103194.44","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25293.53","","","","","","","fee schedule","25293.53","103194.44","Transplants-Case Rate"
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25799.4","","","","","","","fee schedule","25293.53","103194.44","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26558.21","","","","","","","fee schedule","25293.53","103194.44","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Mcc","480","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25293.53","","","","","","","fee schedule","25293.53","103194.44","Psych-Case Rate"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48812.32","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52205.41","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68410.56","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56723.25","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48956.84","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62571.09","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46730.39","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","74216.51","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55816.33","","","","","","","fee schedule","18590.79","74216.51",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","31148.44","31148.44","31148.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","40201.06","40201.06","40201.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","63583.79","61881.82","84260.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","50056.46","50056.46","50056.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16693.9","16571.18","19133.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","49979.14","49979.14","49979.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16320.43","15640.32","16957.44","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17294.63","17294.63","17294.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","41667.22","41667.22","45054","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16879.01","16004.5","17572.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","49694.99","49694.99","49694.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19473.85","","","","","","","fee schedule","18590.79","74216.51","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19148.51","","","","","","","fee schedule","18590.79","74216.51","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18590.79","","","","","","","fee schedule","18590.79","74216.51","Transplants-Case Rate"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18962.61","","","","","","","fee schedule","18590.79","74216.51","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19520.33","","","","","","","fee schedule","18590.79","74216.51","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18590.79","","","","","","","fee schedule","18590.79","74216.51","Psych-Case Rate"
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38010.46","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40652.68","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53271.72","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44170.74","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38122.99","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48724.49","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36389.24","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57792.85","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43464.52","","","","","","","fee schedule","14791.92","57792.85",""
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29795.12","29795.12","29795.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","49334.46","49334.46","49334.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14226.95","14226.95","14226.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13408.41","13408.41","13408.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13244.94","13244.94","13244.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15494.54","","","","","","","fee schedule","14791.92","57792.85","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15235.68","","","","","","","fee schedule","14791.92","57792.85","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14791.92","","","","","","","fee schedule","14791.92","57792.85","Transplants-Case Rate"
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15087.76","","","","","","","fee schedule","14791.92","57792.85","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15531.52","","","","","","","fee schedule","14791.92","57792.85","MSDRG Base Rate"
"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","482","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14791.92","","","","","","","fee schedule","14791.92","57792.85","Psych-Case Rate"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","64599.13","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","69089.61","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","90535.8","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","75068.6","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","64790.39","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","82807.74","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","61843.86","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","98219.5","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","73868.36","","","","","","","fee schedule","24142.8","98219.5",""
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15954.24","15954.24","15954.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15954.24","15954.24","16707.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","23680.49","23680.49","23680.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25289.58","","","","","","","fee schedule","24142.8","98219.5","MSDRG Base Rate"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24867.08","","","","","","","fee schedule","24142.8","98219.5","MSDRG Base Rate"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24142.8","","","","","","","fee schedule","24142.8","98219.5","Transplants-Case Rate"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24625.66","","","","","","","fee schedule","24142.8","98219.5","MSDRG Base Rate"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25349.94","","","","","","","fee schedule","24142.8","98219.5","MSDRG Base Rate"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24142.8","","","","","","","fee schedule","24142.8","98219.5","Psych-Case Rate"
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","484","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75207.57","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80435.47","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","105403.54","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","87396.32","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75430.24","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","96406.39","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","71999.83","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","114349.06","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","85998.99","","","","","","","fee schedule","27873.64","114349.06",""
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","26231.68","26231.68","26231.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29197.64","","","","","","","fee schedule","27873.64","114349.06","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28709.85","","","","","","","fee schedule","27873.64","114349.06","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27873.64","","","","","","","fee schedule","27873.64","114349.06","Transplants-Case Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28431.11","","","","","","","fee schedule","27873.64","114349.06","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29267.32","","","","","","","fee schedule","27873.64","114349.06","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Mcc","485","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27873.64","","","","","","","fee schedule","27873.64","114349.06","Psych-Case Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48733.09","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52120.67","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68299.51","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56631.17","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48877.37","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62469.52","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46654.53","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","74096.04","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55725.72","","","","","","","fee schedule","18562.92","74096.04",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19444.66","","","","","","","fee schedule","18562.92","74096.04","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19119.81","","","","","","","fee schedule","18562.92","74096.04","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18562.92","","","","","","","fee schedule","18562.92","74096.04","Transplants-Case Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18934.18","","","","","","","fee schedule","18562.92","74096.04","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19491.07","","","","","","","fee schedule","18562.92","74096.04","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18562.92","","","","","","","fee schedule","18562.92","74096.04","Psych-Case Rate"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36500.29","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39037.54","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51155.22","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42415.83","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36608.36","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46788.66","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34943.49","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55496.73","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41737.66","","","","","","","fee schedule","14260.81","55496.73",""
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","40982.49","40982.49","40982.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14938.2","","","","","","","fee schedule","14260.81","55496.73","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14688.63","","","","","","","fee schedule","14260.81","55496.73","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14260.81","","","","","","","fee schedule","14260.81","55496.73","Transplants-Case Rate"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14546.03","","","","","","","fee schedule","14260.81","55496.73","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14973.85","","","","","","","fee schedule","14260.81","55496.73","MSDRG Base Rate"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","487","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14260.81","","","","","","","fee schedule","14260.81","55496.73","Psych-Case Rate"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41224.21","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44089.83","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57775.81","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47905.35","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41346.27","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52844.12","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39465.93","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62679.2","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47139.42","","","","","","","fee schedule","15922.15","62679.2",""
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","73612.2","73612.2","73612.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","34557.15","34557.15","34557.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","59394.73","59394.73","59394.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38897","38897","38897","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16678.45","","","","","","","fee schedule","15922.15","62679.2","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16399.81","","","","","","","fee schedule","15922.15","62679.2","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15922.15","","","","","","","fee schedule","15922.15","62679.2","Transplants-Case Rate"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16240.59","","","","","","","fee schedule","15922.15","62679.2","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16718.26","","","","","","","fee schedule","15922.15","62679.2","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","488","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15922.15","","","","","","","fee schedule","15922.15","62679.2","Psych-Case Rate"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26027.02","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27836.24","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36476.92","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30245.18","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26104.08","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33363.28","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24916.92","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","39572.69","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29761.6","","","","","","","fee schedule","10577.51","39572.69",""
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","26761.93","26761.93","26761.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","13255.18","13255.18","13255.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11079.94","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10894.84","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10577.51","","","","","","","fee schedule","10577.51","39572.69","Transplants-Case Rate"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10789.06","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11106.39","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","489","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10577.51","","","","","","","fee schedule","10577.51","39572.69","Psych-Case Rate"
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","490","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back & neck proc exc spinal fusion w/o CC/MCC","491","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","85566.64","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","91514.63","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","119921.8","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","99434.27","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","85819.98","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","109685.38","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","81917.07","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","130099.47","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","97844.47","","","","","","","fee schedule","31516.79","130099.47",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","190973.31","190973.31","190973.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","242464.79","242464.79","242464.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","29926.27","29926.27","29926.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","29706.62","29706.62","29706.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","28914.3","28914.3","28914.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33013.84","","","","","","","fee schedule","31516.79","130099.47","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32462.29","","","","","","","fee schedule","31516.79","130099.47","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31516.79","","","","","","","fee schedule","31516.79","130099.47","Transplants-Case Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32147.13","","","","","","","fee schedule","31516.79","130099.47","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33092.63","","","","","","","fee schedule","31516.79","130099.47","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","492","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31516.79","","","","","","","fee schedule","31516.79","130099.47","Psych-Case Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","59103.81","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","63212.29","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","82834.1","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","68682.66","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","59278.8","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","75763.45","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","56582.93","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","89864.17","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","67584.53","","","","","","","fee schedule","22210.17","89864.17",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","91816.76","91816.76","91816.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","56514.7","56514.7","56514.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","56881.5","56881.5","56881.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","71607.42","71444.04","111751.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21438.02","21001.23","22028.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","89423.31","89423.31","139043.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20559.23","18988.6","20839.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20641.55","19075.02","21540.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","55680","52714","80097.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","61166.45","61166.45","61166.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18914.23","16014.94","21727.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","60054.84","60054.84","60054.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","45317.75","45317.75","45317.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23265.15","","","","","","","fee schedule","22210.17","89864.17","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22876.48","","","","","","","fee schedule","22210.17","89864.17","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22210.17","","","","","","","fee schedule","22210.17","89864.17","Transplants-Case Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22654.37","","","","","","","fee schedule","22210.17","89864.17","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23320.68","","","","","","","fee schedule","22210.17","89864.17","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22210.17","","","","","","","fee schedule","22210.17","89864.17","Psych-Case Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46761.48","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","50012.01","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65536.3","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54340.03","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46899.93","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59942.18","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44767.02","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","71098.32","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53471.22","","","","","","","fee schedule","17869.54","71098.32",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","43686.76","43686.76","43686.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","43975.97","43975.97","43975.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","58234.3","57792.59","62341.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16920.8","16920.8","16920.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","46494.2","46494.2","46494.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15636.46","15636.46","15636.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39288.96","39288.96","39288.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18718.34","","","","","","","fee schedule","17869.54","71098.32","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18405.63","","","","","","","fee schedule","17869.54","71098.32","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17869.54","","","","","","","fee schedule","17869.54","71098.32","Transplants-Case Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18226.93","","","","","","","fee schedule","17869.54","71098.32","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18763.02","","","","","","","fee schedule","17869.54","71098.32","MSDRG Base Rate"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","494","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17869.54","","","","","","","fee schedule","17869.54","71098.32","Psych-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","84496.94","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","90370.57","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","118422.61","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","98191.21","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","84747.11","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","108314.16","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","80892.99","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","128473.05","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","96621.28","","","","","","","fee schedule","31140.59","128473.05",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","78667.81","78667.81","78667.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","77288","77288","77288","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32619.77","","","","","","","fee schedule","31140.59","128473.05","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32074.81","","","","","","","fee schedule","31140.59","128473.05","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31140.59","","","","","","","fee schedule","31140.59","128473.05","Transplants-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31763.4","","","","","","","fee schedule","31140.59","128473.05","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32697.62","","","","","","","fee schedule","31140.59","128473.05","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","495","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31140.59","","","","","","","fee schedule","31140.59","128473.05","Psych-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42039.89","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44962.21","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58918.98","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48853.22","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42164.36","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53889.71","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40246.81","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63919.39","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48072.13","","","","","","","fee schedule","16209.02","63919.39",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15173.17","15173.17","15173.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","42815","42815","42815","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15726.49","15726.49","15726.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17462.56","17462.56","17462.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16978.95","","","","","","","fee schedule","16209.02","63919.39","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16695.29","","","","","","","fee schedule","16209.02","63919.39","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16209.02","","","","","","","fee schedule","16209.02","63919.39","Transplants-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16533.2","","","","","","","fee schedule","16209.02","63919.39","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17019.47","","","","","","","fee schedule","16209.02","63919.39","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16209.02","","","","","","","fee schedule","16209.02","63919.39","Psych-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28159.43","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30116.88","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39465.49","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32723.18","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28242.8","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36096.75","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26958.38","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42814.9","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32199.99","","","","","","","fee schedule","11327.45","42814.9",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11678.65","11678.65","11678.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11865.5","","","","","","","fee schedule","11327.45","42814.9","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11667.27","","","","","","","fee schedule","11327.45","42814.9","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11327.45","","","","","","","fee schedule","11327.45","42814.9","Transplants-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11554","","","","","","","fee schedule","11327.45","42814.9","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11893.82","","","","","","","fee schedule","11327.45","42814.9","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","497","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11327.45","","","","","","","fee schedule","11327.45","42814.9","Psych-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","70306.52","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","75193.74","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","98534.72","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","81700.98","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","70514.68","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","90123.88","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","67307.82","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","106897.29","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","80394.7","","","","","","","fee schedule","26150.01","106897.29",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27392.14","","","","","","","fee schedule","26150.01","106897.29","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26934.51","","","","","","","fee schedule","26150.01","106897.29","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26150.01","","","","","","","fee schedule","26150.01","106897.29","Transplants-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26673.01","","","","","","","fee schedule","26150.01","106897.29","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27457.51","","","","","","","fee schedule","26150.01","106897.29","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","498","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26150.01","","","","","","","fee schedule","26150.01","106897.29","Psych-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46954.91","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","50218.89","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65807.4","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54564.81","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","47093.94","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","60190.14","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44952.2","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","71392.42","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53692.41","","","","","","","fee schedule","17937.57","71392.42",""
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18789.6","","","","","","","fee schedule","17937.57","71392.42","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18475.7","","","","","","","fee schedule","17937.57","71392.42","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17937.57","","","","","","","fee schedule","17937.57","71392.42","Transplants-Case Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18296.32","","","","","","","fee schedule","17937.57","71392.42","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18834.45","","","","","","","fee schedule","17937.57","71392.42","MSDRG Base Rate"
"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","499","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17937.57","","","","","","","fee schedule","17937.57","71392.42","Psych-Case Rate"
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","73755.66","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","78882.64","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","103368.7","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","85709.11","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","73974.04","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","94545.24","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","70609.85","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","112141.52","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","84338.76","","","","","","","fee schedule","27363.03","112141.52",""
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","45791.74","45791.74","45791.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28662.77","","","","","","","fee schedule","27363.03","112141.52","MSDRG Base Rate"
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28183.92","","","","","","","fee schedule","27363.03","112141.52","MSDRG Base Rate"
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27363.03","","","","","","","fee schedule","27363.03","112141.52","Transplants-Case Rate"
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27910.29","","","","","","","fee schedule","27363.03","112141.52","MSDRG Base Rate"
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28731.18","","","","","","","fee schedule","27363.03","112141.52","MSDRG Base Rate"
"Soft Tissue Procedures With Mcc","500","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27363.03","","","","","","","fee schedule","27363.03","112141.52","Psych-Case Rate"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40739.47","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43571.39","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57096.44","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47342.04","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40860.09","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52222.74","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39001.86","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61942.18","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46585.12","","","","","","","fee schedule","15751.68","61942.18",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","40617.99","40617.99","40617.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16210.66","16210.66","16210.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15825.36","15825.36","15825.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","44814.37","44814.37","44814.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16499.88","","","","","","","fee schedule","15751.68","61942.18","MSDRG Base Rate"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16224.23","","","","","","","fee schedule","15751.68","61942.18","MSDRG Base Rate"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15751.68","","","","","","","fee schedule","15751.68","61942.18","Transplants-Case Rate"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16066.71","","","","","","","fee schedule","15751.68","61942.18","MSDRG Base Rate"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16539.26","","","","","","","fee schedule","15751.68","61942.18","MSDRG Base Rate"
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15751.68","","","","","","","fee schedule","15751.68","61942.18","Psych-Case Rate"
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31366.2","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33546.56","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43959.79","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36449.66","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31459.07","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40207.42","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30028.37","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47690.62","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35866.89","","","","","","","fee schedule","12455.22","47690.62",""
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25449.09","25449.09","25449.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","42652.01","42652.01","42652.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","33895.99","33895.99","33895.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13046.84","","","","","","","fee schedule","12455.22","47690.62","MSDRG Base Rate"
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12828.88","","","","","","","fee schedule","12455.22","47690.62","MSDRG Base Rate"
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12455.22","","","","","","","fee schedule","12455.22","47690.62","Transplants-Case Rate"
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12704.32","","","","","","","fee schedule","12455.22","47690.62","MSDRG Base Rate"
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13077.98","","","","","","","fee schedule","12455.22","47690.62","MSDRG Base Rate"
"Soft Tissue Procedures Without Cc/Mcc","502","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12455.22","","","","","","","fee schedule","12455.22","47690.62","Psych-Case Rate"
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","65046.59","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","69568.17","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","91162.91","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","75588.57","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","65239.17","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","83381.32","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","62272.23","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","98899.84","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","74380.02","","","","","","","fee schedule","24300.16","98899.84",""
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21020.76","21020.76","21020.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25454.42","","","","","","","fee schedule","24300.16","98899.84","MSDRG Base Rate"
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25029.16","","","","","","","fee schedule","24300.16","98899.84","MSDRG Base Rate"
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24300.16","","","","","","","fee schedule","24300.16","98899.84","Transplants-Case Rate"
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24786.16","","","","","","","fee schedule","24300.16","98899.84","MSDRG Base Rate"
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25515.17","","","","","","","fee schedule","24300.16","98899.84","MSDRG Base Rate"
"Foot Procedures With Mcc","503","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24300.16","","","","","","","fee schedule","24300.16","98899.84","Psych-Case Rate"
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","43561.71","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","46589.81","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","61051.81","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","50621.67","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","43690.68","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","55840.48","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","41703.72","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","66233.23","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","49812.31","","","","","","","fee schedule","16744.22","66233.23",""
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","49045.17","49045.17","49045.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","40428.44","40428.44","40428.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17539.57","","","","","","","fee schedule","16744.22","66233.23","MSDRG Base Rate"
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17246.55","","","","","","","fee schedule","16744.22","66233.23","MSDRG Base Rate"
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16744.22","","","","","","","fee schedule","16744.22","66233.23","Transplants-Case Rate"
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17079.1","","","","","","","fee schedule","16744.22","66233.23","MSDRG Base Rate"
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17581.43","","","","","","","fee schedule","16744.22","66233.23","MSDRG Base Rate"
"Foot Procedures With Cc","504","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16744.22","","","","","","","fee schedule","16744.22","66233.23","Psych-Case Rate"
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41781.2","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44685.54","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58556.43","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48552.61","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41904.91","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53558.11","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39999.16","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63526.08","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47776.33","","","","","","","fee schedule","16118.04","63526.08",""
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16883.65","","","","","","","fee schedule","16118.04","63526.08","MSDRG Base Rate"
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16601.58","","","","","","","fee schedule","16118.04","63526.08","MSDRG Base Rate"
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16118.04","","","","","","","fee schedule","16118.04","63526.08","Transplants-Case Rate"
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16440.4","","","","","","","fee schedule","16118.04","63526.08","MSDRG Base Rate"
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16923.94","","","","","","","fee schedule","16118.04","63526.08","MSDRG Base Rate"
"Foot Procedures Without Cc/Mcc","505","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16118.04","","","","","","","fee schedule","16118.04","63526.08","Psych-Case Rate"
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31443.11","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33628.81","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44067.57","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36539.03","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31536.2","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40306","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30102","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47807.55","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35954.83","","","","","","","fee schedule","12482.27","47807.55",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10817.89","10817.89","10817.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13075.18","","","","","","","fee schedule","12482.27","47807.55","MSDRG Base Rate"
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12856.74","","","","","","","fee schedule","12482.27","47807.55","MSDRG Base Rate"
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12482.27","","","","","","","fee schedule","12482.27","47807.55","Transplants-Case Rate"
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12731.92","","","","","","","fee schedule","12482.27","47807.55","MSDRG Base Rate"
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13106.38","","","","","","","fee schedule","12482.27","47807.55","MSDRG Base Rate"
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12482.27","","","","","","","fee schedule","12482.27","47807.55","Psych-Case Rate"
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42098.15","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45024.52","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59000.64","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48920.92","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42222.79","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53964.39","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40302.59","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64007.98","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48138.75","","","","","","","fee schedule","16229.51","64007.98",""
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57804.88","57804.88","57804.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17000.41","","","","","","","fee schedule","16229.51","64007.98","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16716.4","","","","","","","fee schedule","16229.51","64007.98","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16229.51","","","","","","","fee schedule","16229.51","64007.98","Transplants-Case Rate"
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16554.1","","","","","","","fee schedule","16229.51","64007.98","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17040.99","","","","","","","fee schedule","16229.51","64007.98","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","507","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16229.51","","","","","","","fee schedule","16229.51","64007.98","Psych-Case Rate"
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35293.09","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37746.42","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49463.33","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41012.98","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35397.59","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45241.19","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33787.78","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53661.25","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40357.25","","","","","","","fee schedule","13836.26","53661.25",""
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","33160.13","33160.13","33160.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14493.48","","","","","","","fee schedule","13836.26","53661.25","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14251.35","","","","","","","fee schedule","13836.26","53661.25","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13836.26","","","","","","","fee schedule","13836.26","53661.25","Transplants-Case Rate"
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14112.99","","","","","","","fee schedule","13836.26","53661.25","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14528.07","","","","","","","fee schedule","13836.26","53661.25","MSDRG Base Rate"
"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","508","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13836.26","","","","","","","fee schedule","13836.26","53661.25","Psych-Case Rate"
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52473.68","","","","","","","fee schedule","46808.97","52473.68",""
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46808.97","","","","","","","fee schedule","46808.97","52473.68",""
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Arthroscopy","509","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","70392.75","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","75285.96","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","98655.57","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","81801.18","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","70601.17","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","90234.42","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","67390.38","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","107028.4","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","80493.3","","","","","","","fee schedule","26180.34","107028.4",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27423.91","","","","","","","fee schedule","26180.34","107028.4","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26965.75","","","","","","","fee schedule","26180.34","107028.4","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26180.34","","","","","","","fee schedule","26180.34","107028.4","Transplants-Case Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26703.95","","","","","","","fee schedule","26180.34","107028.4","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27489.36","","","","","","","fee schedule","26180.34","107028.4","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","510","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26180.34","","","","","","","fee schedule","26180.34","107028.4","Psych-Case Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48460.42","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51829.05","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","67917.36","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56314.31","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48603.9","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62120","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46393.49","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73681.46","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55413.93","","","","","","","fee schedule","18467.03","73681.46",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","31236.56","31236.56","31236.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57740.83","57740.83","57740.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16337.22","16337.22","16337.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16439.67","16439.67","16439.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39791.05","39791.05","39791.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14796.16","14796.16","14796.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19344.21","","","","","","","fee schedule","18467.03","73681.46","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19021.04","","","","","","","fee schedule","18467.03","73681.46","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18467.03","","","","","","","fee schedule","18467.03","73681.46","Transplants-Case Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18836.37","","","","","","","fee schedule","18467.03","73681.46","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19390.38","","","","","","","fee schedule","18467.03","73681.46","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18467.03","","","","","","","fee schedule","18467.03","73681.46","Psych-Case Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38579.1","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41260.85","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54068.67","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44831.54","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38693.32","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49453.42","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36933.63","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58657.44","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44114.75","","","","","","","fee schedule","14991.9","58657.44",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","47345.64","47345.64","47345.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","40263.96","40263.96","40263.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12953.02","12953.02","12953.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15704.02","","","","","","","fee schedule","14991.9","58657.44","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15441.66","","","","","","","fee schedule","14991.9","58657.44","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14991.9","","","","","","","fee schedule","14991.9","58657.44","Transplants-Case Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15291.74","","","","","","","fee schedule","14991.9","58657.44","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15741.5","","","","","","","fee schedule","14991.9","58657.44","MSDRG Base Rate"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","512","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14991.9","","","","","","","fee schedule","14991.9","58657.44","Psych-Case Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36689.06","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39239.43","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51419.79","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42635.19","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36797.69","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47030.64","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35124.21","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55783.75","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41953.52","","","","","","","fee schedule","14327.2","55783.75",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","44724.91","44724.91","44724.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13282.27","13282.27","13282.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11816.03","11816.03","11816.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12261.92","12261.92","12261.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15007.74","","","","","","","fee schedule","14327.2","55783.75","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14757.02","","","","","","","fee schedule","14327.2","55783.75","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14327.2","","","","","","","fee schedule","14327.2","55783.75","Transplants-Case Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14613.74","","","","","","","fee schedule","14327.2","55783.75","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15043.56","","","","","","","fee schedule","14327.2","55783.75","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","513","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14327.2","","","","","","","fee schedule","14327.2","55783.75","Psych-Case Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23824.7","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25480.83","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33390.36","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27685.93","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23895.24","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30540.19","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22808.54","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36224.18","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27243.27","","","","","","","fee schedule","9802.98","36224.18",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","2645.76","2645.76","2645.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10268.62","","","","","","","fee schedule","9802.98","36224.18","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10097.07","","","","","","","fee schedule","9802.98","36224.18","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9802.98","","","","","","","fee schedule","9802.98","36224.18","Transplants-Case Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9999.04","","","","","","","fee schedule","9802.98","36224.18","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10293.13","","","","","","","fee schedule","9802.98","36224.18","MSDRG Base Rate"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","514","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9802.98","","","","","","","fee schedule","9802.98","36224.18","Psych-Case Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","74270.7","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","79433.48","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","104090.53","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","86307.63","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","74490.6","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","95205.45","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","71102.93","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","112924.61","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","84927.7","","","","","","","fee schedule","27544.16","112924.61",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","96850.88","96850.88","96850.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24245.33","24245.33","24245.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","24317.65","24317.65","24317.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","79782","79782","79782","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","26239.07","26239.07","26239.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28852.51","","","","","","","fee schedule","27544.16","112924.61","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28370.48","","","","","","","fee schedule","27544.16","112924.61","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27544.16","","","","","","","fee schedule","27544.16","112924.61","Transplants-Case Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28095.04","","","","","","","fee schedule","27544.16","112924.61","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28921.37","","","","","","","fee schedule","27544.16","112924.61","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","515","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27544.16","","","","","","","fee schedule","27544.16","112924.61","Psych-Case Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48430.12","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51796.64","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","67874.9","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56279.1","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48573.51","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62081.16","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46364.49","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73635.4","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55379.29","","","","","","","fee schedule","18456.38","73635.4",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","19519.4","19519.4","19519.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","61754.19","61754.19","61754.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16124.26","16124.26","16124.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","42643.32","42643.32","42643.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15907.29","2636.93","15911.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16484.54","16484.54","16484.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19253.77","19253.77","19253.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","43680.27","43680.27","43680.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17511.94","17511.94","17511.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19333.06","","","","","","","fee schedule","18456.38","73635.4","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19010.07","","","","","","","fee schedule","18456.38","73635.4","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18456.38","","","","","","","fee schedule","18456.38","73635.4","Transplants-Case Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18825.51","","","","","","","fee schedule","18456.38","73635.4","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19379.2","","","","","","","fee schedule","18456.38","73635.4","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18456.38","","","","","","","fee schedule","18456.38","73635.4","Psych-Case Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35812.79","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38302.25","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50191.7","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41616.91","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35918.83","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45907.38","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34285.31","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54451.43","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40951.52","","","","","","","fee schedule","14019.03","54451.43",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","13967.04","13967.04","13967.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11612.85","11612.85","11612.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12904.27","12904.27","12904.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32270","32270","32270","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","23181.14","23181.14","23181.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14684.93","","","","","","","fee schedule","14019.03","54451.43","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14439.6","","","","","","","fee schedule","14019.03","54451.43","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14019.03","","","","","","","fee schedule","14019.03","54451.43","Transplants-Case Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14299.41","","","","","","","fee schedule","14019.03","54451.43","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14719.98","","","","","","","fee schedule","14019.03","54451.43","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","517","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14019.03","","","","","","","fee schedule","14019.03","54451.43","Psych-Case Rate"
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","87097.78","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","93152.2","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","122067.69","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","101213.56","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","87355.65","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","111648.1","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","83382.9","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","132427.49","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","99595.31","","","","","","","fee schedule","32055.27","132427.49",""
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","13984.42","13984.42","13984.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","106739.22","106739.22","106739.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","30554.07","30554.07","30554.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13984.42","13984.42","13984.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","29124.08","29124.08","29124.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11877.83","11877.83","11877.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33577.9","","","","","","","fee schedule","32055.27","132427.49","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33016.93","","","","","","","fee schedule","32055.27","132427.49","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32055.27","","","","","","","fee schedule","32055.27","132427.49","Transplants-Case Rate"
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32696.38","","","","","","","fee schedule","32055.27","132427.49","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33658.03","","","","","","","fee schedule","32055.27","132427.49","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32055.27","","","","","","","fee schedule","32055.27","132427.49","Psych-Case Rate"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46614.66","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49854.99","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65330.53","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54169.42","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46752.67","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59753.97","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44626.46","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","70875.09","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53303.33","","","","","","","fee schedule","17817.9","70875.09",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","46867.76","46867.76","46867.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","61466.5","61466.5","61466.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17101.39","17101.39","17101.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","54126.39","54126.39","54126.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16496.53","16496.53","16496.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","43289","43289","43289","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15385.08","15385.08","15385.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16125.03","16125.03","16387.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9732.45","9732.45","9732.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18664.25","","","","","","","fee schedule","17817.9","70875.09","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18352.44","","","","","","","fee schedule","17817.9","70875.09","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17817.9","","","","","","","fee schedule","17817.9","70875.09","Transplants-Case Rate"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18174.26","","","","","","","fee schedule","17817.9","70875.09","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18708.8","","","","","","","fee schedule","17817.9","70875.09","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17817.9","","","","","","","fee schedule","17817.9","70875.09","Psych-Case Rate"
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34815.34","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37235.46","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48793.76","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40457.8","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34918.42","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44628.77","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33330.4","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52934.85","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39810.94","","","","","","","fee schedule","13668.24","52934.85",""
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11367.63","11367.63","11367.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","31464","31464","31464","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12286.1","12286.1","12286.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14317.48","","","","","","","fee schedule","13668.24","52934.85","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14078.29","","","","","","","fee schedule","13668.24","52934.85","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13668.24","","","","","","","fee schedule","13668.24","52934.85","Transplants-Case Rate"
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13941.6","","","","","","","fee schedule","13668.24","52934.85","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14351.65","","","","","","","fee schedule","13668.24","52934.85","MSDRG Base Rate"
"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","520","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13668.24","","","","","","","fee schedule","13668.24","52934.85","Psych-Case Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","66890.01","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","71539.74","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","93746.47","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","77730.76","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","67088.05","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","85744.35","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64037.03","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","101702.67","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","76487.96","","","","","","","fee schedule","24948.47","101702.67",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","23660.64","23660.64","23660.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25290.91","25290.91","25290.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26133.52","","","","","","","fee schedule","24948.47","101702.67","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25696.92","","","","","","","fee schedule","24948.47","101702.67","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24948.47","","","","","","","fee schedule","24948.47","101702.67","Transplants-Case Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25447.44","","","","","","","fee schedule","24948.47","101702.67","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26195.89","","","","","","","fee schedule","24948.47","101702.67","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","521","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24948.47","","","","","","","fee schedule","24948.47","101702.67","Psych-Case Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49353","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52783.67","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69168.32","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57351.55","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49499.12","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63264.17","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47248","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75038.58","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56434.59","","","","","","","fee schedule","18780.94","75038.58",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16760.64","15933.52","17081.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17075.44","17041.1","17725.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19673.03","","","","","","","fee schedule","18780.94","75038.58","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19344.37","","","","","","","fee schedule","18780.94","75038.58","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18780.94","","","","","","","fee schedule","18780.94","75038.58","Transplants-Case Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19156.56","","","","","","","fee schedule","18780.94","75038.58","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19719.99","","","","","","","fee schedule","18780.94","75038.58","MSDRG Base Rate"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","522","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18780.94","","","","","","","fee schedule","18780.94","75038.58","Psych-Case Rate"
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","523","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transient ischemia","524","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other heart assist system implant","525","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","526","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"No Longer Valid","527","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Intracranial Vascular Proc w Pdx Hemorrhage","528","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular shunt procedures w CC","529","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ventricular Shunt Procedures w/o CC","530","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w CC","531","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Spinal Procedures w/o CC","532","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36535.25","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39074.92","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51204.22","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42456.45","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36643.42","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46833.47","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34976.95","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55549.88","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41777.64","","","","","","","fee schedule","14273.11","55549.88",""
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14951.08","","","","","","","fee schedule","14273.11","55549.88","MSDRG Base Rate"
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14701.3","","","","","","","fee schedule","14273.11","55549.88","MSDRG Base Rate"
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14273.11","","","","","","","fee schedule","14273.11","55549.88","Transplants-Case Rate"
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14558.57","","","","","","","fee schedule","14273.11","55549.88","MSDRG Base Rate"
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14986.77","","","","","","","fee schedule","14273.11","55549.88","MSDRG Base Rate"
"Fractures Of Femur With Mcc","533","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14273.11","","","","","","","fee schedule","14273.11","55549.88","Psych-Case Rate"
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18786.16","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20092.04","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26328.84","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21830.8","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18841.78","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24081.43","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17984.9","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28563.35","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21481.76","","","","","","","fee schedule","8030.99","28563.35",""
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8412.46","","","","","","","fee schedule","8030.99","28563.35","MSDRG Base Rate"
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8271.92","","","","","","","fee schedule","8030.99","28563.35","MSDRG Base Rate"
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8030.99","","","","","","","fee schedule","8030.99","28563.35","Transplants-Case Rate"
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8191.61","","","","","","","fee schedule","8030.99","28563.35","MSDRG Base Rate"
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8432.54","","","","","","","fee schedule","8030.99","28563.35","MSDRG Base Rate"
"Fractures Of Femur Without Mcc","534","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8030.99","","","","","","","fee schedule","8030.99","28563.35","Psych-Case Rate"
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29877.01","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31953.85","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","41872.68","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","34719.12","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29965.47","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38298.47","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28602.7","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45426.39","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34164.02","","","","","","","fee schedule","11931.49","45426.39",""
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12194.26","12194.26","12194.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12091.84","12091.84","12091.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12498.24","","","","","","","fee schedule","11931.49","45426.39","MSDRG Base Rate"
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12289.43","","","","","","","fee schedule","11931.49","45426.39","MSDRG Base Rate"
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11931.49","","","","","","","fee schedule","11931.49","45426.39","Transplants-Case Rate"
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12170.12","","","","","","","fee schedule","11931.49","45426.39","MSDRG Base Rate"
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12528.06","","","","","","","fee schedule","11931.49","45426.39","MSDRG Base Rate"
"Fractures Of Hip And Pelvis With Mcc","535","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11931.49","","","","","","","fee schedule","11931.49","45426.39","Psych-Case Rate"
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18821.12","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20129.43","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26377.83","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21871.42","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18876.84","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24126.24","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18018.36","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28616.5","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21521.73","","","","","","","fee schedule","8043.29","28616.5",""
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","12931.9","12931.9","12931.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1726.64","1726.64","1726.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10000.86","10000.86","10000.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","20922","20922","20922","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8425.35","","","","","","","fee schedule","8043.29","28616.5","MSDRG Base Rate"
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8284.59","","","","","","","fee schedule","8043.29","28616.5","MSDRG Base Rate"
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8043.29","","","","","","","fee schedule","8043.29","28616.5","Transplants-Case Rate"
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8204.16","","","","","","","fee schedule","8043.29","28616.5","MSDRG Base Rate"
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8445.45","","","","","","","fee schedule","8043.29","28616.5","MSDRG Base Rate"
"Fractures Of Hip And Pelvis Without Mcc","536","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8043.29","","","","","","","fee schedule","8043.29","28616.5","Psych-Case Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22239.96","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23785.93","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31169.35","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25844.35","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22305.81","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28508.76","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21291.39","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33814.67","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25431.14","","","","","","","fee schedule","9245.65","33814.67",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28782.16","28782.16","28782.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6682.8","6682.8","6682.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20174","20174","20174","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9684.82","","","","","","","fee schedule","9245.65","33814.67","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9523.02","","","","","","","fee schedule","9245.65","33814.67","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9245.65","","","","","","","fee schedule","9245.65","33814.67","Transplants-Case Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9430.56","","","","","","","fee schedule","9245.65","33814.67","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9707.93","","","","","","","fee schedule","9245.65","33814.67","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","537","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9245.65","","","","","","","fee schedule","9245.65","33814.67","Psych-Case Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16786.59","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17953.48","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23526.44","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19507.16","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16836.29","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21518.24","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16070.61","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25523.11","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19195.27","","","","","","","fee schedule","7327.77","25523.11",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7675.84","","","","","","","fee schedule","7327.77","25523.11","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7547.6","","","","","","","fee schedule","7327.77","25523.11","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7327.77","","","","","","","fee schedule","7327.77","25523.11","Transplants-Case Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7474.33","","","","","","","fee schedule","7327.77","25523.11","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7694.16","","","","","","","fee schedule","7327.77","25523.11","MSDRG Base Rate"
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","538","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7327.77","","","","","","","fee schedule","7327.77","25523.11","Psych-Case Rate"
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45903.86","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49094.77","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","64334.34","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","53343.42","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46039.77","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58842.82","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43945.98","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","69794.35","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","52490.54","","","","","","","fee schedule","17567.92","69794.35",""
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8504.57","6946.88","14401.69","47","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","32436.16","32436.16","32436.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17442.83","17442.83","17442.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8504.57","6903.72","15081.9","70","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16130.84","16130.84","16130.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8825.5","8427.46","14945.15","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2567.15","2567.15","2567.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18402.4","","","","","","","fee schedule","17567.92","69794.35","MSDRG Base Rate"
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18094.96","","","","","","","fee schedule","17567.92","69794.35","MSDRG Base Rate"
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17567.92","","","","","","","fee schedule","17567.92","69794.35","Transplants-Case Rate"
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17919.28","","","","","","","fee schedule","17567.92","69794.35","MSDRG Base Rate"
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18446.32","","","","","","","fee schedule","17567.92","69794.35","MSDRG Base Rate"
"Osteomyelitis With Mcc","539","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17567.92","","","","","","","fee schedule","17567.92","69794.35","Psych-Case Rate"
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30210.27","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32310.28","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42339.75","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35106.4","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30299.72","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38725.67","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28921.75","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45933.09","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34545.1","","","","","","","fee schedule","12048.7","45933.09",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2815.14","2815.14","3070.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9452.37","7274.99","12596.39","156","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17518.97","17518.97","17518.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11131.38","11131.38","11131.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9452.37","6946.88","12306.31","238","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9366.67","7209.03","12770.7","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2815.14","2503.69","3404.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2815.14","2503.69","11900.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12621.01","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12410.16","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12048.7","","","","","","","fee schedule","12048.7","45933.09","Transplants-Case Rate"
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12289.67","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12651.14","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Osteomyelitis With Cc","540","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12048.7","","","","","","","fee schedule","12048.7","45933.09","Psych-Case Rate"
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18350.36","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19625.95","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25718.06","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21324.37","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18404.69","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23522.79","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17567.68","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27900.73","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20983.42","","","","","","","fee schedule","7877.73","27900.73",""
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12016.9","12016.9","12016.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11373.59","8989.78","11373.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6903.52","6903.52","6903.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8908.26","8908.26","8908.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8251.92","","","","","","","fee schedule","7877.73","27900.73","MSDRG Base Rate"
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8114.06","","","","","","","fee schedule","7877.73","27900.73","MSDRG Base Rate"
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7877.73","","","","","","","fee schedule","7877.73","27900.73","Transplants-Case Rate"
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8035.28","","","","","","","fee schedule","7877.73","27900.73","MSDRG Base Rate"
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8271.62","","","","","","","fee schedule","7877.73","27900.73","MSDRG Base Rate"
"Osteomyelitis Without Cc/Mcc","541","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7877.73","","","","","","","fee schedule","7877.73","27900.73","Psych-Case Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41168.28","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44030.01","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57697.42","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47840.35","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41290.17","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52772.42","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39412.38","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","62594.16","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47075.46","","","","","","","fee schedule","15902.48","62594.16",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","8914.64","8914.64","8914.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10886.52","7483.58","11687.62","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","44042.69","44042.69","44042.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16561.36","16561.36","16561.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16311.5","16311.5","16311.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16168.74","16168.74","16168.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7837.05","7483.58","11400.71","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38333","38333","38333","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14296","14296","14296","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","32823.31","32823.31","32823.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9037.89","9037.89","17259.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16657.85","","","","","","","fee schedule","15902.48","62594.16","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16379.55","","","","","","","fee schedule","15902.48","62594.16","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15902.48","","","","","","","fee schedule","15902.48","62594.16","Transplants-Case Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16220.53","","","","","","","fee schedule","15902.48","62594.16","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16697.6","","","","","","","fee schedule","15902.48","62594.16","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","542","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15902.48","","","","","","","fee schedule","15902.48","62594.16","Psych-Case Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23957.54","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25622.9","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33576.54","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27840.3","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24028.47","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30710.47","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22935.71","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36426.15","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27395.17","","","","","","","fee schedule","9849.7","36426.15",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5272.42","5272.42","6023.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","23705.81","23705.81","23705.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","2651.49","2651.49","2651.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7967.41","7967.41","7967.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","23376.57","23376.57","23376.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8612.48","2062.11","8902.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6023.13","5272.42","11726.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","23290","23290","23290","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8867.09","8867.09","8867.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11707.39","11707.39","11707.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10317.56","","","","","","","fee schedule","9849.7","36426.15","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10145.19","","","","","","","fee schedule","9849.7","36426.15","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9849.7","","","","","","","fee schedule","9849.7","36426.15","Transplants-Case Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10046.69","","","","","","","fee schedule","9849.7","36426.15","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10342.19","","","","","","","fee schedule","9849.7","36426.15","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9849.7","","","","","","","fee schedule","9849.7","36426.15","Psych-Case Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17585.95","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18808.41","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24646.75","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20436.08","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17638.02","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22542.92","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16835.88","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26738.5","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20109.34","","","","","","","fee schedule","7608.89","26738.5",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5899.23","5899.23","5899.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9125.39","9125.39","9125.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7970.31","","","","","","","fee schedule","7608.89","26738.5","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7837.16","","","","","","","fee schedule","7608.89","26738.5","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7608.89","","","","","","","fee schedule","7608.89","26738.5","Transplants-Case Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7761.07","","","","","","","fee schedule","7608.89","26738.5","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7989.33","","","","","","","fee schedule","7608.89","26738.5","MSDRG Base Rate"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","544","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7608.89","","","","","","","fee schedule","7608.89","26738.5","Psych-Case Rate"
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","57836.02","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","61856.37","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","81057.29","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","67209.4","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","58007.26","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","74138.31","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","55369.21","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","87936.56","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","66134.82","","","","","","","fee schedule","21764.3","87936.56",""
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","70045.59","49724.79","153798.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19325.56","19325.56","22062.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","223977.1","223977.1","223977.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","65191","65191","65191","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","21057.53","21057.53","21057.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22798.1","","","","","","","fee schedule","21764.3","87936.56","MSDRG Base Rate"
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22417.23","","","","","","","fee schedule","21764.3","87936.56","MSDRG Base Rate"
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21764.3","","","","","","","fee schedule","21764.3","87936.56","Transplants-Case Rate"
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22199.59","","","","","","","fee schedule","21764.3","87936.56","MSDRG Base Rate"
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22852.52","","","","","","","fee schedule","21764.3","87936.56","MSDRG Base Rate"
"Connective Tissue Disorders With Mcc","545","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21764.3","","","","","","","fee schedule","21764.3","87936.56","Psych-Case Rate"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26879.99","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28748.5","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37672.35","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31236.38","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26959.57","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34456.67","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25733.51","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40869.58","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30736.96","","","","","","","fee schedule","10877.48","40869.58",""
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","29747.97","29747.97","29747.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9913.48","9913.48","9913.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8906.76","8906.76","11023.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20598.68","20598.68","20598.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","39082","39082","39082","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","29870","29870","29870","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9580.5","9580.5","9580.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19269.75","19269.75","19269.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11394.16","","","","","","","fee schedule","10877.48","40869.58","MSDRG Base Rate"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11203.8","","","","","","","fee schedule","10877.48","40869.58","MSDRG Base Rate"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10877.48","","","","","","","fee schedule","10877.48","40869.58","Transplants-Case Rate"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11095.03","","","","","","","fee schedule","10877.48","40869.58","MSDRG Base Rate"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11421.35","","","","","","","fee schedule","10877.48","40869.58","MSDRG Base Rate"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10877.48","","","","","","","fee schedule","10877.48","40869.58","Psych-Case Rate"
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19487.64","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20842.29","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27311.96","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22645.97","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19545.34","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24980.64","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18656.46","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29629.91","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22283.89","","","","","","","fee schedule","8277.69","29629.91",""
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11030.41","11030.41","38647.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11030.41","8843.61","13957.8","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8670.88","","","","","","","fee schedule","8277.69","29629.91","MSDRG Base Rate"
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8526.02","","","","","","","fee schedule","8277.69","29629.91","MSDRG Base Rate"
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8277.69","","","","","","","fee schedule","8277.69","29629.91","Transplants-Case Rate"
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8443.24","","","","","","","fee schedule","8277.69","29629.91","MSDRG Base Rate"
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8691.57","","","","","","","fee schedule","8277.69","29629.91","MSDRG Base Rate"
"Connective Tissue Disorders Without Cc/Mcc","547","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8277.69","","","","","","","fee schedule","8277.69","29629.91","Psych-Case Rate"
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44999.62","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48127.68","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63067.06","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52292.63","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45132.86","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57683.71","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43080.31","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68419.51","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51456.55","","","","","","","fee schedule","17249.92","68419.51",""
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7594.44","7251.93","42015.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16263.59","7251.93","43999.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","16877.31","16877.31","16877.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18069.29","","","","","","","fee schedule","17249.92","68419.51","MSDRG Base Rate"
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17767.42","","","","","","","fee schedule","17249.92","68419.51","MSDRG Base Rate"
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17249.92","","","","","","","fee schedule","17249.92","68419.51","Transplants-Case Rate"
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17594.92","","","","","","","fee schedule","17249.92","68419.51","MSDRG Base Rate"
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18112.42","","","","","","","fee schedule","17249.92","68419.51","MSDRG Base Rate"
"Septic Arthritis With Mcc","548","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17249.92","","","","","","","fee schedule","17249.92","68419.51","Psych-Case Rate"
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28133.8","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30089.46","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39429.57","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32693.39","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28217.09","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36063.89","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26933.84","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42775.92","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32170.67","","","","","","","fee schedule","11318.43","42775.92",""
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10019.55","10019.55","10019.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","31147","31147","31147","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11856.06","","","","","","","fee schedule","11318.43","42775.92","MSDRG Base Rate"
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11657.98","","","","","","","fee schedule","11318.43","42775.92","MSDRG Base Rate"
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11318.43","","","","","","","fee schedule","11318.43","42775.92","Transplants-Case Rate"
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11544.8","","","","","","","fee schedule","11318.43","42775.92","MSDRG Base Rate"
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11884.35","","","","","","","fee schedule","11318.43","42775.92","MSDRG Base Rate"
"Septic Arthritis With Cc","549","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11318.43","","","","","","","fee schedule","11318.43","42775.92","Psych-Case Rate"
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20370.9","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21786.94","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28549.85","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23672.38","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20431.21","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26112.86","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19502.05","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30972.86","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23293.89","","","","","","","fee schedule","8588.32","30972.86",""
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8996.27","","","","","","","fee schedule","8588.32","30972.86","MSDRG Base Rate"
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8845.97","","","","","","","fee schedule","8588.32","30972.86","MSDRG Base Rate"
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8588.32","","","","","","","fee schedule","8588.32","30972.86","Transplants-Case Rate"
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8760.09","","","","","","","fee schedule","8588.32","30972.86","MSDRG Base Rate"
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9017.74","","","","","","","fee schedule","8588.32","30972.86","MSDRG Base Rate"
"Septic Arthritis Without Cc/Mcc","550","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8588.32","","","","","","","fee schedule","8588.32","30972.86","Psych-Case Rate"
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39061.51","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41776.79","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54744.78","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45392.14","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39177.16","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50071.81","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37395.47","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59390.93","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44666.39","","","","","","","fee schedule","15161.56","59390.93",""
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29165.24","29165.24","29165.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50891.67","50891.67","50891.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4406.36","4406.36","4406.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14347.59","14347.59","14347.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13071.02","12680","14976.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13498","13498","13498","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","37462","37462","37462","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","45473.85","45473.85","45473.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15881.73","","","","","","","fee schedule","15161.56","59390.93","MSDRG Base Rate"
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15616.41","","","","","","","fee schedule","15161.56","59390.93","MSDRG Base Rate"
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15161.56","","","","","","","fee schedule","15161.56","59390.93","Transplants-Case Rate"
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15464.79","","","","","","","fee schedule","15161.56","59390.93","MSDRG Base Rate"
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15919.64","","","","","","","fee schedule","15161.56","59390.93","MSDRG Base Rate"
"Medical Back Problems With Mcc","551","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15161.56","","","","","","","fee schedule","15161.56","59390.93","Psych-Case Rate"
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22403.1","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23960.4","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31397.98","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26033.93","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22469.43","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28717.88","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21447.56","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34062.7","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25617.68","","","","","","","fee schedule","9303.02","34062.7",""
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","47772.8","47772.8","47772.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","21933.28","20005.41","23033.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24320.7","19095.36","30185.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8411.15","8411.15","8411.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2740.03","1578.12","7447.46","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8920.91","8231.8","26295.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20660","20660","20660","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","24867","24867","24867","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7533.8","6519.23","8530.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","5174.47","5174.47","5174.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9744.91","","","","","","","fee schedule","9303.02","34062.7","MSDRG Base Rate"
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9582.11","","","","","","","fee schedule","9303.02","34062.7","MSDRG Base Rate"
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9303.02","","","","","","","fee schedule","9303.02","34062.7","Transplants-Case Rate"
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9489.08","","","","","","","fee schedule","9303.02","34062.7","MSDRG Base Rate"
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9768.17","","","","","","","fee schedule","9303.02","34062.7","MSDRG Base Rate"
"Medical Back Problems Without Mcc","552","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9303.02","","","","","","","fee schedule","9303.02","34062.7","Psych-Case Rate"
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30210.27","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32310.28","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42339.75","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35106.4","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30299.72","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38725.67","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28921.75","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45933.09","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34545.1","","","","","","","fee schedule","12048.7","45933.09",""
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10068.13","10068.13","10203.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12621.01","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12410.16","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12048.7","","","","","","","fee schedule","12048.7","45933.09","Transplants-Case Rate"
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12289.67","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12651.14","","","","","","","fee schedule","12048.7","45933.09","MSDRG Base Rate"
"Bone Diseases And Arthropathies With Mcc","553","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12048.7","","","","","","","fee schedule","12048.7","45933.09","Psych-Case Rate"
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19345.48","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20690.24","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27112.73","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22480.77","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19402.76","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24798.41","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18520.36","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29413.76","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22121.33","","","","","","","fee schedule","8227.7","29413.76",""
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8078.26","8078.26","8078.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7183.04","7183.04","7183.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6537.54","6537.54","6537.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7744.53","7744.53","7744.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8618.52","","","","","","","fee schedule","8227.7","29413.76","MSDRG Base Rate"
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8474.53","","","","","","","fee schedule","8227.7","29413.76","MSDRG Base Rate"
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8227.7","","","","","","","fee schedule","8227.7","29413.76","Transplants-Case Rate"
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8392.25","","","","","","","fee schedule","8227.7","29413.76","MSDRG Base Rate"
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8639.09","","","","","","","fee schedule","8227.7","29413.76","MSDRG Base Rate"
"Bone Diseases And Arthropathies Without Mcc","554","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8227.7","","","","","","","fee schedule","8227.7","29413.76","Psych-Case Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30804.55","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32945.87","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43172.63","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35796.99","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30895.75","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39487.45","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29490.68","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46836.66","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35224.65","","","","","","","fee schedule","12257.7","46836.66",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12839.94","","","","","","","fee schedule","12257.7","46836.66","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12625.43","","","","","","","fee schedule","12257.7","46836.66","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12257.7","","","","","","","fee schedule","12257.7","46836.66","Transplants-Case Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12502.85","","","","","","","fee schedule","12257.7","46836.66","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12870.58","","","","","","","fee schedule","12257.7","46836.66","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","555","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12257.7","","","","","","","fee schedule","12257.7","46836.66","Psych-Case Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19357.13","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20702.71","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27129.06","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22494.31","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19414.44","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24813.34","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18531.52","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29431.48","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22134.66","","","","","","","fee schedule","8231.79","29431.48",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","24920.85","24920.85","24920.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","26013.56","26013.56","26013.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2152.16","2152.16","7823.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6392.43","6392.43","6392.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14588.8","14588.8","14588.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6241.65","6241.65","6241.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8622.8","","","","","","","fee schedule","8231.79","29431.48","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8478.74","","","","","","","fee schedule","8231.79","29431.48","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8231.79","","","","","","","fee schedule","8231.79","29431.48","Transplants-Case Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8396.43","","","","","","","fee schedule","8231.79","29431.48","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8643.38","","","","","","","fee schedule","8231.79","29431.48","MSDRG Base Rate"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","556","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8231.79","","","","","","","fee schedule","8231.79","29431.48","Psych-Case Rate"
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34652.2","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37060.98","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48565.13","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40268.23","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34754.8","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44419.65","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33174.23","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52686.81","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39624.4","","","","","","","fee schedule","13610.87","52686.81",""
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13643.78","13643.78","13643.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12336.94","12336.94","12336.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14257.39","","","","","","","fee schedule","13610.87","52686.81","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14019.2","","","","","","","fee schedule","13610.87","52686.81","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13610.87","","","","","","","fee schedule","13610.87","52686.81","Transplants-Case Rate"
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13883.09","","","","","","","fee schedule","13610.87","52686.81","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14291.41","","","","","","","fee schedule","13610.87","52686.81","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis With Mcc","557","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13610.87","","","","","","","fee schedule","13610.87","52686.81","Psych-Case Rate"
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20816.03","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22263.01","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29173.7","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24189.64","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20877.66","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26683.46","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19928.19","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31649.65","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23802.89","","","","","","","fee schedule","8744.87","31649.65",""
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9801.28","9801.28","9801.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","10292.07","10292.07","10292.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","13177.96","13177.96","13177.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","5147.88","5147.88","5147.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6319.89","6319.89","6905.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18465","18465","18465","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7300.32","7300.32","7300.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9160.25","","","","","","","fee schedule","8744.87","31649.65","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9007.22","","","","","","","fee schedule","8744.87","31649.65","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8744.87","","","","","","","fee schedule","8744.87","31649.65","Transplants-Case Rate"
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8919.77","","","","","","","fee schedule","8744.87","31649.65","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9182.11","","","","","","","fee schedule","8744.87","31649.65","MSDRG Base Rate"
"Tendonitis, Myositis And Bursitis Without Mcc","558","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8744.87","","","","","","","fee schedule","8744.87","31649.65","Psych-Case Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","43461.49","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","46482.63","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","60911.36","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","50505.22","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","43590.17","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","55712.02","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","41607.78","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","66080.87","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","49697.72","","","","","","","fee schedule","16708.98","66080.87",""
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","84842.17","84842.17","84842.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","29865.84","29865.84","29865.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","58137.46","58137.46","58137.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16522.52","16522.52","16522.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","73819.15","73819.15","73819.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","59025.87","59025.87","59025.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38152","38152","38152","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15274.76","15274.76","15274.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17502.66","","","","","","","fee schedule","16708.98","66080.87","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17210.25","","","","","","","fee schedule","16708.98","66080.87","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16708.98","","","","","","","fee schedule","16708.98","66080.87","Transplants-Case Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17043.16","","","","","","","fee schedule","16708.98","66080.87","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17544.43","","","","","","","fee schedule","16708.98","66080.87","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","559","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16708.98","","","","","","","fee schedule","16708.98","66080.87","Psych-Case Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26243.76","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28068.04","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36780.68","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30497.04","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26321.46","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33641.11","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25124.42","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","39902.23","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30009.44","","","","","","","fee schedule","10653.73","39902.23",""
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2075.07","2075.07","2075.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6688.83","5875.15","8144.44","301","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","31756.34","31756.34","35662.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","43933.65","43933.65","43933.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33178.68","33178.68","33178.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6387.16","5610.17","7777.11","554","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","25002","25002","25002","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11070.83","11070.83","11070.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","36546.89","36546.89","36546.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6628.18","5821.87","8070.59","115","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2039.15","1860.95","2297.08","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2039.15","2039.15","5883.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11159.78","","","","","","","fee schedule","10653.73","39902.23","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10973.34","","","","","","","fee schedule","10653.73","39902.23","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10653.73","","","","","","","fee schedule","10653.73","39902.23","Transplants-Case Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10866.8","","","","","","","fee schedule","10653.73","39902.23","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11186.42","","","","","","","fee schedule","10653.73","39902.23","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue With Cc","560","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10653.73","","","","","","","fee schedule","10653.73","39902.23","Psych-Case Rate"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18734.89","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20037.21","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26256.98","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21771.22","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18790.36","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24015.71","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17935.81","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28485.39","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21423.13","","","","","","","fee schedule","8012.96","28485.39",""
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6883.58","4531.05","17461.2","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","4326.7","3379.92","7208.7","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","4489.97","4489.97","4489.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1550.6","1550.6","1550.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8393.58","","","","","","","fee schedule","8012.96","28485.39","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8253.35","","","","","","","fee schedule","8012.96","28485.39","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8012.96","","","","","","","fee schedule","8012.96","28485.39","Transplants-Case Rate"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8173.22","","","","","","","fee schedule","8012.96","28485.39","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8413.61","","","","","","","fee schedule","8012.96","28485.39","MSDRG Base Rate"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","561","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8012.96","","","","","","","fee schedule","8012.96","28485.39","Psych-Case Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33204.96","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35513.14","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46536.82","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38586.43","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33303.28","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42564.48","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31788.71","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50486.36","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37969.5","","","","","","","fee schedule","13101.89","50486.36",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","44085.36","44085.36","44085.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12657.75","12657.75","12657.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11937.15","11937.15","11937.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10461.14","10461.14","10461.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13724.23","","","","","","","fee schedule","13101.89","50486.36","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13494.95","","","","","","","fee schedule","13101.89","50486.36","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13101.89","","","","","","","fee schedule","13101.89","50486.36","Transplants-Case Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13363.93","","","","","","","fee schedule","13101.89","50486.36","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13756.98","","","","","","","fee schedule","13101.89","50486.36","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","562","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13101.89","","","","","","","fee schedule","13101.89","50486.36","Psych-Case Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20869.63","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22320.34","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29248.82","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24251.93","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20931.42","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26752.17","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19979.5","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31731.15","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23864.18","","","","","","","fee schedule","8763.72","31731.15",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","20896.17","20896.17","20896.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20961.88","20961.88","20961.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8135.29","8135.29","8135.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17855.75","17855.75","17855.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6880.5","6880.5","6880.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7899.66","7899.66","7899.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11398.76","11398.76","11398.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8221.03","8065.84","8221.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12387.61","12387.61","12387.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9180","","","","","","","fee schedule","8763.72","31731.15","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9026.63","","","","","","","fee schedule","8763.72","31731.15","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8763.72","","","","","","","fee schedule","8763.72","31731.15","Transplants-Case Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8938.99","","","","","","","fee schedule","8763.72","31731.15","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9201.91","","","","","","","fee schedule","8763.72","31731.15","MSDRG Base Rate"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","563","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8763.72","","","","","","","fee schedule","8763.72","31731.15","Psych-Case Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35973.6","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38474.23","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50417.06","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41803.78","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36080.11","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46113.51","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34439.26","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54695.92","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41135.4","","","","","","","fee schedule","14075.58","54695.92",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4415.91","4415.91","4415.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12350.82","12350.82","12350.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","4415.91","3636.03","8109.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1509.5","1509.5","1509.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14744.17","","","","","","","fee schedule","14075.58","54695.92","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14497.85","","","","","","","fee schedule","14075.58","54695.92","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14075.58","","","","","","","fee schedule","14075.58","54695.92","Transplants-Case Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14357.09","","","","","","","fee schedule","14075.58","54695.92","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14779.36","","","","","","","fee schedule","14075.58","54695.92","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","564","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14075.58","","","","","","","fee schedule","14075.58","54695.92","Psych-Case Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22708.39","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24286.92","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31825.85","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26388.7","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22775.63","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29109.23","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21739.84","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34526.89","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25966.79","","","","","","","fee schedule","9410.39","34526.89",""
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","29043.67","29043.67","29043.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8061.75","8061.75","9610.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8753.44","8753.44","8753.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7975.31","7975.31","8033.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","25098.09","25098.09","25098.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9282.67","9282.67","9282.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9857.38","","","","","","","fee schedule","9410.39","34526.89","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9692.7","","","","","","","fee schedule","9410.39","34526.89","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9410.39","","","","","","","fee schedule","9410.39","34526.89","Transplants-Case Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9598.6","","","","","","","fee schedule","9410.39","34526.89","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9880.91","","","","","","","fee schedule","9410.39","34526.89","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9410.39","","","","","","","fee schedule","9410.39","34526.89","Psych-Case Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17462.44","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18676.3","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24473.64","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20292.54","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17514.14","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22384.59","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16717.63","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26550.7","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19968.1","","","","","","","fee schedule","7565.46","26550.7",""
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","5613.79","5613.79","5613.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1524.4","1524.4","2425.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5992.68","5722.4","8186.63","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5992.68","5722.4","8186.63","131","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15104.59","15104.59","15104.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6218.82","4495.94","8495.56","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6862.31","6862.31","6862.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1665.66","1665.66","1665.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7924.82","","","","","","","fee schedule","7565.46","26550.7","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7792.42","","","","","","","fee schedule","7565.46","26550.7","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7565.46","","","","","","","fee schedule","7565.46","26550.7","Transplants-Case Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7716.77","","","","","","","fee schedule","7565.46","26550.7","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7943.73","","","","","","","fee schedule","7565.46","26550.7","MSDRG Base Rate"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","566","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7565.46","","","","","","","fee schedule","7565.46","26550.7","Psych-Case Rate"
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","567","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","568","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Small & Large Bowel Procedures w CC w Major Gi Dx","569","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","68542.34","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","73306.92","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","96062.21","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","79650.87","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","68745.27","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","87862.42","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","65618.88","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","104214.94","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","78377.37","","","","","","","fee schedule","25529.57","104214.94",""
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","3644.17","3644.17","3644.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26742.22","","","","","","","fee schedule","25529.57","104214.94","MSDRG Base Rate"
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26295.46","","","","","","","fee schedule","25529.57","104214.94","MSDRG Base Rate"
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25529.57","","","","","","","fee schedule","25529.57","104214.94","Transplants-Case Rate"
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26040.16","","","","","","","fee schedule","25529.57","104214.94","MSDRG Base Rate"
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26806.05","","","","","","","fee schedule","25529.57","104214.94","MSDRG Base Rate"
"Skin Debridement With Mcc","570","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25529.57","","","","","","","fee schedule","25529.57","104214.94","Psych-Case Rate"
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39373.8","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42110.79","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55182.45","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45755.04","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39490.37","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50472.12","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37694.43","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59865.74","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45023.49","","","","","","","fee schedule","15271.39","59865.74",""
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","35938.6","35938.6","35938.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45124.96","45124.96","45124.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12229.22","12229.22","12229.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12994.28","12994.28","12994.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13216.44","13216.44","13216.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","26010.58","26010.58","26010.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15996.78","","","","","","","fee schedule","15271.39","59865.74","MSDRG Base Rate"
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15729.53","","","","","","","fee schedule","15271.39","59865.74","MSDRG Base Rate"
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15271.39","","","","","","","fee schedule","15271.39","59865.74","Transplants-Case Rate"
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15576.82","","","","","","","fee schedule","15271.39","59865.74","MSDRG Base Rate"
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16034.96","","","","","","","fee schedule","15271.39","59865.74","MSDRG Base Rate"
"Skin Debridement With Cc","571","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15271.39","","","","","","","fee schedule","15271.39","59865.74","Psych-Case Rate"
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26714.52","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28571.53","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37440.45","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31044.1","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26793.62","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34244.57","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25575.1","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40617.99","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30547.75","","","","","","","fee schedule","10819.29","40617.99",""
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9658.52","9658.52","9658.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11333.21","","","","","","","fee schedule","10819.29","40617.99","MSDRG Base Rate"
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11143.87","","","","","","","fee schedule","10819.29","40617.99","MSDRG Base Rate"
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10819.29","","","","","","","fee schedule","10819.29","40617.99","Transplants-Case Rate"
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11035.68","","","","","","","fee schedule","10819.29","40617.99","MSDRG Base Rate"
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11360.25","","","","","","","fee schedule","10819.29","40617.99","MSDRG Base Rate"
"Skin Debridement Without Cc/Mcc","572","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10819.29","","","","","","","fee schedule","10819.29","40617.99","Psych-Case Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","152680.38","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","163293.65","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","213981.83","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","177425.01","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","153132.42","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","195716.52","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","146168.29","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","232142.31","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","174588.26","","","","","","","fee schedule","55119.8","232142.31",""
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","73400.93","73400.93","73400.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","48924.56","48924.56","48924.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22567.86","22567.86","22567.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","57737.99","","","","","","","fee schedule","55119.8","232142.31","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","56773.39","","","","","","","fee schedule","55119.8","232142.31","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","55119.8","","","","","","","fee schedule","55119.8","232142.31","Transplants-Case Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","56222.2","","","","","","","fee schedule","55119.8","232142.31","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","57875.79","","","","","","","fee schedule","55119.8","232142.31","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","573","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","55119.8","","","","","","","fee schedule","55119.8","232142.31","Psych-Case Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","80900.98","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","86524.65","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","113382.87","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","94012.45","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","81140.5","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","103704.6","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","77450.41","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","123005.59","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","92509.34","","","","","","","fee schedule","29875.94","123005.59",""
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","59746.93","59746.93","59746.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31295.05","","","","","","","fee schedule","29875.94","123005.59","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30772.22","","","","","","","fee schedule","29875.94","123005.59","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29875.94","","","","","","","fee schedule","29875.94","123005.59","Transplants-Case Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30473.46","","","","","","","fee schedule","29875.94","123005.59","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31369.74","","","","","","","fee schedule","29875.94","123005.59","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis With Cc","574","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29875.94","","","","","","","fee schedule","29875.94","123005.59","Psych-Case Rate"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41879.09","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44790.23","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58693.61","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48666.35","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42003.08","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53683.58","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40092.87","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63674.9","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47888.25","","","","","","","fee schedule","16152.46","63674.9",""
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16919.7","","","","","","","fee schedule","16152.46","63674.9","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16637.03","","","","","","","fee schedule","16152.46","63674.9","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16152.46","","","","","","","fee schedule","16152.46","63674.9","Transplants-Case Rate"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16475.51","","","","","","","fee schedule","16152.46","63674.9","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16960.08","","","","","","","fee schedule","16152.46","63674.9","MSDRG Base Rate"
"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","575","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16152.46","","","","","","","fee schedule","16152.46","63674.9","Psych-Case Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","114222.47","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","122162.41","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","160082.99","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","132734.3","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","114560.65","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","146418.45","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","109350.67","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","173669.12","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","130612.08","","","","","","","fee schedule","41594.66","173669.12",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","44911.77","44911.77","44911.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","43023.97","43023.97","43023.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43570.41","","","","","","","fee schedule","41594.66","173669.12","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","42842.5","","","","","","","fee schedule","41594.66","173669.12","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41594.66","","","","","","","fee schedule","41594.66","173669.12","Transplants-Case Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42426.55","","","","","","","fee schedule","41594.66","173669.12","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43674.39","","","","","","","fee schedule","41594.66","173669.12","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","576","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41594.66","","","","","","","fee schedule","41594.66","173669.12","Psych-Case Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","61774.56","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","66068.7","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","86577.16","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","71786.26","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","61957.46","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","79187.01","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","59139.77","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","93924.9","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","70638.5","","","","","","","fee schedule","23149.44","93924.9",""
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","49906.88","49906.88","49906.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7208.84","7208.84","7208.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21650.35","21650.35","21650.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20426.26","20426.26","20426.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","22175.89","22175.89","22175.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24249.04","","","","","","","fee schedule","23149.44","93924.9","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23843.92","","","","","","","fee schedule","23149.44","93924.9","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23149.44","","","","","","","fee schedule","23149.44","93924.9","Transplants-Case Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23612.43","","","","","","","fee schedule","23149.44","93924.9","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24306.91","","","","","","","fee schedule","23149.44","93924.9","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","577","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23149.44","","","","","","","fee schedule","23149.44","93924.9","Psych-Case Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37437.15","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40039.52","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52468.24","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43504.52","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37547.99","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47989.59","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35840.39","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56921.18","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42808.95","","","","","","","fee schedule","14590.3","56921.18",""
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13312.64","13312.64","13312.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14388.45","14388.45","14388.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15283.34","","","","","","","fee schedule","14590.3","56921.18","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15028.01","","","","","","","fee schedule","14590.3","56921.18","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14590.3","","","","","","","fee schedule","14590.3","56921.18","Transplants-Case Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14882.11","","","","","","","fee schedule","14590.3","56921.18","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15319.82","","","","","","","fee schedule","14590.3","56921.18","MSDRG Base Rate"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","578","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14590.3","","","","","","","fee schedule","14590.3","56921.18","Psych-Case Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75473.24","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80719.61","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","105775.89","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","87705.06","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75696.7","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","96746.95","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","72254.17","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","114753.01","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","86302.79","","","","","","","fee schedule","27967.08","114753.01",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","26433.29","26433.29","26433.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","27381.62","27381.62","27381.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12620.36","12620.36","12620.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","70701","70701","70701","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","26610.66","26610.66","27100.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29295.52","","","","","","","fee schedule","27967.08","114753.01","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28806.09","","","","","","","fee schedule","27967.08","114753.01","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27967.08","","","","","","","fee schedule","27967.08","114753.01","Transplants-Case Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28526.42","","","","","","","fee schedule","27967.08","114753.01","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29365.43","","","","","","","fee schedule","27967.08","114753.01","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","579","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27967.08","","","","","","","fee schedule","27967.08","114753.01","Psych-Case Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40271.04","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43070.4","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56439.94","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46797.7","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40390.27","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51622.27","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38553.41","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61229.95","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46049.47","","","","","","","fee schedule","15586.94","61229.95",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","33451.73","33451.73","33451.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","35545.64","35545.64","35545.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13928.73","13928.73","13928.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13894.14","13894.14","13894.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","3725.24","3725.24","3725.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14226.06","14226.06","14226.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1795.02","1795.02","1795.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16327.32","","","","","","","fee schedule","15586.94","61229.95","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16054.55","","","","","","","fee schedule","15586.94","61229.95","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15586.94","","","","","","","fee schedule","15586.94","61229.95","Transplants-Case Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15898.68","","","","","","","fee schedule","15586.94","61229.95","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16366.29","","","","","","","fee schedule","15586.94","61229.95","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15586.94","","","","","","","fee schedule","15586.94","61229.95","Psych-Case Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33631.45","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35969.27","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","47134.53","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39082.03","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33731.02","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43111.17","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32197","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","51134.81","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38457.17","","","","","","","fee schedule","13251.88","51134.81",""
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3204.38","3204.38","3204.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3693.25","2204.81","11076.45","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","44724.3","44724.3","44724.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12648.66","12648.66","12648.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","3526.68","2231.69","6268.43","62","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","29581","29581","29581","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6211.59","2425.29","11494.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5964.9","5964.9","5964.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13881.34","","","","","","","fee schedule","13251.88","51134.81","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13649.44","","","","","","","fee schedule","13251.88","51134.81","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13251.88","","","","","","","fee schedule","13251.88","51134.81","Transplants-Case Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13516.92","","","","","","","fee schedule","13251.88","51134.81","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13914.47","","","","","","","fee schedule","13251.88","51134.81","MSDRG Base Rate"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","581","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13251.88","","","","","","","fee schedule","13251.88","51134.81","Psych-Case Rate"
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44899.41","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48020.51","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","62926.61","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52176.18","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45032.35","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57555.25","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42984.37","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68267.14","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51341.96","","","","","","","fee schedule","17214.67","68267.14",""
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18032.37","","","","","","","fee schedule","17214.67","68267.14","MSDRG Base Rate"
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17731.11","","","","","","","fee schedule","17214.67","68267.14","MSDRG Base Rate"
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17214.67","","","","","","","fee schedule","17214.67","68267.14","Transplants-Case Rate"
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17558.96","","","","","","","fee schedule","17214.67","68267.14","MSDRG Base Rate"
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18075.4","","","","","","","fee schedule","17214.67","68267.14","MSDRG Base Rate"
"Mastectomy For Malignancy With Cc/Mcc","582","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17214.67","","","","","","","fee schedule","17214.67","68267.14","Psych-Case Rate"
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40187.14","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42980.67","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56322.35","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46700.2","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40306.13","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51514.73","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38473.09","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61102.39","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45953.54","","","","","","","fee schedule","15557.43","61102.39",""
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16296.41","","","","","","","fee schedule","15557.43","61102.39","MSDRG Base Rate"
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16024.15","","","","","","","fee schedule","15557.43","61102.39","MSDRG Base Rate"
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15557.43","","","","","","","fee schedule","15557.43","61102.39","Transplants-Case Rate"
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15868.58","","","","","","","fee schedule","15557.43","61102.39","MSDRG Base Rate"
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16335.3","","","","","","","fee schedule","15557.43","61102.39","MSDRG Base Rate"
"Mastectomy For Malignancy Without Cc/Mcc","583","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15557.43","","","","","","","fee schedule","15557.43","61102.39","Psych-Case Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49889.01","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53356.95","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69919.54","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57974.44","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","50036.72","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63951.27","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47761.16","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75853.56","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","57047.51","","","","","","","fee schedule","18969.45","75853.56",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18597.35","18597.35","18597.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18093.8","18093.8","18093.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8590.46","8590.46","8590.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19870.5","","","","","","","fee schedule","18969.45","75853.56","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19538.53","","","","","","","fee schedule","18969.45","75853.56","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18969.45","","","","","","","fee schedule","18969.45","75853.56","Transplants-Case Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19348.84","","","","","","","fee schedule","18969.45","75853.56","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19917.92","","","","","","","fee schedule","18969.45","75853.56","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","584","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18969.45","","","","","","","fee schedule","18969.45","75853.56","Psych-Case Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44957.68","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48082.82","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63008.26","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52243.89","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45090.78","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57629.93","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43040.15","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68355.73","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51408.59","","","","","","","fee schedule","17235.16","68355.73",""
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","18597.35","18597.35","18597.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16829.82","16829.82","16829.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18053.83","","","","","","","fee schedule","17235.16","68355.73","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17752.21","","","","","","","fee schedule","17235.16","68355.73","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17235.16","","","","","","","fee schedule","17235.16","68355.73","Transplants-Case Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17579.86","","","","","","","fee schedule","17235.16","68355.73","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18096.92","","","","","","","fee schedule","17235.16","68355.73","MSDRG Base Rate"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","585","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17235.16","","","","","","","fee schedule","17235.16","68355.73","Psych-Case Rate"
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45102.17","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48237.35","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63210.77","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52411.79","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45235.7","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57815.15","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43178.48","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68575.42","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51573.81","","","","","","","fee schedule","17285.98","68575.42",""
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18666.12","18666.12","18666.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17703.9","17703.9","17703.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18202.73","18202.73","18202.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18107.06","","","","","","","fee schedule","17285.98","68575.42","MSDRG Base Rate"
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17804.56","","","","","","","fee schedule","17285.98","68575.42","MSDRG Base Rate"
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17285.98","","","","","","","fee schedule","17285.98","68575.42","Transplants-Case Rate"
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17631.7","","","","","","","fee schedule","17285.98","68575.42","MSDRG Base Rate"
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18150.28","","","","","","","fee schedule","17285.98","68575.42","MSDRG Base Rate"
"Skin Ulcers With Mcc","592","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17285.98","","","","","","","fee schedule","17285.98","68575.42","Psych-Case Rate"
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27646.72","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29568.53","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38746.93","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32127.38","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27728.58","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35439.53","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26467.54","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42035.35","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31613.71","","","","","","","fee schedule","11147.13","42035.35",""
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22287.98","22287.98","22287.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9554.48","9554.48","9554.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10815.56","10815.56","10815.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11676.62","","","","","","","fee schedule","11147.13","42035.35","MSDRG Base Rate"
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11481.54","","","","","","","fee schedule","11147.13","42035.35","MSDRG Base Rate"
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11147.13","","","","","","","fee schedule","11147.13","42035.35","Transplants-Case Rate"
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11370.07","","","","","","","fee schedule","11147.13","42035.35","MSDRG Base Rate"
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11704.49","","","","","","","fee schedule","11147.13","42035.35","MSDRG Base Rate"
"Skin Ulcers With Cc","593","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11147.13","","","","","","","fee schedule","11147.13","42035.35","Psych-Case Rate"
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20200.77","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21604.99","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28311.42","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23474.68","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20260.58","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25894.78","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19339.17","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30714.19","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23099.35","","","","","","","fee schedule","8528.49","30714.19",""
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8933.59","","","","","","","fee schedule","8528.49","30714.19","MSDRG Base Rate"
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8784.34","","","","","","","fee schedule","8528.49","30714.19","MSDRG Base Rate"
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8528.49","","","","","","","fee schedule","8528.49","30714.19","Transplants-Case Rate"
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8699.06","","","","","","","fee schedule","8528.49","30714.19","MSDRG Base Rate"
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8954.91","","","","","","","fee schedule","8528.49","30714.19","MSDRG Base Rate"
"Skin Ulcers Without Cc/Mcc","594","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8528.49","","","","","","","fee schedule","8528.49","30714.19","Psych-Case Rate"
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49422.91","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52858.45","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69266.3","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57432.8","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49569.24","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63353.79","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47314.94","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75144.88","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56514.53","","","","","","","fee schedule","18805.53","75144.88",""
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16768.35","16381.25","19062.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","106188.23","106188.23","106188.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16196.36","16196.36","16196.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","46087.39","46087.39","46087.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17442.98","17442.98","17442.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19698.79","","","","","","","fee schedule","18805.53","75144.88","MSDRG Base Rate"
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19369.7","","","","","","","fee schedule","18805.53","75144.88","MSDRG Base Rate"
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18805.53","","","","","","","fee schedule","18805.53","75144.88","Transplants-Case Rate"
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19181.64","","","","","","","fee schedule","18805.53","75144.88","MSDRG Base Rate"
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19745.81","","","","","","","fee schedule","18805.53","75144.88","MSDRG Base Rate"
"Major Skin Disorders With Mcc","595","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18805.53","","","","","","","fee schedule","18805.53","75144.88","Psych-Case Rate"
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25227.66","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26981.31","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35356.62","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29316.27","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25302.36","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32338.61","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24151.66","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38357.31","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28847.54","","","","","","","fee schedule","10296.38","38357.31",""
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","24604.75","24604.75","24604.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33858.97","33858.97","33858.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9179.55","9179.55","9179.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18008.93","18008.93","18008.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10785.46","","","","","","","fee schedule","10296.38","38357.31","MSDRG Base Rate"
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10605.27","","","","","","","fee schedule","10296.38","38357.31","MSDRG Base Rate"
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10296.38","","","","","","","fee schedule","10296.38","38357.31","Transplants-Case Rate"
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10502.31","","","","","","","fee schedule","10296.38","38357.31","MSDRG Base Rate"
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10811.2","","","","","","","fee schedule","10296.38","38357.31","MSDRG Base Rate"
"Major Skin Disorders Without Mcc","596","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10296.38","","","","","","","fee schedule","10296.38","38357.31","Psych-Case Rate"
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38851.77","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41552.47","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54450.82","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45148.4","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38966.8","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49802.95","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37194.67","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59072.02","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44426.55","","","","","","","fee schedule","15087.8","59072.02",""
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","52906.23","52906.23","52906.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15703.84","15703.84","15703.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15804.47","","","","","","","fee schedule","15087.8","59072.02","MSDRG Base Rate"
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15540.43","","","","","","","fee schedule","15087.8","59072.02","MSDRG Base Rate"
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15087.8","","","","","","","fee schedule","15087.8","59072.02","Transplants-Case Rate"
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15389.56","","","","","","","fee schedule","15087.8","59072.02","MSDRG Base Rate"
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15842.19","","","","","","","fee schedule","15087.8","59072.02","MSDRG Base Rate"
"Malignant Breast Disorders With Mcc","597","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15087.8","","","","","","","fee schedule","15087.8","59072.02","Psych-Case Rate"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26364.95","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28197.65","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36950.52","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30637.87","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26443.01","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33796.46","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25240.43","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40086.48","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30148.01","","","","","","","fee schedule","10696.35","40086.48",""
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11204.43","","","","","","","fee schedule","10696.35","40086.48","MSDRG Base Rate"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11017.24","","","","","","","fee schedule","10696.35","40086.48","MSDRG Base Rate"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10696.35","","","","","","","fee schedule","10696.35","40086.48","Transplants-Case Rate"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10910.28","","","","","","","fee schedule","10696.35","40086.48","MSDRG Base Rate"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11231.17","","","","","","","fee schedule","10696.35","40086.48","MSDRG Base Rate"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10696.35","","","","","","","fee schedule","10696.35","40086.48","Psych-Case Rate"
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17930.87","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19177.3","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25130.14","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20836.89","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17983.96","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22985.06","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17166.08","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27262.92","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20503.74","","","","","","","fee schedule","7730.2","27262.92",""
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8097.38","","","","","","","fee schedule","7730.2","27262.92","MSDRG Base Rate"
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7962.11","","","","","","","fee schedule","7730.2","27262.92","MSDRG Base Rate"
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7730.2","","","","","","","fee schedule","7730.2","27262.92","Transplants-Case Rate"
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7884.8","","","","","","","fee schedule","7730.2","27262.92","MSDRG Base Rate"
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8116.71","","","","","","","fee schedule","7730.2","27262.92","MSDRG Base Rate"
"Malignant Breast Disorders Without Cc/Mcc","599","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7730.2","","","","","","","fee schedule","7730.2","27262.92","Psych-Case Rate"
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24274.49","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25961.88","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34020.74","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28208.61","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24346.36","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31116.76","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23239.14","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36908.05","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27757.6","","","","","","","fee schedule","9961.16","36908.05",""
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10434.32","","","","","","","fee schedule","9961.16","36908.05","MSDRG Base Rate"
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10259.99","","","","","","","fee schedule","9961.16","36908.05","MSDRG Base Rate"
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9961.16","","","","","","","fee schedule","9961.16","36908.05","Transplants-Case Rate"
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10160.38","","","","","","","fee schedule","9961.16","36908.05","MSDRG Base Rate"
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10459.22","","","","","","","fee schedule","9961.16","36908.05","MSDRG Base Rate"
"Non-Malignant Breast Disorders With Cc/Mcc","600","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9961.16","","","","","","","fee schedule","9961.16","36908.05","Psych-Case Rate"
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14099.53","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15079.63","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","19760.51","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16384.61","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14141.27","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18073.77","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","13498.16","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","21437.57","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16122.65","","","","","","","fee schedule","6382.76","21437.57",""
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6685.94","","","","","","","fee schedule","6382.76","21437.57","MSDRG Base Rate"
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6574.24","","","","","","","fee schedule","6382.76","21437.57","MSDRG Base Rate"
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6382.76","","","","","","","fee schedule","6382.76","21437.57","Transplants-Case Rate"
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6510.42","","","","","","","fee schedule","6382.76","21437.57","MSDRG Base Rate"
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6701.9","","","","","","","fee schedule","6382.76","21437.57","MSDRG Base Rate"
"Non-Malignant Breast Disorders Without Cc/Mcc","601","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6382.76","","","","","","","fee schedule","6382.76","21437.57","Psych-Case Rate"
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33123.4","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35425.9","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46422.5","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38491.65","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33221.47","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42459.92","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31710.62","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50362.34","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37876.22","","","","","","","fee schedule","13073.21","50362.34",""
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","148707.63","148707.63","155731.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19013.07","19013.07","19013.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13339.64","13339.64","13339.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12001.97","12001.97","12001.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11912","11912","12998.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","117533.09","48687.18","148707.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","16284.11","16284.11","16284.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","36734.68","36734.68","36734.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11722.92","11407.7","12547.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","161608","161608","161608","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13694.19","","","","","","","fee schedule","13073.21","50362.34","MSDRG Base Rate"
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13465.41","","","","","","","fee schedule","13073.21","50362.34","MSDRG Base Rate"
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13073.21","","","","","","","fee schedule","13073.21","50362.34","Transplants-Case Rate"
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13334.67","","","","","","","fee schedule","13073.21","50362.34","MSDRG Base Rate"
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13726.87","","","","","","","fee schedule","13073.21","50362.34","MSDRG Base Rate"
"Cellulitis With Mcc","602","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13073.21","","","","","","","fee schedule","13073.21","50362.34","Psych-Case Rate"
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20296.32","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21707.18","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28445.34","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23585.71","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20356.42","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26017.27","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19430.65","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30859.47","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23208.61","","","","","","","fee schedule","8562.1","30859.47",""
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","13284.99","13284.99","13284.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","6214.83","6214.83","13978.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","12090.34","12090.34","12090.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17922.22","17922.22","17922.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","6717.98","6338.32","25622.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8695.94","8695.94","8695.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6145.46","6145.46","6145.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","19430.65","19430.65","19430.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6035.74","5564.75","8344.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7138.24","6623.18","10947.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12620.36","8695.94","12620.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18743.16","14039.43","19121","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","22728","22728","22728","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7094.14","7094.14","7094.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","6780.06","6780.06","6780.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","4304.5","4304.5","4304.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8968.8","","","","","","","fee schedule","8562.1","30859.47","MSDRG Base Rate"
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8818.96","","","","","","","fee schedule","8562.1","30859.47","MSDRG Base Rate"
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8562.1","","","","","","","fee schedule","8562.1","30859.47","Transplants-Case Rate"
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8733.34","","","","","","","fee schedule","8562.1","30859.47","MSDRG Base Rate"
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8990.2","","","","","","","fee schedule","8562.1","30859.47","MSDRG Base Rate"
"Cellulitis Without Mcc","603","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8562.1","","","","","","","fee schedule","8562.1","30859.47","Psych-Case Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34307.29","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36692.09","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48081.73","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39867.41","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34408.87","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43977.52","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32844.02","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52162.39","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39229.99","","","","","","","fee schedule","13489.57","52162.39",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13711.62","13711.62","13711.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13453.07","13453.07","13453.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14130.32","","","","","","","fee schedule","13489.57","52162.39","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13894.26","","","","","","","fee schedule","13489.57","52162.39","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13489.57","","","","","","","fee schedule","13489.57","52162.39","Transplants-Case Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13759.36","","","","","","","fee schedule","13489.57","52162.39","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14164.05","","","","","","","fee schedule","13489.57","52162.39","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","604","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13489.57","","","","","","","fee schedule","13489.57","52162.39","Psych-Case Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21347.38","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22831.3","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29918.39","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24807.11","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21410.58","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27364.58","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20436.88","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32457.54","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24410.48","","","","","","","fee schedule","8931.74","32457.54",""
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","32197.56","32197.56","32197.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20837.89","20837.89","20837.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8144.62","8144.62","8144.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7720.96","7720.96","7720.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","16616.14","16616.14","16616.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8579.4","8579.4","8579.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9356","","","","","","","fee schedule","8931.74","32457.54","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9199.69","","","","","","","fee schedule","8931.74","32457.54","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8931.74","","","","","","","fee schedule","8931.74","32457.54","Transplants-Case Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9110.37","","","","","","","fee schedule","8931.74","32457.54","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9378.33","","","","","","","fee schedule","8931.74","32457.54","MSDRG Base Rate"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","605","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8931.74","","","","","","","fee schedule","8931.74","32457.54","Psych-Case Rate"
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35265.13","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37716.51","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49424.14","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40980.48","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35369.54","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45205.34","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33761.01","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53618.73","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40325.27","","","","","","","fee schedule","13826.42","53618.73",""
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","33045.57","33045.57","33045.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13465.74","13465.74","14228.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14122.91","14122.91","14122.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26196.4","26196.4","26196.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12715.17","12715.17","12715.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14483.17","","","","","","","fee schedule","13826.42","53618.73","MSDRG Base Rate"
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14241.21","","","","","","","fee schedule","13826.42","53618.73","MSDRG Base Rate"
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13826.42","","","","","","","fee schedule","13826.42","53618.73","Transplants-Case Rate"
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14102.95","","","","","","","fee schedule","13826.42","53618.73","MSDRG Base Rate"
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14517.74","","","","","","","fee schedule","13826.42","53618.73","MSDRG Base Rate"
"Minor Skin Disorders With Mcc","606","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13826.42","","","","","","","fee schedule","13826.42","53618.73","Psych-Case Rate"
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21123.65","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22592.02","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29604.84","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24547.12","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21186.19","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27077.79","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20222.69","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32117.38","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24154.65","","","","","","","fee schedule","8853.06","32117.38",""
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","23624.84","23624.84","23624.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","100564.63","100564.63","128946.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22258.6","22258.6","22258.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7155.59","6924.79","8292.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","19281.17","19281.17","19281.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7714.83","7714.83","8219.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","96029.01","70619.93","128946.14","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18976","18976","18976","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","99652.75","99652.75","99652.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","17938.29","17938.29","17938.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","23624.84","23624.84","23624.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9273.58","","","","","","","fee schedule","8853.06","32117.38","MSDRG Base Rate"
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9118.65","","","","","","","fee schedule","8853.06","32117.38","MSDRG Base Rate"
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8853.06","","","","","","","fee schedule","8853.06","32117.38","Transplants-Case Rate"
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9030.12","","","","","","","fee schedule","8853.06","32117.38","MSDRG Base Rate"
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9295.71","","","","","","","fee schedule","8853.06","32117.38","MSDRG Base Rate"
"Minor Skin Disorders Without Mcc","607","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8853.06","","","","","","","fee schedule","8853.06","32117.38","Psych-Case Rate"
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51079.9","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54630.62","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71588.57","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59358.33","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51231.13","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65477.83","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48901.25","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77664.24","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58409.28","","","","","","","fee schedule","19388.27","77664.24",""
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","108189.9","108189.9","108189.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","77900.63","77900.63","77900.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","19151.87","18288.08","26227.79","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","53065.3","53065.3","53065.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","71026","64874.11","71376","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18322.11","18322.11","19964.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18870.91","18870.91","18870.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","19499.05","19499.05","19499.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19151.87","18288.08","27466.58","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","48788.2","47693.49","48820.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","58964.09","58964.09","58964.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","18978.2","18978.2","18978.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3289.62","3289.62","3289.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20309.21","","","","","","","fee schedule","19388.27","77664.24","MSDRG Base Rate"
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19969.92","","","","","","","fee schedule","19388.27","77664.24","MSDRG Base Rate"
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19388.27","","","","","","","fee schedule","19388.27","77664.24","Transplants-Case Rate"
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19776.04","","","","","","","fee schedule","19388.27","77664.24","MSDRG Base Rate"
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20357.68","","","","","","","fee schedule","19388.27","77664.24","MSDRG Base Rate"
"Adrenal And Pituitary Procedures With Cc/Mcc","614","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19388.27","","","","","","","fee schedule","19388.27","77664.24","Psych-Case Rate"
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32610.69","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34877.55","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45703.94","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37895.84","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32707.24","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41802.69","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31219.78","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49582.8","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37289.95","","","","","","","fee schedule","12892.89","49582.8",""
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","50092.5","50092.5","50092.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29456.38","29456.38","29456.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","43824.68","42387.79","44726.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","31459","31459","31459","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","36970","36970","36970","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13505.3","","","","","","","fee schedule","12892.89","49582.8","MSDRG Base Rate"
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13279.68","","","","","","","fee schedule","12892.89","49582.8","MSDRG Base Rate"
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12892.89","","","","","","","fee schedule","12892.89","49582.8","Transplants-Case Rate"
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13150.75","","","","","","","fee schedule","12892.89","49582.8","MSDRG Base Rate"
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13537.53","","","","","","","fee schedule","12892.89","49582.8","MSDRG Base Rate"
"Adrenal And Pituitary Procedures Without Cc/Mcc","615","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12892.89","","","","","","","fee schedule","12892.89","49582.8","Psych-Case Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","81273.86","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","86923.45","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","113905.46","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","94445.77","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","81514.49","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","104182.59","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","77807.38","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","123572.53","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","92935.72","","","","","","","fee schedule","30007.08","123572.53",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","31412.76","31412.76","31412.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","30118.05","30118.05","30118.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","31432.42","","","","","","","fee schedule","30007.08","123572.53","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30907.29","","","","","","","fee schedule","30007.08","123572.53","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30007.08","","","","","","","fee schedule","30007.08","123572.53","Transplants-Case Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30607.22","","","","","","","fee schedule","30007.08","123572.53","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31507.43","","","","","","","fee schedule","30007.08","123572.53","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","616","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30007.08","","","","","","","fee schedule","30007.08","123572.53","Psych-Case Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","43587.34","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","46617.23","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","61087.74","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","50651.46","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","43716.39","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","55873.34","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","41728.26","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","66272.21","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","49841.62","","","","","","","fee schedule","16753.23","66272.21",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","45857.25","45857.25","45857.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","59652.66","38288.87","60495.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15172.63","15172.63","16981.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","31609.6","31609.6","31609.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","41921","41921","41921","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15484.63","15484.63","15484.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15642.12","15642.12","18128.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17549.01","","","","","","","fee schedule","16753.23","66272.21","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17255.83","","","","","","","fee schedule","16753.23","66272.21","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16753.23","","","","","","","fee schedule","16753.23","66272.21","Transplants-Case Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17088.29","","","","","","","fee schedule","16753.23","66272.21","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17590.89","","","","","","","fee schedule","16753.23","66272.21","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16753.23","","","","","","","fee schedule","16753.23","66272.21","Psych-Case Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33053.48","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35351.13","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46324.51","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38410.4","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33151.34","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42370.29","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31643.69","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50256.04","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37796.28","","","","","","","fee schedule","13048.62","50256.04",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13668.43","","","","","","","fee schedule","13048.62","50256.04","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13440.08","","","","","","","fee schedule","13048.62","50256.04","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13048.62","","","","","","","fee schedule","13048.62","50256.04","Transplants-Case Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13309.59","","","","","","","fee schedule","13048.62","50256.04","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13701.05","","","","","","","fee schedule","13048.62","50256.04","MSDRG Base Rate"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","618","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13048.62","","","","","","","fee schedule","13048.62","50256.04","Psych-Case Rate"
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","67290.86","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","71968.45","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","94308.26","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","78196.57","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","67490.09","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","86258.19","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64420.78","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","102312.13","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","76946.32","","","","","","","fee schedule","25089.44","102312.13",""
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","172368.62","172368.62","172368.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26281.19","","","","","","","fee schedule","25089.44","102312.13","MSDRG Base Rate"
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25842.12","","","","","","","fee schedule","25089.44","102312.13","MSDRG Base Rate"
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25089.44","","","","","","","fee schedule","25089.44","102312.13","Transplants-Case Rate"
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25591.23","","","","","","","fee schedule","25089.44","102312.13","MSDRG Base Rate"
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26343.91","","","","","","","fee schedule","25089.44","102312.13","MSDRG Base Rate"
"O.R. Procedures For Obesity With Mcc","619","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25089.44","","","","","","","fee schedule","25089.44","102312.13","Psych-Case Rate"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37294.99","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39887.48","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52269","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43339.32","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37405.41","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","47807.36","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35704.29","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","56705.03","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42646.39","","","","","","","fee schedule","14540.3","56705.03",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","25202.81","25202.81","25202.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12810.29","12810.29","13415.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","35178.95","35178.95","35178.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","49666.44","49666.44","49666.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12766.59","12766.59","12766.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","34697.73","34697.73","34697.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13749.04","13179.13","14346.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","27648","25859.2","34560","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13457.53","13457.53","13457.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12810.29","12810.29","12810.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13293.7","13293.7","13293.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","23249.14","23249.14","23249.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15230.96","","","","","","","fee schedule","14540.3","56705.03","MSDRG Base Rate"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14976.51","","","","","","","fee schedule","14540.3","56705.03","MSDRG Base Rate"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14540.3","","","","","","","fee schedule","14540.3","56705.03","Transplants-Case Rate"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14831.11","","","","","","","fee schedule","14540.3","56705.03","MSDRG Base Rate"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15267.32","","","","","","","fee schedule","14540.3","56705.03","MSDRG Base Rate"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14540.3","","","","","","","fee schedule","14540.3","56705.03","Psych-Case Rate"
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35153.26","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37596.87","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49267.36","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40850.49","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35257.34","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45061.94","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33653.91","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53448.65","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40197.35","","","","","","","fee schedule","13787.08","53448.65",""
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","24270.79","24270.79","24270.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11944.67","11405.95","54451.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","34435.56","34435.56","34435.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","42956.51","41653.78","43596.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12664.48","12664.48","12664.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","35096.11","35096.11","35096.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","28939.91","28939.91","28939.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12400.12","12400.12","12400.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","25273.6","23636","31592","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12651.28","12651.28","12651.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13180.08","11405.95","13802.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","35161.78","35161.78","36911.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12395.42","12395.42","92355.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3981.75","3981.75","3981.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14441.97","","","","","","","fee schedule","13787.08","53448.65","MSDRG Base Rate"
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14200.69","","","","","","","fee schedule","13787.08","53448.65","MSDRG Base Rate"
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13787.08","","","","","","","fee schedule","13787.08","53448.65","Transplants-Case Rate"
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14062.82","","","","","","","fee schedule","13787.08","53448.65","MSDRG Base Rate"
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14476.43","","","","","","","fee schedule","13787.08","53448.65","MSDRG Base Rate"
"O.R. Procedures For Obesity Without Cc/Mcc","621","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13787.08","","","","","","","fee schedule","13787.08","53448.65","Psych-Case Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","82947.16","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","88713.06","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","116250.59","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","96390.25","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83192.74","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","106327.54","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79409.31","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126116.69","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","94849.12","","","","","","","fee schedule","30595.56","126116.69",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18071.46","17256.42","39948.9","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17321.13","17321.13","31417.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","29475.99","29475.99","31017.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","29596.06","29596.06","29596.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","39948.9","17256.42","41835.75","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","17907.6","17907.6","41456.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","23624.84","23624.84","23624.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32048.85","","","","","","","fee schedule","30595.56","126116.69","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31513.43","","","","","","","fee schedule","30595.56","126116.69","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30595.56","","","","","","","fee schedule","30595.56","126116.69","Transplants-Case Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31207.47","","","","","","","fee schedule","30595.56","126116.69","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32125.34","","","","","","","fee schedule","30595.56","126116.69","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","622","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30595.56","","","","","","","fee schedule","30595.56","126116.69","Psych-Case Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41806.84","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44712.96","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58592.36","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48582.4","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41930.62","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53590.97","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40023.7","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63565.05","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47805.64","","","","","","","fee schedule","16127.06","63565.05",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","38641.38","38641.38","38641.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14528.9","14528.9","14528.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14905.25","14905.25","14905.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13873.62","13873.62","16913.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16893.1","","","","","","","fee schedule","16127.06","63565.05","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16610.87","","","","","","","fee schedule","16127.06","63565.05","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16127.06","","","","","","","fee schedule","16127.06","63565.05","Transplants-Case Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16449.6","","","","","","","fee schedule","16127.06","63565.05","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16933.41","","","","","","","fee schedule","16127.06","63565.05","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16127.06","","","","","","","fee schedule","16127.06","63565.05","Psych-Case Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29175.53","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31203.61","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","40889.56","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","33903.96","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29261.91","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37399.26","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27931.14","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","44359.82","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33361.88","","","","","","","fee schedule","11684.79","44359.82",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12239.82","","","","","","","fee schedule","11684.79","44359.82","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12035.33","","","","","","","fee schedule","11684.79","44359.82","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11684.79","","","","","","","fee schedule","11684.79","44359.82","Transplants-Case Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11918.49","","","","","","","fee schedule","11684.79","44359.82","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12269.03","","","","","","","fee schedule","11684.79","44359.82","MSDRG Base Rate"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","624","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11684.79","","","","","","","fee schedule","11684.79","44359.82","Psych-Case Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","70383.43","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","75275.99","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","98642.51","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","81790.35","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","70591.82","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","90222.47","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","67381.45","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","107014.22","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","80482.64","","","","","","","fee schedule","26177.06","107014.22",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15523.4","15523.4","15523.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","106849.37","106849.37","106849.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","25754.67","25754.67","25754.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","15523.4","14823.28","32018.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","23329.56","23329.56","23329.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","20248.9","20248.9","20248.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27420.47","","","","","","","fee schedule","26177.06","107014.22","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26962.37","","","","","","","fee schedule","26177.06","107014.22","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26177.06","","","","","","","fee schedule","26177.06","107014.22","Transplants-Case Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26700.6","","","","","","","fee schedule","26177.06","107014.22","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27485.91","","","","","","","fee schedule","26177.06","107014.22","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","625","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26177.06","","","","","","","fee schedule","26177.06","107014.22","Psych-Case Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34943.52","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37372.55","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48973.4","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40606.75","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35046.98","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44793.08","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33453.11","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53129.74","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39957.51","","","","","","","fee schedule","13713.32","53129.74",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","2959.76","1926.66","7518.11","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13617.86","13617.86","13617.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","66712.5","66712.5","66712.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","2959.76","2017.65","7518.11","73","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","33134","33134","33134","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","3071.45","3071.45","7801.82","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2599.42","2599.42","2599.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14364.7","","","","","","","fee schedule","13713.32","53129.74","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14124.72","","","","","","","fee schedule","13713.32","53129.74","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13713.32","","","","","","","fee schedule","13713.32","53129.74","Transplants-Case Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13987.59","","","","","","","fee schedule","13713.32","53129.74","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14398.99","","","","","","","fee schedule","13713.32","53129.74","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13713.32","","","","","","","fee schedule","13713.32","53129.74","Psych-Case Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30956.03","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33107.88","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43384.93","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35973.02","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31047.68","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39681.63","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29635.7","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47066.98","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35397.87","","","","","","","fee schedule","12310.97","47066.98",""
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12895.74","","","","","","","fee schedule","12310.97","47066.98","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12680.3","","","","","","","fee schedule","12310.97","47066.98","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12310.97","","","","","","","fee schedule","12310.97","47066.98","Transplants-Case Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12557.19","","","","","","","fee schedule","12310.97","47066.98","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12926.52","","","","","","","fee schedule","12310.97","47066.98","MSDRG Base Rate"
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","627","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12310.97","","","","","","","fee schedule","12310.97","47066.98","Psych-Case Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","86853.07","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","92890.49","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","121724.74","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","100929.2","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","87110.22","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","111334.42","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","83148.63","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","132055.43","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","99315.49","","","","","","","fee schedule","31969.21","132055.43",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","36954.35","36954.35","48686.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","33163.09","33163.09","33163.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","86641","86641","86641","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","31339.06","31339.06","31339.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33487.75","","","","","","","fee schedule","31969.21","132055.43","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32928.29","","","","","","","fee schedule","31969.21","132055.43","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31969.21","","","","","","","fee schedule","31969.21","132055.43","Transplants-Case Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32608.59","","","","","","","fee schedule","31969.21","132055.43","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33567.67","","","","","","","fee schedule","31969.21","132055.43","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","628","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31969.21","","","","","","","fee schedule","31969.21","132055.43","Psych-Case Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","50776.93","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","54306.59","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","71163.97","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59006.26","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","50927.27","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65089.47","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","48611.21","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","77203.6","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58062.84","","","","","","","fee schedule","19281.72","77203.6",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","69389.56","69389.56","69389.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18076.28","18076.28","18076.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","19225.81","19225.81","19225.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","47741.54","47741.54","47741.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20197.6","","","","","","","fee schedule","19281.72","77203.6","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19860.17","","","","","","","fee schedule","19281.72","77203.6","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19281.72","","","","","","","fee schedule","19281.72","77203.6","Transplants-Case Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19667.35","","","","","","","fee schedule","19281.72","77203.6","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20245.81","","","","","","","fee schedule","19281.72","77203.6","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19281.72","","","","","","","fee schedule","19281.72","77203.6","Psych-Case Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34013.65","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36378.04","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","47670.19","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39526.18","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34114.35","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43601.1","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32562.9","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","51715.92","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38894.22","","","","","","","fee schedule","13386.29","51715.92",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14022.14","","","","","","","fee schedule","13386.29","51715.92","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13787.88","","","","","","","fee schedule","13386.29","51715.92","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13386.29","","","","","","","fee schedule","13386.29","51715.92","Transplants-Case Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13654.02","","","","","","","fee schedule","13386.29","51715.92","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14055.6","","","","","","","fee schedule","13386.29","51715.92","MSDRG Base Rate"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","630","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13386.29","","","","","","","fee schedule","13386.29","51715.92","Psych-Case Rate"
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33482.29","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35809.75","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46925.5","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38908.71","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33581.43","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42919.98","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32054.21","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50908.03","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38286.62","","","","","","","fee schedule","13199.42","50908.03",""
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","40843.96","40843.96","40843.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45509.86","27734.58","45609.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","33604.11","33604.11","34335.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11607.52","1261.1","13583.39","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","26618.57","26618.57","32491.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11031.42","9570.3","12530.04","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13259.9","12894.41","13259.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","31073","31073","31073","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","37574","37574","37574","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9250.54","1261.1","11862.2","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","13394.48","13394.48","13394.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13826.39","","","","","","","fee schedule","13199.42","50908.03","MSDRG Base Rate"
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13595.4","","","","","","","fee schedule","13199.42","50908.03","MSDRG Base Rate"
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13199.42","","","","","","","fee schedule","13199.42","50908.03","Transplants-Case Rate"
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13463.41","","","","","","","fee schedule","13199.42","50908.03","MSDRG Base Rate"
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13859.39","","","","","","","fee schedule","13199.42","50908.03","MSDRG Base Rate"
"Diabetes With Mcc","637","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13199.42","","","","","","","fee schedule","13199.42","50908.03","Psych-Case Rate"
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20885.94","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22337.79","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29271.68","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24270.89","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20947.78","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26773.08","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19995.12","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31755.95","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23882.83","","","","","","","fee schedule","8769.46","31755.95",""
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","16236.39","16236.39","16236.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","5894.75","5894.75","5894.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","20494.83","20494.83","20494.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25853.22","17084.7","28346.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17266.45","17266.45","18632.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7482.45","7124.89","8756.45","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","20074.88","17456.66","20463.65","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6930.51","1702.29","8310.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8331.32","6963.61","8557.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","16101.99","11169.69","20135.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","28084.78","28084.78","28084.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","13790.8","13790.8","22223.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7295.66","7241.76","7798.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","23787.58","23787.58","23787.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19651.27","19651.27","19651.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9186.01","","","","","","","fee schedule","8769.46","31755.95","MSDRG Base Rate"
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9032.54","","","","","","","fee schedule","8769.46","31755.95","MSDRG Base Rate"
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8769.46","","","","","","","fee schedule","8769.46","31755.95","Transplants-Case Rate"
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8944.85","","","","","","","fee schedule","8769.46","31755.95","MSDRG Base Rate"
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9207.93","","","","","","","fee schedule","8769.46","31755.95","MSDRG Base Rate"
"Diabetes With Cc","638","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8769.46","","","","","","","fee schedule","8769.46","31755.95","Psych-Case Rate"
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14477.07","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15483.41","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20289.63","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16823.34","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14519.93","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18557.73","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","13859.59","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22011.6","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16554.36","","","","","","","fee schedule","6515.54","22011.6",""
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","6539.96","6539.96","6539.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","15109.75","15109.75","15109.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6369.9","1877.73","11950.71","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","8457.37","8457.37","11833.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","16148.89","16148.89","17124.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6670.76","6369.9","11950.71","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","13257","13257","13757","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","16496.95","16496.95","16496.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","4912.07","4912.07","4912.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6922.49","6610.27","12401.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3289.62","3289.62","3289.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6825.03","","","","","","","fee schedule","6515.54","22011.6","MSDRG Base Rate"
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6711.01","","","","","","","fee schedule","6515.54","22011.6","MSDRG Base Rate"
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6515.54","","","","","","","fee schedule","6515.54","22011.6","Transplants-Case Rate"
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6645.85","","","","","","","fee schedule","6515.54","22011.6","MSDRG Base Rate"
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6841.32","","","","","","","fee schedule","6515.54","22011.6","MSDRG Base Rate"
"Diabetes Without Cc/Mcc","639","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6515.54","","","","","","","fee schedule","6515.54","22011.6","Psych-Case Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31126.16","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33289.83","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43623.37","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36170.72","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31218.31","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39899.71","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29798.57","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47325.65","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35592.4","","","","","","","fee schedule","12370.8","47325.65",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","51685.09","51685.09","51685.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","657.09","657.09","657.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","1966.42","1877.73","2453.13","321","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","31737.87","31737.87","31919.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","35577.27","35577.27","35577.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12145.11","11877.81","12178.63","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10097.91","2046.7","13262.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10508.78","10493.37","12426.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","1966.42","1877.73","2453.13","621","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21872.11","20870.86","29158","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","30894.48","30894.48","30894.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10637.67","9686.45","12052.28","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","64754.15","64754.15","64754.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","2040.62","1948.58","2545.7","149","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","788.77","657.09","2599.42","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","918.89","657.09","2599.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12958.41","","","","","","","fee schedule","12370.8","47325.65","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12741.92","","","","","","","fee schedule","12370.8","47325.65","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12370.8","","","","","","","fee schedule","12370.8","47325.65","Transplants-Case Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12618.22","","","","","","","fee schedule","12370.8","47325.65","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12989.34","","","","","","","fee schedule","12370.8","47325.65","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","640","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12370.8","","","","","","","fee schedule","12370.8","47325.65","Psych-Case Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18135.95","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19396.64","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25417.57","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21075.21","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18189.65","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23247.95","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17362.42","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27574.74","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20738.25","","","","","","","fee schedule","7802.32","27574.74",""
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18674.68","18674.68","18674.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","15563.65","13683.04","24122.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7936.94","7936.94","7936.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6361.15","2185.67","7534.21","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6899.91","5872.52","8025.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15564","15518.07","17158","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","20078","20078","20078","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6408.57","5502.67","7680.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","14668.55","14668.55","14668.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8172.93","","","","","","","fee schedule","7802.32","27574.74","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8036.39","","","","","","","fee schedule","7802.32","27574.74","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7802.32","","","","","","","fee schedule","7802.32","27574.74","Transplants-Case Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7958.37","","","","","","","fee schedule","7802.32","27574.74","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8192.44","","","","","","","fee schedule","7802.32","27574.74","MSDRG Base Rate"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","641","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7802.32","","","","","","","fee schedule","7802.32","27574.74","Psych-Case Rate"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33142.04","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35445.84","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46448.63","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38513.31","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33240.17","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42483.82","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31728.47","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50390.69","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37897.54","","","","","","","fee schedule","13079.76","50390.69",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13256.2","13256.2","13256.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","31222","31222","31222","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13701.05","","","","","","","fee schedule","13079.76","50390.69","MSDRG Base Rate"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13472.15","","","","","","","fee schedule","13079.76","50390.69","MSDRG Base Rate"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13079.76","","","","","","","fee schedule","13079.76","50390.69","Transplants-Case Rate"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13341.36","","","","","","","fee schedule","13079.76","50390.69","MSDRG Base Rate"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13733.75","","","","","","","fee schedule","13079.76","50390.69","MSDRG Base Rate"
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13079.76","","","","","","","fee schedule","13079.76","50390.69","Psych-Case Rate"
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38362.36","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41029.04","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53764.92","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44579.68","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38475.94","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49175.59","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36726.14","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58327.91","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43866.92","","","","","","","fee schedule","14915.68","58327.91",""
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","16320.67","15809.29","37732.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","39340.14","39340.14","39340.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13210.26","12530.14","14078.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","94834.51","94834.51","94834.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12653.92","12653.92","15117.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13147.08","13147.08","13169.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24892.39","24892.39","24892.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15624.17","","","","","","","fee schedule","14915.68","58327.91","MSDRG Base Rate"
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15363.15","","","","","","","fee schedule","14915.68","58327.91","MSDRG Base Rate"
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14915.68","","","","","","","fee schedule","14915.68","58327.91","Transplants-Case Rate"
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15213.99","","","","","","","fee schedule","14915.68","58327.91","MSDRG Base Rate"
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15661.46","","","","","","","fee schedule","14915.68","58327.91","MSDRG Base Rate"
"Endocrine Disorders With Mcc","643","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14915.68","","","","","","","fee schedule","14915.68","58327.91","Psych-Case Rate"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23887.63","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25548.13","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33478.55","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27759.05","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23958.35","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30620.85","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22868.78","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36319.85","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27315.23","","","","","","","fee schedule","9825.11","36319.85",""
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","1852.78","1852.78","1852.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","23091.32","23091.32","23091.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23497.23","23497.23","23497.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","15954.61","13100.03","19880.47","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8948.59","8948.59","9154.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7217","7217","9580.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8939.91","8939.91","8939.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22670.08","13443.36","33526.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9469.04","9469.04","9469.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10291.8","","","","","","","fee schedule","9825.11","36319.85","MSDRG Base Rate"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10119.86","","","","","","","fee schedule","9825.11","36319.85","MSDRG Base Rate"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9825.11","","","","","","","fee schedule","9825.11","36319.85","Transplants-Case Rate"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10021.61","","","","","","","fee schedule","9825.11","36319.85","MSDRG Base Rate"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10316.37","","","","","","","fee schedule","9825.11","36319.85","MSDRG Base Rate"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9825.11","","","","","","","fee schedule","9825.11","36319.85","Psych-Case Rate"
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17905.23","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19149.88","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25094.21","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20807.1","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17958.24","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22952.19","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17141.54","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27223.94","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20474.43","","","","","","","fee schedule","7721.18","27223.94",""
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19716.31","19716.31","19716.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","16269.68","16269.68","16269.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8087.94","","","","","","","fee schedule","7721.18","27223.94","MSDRG Base Rate"
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7952.82","","","","","","","fee schedule","7721.18","27223.94","MSDRG Base Rate"
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7721.18","","","","","","","fee schedule","7721.18","27223.94","Transplants-Case Rate"
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7875.6","","","","","","","fee schedule","7721.18","27223.94","MSDRG Base Rate"
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8107.24","","","","","","","fee schedule","7721.18","27223.94","MSDRG Base Rate"
"Endocrine Disorders Without Cc/Mcc","645","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7721.18","","","","","","","fee schedule","7721.18","27223.94","Psych-Case Rate"
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","109566.13","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","117182.4","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","153557.13","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","127323.31","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","109890.52","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","140449.62","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","104892.94","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","166589.41","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","125287.61","","","","","","","fee schedule","39957.09","166589.41",""
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","39053.83","38018.76","39119.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","39971.83","35805.84","106245.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","39168.72","39168.72","39168.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","3966.61","3966.61","37515.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41855.05","","","","","","","fee schedule","39957.09","166589.41","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41155.8","","","","","","","fee schedule","39957.09","166589.41","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39957.09","","","","","","","fee schedule","39957.09","166589.41","Transplants-Case Rate"
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40756.23","","","","","","","fee schedule","39957.09","166589.41","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41954.94","","","","","","","fee schedule","39957.09","166589.41","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis With Mcc","650","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39957.09","","","","","","","fee schedule","39957.09","166589.41","Psych-Case Rate"
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","86363.67","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","92367.07","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","121038.84","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","100360.48","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","86619.37","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","110707.07","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","82680.1","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","131311.32","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","98755.86","","","","","","","fee schedule","31797.1","131311.32",""
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","114621","114621","114621","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33307.46","","","","","","","fee schedule","31797.1","131311.32","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32751.01","","","","","","","fee schedule","31797.1","131311.32","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31797.1","","","","","","","fee schedule","31797.1","131311.32","Transplants-Case Rate"
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32433.04","","","","","","","fee schedule","31797.1","131311.32","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33386.96","","","","","","","fee schedule","31797.1","131311.32","MSDRG Base Rate"
"Kidney Transplant With Hemodialysis Without Mcc","651","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31797.1","","","","","","","fee schedule","31797.1","131311.32","Psych-Case Rate"
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75263.5","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80495.29","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","105481.93","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","87461.32","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75486.33","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","96478.08","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","72053.37","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","114434.1","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","86062.95","","","","","","","fee schedule","27893.32","114434.1",""
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","232117.79","232117.79","232117.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","230141.07","230141.07","237923.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25223.33","24157.4","26480","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","28040.05","24267.53","28040.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","126531.46","126531.46","126531.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","26536.89","26536.89","26536.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","114621","114621","119977","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","2644.29","2644.29","2644.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","119977","119977","119977","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29218.25","","","","","","","fee schedule","27893.32","114434.1","MSDRG Base Rate"
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28730.12","","","","","","","fee schedule","27893.32","114434.1","MSDRG Base Rate"
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27893.32","","","","","","","fee schedule","27893.32","114434.1","Transplants-Case Rate"
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28451.19","","","","","","","fee schedule","27893.32","114434.1","MSDRG Base Rate"
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29287.99","","","","","","","fee schedule","27893.32","114434.1","MSDRG Base Rate"
"Kidney Transplant","652","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27893.32","","","","","","","fee schedule","27893.32","114434.1","Psych-Case Rate"
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","121102.1","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","129520.27","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","169724.82","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","140728.9","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","121460.65","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","155237.25","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","115936.88","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","184129.24","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","138478.86","","","","","","","fee schedule","44014.14","184129.24",""
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","137720.89","137720.89","137720.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","162746.05","162746.05","162746.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","35620.99","35620.99","35620.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","46104.81","","","","","","","fee schedule","44014.14","184129.24","MSDRG Base Rate"
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","45334.56","","","","","","","fee schedule","44014.14","184129.24","MSDRG Base Rate"
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","44014.14","","","","","","","fee schedule","44014.14","184129.24","Transplants-Case Rate"
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","44894.42","","","","","","","fee schedule","44014.14","184129.24","MSDRG Base Rate"
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46214.85","","","","","","","fee schedule","44014.14","184129.24","MSDRG Base Rate"
"Major Bladder Procedures With Mcc","653","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","44014.14","","","","","","","fee schedule","44014.14","184129.24","Psych-Case Rate"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","65237.69","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","69772.55","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","91430.74","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","75810.64","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","65430.84","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","83626.29","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","62455.18","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","99190.4","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","74598.55","","","","","","","fee schedule","24367.37","99190.4",""
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","84738.94","84738.94","84738.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","87685.35","87685.35","88035.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24396.54","24396.54","24396.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","22416.21","22416.21","22416.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","24485.73","24485.73","24485.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","22436.8","22436.8","22436.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","72922.97","72922.97","72922.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25524.82","","","","","","","fee schedule","24367.37","99190.4","MSDRG Base Rate"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25098.39","","","","","","","fee schedule","24367.37","99190.4","MSDRG Base Rate"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24367.37","","","","","","","fee schedule","24367.37","99190.4","Transplants-Case Rate"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24854.72","","","","","","","fee schedule","24367.37","99190.4","MSDRG Base Rate"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25585.74","","","","","","","fee schedule","24367.37","99190.4","MSDRG Base Rate"
"Major Bladder Procedures With Cc","654","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24367.37","","","","","","","fee schedule","24367.37","99190.4","Psych-Case Rate"
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49327.36","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52756.26","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69132.39","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57321.76","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49473.41","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63231.31","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47223.46","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","74999.6","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56405.27","","","","","","","fee schedule","18771.92","74999.6",""
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","66289.8","66289.8","66289.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17533.51","17533.51","17533.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19663.59","","","","","","","fee schedule","18771.92","74999.6","MSDRG Base Rate"
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19335.08","","","","","","","fee schedule","18771.92","74999.6","MSDRG Base Rate"
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18771.92","","","","","","","fee schedule","18771.92","74999.6","Transplants-Case Rate"
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19147.36","","","","","","","fee schedule","18771.92","74999.6","MSDRG Base Rate"
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19710.52","","","","","","","fee schedule","18771.92","74999.6","MSDRG Base Rate"
"Major Bladder Procedures Without Cc/Mcc","655","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18771.92","","","","","","","fee schedule","18771.92","74999.6","Psych-Case Rate"
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","74198.46","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","79356.22","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","103989.28","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","86223.67","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","74418.14","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","95112.84","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","71033.76","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","112814.77","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","84845.09","","","","","","","fee schedule","27518.76","112814.77",""
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","164242.16","164242.16","164242.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","27611.23","27611.23","27611.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28825.9","","","","","","","fee schedule","27518.76","112814.77","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28344.32","","","","","","","fee schedule","27518.76","112814.77","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27518.76","","","","","","","fee schedule","27518.76","112814.77","Transplants-Case Rate"
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28069.14","","","","","","","fee schedule","27518.76","112814.77","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28894.7","","","","","","","fee schedule","27518.76","112814.77","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Mcc","656","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27518.76","","","","","","","fee schedule","27518.76","112814.77","Psych-Case Rate"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42648.15","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45612.75","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59771.46","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49560.06","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42774.42","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54669.42","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40829.13","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64844.22","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48767.67","","","","","","","fee schedule","16422.93","64844.22",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","41605.73","41605.73","41605.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57254.26","57254.26","57254.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15941.34","15353.26","16901.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16646.12","16646.12","16646.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15328.96","15328.96","15328.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","35836.64","35836.64","35836.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17203.02","","","","","","","fee schedule","16422.93","64844.22","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16915.62","","","","","","","fee schedule","16422.93","64844.22","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16422.93","","","","","","","fee schedule","16422.93","64844.22","Transplants-Case Rate"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16751.39","","","","","","","fee schedule","16422.93","64844.22","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17244.08","","","","","","","fee schedule","16422.93","64844.22","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16422.93","","","","","","","fee schedule","16422.93","64844.22","Psych-Case Rate"
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36164.7","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38678.62","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50684.89","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42025.85","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36271.77","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46358.47","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34622.21","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54986.48","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41353.92","","","","","","","fee schedule","14142.79","54986.48",""
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","35944.1","35944.1","35944.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13055.59","13055.59","13055.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13034.63","13034.63","13034.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14814.57","","","","","","","fee schedule","14142.79","54986.48","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14567.07","","","","","","","fee schedule","14142.79","54986.48","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14142.79","","","","","","","fee schedule","14142.79","54986.48","Transplants-Case Rate"
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14425.65","","","","","","","fee schedule","14142.79","54986.48","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14849.93","","","","","","","fee schedule","14142.79","54986.48","MSDRG Base Rate"
"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","658","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14142.79","","","","","","","fee schedule","14142.79","54986.48","Psych-Case Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","59215.67","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","63331.93","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","82990.88","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","68812.65","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","59391","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","75906.85","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","56690.02","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","90034.25","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","67712.44","","","","","","","fee schedule","22249.51","90034.25",""
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20274.58","19760.16","22184.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","21957.46","19958.16","22356.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20227.66","20227.66","20227.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23306.36","","","","","","","fee schedule","22249.51","90034.25","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22917","","","","","","","fee schedule","22249.51","90034.25","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22249.51","","","","","","","fee schedule","22249.51","90034.25","Transplants-Case Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22694.5","","","","","","","fee schedule","22249.51","90034.25","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23361.99","","","","","","","fee schedule","22249.51","90034.25","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","659","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22249.51","","","","","","","fee schedule","22249.51","90034.25","Psych-Case Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30802.22","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32943.37","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43169.37","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35794.28","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30893.42","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39484.47","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29488.45","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46833.12","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35221.98","","","","","","","fee schedule","12256.88","46833.12",""
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","58038.42","58038.42","58038.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","21625.94","21625.94","21625.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","34470.61","34470.61","34470.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","27536.91","27536.91","27536.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11361.79","11361.79","11949.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1163.66","1163.66","9714.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16921.16","16921.16","17720.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","29418","29418","29418","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12312.47","12312.47","12312.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10662.9","10662.9","10662.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","88444.59","88444.59","88444.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12839.08","","","","","","","fee schedule","12256.88","46833.12","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12624.59","","","","","","","fee schedule","12256.88","46833.12","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12256.88","","","","","","","fee schedule","12256.88","46833.12","Transplants-Case Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12502.02","","","","","","","fee schedule","12256.88","46833.12","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12869.72","","","","","","","fee schedule","12256.88","46833.12","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12256.88","","","","","","","fee schedule","12256.88","46833.12","Psych-Case Rate"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24130","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25807.35","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33818.23","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28040.7","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24201.44","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30931.54","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23100.81","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36688.36","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27592.37","","","","","","","fee schedule","9910.35","36688.36",""
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","42885.64","42885.64","42885.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","27978.87","27978.87","27978.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8931.91","8931.91","8931.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21964","21964","21964","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9268.64","9268.64","9268.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10381.09","","","","","","","fee schedule","9910.35","36688.36","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10207.66","","","","","","","fee schedule","9910.35","36688.36","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9910.35","","","","","","","fee schedule","9910.35","36688.36","Transplants-Case Rate"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10108.56","","","","","","","fee schedule","9910.35","36688.36","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10405.87","","","","","","","fee schedule","9910.35","36688.36","MSDRG Base Rate"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","661","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9910.35","","","","","","","fee schedule","9910.35","36688.36","Psych-Case Rate"
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","71348.26","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","76307.89","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","99994.71","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","82911.54","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","71559.5","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","91459.25","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","68305.13","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","108481.19","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","81585.91","","","","","","","fee schedule","26516.38","108481.19",""
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11362.79","8564.17","25248.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8968.68","4282.08","17355.7","62","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","26645.88","26645.88","26645.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11791.57","8887.35","12348.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","27775.91","","","","","","","fee schedule","26516.38","108481.19","MSDRG Base Rate"
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27311.87","","","","","","","fee schedule","26516.38","108481.19","MSDRG Base Rate"
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26516.38","","","","","","","fee schedule","26516.38","108481.19","Transplants-Case Rate"
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27046.71","","","","","","","fee schedule","26516.38","108481.19","MSDRG Base Rate"
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27842.2","","","","","","","fee schedule","26516.38","108481.19","MSDRG Base Rate"
"Minor Bladder Procedures With Mcc","662","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26516.38","","","","","","","fee schedule","26516.38","108481.19","Psych-Case Rate"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35428.26","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37890.99","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49652.77","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41170.06","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35533.15","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45414.45","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33917.18","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53866.77","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40511.81","","","","","","","fee schedule","13883.8","53866.77",""
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8064.89","8064.89","12717.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","46586.64","46586.64","46586.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13818.19","13818.19","13818.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8064.89","8064.89","12717.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13219.22","13219.22","13219.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14543.28","","","","","","","fee schedule","13883.8","53866.77","MSDRG Base Rate"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14300.31","","","","","","","fee schedule","13883.8","53866.77","MSDRG Base Rate"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13883.8","","","","","","","fee schedule","13883.8","53866.77","Transplants-Case Rate"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14161.48","","","","","","","fee schedule","13883.8","53866.77","MSDRG Base Rate"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14577.99","","","","","","","fee schedule","13883.8","53866.77","MSDRG Base Rate"
"Minor Bladder Procedures With Cc","663","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13883.8","","","","","","","fee schedule","13883.8","53866.77","Psych-Case Rate"
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24398","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26093.98","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34193.85","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28352.15","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24470.24","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31275.09","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23357.39","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37095.85","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27898.84","","","","","","","fee schedule","10004.6","37095.85",""
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33818.26","33818.26","33818.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10479.82","","","","","","","fee schedule","10004.6","37095.85","MSDRG Base Rate"
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10304.74","","","","","","","fee schedule","10004.6","37095.85","MSDRG Base Rate"
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10004.6","","","","","","","fee schedule","10004.6","37095.85","Transplants-Case Rate"
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10204.69","","","","","","","fee schedule","10004.6","37095.85","MSDRG Base Rate"
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10504.83","","","","","","","fee schedule","10004.6","37095.85","MSDRG Base Rate"
"Minor Bladder Procedures Without Cc/Mcc","664","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10004.6","","","","","","","fee schedule","10004.6","37095.85","Psych-Case Rate"
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","72739.57","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","77795.91","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","101944.63","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","84528.34","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","72954.93","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","93242.73","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","69637.09","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","110596.6","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","83176.86","","","","","","","fee schedule","27005.68","110596.6",""
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28288.45","","","","","","","fee schedule","27005.68","110596.6","MSDRG Base Rate"
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27815.85","","","","","","","fee schedule","27005.68","110596.6","MSDRG Base Rate"
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27005.68","","","","","","","fee schedule","27005.68","110596.6","Transplants-Case Rate"
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27545.79","","","","","","","fee schedule","27005.68","110596.6","MSDRG Base Rate"
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28355.96","","","","","","","fee schedule","27005.68","110596.6","MSDRG Base Rate"
"Prostatectomy With Mcc","665","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27005.68","","","","","","","fee schedule","27005.68","110596.6","Psych-Case Rate"
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40767.44","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43601.3","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57135.64","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47374.54","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40888.14","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52258.59","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39028.63","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61984.7","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46617.1","","","","","","","fee schedule","15761.51","61984.7",""
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16510.18","","","","","","","fee schedule","15761.51","61984.7","MSDRG Base Rate"
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16234.36","","","","","","","fee schedule","15761.51","61984.7","MSDRG Base Rate"
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15761.51","","","","","","","fee schedule","15761.51","61984.7","Transplants-Case Rate"
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16076.74","","","","","","","fee schedule","15761.51","61984.7","MSDRG Base Rate"
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16549.59","","","","","","","fee schedule","15761.51","61984.7","MSDRG Base Rate"
"Prostatectomy With Cc","666","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15761.51","","","","","","","fee schedule","15761.51","61984.7","Psych-Case Rate"
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25779.99","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27572.04","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36130.7","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29958.11","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25856.32","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33046.62","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24680.43","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","39197.09","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29479.12","","","","","","","fee schedule","10490.63","39197.09",""
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10988.93","","","","","","","fee schedule","10490.63","39197.09","MSDRG Base Rate"
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10805.35","","","","","","","fee schedule","10490.63","39197.09","MSDRG Base Rate"
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10490.63","","","","","","","fee schedule","10490.63","39197.09","Transplants-Case Rate"
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10700.44","","","","","","","fee schedule","10490.63","39197.09","MSDRG Base Rate"
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11015.16","","","","","","","fee schedule","10490.63","39197.09","MSDRG Base Rate"
"Prostatectomy Without Cc/Mcc","667","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10490.63","","","","","","","fee schedule","10490.63","39197.09","Psych-Case Rate"
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","68050.6","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","72781","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","95373.04","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","79079.44","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","68252.08","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","87232.08","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","65148.12","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","103467.28","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","77815.08","","","","","","","fee schedule","25356.64","103467.28",""
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25204.71","25204.71","25204.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26561.08","","","","","","","fee schedule","25356.64","103467.28","MSDRG Base Rate"
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26117.34","","","","","","","fee schedule","25356.64","103467.28","MSDRG Base Rate"
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25356.64","","","","","","","fee schedule","25356.64","103467.28","Transplants-Case Rate"
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25863.77","","","","","","","fee schedule","25356.64","103467.28","MSDRG Base Rate"
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26624.47","","","","","","","fee schedule","25356.64","103467.28","MSDRG Base Rate"
"Transurethral Procedures With Mcc","668","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25356.64","","","","","","","fee schedule","25356.64","103467.28","Psych-Case Rate"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36169.36","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38683.6","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50691.42","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42031.26","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36276.45","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46364.45","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34626.67","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54993.57","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41359.25","","","","","","","fee schedule","14144.43","54993.57",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12307.44","12307.44","12307.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12375.71","12067.31","12957.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14502.27","14502.27","14502.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12406.1","12201.76","12961.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14816.29","","","","","","","fee schedule","14144.43","54993.57","MSDRG Base Rate"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14568.76","","","","","","","fee schedule","14144.43","54993.57","MSDRG Base Rate"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14144.43","","","","","","","fee schedule","14144.43","54993.57","Transplants-Case Rate"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14427.32","","","","","","","fee schedule","14144.43","54993.57","MSDRG Base Rate"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14851.65","","","","","","","fee schedule","14144.43","54993.57","MSDRG Base Rate"
"Transurethral Procedures With Cc","669","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14144.43","","","","","","","fee schedule","14144.43","54993.57","Psych-Case Rate"
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22775.98","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24359.2","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31920.57","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26467.24","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22843.41","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29195.86","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21804.54","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34629.65","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26044.07","","","","","","","fee schedule","9434.16","34629.65",""
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8586.48","8586.48","8586.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9882.28","","","","","","","fee schedule","9434.16","34629.65","MSDRG Base Rate"
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9717.18","","","","","","","fee schedule","9434.16","34629.65","MSDRG Base Rate"
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9434.16","","","","","","","fee schedule","9434.16","34629.65","Transplants-Case Rate"
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9622.84","","","","","","","fee schedule","9434.16","34629.65","MSDRG Base Rate"
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9905.87","","","","","","","fee schedule","9434.16","34629.65","MSDRG Base Rate"
"Transurethral Procedures Without Cc/Mcc","670","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9434.16","","","","","","","fee schedule","9434.16","34629.65","Psych-Case Rate"
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","41832.48","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44740.38","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58628.29","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48612.19","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","41956.33","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53623.83","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40048.25","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63604.03","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","47834.96","","","","","","","fee schedule","16136.07","63604.03",""
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15248.58","15248.58","15248.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16902.53","","","","","","","fee schedule","16136.07","63604.03","MSDRG Base Rate"
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16620.15","","","","","","","fee schedule","16136.07","63604.03","MSDRG Base Rate"
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16136.07","","","","","","","fee schedule","16136.07","63604.03","Transplants-Case Rate"
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16458.79","","","","","","","fee schedule","16136.07","63604.03","MSDRG Base Rate"
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16942.87","","","","","","","fee schedule","16136.07","63604.03","MSDRG Base Rate"
"Urethral Procedures With Cc/Mcc","671","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16136.07","","","","","","","fee schedule","16136.07","63604.03","Psych-Case Rate"
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25157.75","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26906.54","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35258.63","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29235.02","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25232.23","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32248.98","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24084.72","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38251","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28767.6","","","","","","","fee schedule","10271.79","38251",""
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10759.7","","","","","","","fee schedule","10271.79","38251","MSDRG Base Rate"
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10579.94","","","","","","","fee schedule","10271.79","38251","MSDRG Base Rate"
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10271.79","","","","","","","fee schedule","10271.79","38251","Transplants-Case Rate"
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10477.23","","","","","","","fee schedule","10271.79","38251","MSDRG Base Rate"
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10785.38","","","","","","","fee schedule","10271.79","38251","MSDRG Base Rate"
"Urethral Procedures Without Cc/Mcc","672","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10271.79","","","","","","","fee schedule","10271.79","38251","Psych-Case Rate"
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","97918.29","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","104724.88","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","137232.66","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","113787.73","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","98208.2","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","125518.6","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","93741.9","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","148879.49","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","111968.44","","","","","","","fee schedule","35860.7","148879.49",""
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","95351.11","95351.11","95351.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","124950.63","106076.12","131589.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","34186.85","34031.78","36620.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","98889.24","98889.24","98889.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","35161.79","32835.53","56340.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","34832.4","34783.76","36038.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12886.56","12886.56","12886.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","64500.63","64500.63","64500.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","54033.71","54033.71","54033.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","34217.08","34217.08","35404.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37564.08","","","","","","","fee schedule","35860.7","148879.49","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36936.52","","","","","","","fee schedule","35860.7","148879.49","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35860.7","","","","","","","fee schedule","35860.7","148879.49","Transplants-Case Rate"
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36577.91","","","","","","","fee schedule","35860.7","148879.49","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37653.74","","","","","","","fee schedule","35860.7","148879.49","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Mcc","673","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35860.7","","","","","","","fee schedule","35860.7","148879.49","Psych-Case Rate"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54501.07","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","58289.61","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","76383.35","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","63333.97","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54662.44","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69863.34","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","52176.5","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","82865.95","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","62321.35","","","","","","","fee schedule","20591.45","82865.95",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","54853.57","54853.57","54853.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","72296.78","72296.78","72296.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18858.39","18858.39","19164.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","22108.07","22108.07","22108.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","50679","50679","50679","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18839.11","18839.11","19728.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18770.01","17736.91","20324.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21569.54","","","","","","","fee schedule","20591.45","82865.95","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21209.19","","","","","","","fee schedule","20591.45","82865.95","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20591.45","","","","","","","fee schedule","20591.45","82865.95","Transplants-Case Rate"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21003.28","","","","","","","fee schedule","20591.45","82865.95","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21621.02","","","","","","","fee schedule","20591.45","82865.95","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20591.45","","","","","","","fee schedule","20591.45","82865.95","Psych-Case Rate"
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38252.83","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40911.9","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53611.41","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44452.39","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38366.08","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49035.18","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36621.28","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58161.37","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43741.67","","","","","","","fee schedule","14877.16","58161.37",""
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","38898.9","38898.9","38898.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15583.83","","","","","","","fee schedule","14877.16","58161.37","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15323.47","","","","","","","fee schedule","14877.16","58161.37","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14877.16","","","","","","","fee schedule","14877.16","58161.37","Transplants-Case Rate"
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15174.7","","","","","","","fee schedule","14877.16","58161.37","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15621.02","","","","","","","fee schedule","14877.16","58161.37","MSDRG Base Rate"
"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","675","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14877.16","","","","","","","fee schedule","14877.16","58161.37","Psych-Case Rate"
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34514.71","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36913.93","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48372.42","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40108.44","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34616.89","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44243.39","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33042.59","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52477.75","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39467.17","","","","","","","fee schedule","13562.51","52477.75",""
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","47038.01","36672.53","50642.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25694.15","25694.15","25694.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11982.48","11173.98","13957.16","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","33508.89","33508.89","33508.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11414.7","11008.03","13745.7","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13235.11","11592.63","13624.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","32476","30874","32476","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","38753","38753","38753","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11766.21","7366.04","13383.21","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14206.73","","","","","","","fee schedule","13562.51","52477.75","MSDRG Base Rate"
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13969.39","","","","","","","fee schedule","13562.51","52477.75","MSDRG Base Rate"
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13562.51","","","","","","","fee schedule","13562.51","52477.75","Transplants-Case Rate"
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13833.76","","","","","","","fee schedule","13562.51","52477.75","MSDRG Base Rate"
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14240.64","","","","","","","fee schedule","13562.51","52477.75","MSDRG Base Rate"
"Renal Failure With Mcc","682","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13562.51","","","","","","","fee schedule","13562.51","52477.75","Psych-Case Rate"
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20410.52","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21829.32","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28605.38","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23718.42","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20470.95","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26163.65","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19539.97","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31033.1","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23339.19","","","","","","","fee schedule","8602.26","31033.1",""
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","14539.85","14539.85","53815.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18057.25","17467.56","19629.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21486.08","16064.66","26510.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7336.44","6915.57","8539.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6760.95","1468.31","8404.88","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7213.51","7213.51","8359.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18881.65","15931","19016","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7008.91","6565.38","9327.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9010.87","","","","","","","fee schedule","8602.26","31033.1","MSDRG Base Rate"
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8860.33","","","","","","","fee schedule","8602.26","31033.1","MSDRG Base Rate"
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8602.26","","","","","","","fee schedule","8602.26","31033.1","Transplants-Case Rate"
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8774.31","","","","","","","fee schedule","8602.26","31033.1","MSDRG Base Rate"
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9032.37","","","","","","","fee schedule","8602.26","31033.1","MSDRG Base Rate"
"Renal Failure With Cc","683","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8602.26","","","","","","","fee schedule","8602.26","31033.1","Psych-Case Rate"
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","13989.99","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","14962.48","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","19607","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16257.32","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14031.41","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","17933.36","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","13393.29","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","21271.03","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","15997.39","","","","","","","fee schedule","6344.24","21271.03",""
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5342.87","5342.87","5342.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5225.59","5225.59","5225.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","13629.09","13629.09","13629.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","13782.09","13782.09","13782.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6645.59","","","","","","","fee schedule","6344.24","21271.03","MSDRG Base Rate"
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6534.57","","","","","","","fee schedule","6344.24","21271.03","MSDRG Base Rate"
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6344.24","","","","","","","fee schedule","6344.24","21271.03","Transplants-Case Rate"
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6471.12","","","","","","","fee schedule","6344.24","21271.03","MSDRG Base Rate"
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6661.45","","","","","","","fee schedule","6344.24","21271.03","MSDRG Base Rate"
"Renal Failure Without Cc/Mcc","684","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6344.24","","","","","","","fee schedule","6344.24","21271.03","Psych-Case Rate"
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Admit For Renal Dialysis","685","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42035.23","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44957.22","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58912.45","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48847.8","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42159.68","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53883.73","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40242.35","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63912.31","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48066.8","","","","","","","fee schedule","16207.38","63912.31",""
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","42071.85","42071.85","42071.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16427.55","16427.55","16427.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14782.25","14782.25","14782.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16977.23","","","","","","","fee schedule","16207.38","63912.31","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16693.6","","","","","","","fee schedule","16207.38","63912.31","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16207.38","","","","","","","fee schedule","16207.38","63912.31","Transplants-Case Rate"
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16531.53","","","","","","","fee schedule","16207.38","63912.31","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17017.75","","","","","","","fee schedule","16207.38","63912.31","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Mcc","686","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16207.38","","","","","","","fee schedule","16207.38","63912.31","Psych-Case Rate"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24418.98","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26116.42","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34223.24","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28376.52","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24491.28","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31301.98","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23377.47","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37127.75","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27922.82","","","","","","","fee schedule","10011.98","37127.75",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","31395.72","31395.72","31395.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","27095.82","27095.82","27095.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10487.55","","","","","","","fee schedule","10011.98","37127.75","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10312.34","","","","","","","fee schedule","10011.98","37127.75","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10011.98","","","","","","","fee schedule","10011.98","37127.75","Transplants-Case Rate"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10212.22","","","","","","","fee schedule","10011.98","37127.75","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10512.58","","","","","","","fee schedule","10011.98","37127.75","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10011.98","","","","","","","fee schedule","10011.98","37127.75","Psych-Case Rate"
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18417.94","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19698.23","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25812.78","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21402.9","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18472.47","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23609.42","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17632.38","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28003.49","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21060.7","","","","","","","fee schedule","7901.49","28003.49",""
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17632.38","17632.38","17632.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8276.81","","","","","","","fee schedule","7901.49","28003.49","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8138.53","","","","","","","fee schedule","7901.49","28003.49","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7901.49","","","","","","","fee schedule","7901.49","28003.49","Transplants-Case Rate"
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8059.52","","","","","","","fee schedule","7901.49","28003.49","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8296.56","","","","","","","fee schedule","7901.49","28003.49","MSDRG Base Rate"
"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","688","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7901.49","","","","","","","fee schedule","7901.49","28003.49","Psych-Case Rate"
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27040.79","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28920.48","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37897.72","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31423.24","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27120.85","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34662.8","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25887.45","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41114.07","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30920.83","","","","","","","fee schedule","10934.03","41114.07",""
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25662.99","25662.99","35710.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11992.82","11992.82","11992.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8337.94","2184.69","10178.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10576.52","9027.66","10982.76","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","39510","39510","39510","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9170.38","9157.66","9434.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11453.4","","","","","","","fee schedule","10934.03","41114.07","MSDRG Base Rate"
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11262.05","","","","","","","fee schedule","10934.03","41114.07","MSDRG Base Rate"
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10934.03","","","","","","","fee schedule","10934.03","41114.07","Transplants-Case Rate"
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11152.71","","","","","","","fee schedule","10934.03","41114.07","MSDRG Base Rate"
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11480.73","","","","","","","fee schedule","10934.03","41114.07","MSDRG Base Rate"
"Kidney And Urinary Tract Infections With Mcc","689","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10934.03","","","","","","","fee schedule","10934.03","41114.07","Psych-Case Rate"
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18865.4","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20176.79","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26439.89","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21922.88","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18921.25","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24183","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18060.75","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28683.82","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21572.37","","","","","","","fee schedule","8058.86","28683.82",""
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","17523.09","17523.09","17523.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","19181.34","19181.34","19181.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17609.24","12113.75","25136.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","38095.79","38095.79","38095.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7825.1","6276.7","8291.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17906.81","17906.81","18060.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5359.79","1960.29","7078.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15795.41","14596","17021","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6466.21","6466.21","8092.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","105806.17","105806.17","105806.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6816.26","6500.12","7947.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","16353.42","16353.42","16353.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8441.66","","","","","","","fee schedule","8058.86","28683.82","MSDRG Base Rate"
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8300.63","","","","","","","fee schedule","8058.86","28683.82","MSDRG Base Rate"
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8058.86","","","","","","","fee schedule","8058.86","28683.82","Transplants-Case Rate"
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8220.04","","","","","","","fee schedule","8058.86","28683.82","MSDRG Base Rate"
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8461.8","","","","","","","fee schedule","8058.86","28683.82","MSDRG Base Rate"
"Kidney And Urinary Tract Infections Without Mcc","690","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8058.86","","","","","","","fee schedule","8058.86","28683.82","Psych-Case Rate"
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W Cc/Mcc","691","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","692","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31333.57","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33511.66","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43914.06","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36411.75","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31426.34","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40165.59","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29997.14","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47641.01","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35829.58","","","","","","","fee schedule","12443.75","47641.01",""
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11422.07","11422.07","11422.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13034.83","","","","","","","fee schedule","12443.75","47641.01","MSDRG Base Rate"
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12817.06","","","","","","","fee schedule","12443.75","47641.01","MSDRG Base Rate"
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12443.75","","","","","","","fee schedule","12443.75","47641.01","Transplants-Case Rate"
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12692.62","","","","","","","fee schedule","12443.75","47641.01","MSDRG Base Rate"
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13065.94","","","","","","","fee schedule","12443.75","47641.01","MSDRG Base Rate"
"Urinary Stones With Mcc","693","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12443.75","","","","","","","fee schedule","12443.75","47641.01","Psych-Case Rate"
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18217.52","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19483.87","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","25531.89","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21170","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18271.46","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23352.51","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17440.51","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","27698.76","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20831.52","","","","","","","fee schedule","7831.01","27698.76",""
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22954.51","22954.51","22954.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","26089.33","26089.33","26089.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7263.68","7263.68","7263.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","24912.66","24912.66","24912.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8202.98","","","","","","","fee schedule","7831.01","27698.76","MSDRG Base Rate"
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8065.94","","","","","","","fee schedule","7831.01","27698.76","MSDRG Base Rate"
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7831.01","","","","","","","fee schedule","7831.01","27698.76","Transplants-Case Rate"
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7987.63","","","","","","","fee schedule","7831.01","27698.76","MSDRG Base Rate"
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8222.56","","","","","","","fee schedule","7831.01","27698.76","MSDRG Base Rate"
"Urinary Stones Without Mcc","694","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7831.01","","","","","","","fee schedule","7831.01","27698.76","Psych-Case Rate"
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26656.26","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28509.22","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37358.8","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30976.39","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26735.18","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34169.88","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25519.32","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40529.41","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30481.13","","","","","","","fee schedule","10798.8","40529.41",""
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","16714.66","16714.66","16714.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11112.2","11112.2","11112.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","32983.1","31495.52","63850.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","21349.89","21349.89","21349.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11311.74","","","","","","","fee schedule","10798.8","40529.41","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11122.76","","","","","","","fee schedule","10798.8","40529.41","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10798.8","","","","","","","fee schedule","10798.8","40529.41","Transplants-Case Rate"
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11014.78","","","","","","","fee schedule","10798.8","40529.41","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11338.74","","","","","","","fee schedule","10798.8","40529.41","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms With Mcc","695","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10798.8","","","","","","","fee schedule","10798.8","40529.41","Psych-Case Rate"
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16057.15","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17173.33","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22504.12","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18659.5","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16104.69","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20583.19","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15372.28","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24414.03","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18361.16","","","","","","","fee schedule","7071.23","24414.03",""
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","45226.13","45226.13","45226.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6887.94","6887.94","6887.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5152.62","5152.62","5152.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","25674.33","25674.33","25674.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7407.11","","","","","","","fee schedule","7071.23","24414.03","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7283.37","","","","","","","fee schedule","7071.23","24414.03","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7071.23","","","","","","","fee schedule","7071.23","24414.03","Transplants-Case Rate"
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7212.65","","","","","","","fee schedule","7071.23","24414.03","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7424.79","","","","","","","fee schedule","7071.23","24414.03","MSDRG Base Rate"
"Kidney And Urinary Tract Signs And Symptoms Without Mcc","696","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7071.23","","","","","","","fee schedule","7071.23","24414.03","Psych-Case Rate"
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25118.13","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26864.17","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35203.1","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29188.98","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25192.5","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32198.2","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24046.8","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38190.77","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28722.29","","","","","","","fee schedule","10257.86","38190.77",""
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10745.11","","","","","","","fee schedule","10257.86","38190.77","MSDRG Base Rate"
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10565.6","","","","","","","fee schedule","10257.86","38190.77","MSDRG Base Rate"
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10257.86","","","","","","","fee schedule","10257.86","38190.77","Transplants-Case Rate"
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10463.02","","","","","","","fee schedule","10257.86","38190.77","MSDRG Base Rate"
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10770.75","","","","","","","fee schedule","10257.86","38190.77","MSDRG Base Rate"
"Urethral Stricture","697","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10257.86","","","","","","","fee schedule","10257.86","38190.77","Psych-Case Rate"
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38555.79","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41235.92","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54036.01","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44804.46","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38669.95","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49423.55","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36911.32","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58622.01","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44088.11","","","","","","","fee schedule","14983.71","58622.01",""
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","35769.55","35769.55","35769.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","44706.19","26983.54","52644.11","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15026.78","13447.45","15222.55","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14152.73","12473.48","20438.08","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14689.77","13047.29","15053.41","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","24318.31","24318.31","24318.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","7179.61","7179.61","7179.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12911.6","1452.19","14430.12","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15695.44","","","","","","","fee schedule","14983.71","58622.01","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15433.22","","","","","","","fee schedule","14983.71","58622.01","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14983.71","","","","","","","fee schedule","14983.71","58622.01","Transplants-Case Rate"
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15283.38","","","","","","","fee schedule","14983.71","58622.01","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15732.9","","","","","","","fee schedule","14983.71","58622.01","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Mcc","698","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14983.71","","","","","","","fee schedule","14983.71","58622.01","Psych-Case Rate"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23654.58","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25298.88","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33151.93","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27488.23","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23724.61","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30322.11","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22645.67","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35965.51","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27048.74","","","","","","","fee schedule","9743.15","35965.51",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","20429.55","20429.55","20429.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","24257.49","20726.13","31942.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","30315.38","27928.59","44435.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8019.3","7969.32","10025.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8052.29","7119.78","9872.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7728.2","7728.2","7728.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20962","20962","22390","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8597","8092.3","10047.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","26451.11","26451.11","26451.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10205.95","","","","","","","fee schedule","9743.15","35965.51","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10035.44","","","","","","","fee schedule","9743.15","35965.51","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9743.15","","","","","","","fee schedule","9743.15","35965.51","Transplants-Case Rate"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9938.01","","","","","","","fee schedule","9743.15","35965.51","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10230.31","","","","","","","fee schedule","9743.15","35965.51","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9743.15","","","","","","","fee schedule","9743.15","35965.51","Psych-Case Rate"
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16078.12","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17195.76","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22533.51","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18683.87","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16125.72","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20610.07","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15392.36","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24445.92","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18385.15","","","","","","","fee schedule","7078.61","24445.92",""
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","4452.65","4452.65","4452.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","15488.3","15488.3","15488.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7414.84","","","","","","","fee schedule","7078.61","24445.92","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7290.97","","","","","","","fee schedule","7078.61","24445.92","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7078.61","","","","","","","fee schedule","7078.61","24445.92","Transplants-Case Rate"
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7220.18","","","","","","","fee schedule","7078.61","24445.92","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7432.54","","","","","","","fee schedule","7078.61","24445.92","MSDRG Base Rate"
"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","700","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7078.61","","","","","","","fee schedule","7078.61","24445.92","Psych-Case Rate"
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46616.99","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49857.48","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65333.8","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54172.12","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46755.01","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59756.96","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44628.69","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","70878.63","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53305.99","","","","","","","fee schedule","17818.72","70878.63",""
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15130.42","15130.42","15130.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","41187.07","41187.07","41187.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18665.11","","","","","","","fee schedule","17818.72","70878.63","MSDRG Base Rate"
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18353.28","","","","","","","fee schedule","17818.72","70878.63","MSDRG Base Rate"
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17818.72","","","","","","","fee schedule","17818.72","70878.63","Transplants-Case Rate"
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18175.09","","","","","","","fee schedule","17818.72","70878.63","MSDRG Base Rate"
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18709.66","","","","","","","fee schedule","17818.72","70878.63","MSDRG Base Rate"
"Major Male Pelvic Procedures With Cc/Mcc","707","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17818.72","","","","","","","fee schedule","17818.72","70878.63","Psych-Case Rate"
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35754.53","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38239.94","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50110.04","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41549.2","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35860.39","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45832.69","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34229.54","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54362.84","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40884.9","","","","","","","fee schedule","13998.54","54362.84",""
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","12672.2","12672.2","12672.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14663.47","","","","","","","fee schedule","13998.54","54362.84","MSDRG Base Rate"
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14418.5","","","","","","","fee schedule","13998.54","54362.84","MSDRG Base Rate"
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13998.54","","","","","","","fee schedule","13998.54","54362.84","Transplants-Case Rate"
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14278.51","","","","","","","fee schedule","13998.54","54362.84","MSDRG Base Rate"
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14698.47","","","","","","","fee schedule","13998.54","54362.84","MSDRG Base Rate"
"Major Male Pelvic Procedures Without Cc/Mcc","708","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13998.54","","","","","","","fee schedule","13998.54","54362.84","Psych-Case Rate"
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54233.07","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","58002.97","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","76007.74","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","63022.52","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54393.64","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69519.79","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","51919.93","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","82458.46","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","62014.89","","","","","","","fee schedule","20497.19","82458.46",""
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21470.81","","","","","","","fee schedule","20497.19","82458.46","MSDRG Base Rate"
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21112.11","","","","","","","fee schedule","20497.19","82458.46","MSDRG Base Rate"
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20497.19","","","","","","","fee schedule","20497.19","82458.46","Transplants-Case Rate"
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20907.13","","","","","","","fee schedule","20497.19","82458.46","MSDRG Base Rate"
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21522.05","","","","","","","fee schedule","20497.19","82458.46","MSDRG Base Rate"
"Penis Procedures With Cc/Mcc","709","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20497.19","","","","","","","fee schedule","20497.19","82458.46","Psych-Case Rate"
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32654.97","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34924.91","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45765.99","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37947.3","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32751.65","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41859.45","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31262.17","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49650.12","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37340.58","","","","","","","fee schedule","12908.46","49650.12",""
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","64333.5","29610.59","152593.65","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","64333.5","14719.68","73634.37","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","23860.87","23860.87","147742.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13521.61","","","","","","","fee schedule","12908.46","49650.12","MSDRG Base Rate"
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13295.71","","","","","","","fee schedule","12908.46","49650.12","MSDRG Base Rate"
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12908.46","","","","","","","fee schedule","12908.46","49650.12","Transplants-Case Rate"
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13166.63","","","","","","","fee schedule","12908.46","49650.12","MSDRG Base Rate"
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13553.88","","","","","","","fee schedule","12908.46","49650.12","MSDRG Base Rate"
"Penis Procedures Without Cc/Mcc","710","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12908.46","","","","","","","fee schedule","12908.46","49650.12","Psych-Case Rate"
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48562.96","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51938.72","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68061.08","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56433.47","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48706.74","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62251.44","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46491.66","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73837.37","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55531.19","","","","","","","fee schedule","18503.09","73837.37",""
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18072.97","17257.86","55566.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","38221.89","38221.89","38221.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","29600.52","17257.86","58190.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","32168.36","32168.36","32168.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19381.99","","","","","","","fee schedule","18503.09","73837.37","MSDRG Base Rate"
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19058.18","","","","","","","fee schedule","18503.09","73837.37","MSDRG Base Rate"
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18503.09","","","","","","","fee schedule","18503.09","73837.37","Transplants-Case Rate"
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18873.15","","","","","","","fee schedule","18503.09","73837.37","MSDRG Base Rate"
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19428.24","","","","","","","fee schedule","18503.09","73837.37","MSDRG Base Rate"
"Testes Procedures With Cc/Mcc","711","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18503.09","","","","","","","fee schedule","18503.09","73837.37","Psych-Case Rate"
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25628.51","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27410.02","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35918.4","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29782.08","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25704.39","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32852.44","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24535.41","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38966.77","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29305.91","","","","","","","fee schedule","10437.35","38966.77",""
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24719.85","24719.85","24719.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10933.12","","","","","","","fee schedule","10437.35","38966.77","MSDRG Base Rate"
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10750.47","","","","","","","fee schedule","10437.35","38966.77","MSDRG Base Rate"
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10437.35","","","","","","","fee schedule","10437.35","38966.77","Transplants-Case Rate"
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10646.1","","","","","","","fee schedule","10437.35","38966.77","MSDRG Base Rate"
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10959.22","","","","","","","fee schedule","10437.35","38966.77","MSDRG Base Rate"
"Testes Procedures Without Cc/Mcc","712","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10437.35","","","","","","","fee schedule","10437.35","38966.77","Psych-Case Rate"
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35036.74","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37472.25","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49104.05","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40715.08","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35140.47","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44912.57","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33542.36","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53271.48","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40064.11","","","","","","","fee schedule","13746.1","53271.48",""
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","21197.24","21197.24","21197.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12454.66","12454.66","12454.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12540.14","12540.14","12540.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14399.04","","","","","","","fee schedule","13746.1","53271.48","MSDRG Base Rate"
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14158.48","","","","","","","fee schedule","13746.1","53271.48","MSDRG Base Rate"
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13746.1","","","","","","","fee schedule","13746.1","53271.48","Transplants-Case Rate"
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14021.02","","","","","","","fee schedule","13746.1","53271.48","MSDRG Base Rate"
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14433.4","","","","","","","fee schedule","13746.1","53271.48","MSDRG Base Rate"
"Transurethral Prostatectomy With Cc/Mcc","713","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13746.1","","","","","","","fee schedule","13746.1","53271.48","Psych-Case Rate"
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24642.71","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26355.7","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34536.8","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28636.51","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24715.67","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31588.77","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23591.65","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37467.91","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28178.65","","","","","","","fee schedule","10090.66","37467.91",""
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28025.61","28025.61","28025.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10569.97","","","","","","","fee schedule","10090.66","37467.91","MSDRG Base Rate"
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10393.38","","","","","","","fee schedule","10090.66","37467.91","MSDRG Base Rate"
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10090.66","","","","","","","fee schedule","10090.66","37467.91","Transplants-Case Rate"
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10292.47","","","","","","","fee schedule","10090.66","37467.91","MSDRG Base Rate"
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10595.19","","","","","","","fee schedule","10090.66","37467.91","MSDRG Base Rate"
"Transurethral Prostatectomy Without Cc/Mcc","714","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10090.66","","","","","","","fee schedule","10090.66","37467.91","Psych-Case Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","52140.28","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","55764.7","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","73074.69","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","60590.56","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","52294.65","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","66837.1","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49916.4","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","79276.49","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","59621.81","","","","","","","fee schedule","19761.19","79276.49",""
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","21469.38","21469.38","21469.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","49079","49079","49079","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20699.85","","","","","","","fee schedule","19761.19","79276.49","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20354.03","","","","","","","fee schedule","19761.19","79276.49","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19761.19","","","","","","","fee schedule","19761.19","79276.49","Transplants-Case Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20156.41","","","","","","","fee schedule","19761.19","79276.49","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20749.25","","","","","","","fee schedule","19761.19","79276.49","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc","715","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19761.19","","","","","","","fee schedule","19761.19","79276.49","Psych-Case Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34281.66","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36664.68","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48045.8","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39837.62","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34383.15","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43944.65","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32819.48","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52123.41","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39200.68","","","","","","","fee schedule","13480.55","52123.41",""
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14120.88","","","","","","","fee schedule","13480.55","52123.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13884.97","","","","","","","fee schedule","13480.55","52123.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13480.55","","","","","","","fee schedule","13480.55","52123.41","Transplants-Case Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13750.16","","","","","","","fee schedule","13480.55","52123.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14154.58","","","","","","","fee schedule","13480.55","52123.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc","716","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13480.55","","","","","","","fee schedule","13480.55","52123.41","Psych-Case Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44058.1","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47120.71","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","61747.51","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51198.52","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44188.55","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","56476.8","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42178.95","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","66987.98","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","50379.93","","","","","","","fee schedule","16918.8","66987.98",""
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","49334.56","49334.56","49334.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15689.57","15689.57","15689.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13887.62","13887.62","15060.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16101.83","16101.83","16101.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14994.04","14994.04","14994.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17722.44","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17426.36","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16918.8","","","","","","","fee schedule","16918.8","66987.98","Transplants-Case Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17257.18","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17764.74","","","","","","","fee schedule","16918.8","66987.98","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc","717","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16918.8","","","","","","","fee schedule","16918.8","66987.98","Psych-Case Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31300.95","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33476.77","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43868.33","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36373.83","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31393.62","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40123.77","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29965.9","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47591.41","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35792.27","","","","","","","fee schedule","12432.27","47591.41",""
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","38581.88","38581.88","38581.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10803.33","10803.33","10803.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13022.8","","","","","","","fee schedule","12432.27","47591.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12805.24","","","","","","","fee schedule","12432.27","47591.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12432.27","","","","","","","fee schedule","12432.27","47591.41","Transplants-Case Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12680.92","","","","","","","fee schedule","12432.27","47591.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13053.88","","","","","","","fee schedule","12432.27","47591.41","MSDRG Base Rate"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","718","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12432.27","","","","","","","fee schedule","12432.27","47591.41","Psych-Case Rate"
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42175.06","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45106.77","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59108.42","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49010.3","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42299.93","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54062.98","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40376.22","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64124.91","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48226.7","","","","","","","fee schedule","16256.55","64124.91",""
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6903.72","6903.72","6903.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","71421.15","71421.15","71421.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17028.74","","","","","","","fee schedule","16256.55","64124.91","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16744.25","","","","","","","fee schedule","16256.55","64124.91","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16256.55","","","","","","","fee schedule","16256.55","64124.91","Transplants-Case Rate"
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16581.68","","","","","","","fee schedule","16256.55","64124.91","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17069.38","","","","","","","fee schedule","16256.55","64124.91","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Mcc","722","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16256.55","","","","","","","fee schedule","16256.55","64124.91","Psych-Case Rate"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26630.62","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28481.8","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37322.87","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30946.6","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26709.47","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34137.02","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25494.78","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40490.43","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30451.81","","","","","","","fee schedule","10789.78","40490.43",""
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11159.62","11159.62","11159.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5289.3","5289.3","5289.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11058.42","11058.42","11058.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11302.29","","","","","","","fee schedule","10789.78","40490.43","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11113.47","","","","","","","fee schedule","10789.78","40490.43","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10789.78","","","","","","","fee schedule","10789.78","40490.43","Transplants-Case Rate"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11005.58","","","","","","","fee schedule","10789.78","40490.43","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11329.27","","","","","","","fee schedule","10789.78","40490.43","MSDRG Base Rate"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10789.78","","","","","","","fee schedule","10789.78","40490.43","Psych-Case Rate"
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15281.09","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16343.32","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21416.47","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17757.67","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15326.33","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19588.38","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14629.32","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23234.07","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17473.75","","","","","","","fee schedule","6798.3","23234.07",""
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","14335.5","14335.5","14335.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7121.22","","","","","","","fee schedule","6798.3","23234.07","MSDRG Base Rate"
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7002.25","","","","","","","fee schedule","6798.3","23234.07","MSDRG Base Rate"
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6798.3","","","","","","","fee schedule","6798.3","23234.07","Transplants-Case Rate"
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6934.27","","","","","","","fee schedule","6798.3","23234.07","MSDRG Base Rate"
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7138.22","","","","","","","fee schedule","6798.3","23234.07","MSDRG Base Rate"
"Malignancy, Male Reproductive System Without Cc/Mcc","724","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6798.3","","","","","","","fee schedule","6798.3","23234.07","Psych-Case Rate"
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27271.51","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29167.24","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38221.07","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31691.36","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27352.25","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34958.55","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26108.33","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41464.87","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31184.66","","","","","","","fee schedule","11015.18","41464.87",""
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","9285.55","9285.55","9285.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10431.38","10431.38","10431.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11538.4","","","","","","","fee schedule","11015.18","41464.87","MSDRG Base Rate"
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11345.64","","","","","","","fee schedule","11015.18","41464.87","MSDRG Base Rate"
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11015.18","","","","","","","fee schedule","11015.18","41464.87","Transplants-Case Rate"
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11235.48","","","","","","","fee schedule","11015.18","41464.87","MSDRG Base Rate"
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11565.94","","","","","","","fee schedule","11015.18","41464.87","MSDRG Base Rate"
"Benign Prostatic Hypertrophy With Mcc","725","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11015.18","","","","","","","fee schedule","11015.18","41464.87","Psych-Case Rate"
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16826.21","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17995.85","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23581.96","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19553.2","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16876.03","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21569.03","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16108.54","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25583.35","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19240.58","","","","","","","fee schedule","7341.7","25583.35",""
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","6421.7","6421.7","6421.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6172.1","6172.1","6172.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7690.43","","","","","","","fee schedule","7341.7","25583.35","MSDRG Base Rate"
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7561.95","","","","","","","fee schedule","7341.7","25583.35","MSDRG Base Rate"
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7341.7","","","","","","","fee schedule","7341.7","25583.35","Transplants-Case Rate"
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7488.53","","","","","","","fee schedule","7341.7","25583.35","MSDRG Base Rate"
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7708.78","","","","","","","fee schedule","7341.7","25583.35","MSDRG Base Rate"
"Benign Prostatic Hypertrophy Without Mcc","726","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7341.7","","","","","","","fee schedule","7341.7","25583.35","Psych-Case Rate"
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34558.98","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36961.28","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48434.48","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40159.9","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34661.3","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44300.15","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33084.98","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52545.08","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39517.8","","","","","","","fee schedule","13578.08","52545.08",""
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14223.04","","","","","","","fee schedule","13578.08","52545.08","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13985.42","","","","","","","fee schedule","13578.08","52545.08","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13578.08","","","","","","","fee schedule","13578.08","52545.08","Transplants-Case Rate"
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13849.64","","","","","","","fee schedule","13578.08","52545.08","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14256.98","","","","","","","fee schedule","13578.08","52545.08","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System With Mcc","727","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13578.08","","","","","","","fee schedule","13578.08","52545.08","Psych-Case Rate"
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18905.02","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20219.16","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26495.41","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21968.92","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18960.99","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","24233.79","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18098.68","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28744.06","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21617.67","","","","","","","fee schedule","8072.79","28744.06",""
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9836.48","9836.48","9836.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","18230.32","18230.32","18230.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5477.24","5477.24","5477.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8456.25","","","","","","","fee schedule","8072.79","28744.06","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8314.97","","","","","","","fee schedule","8072.79","28744.06","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8072.79","","","","","","","fee schedule","8072.79","28744.06","Transplants-Case Rate"
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8234.25","","","","","","","fee schedule","8072.79","28744.06","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8476.43","","","","","","","fee schedule","8072.79","28744.06","MSDRG Base Rate"
"Inflammation Of The Male Reproductive System Without Mcc","728","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8072.79","","","","","","","fee schedule","8072.79","28744.06","Psych-Case Rate"
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24673","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26388.1","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34579.26","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28671.71","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24746.05","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31627.6","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23620.66","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37513.98","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28213.3","","","","","","","fee schedule","10101.32","37513.98",""
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8281","8281","8281","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10581.13","","","","","","","fee schedule","10101.32","37513.98","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10404.36","","","","","","","fee schedule","10101.32","37513.98","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10101.32","","","","","","","fee schedule","10101.32","37513.98","Transplants-Case Rate"
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10303.35","","","","","","","fee schedule","10101.32","37513.98","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10606.39","","","","","","","fee schedule","10101.32","37513.98","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses With Cc/Mcc","729","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10101.32","","","","","","","fee schedule","10101.32","37513.98","Psych-Case Rate"
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15660.96","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16749.6","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21948.86","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18199.1","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15707.33","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20075.33","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14992.99","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23811.65","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17908.13","","","","","","","fee schedule","6931.9","23811.65",""
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7261.17","","","","","","","fee schedule","6931.9","23811.65","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7139.86","","","","","","","fee schedule","6931.9","23811.65","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6931.9","","","","","","","fee schedule","6931.9","23811.65","Transplants-Case Rate"
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7070.54","","","","","","","fee schedule","6931.9","23811.65","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7278.5","","","","","","","fee schedule","6931.9","23811.65","MSDRG Base Rate"
"Other Male Reproductive System Diagnoses Without Cc/Mcc","730","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6931.9","","","","","","","fee schedule","6931.9","23811.65","Psych-Case Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49639.65","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53090.25","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69570.06","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57684.66","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49786.62","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63631.62","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47522.43","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75474.42","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56762.37","","","","","","","fee schedule","18881.75","75474.42",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19778.63","","","","","","","fee schedule","18881.75","75474.42","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19448.2","","","","","","","fee schedule","18881.75","75474.42","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18881.75","","","","","","","fee schedule","18881.75","75474.42","Transplants-Case Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19259.39","","","","","","","fee schedule","18881.75","75474.42","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19825.84","","","","","","","fee schedule","18881.75","75474.42","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","734","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18881.75","","","","","","","fee schedule","18881.75","75474.42","Psych-Case Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31356.88","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33536.59","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","43946.72","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36438.83","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31449.72","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40195.47","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30019.45","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47676.45","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35856.23","","","","","","","fee schedule","12451.94","47676.45",""
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13043.41","","","","","","","fee schedule","12451.94","47676.45","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12825.5","","","","","","","fee schedule","12451.94","47676.45","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12451.94","","","","","","","fee schedule","12451.94","47676.45","Transplants-Case Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12700.98","","","","","","","fee schedule","12451.94","47676.45","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13074.54","","","","","","","fee schedule","12451.94","47676.45","MSDRG Base Rate"
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","735","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12451.94","","","","","","","fee schedule","12451.94","47676.45","Psych-Case Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","83303.72","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","89094.41","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","116750.32","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","96804.61","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83550.36","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","106784.61","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79750.67","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126658.83","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","95256.85","","","","","","","fee schedule","30720.95","126658.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32180.2","","","","","","","fee schedule","30720.95","126658.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31642.58","","","","","","","fee schedule","30720.95","126658.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30720.95","","","","","","","fee schedule","30720.95","126658.83","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31335.37","","","","","","","fee schedule","30720.95","126658.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32257","","","","","","","fee schedule","30720.95","126658.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","736","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30720.95","","","","","","","fee schedule","30720.95","126658.83","Psych-Case Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48022.28","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51360.46","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","67303.32","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","55805.17","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48164.46","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","61558.36","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","45974.05","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73015.3","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","54912.93","","","","","","","fee schedule","18312.94","73015.3",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19182.8","","","","","","","fee schedule","18312.94","73015.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18862.33","","","","","","","fee schedule","18312.94","73015.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18312.94","","","","","","","fee schedule","18312.94","73015.3","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18679.2","","","","","","","fee schedule","18312.94","73015.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19228.59","","","","","","","fee schedule","18312.94","73015.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","737","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18312.94","","","","","","","fee schedule","18312.94","73015.3","Psych-Case Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34223.39","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36602.36","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","47964.15","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39769.92","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34324.72","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43869.97","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32763.7","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52034.83","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39134.06","","","","","","","fee schedule","13460.06","52034.83",""
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14099.41","","","","","","","fee schedule","13460.06","52034.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13863.86","","","","","","","fee schedule","13460.06","52034.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13460.06","","","","","","","fee schedule","13460.06","52034.83","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13729.26","","","","","","","fee schedule","13460.06","52034.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14133.06","","","","","","","fee schedule","13460.06","52034.83","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","738","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13460.06","","","","","","","fee schedule","13460.06","52034.83","Psych-Case Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","83497.15","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","89301.29","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","117021.41","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","97029.39","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","83744.37","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","107032.57","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","79935.85","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","126952.94","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","95478.04","","","","","","","fee schedule","30788.98","126952.94",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32251.46","","","","","","","fee schedule","30788.98","126952.94","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31712.65","","","","","","","fee schedule","30788.98","126952.94","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30788.98","","","","","","","fee schedule","30788.98","126952.94","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31404.76","","","","","","","fee schedule","30788.98","126952.94","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32328.43","","","","","","","fee schedule","30788.98","126952.94","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","739","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30788.98","","","","","","","fee schedule","30788.98","126952.94","Psych-Case Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42172.73","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45104.28","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59105.16","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49007.59","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42297.59","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54059.99","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40373.99","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64121.37","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48224.03","","","","","","","fee schedule","16255.73","64121.37",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3793.82","3793.82","3793.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","84728.85","84728.85","84728.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17027.88","","","","","","","fee schedule","16255.73","64121.37","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16743.4","","","","","","","fee schedule","16255.73","64121.37","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16255.73","","","","","","","fee schedule","16255.73","64121.37","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16580.84","","","","","","","fee schedule","16255.73","64121.37","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17068.52","","","","","","","fee schedule","16255.73","64121.37","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","740","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16255.73","","","","","","","fee schedule","16255.73","64121.37","Psych-Case Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33235.26","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35545.54","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46579.28","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38621.64","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33333.66","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42603.31","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31817.72","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50532.43","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38004.14","","","","","","","fee schedule","13112.55","50532.43",""
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13735.4","","","","","","","fee schedule","13112.55","50532.43","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13505.93","","","","","","","fee schedule","13112.55","50532.43","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13112.55","","","","","","","fee schedule","13112.55","50532.43","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13374.8","","","","","","","fee schedule","13112.55","50532.43","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13768.18","","","","","","","fee schedule","13112.55","50532.43","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","741","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13112.55","","","","","","","fee schedule","13112.55","50532.43","Psych-Case Rate"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42760.01","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45732.39","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59928.24","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49690.05","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42886.62","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54812.82","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40936.22","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","65014.3","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48895.59","","","","","","","fee schedule","16462.27","65014.3",""
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","59269.85","59269.85","59269.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","55111.68","55111.68","55111.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57210.42","57210.42","57210.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","40936.22","40936.22","40936.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","40103","40103","40103","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","47128","47128","47128","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","39815.47","39815.47","39815.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","63272.32","63272.32","63272.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17244.23","","","","","","","fee schedule","16462.27","65014.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16956.14","","","","","","","fee schedule","16462.27","65014.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16462.27","","","","","","","fee schedule","16462.27","65014.3","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16791.52","","","","","","","fee schedule","16462.27","65014.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17285.38","","","","","","","fee schedule","16462.27","65014.3","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","742","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16462.27","","","","","","","fee schedule","16462.27","65014.3","Psych-Case Rate"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28914.51","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30924.45","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","40523.74","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","33600.64","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29000.12","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37064.67","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27681.26","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","43962.96","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33063.41","","","","","","","fee schedule","11593","43962.96",""
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","34071.62","34071.62","34071.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","25733.81","25733.81","25733.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12143.67","","","","","","","fee schedule","11593","43962.96","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11940.79","","","","","","","fee schedule","11593","43962.96","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11593","","","","","","","fee schedule","11593","43962.96","Transplants-Case Rate"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11824.86","","","","","","","fee schedule","11593","43962.96","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12172.65","","","","","","","fee schedule","11593","43962.96","MSDRG Base Rate"
"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","743","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11593","","","","","","","fee schedule","11593","43962.96","Psych-Case Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","47754.28","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51073.82","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","66927.7","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","55493.73","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","47895.66","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","61214.81","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","45717.47","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","72607.81","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","54606.47","","","","","","","fee schedule","18218.69","72607.81",""
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","57526.1","57526.1","57526.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17192.73","17192.73","17192.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19084.08","","","","","","","fee schedule","18218.69","72607.81","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18765.25","","","","","","","fee schedule","18218.69","72607.81","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18218.69","","","","","","","fee schedule","18218.69","72607.81","Transplants-Case Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18583.06","","","","","","","fee schedule","18218.69","72607.81","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19129.62","","","","","","","fee schedule","18218.69","72607.81","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","744","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18218.69","","","","","","","fee schedule","18218.69","72607.81","Psych-Case Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26509.44","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28352.19","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37153.03","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30805.78","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26587.93","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33981.68","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25378.76","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40306.18","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30313.24","","","","","","","fee schedule","10747.16","40306.18",""
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8916.33","8916.33","8916.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11257.65","","","","","","","fee schedule","10747.16","40306.18","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11069.57","","","","","","","fee schedule","10747.16","40306.18","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10747.16","","","","","","","fee schedule","10747.16","40306.18","Transplants-Case Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10962.1","","","","","","","fee schedule","10747.16","40306.18","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11284.52","","","","","","","fee schedule","10747.16","40306.18","MSDRG Base Rate"
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","745","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10747.16","","","","","","","fee schedule","10747.16","40306.18","Psych-Case Rate"
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40483.12","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43297.22","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56737.16","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47044.14","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40602.98","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51894.13","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38756.44","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61552.4","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46291.98","","","","","","","fee schedule","15661.52","61552.4",""
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3264.33","3264.33","3264.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16405.44","","","","","","","fee schedule","15661.52","61552.4","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16131.37","","","","","","","fee schedule","15661.52","61552.4","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15661.52","","","","","","","fee schedule","15661.52","61552.4","Transplants-Case Rate"
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15974.75","","","","","","","fee schedule","15661.52","61552.4","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16444.6","","","","","","","fee schedule","15661.52","61552.4","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures With Cc/Mcc","746","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15661.52","","","","","","","fee schedule","15661.52","61552.4","Psych-Case Rate"
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20035.31","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21428.02","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28079.52","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23282.4","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20094.63","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25682.68","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19180.77","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30462.61","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22910.15","","","","","","","fee schedule","8470.3","30462.61",""
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8872.64","","","","","","","fee schedule","8470.3","30462.61","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8724.41","","","","","","","fee schedule","8470.3","30462.61","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8470.3","","","","","","","fee schedule","8470.3","30462.61","Transplants-Case Rate"
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8639.71","","","","","","","fee schedule","8470.3","30462.61","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8893.82","","","","","","","fee schedule","8470.3","30462.61","MSDRG Base Rate"
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","747","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8470.3","","","","","","","fee schedule","8470.3","30462.61","Psych-Case Rate"
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32331.03","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34578.45","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45311.99","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37570.86","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32426.75","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41444.2","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30952.05","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49157.59","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36970.16","","","","","","","fee schedule","12794.54","49157.59",""
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13402.28","","","","","","","fee schedule","12794.54","49157.59","MSDRG Base Rate"
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13178.38","","","","","","","fee schedule","12794.54","49157.59","MSDRG Base Rate"
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12794.54","","","","","","","fee schedule","12794.54","49157.59","Transplants-Case Rate"
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13050.43","","","","","","","fee schedule","12794.54","49157.59","MSDRG Base Rate"
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13434.27","","","","","","","fee schedule","12794.54","49157.59","MSDRG Base Rate"
"Female Reproductive System Reconstructive Procedures","748","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12794.54","","","","","","","fee schedule","12794.54","49157.59","Psych-Case Rate"
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","59837.92","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","63997.43","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","83862.95","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","69535.74","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","60015.08","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","76704.48","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","57285.72","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","90980.34","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","68423.97","","","","","","","fee schedule","22468.35","90980.34",""
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","47598.84","47598.84","47598.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23535.6","","","","","","","fee schedule","22468.35","90980.34","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23142.4","","","","","","","fee schedule","22468.35","90980.34","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22468.35","","","","","","","fee schedule","22468.35","90980.34","Transplants-Case Rate"
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22917.72","","","","","","","fee schedule","22468.35","90980.34","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23591.77","","","","","","","fee schedule","22468.35","90980.34","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures With Cc/Mcc","749","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22468.35","","","","","","","fee schedule","22468.35","90980.34","Psych-Case Rate"
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34393.52","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36784.32","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48202.58","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39967.62","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34495.35","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44088.05","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32926.57","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52293.5","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39328.59","","","","","","","fee schedule","13519.89","52293.5",""
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7946.05","2529.22","29135.49","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7946.05","1324.34","21498.37","82","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6660","2498.76","11930.28","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14162.08","","","","","","","fee schedule","13519.89","52293.5","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13925.49","","","","","","","fee schedule","13519.89","52293.5","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13519.89","","","","","","","fee schedule","13519.89","52293.5","Transplants-Case Rate"
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13790.29","","","","","","","fee schedule","13519.89","52293.5","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14195.88","","","","","","","fee schedule","13519.89","52293.5","MSDRG Base Rate"
"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","750","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13519.89","","","","","","","fee schedule","13519.89","52293.5","Psych-Case Rate"
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42920.82","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45904.37","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","60153.61","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49876.92","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","43047.9","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","55018.95","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","41090.17","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","65258.8","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","49079.46","","","","","","","fee schedule","16518.83","65258.8",""
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15175.36","2648.69","17216.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5058.44","1264.61","7587.66","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5965.14","2386.06","15916.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17303.47","","","","","","","fee schedule","16518.83","65258.8","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17014.39","","","","","","","fee schedule","16518.83","65258.8","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16518.83","","","","","","","fee schedule","16518.83","65258.8","Transplants-Case Rate"
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16849.21","","","","","","","fee schedule","16518.83","65258.8","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17344.77","","","","","","","fee schedule","16518.83","65258.8","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Mcc","754","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16518.83","","","","","","","fee schedule","16518.83","65258.8","Psych-Case Rate"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25351.18","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27113.42","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35529.72","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29459.8","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25426.24","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32496.94","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24269.91","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38545.11","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28988.78","","","","","","","fee schedule","10339.82","38545.11",""
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","3793.82","2107.86","7946.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5297.36","2529.22","8852.27","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5550","5550","5550","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10830.96","","","","","","","fee schedule","10339.82","38545.11","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10650.01","","","","","","","fee schedule","10339.82","38545.11","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10339.82","","","","","","","fee schedule","10339.82","38545.11","Transplants-Case Rate"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10546.62","","","","","","","fee schedule","10339.82","38545.11","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10856.81","","","","","","","fee schedule","10339.82","38545.11","MSDRG Base Rate"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10339.82","","","","","","","fee schedule","10339.82","38545.11","Psych-Case Rate"
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22384.45","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23940.46","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31371.85","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26012.26","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22450.73","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28693.98","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21429.72","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34034.36","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25596.36","","","","","","","fee schedule","9296.46","34034.36",""
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","7946.05","2648.69","8852.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","3793.82","1324.34","10116.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7158.17","7158.17","7158.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9738.04","","","","","","","fee schedule","9296.46","34034.36","MSDRG Base Rate"
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9575.35","","","","","","","fee schedule","9296.46","34034.36","MSDRG Base Rate"
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9296.46","","","","","","","fee schedule","9296.46","34034.36","Transplants-Case Rate"
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9482.39","","","","","","","fee schedule","9296.46","34034.36","MSDRG Base Rate"
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9761.28","","","","","","","fee schedule","9296.46","34034.36","MSDRG Base Rate"
"Malignancy, Female Reproductive System Without Cc/Mcc","756","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9296.46","","","","","","","fee schedule","9296.46","34034.36","Psych-Case Rate"
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33370.43","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35690.11","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46768.72","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38778.72","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33469.23","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42776.58","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31947.12","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50737.94","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38158.7","","","","","","","fee schedule","13160.08","50737.94",""
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","473.23","473.23","473.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5297.36","5297.36","8852.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13785.18","","","","","","","fee schedule","13160.08","50737.94","MSDRG Base Rate"
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13554.88","","","","","","","fee schedule","13160.08","50737.94","MSDRG Base Rate"
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13160.08","","","","","","","fee schedule","13160.08","50737.94","Transplants-Case Rate"
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13423.28","","","","","","","fee schedule","13160.08","50737.94","MSDRG Base Rate"
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13818.08","","","","","","","fee schedule","13160.08","50737.94","MSDRG Base Rate"
"Infections, Female Reproductive System With Mcc","757","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13160.08","","","","","","","fee schedule","13160.08","50737.94","Psych-Case Rate"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22815.6","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24401.58","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31976.1","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26513.28","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22883.15","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29246.65","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21842.47","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34689.89","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26089.37","","","","","","","fee schedule","9448.09","34689.89",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","6710.48","6710.48","6710.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8031.79","5184.26","8411.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9896.87","","","","","","","fee schedule","9448.09","34689.89","MSDRG Base Rate"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9731.53","","","","","","","fee schedule","9448.09","34689.89","MSDRG Base Rate"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9448.09","","","","","","","fee schedule","9448.09","34689.89","Transplants-Case Rate"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9637.05","","","","","","","fee schedule","9448.09","34689.89","MSDRG Base Rate"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9920.49","","","","","","","fee schedule","9448.09","34689.89","MSDRG Base Rate"
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9448.09","","","","","","","fee schedule","9448.09","34689.89","Psych-Case Rate"
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15465.2","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16540.23","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21674.5","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17971.62","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15510.99","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19824.39","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14805.58","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23514","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17684.28","","","","","","","fee schedule","6863.05","23514",""
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18294.16","18294.16","18294.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1598.36","1598.36","1598.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5184.26","5184.26","5184.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5379.89","5379.89","5379.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7189.04","","","","","","","fee schedule","6863.05","23514","MSDRG Base Rate"
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7068.94","","","","","","","fee schedule","6863.05","23514","MSDRG Base Rate"
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6863.05","","","","","","","fee schedule","6863.05","23514","Transplants-Case Rate"
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7000.31","","","","","","","fee schedule","6863.05","23514","MSDRG Base Rate"
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7206.2","","","","","","","fee schedule","6863.05","23514","MSDRG Base Rate"
"Infections, Female Reproductive System Without Cc/Mcc","759","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6863.05","","","","","","","fee schedule","6863.05","23514","Psych-Case Rate"
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23479.79","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25111.94","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32906.97","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27285.12","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23549.31","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30098.06","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22478.33","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35699.76","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26848.87","","","","","","","fee schedule","9681.68","35699.76",""
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","22214.19","22214.19","22214.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7464.65","7464.65","7464.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","2648.69","2529.22","9270.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","12250.98","12250.98","12250.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5641.81","5641.81","5641.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10141.56","","","","","","","fee schedule","9681.68","35699.76","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9972.13","","","","","","","fee schedule","9681.68","35699.76","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9681.68","","","","","","","fee schedule","9681.68","35699.76","Transplants-Case Rate"
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9875.31","","","","","","","fee schedule","9681.68","35699.76","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10165.76","","","","","","","fee schedule","9681.68","35699.76","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","760","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9681.68","","","","","","","fee schedule","9681.68","35699.76","Psych-Case Rate"
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","13295.5","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","14219.71","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","18633.67","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","15450.28","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","13334.87","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","17043.12","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","12728.43","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","20215.1","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","15203.25","","","","","","","fee schedule","6100","20215.1",""
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","955.29","955.29","955.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6389.75","","","","","","","fee schedule","6100","20215.1","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6283","","","","","","","fee schedule","6100","20215.1","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6100","","","","","","","fee schedule","6100","20215.1","Transplants-Case Rate"
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6222","","","","","","","fee schedule","6100","20215.1","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6405","","","","","","","fee schedule","6100","20215.1","MSDRG Base Rate"
"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","761","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6100","","","","","","","fee schedule","6100","20215.1","Psych-Case Rate"
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W Cc/Mcc","765","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section W/O Cc/Mcc","766","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Sterilization &/Or D&C","767","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24973.64","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26709.63","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35000.6","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29021.07","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25047.58","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32012.98","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23908.47","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37971.07","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28557.07","","","","","","","fee schedule","10207.04","37971.07",""
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","26229.4","26229.4","26229.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","10531.47","10531.47","10531.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","24950.69","20931.51","33842.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","32835.02","27555.49","34335.02","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","23717.19","21963.27","24159.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21786.09","19234.28","23569","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","22764.06","22764.06","22764.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","26582.54","26582.54","26582.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10691.87","","","","","","","fee schedule","10207.04","37971.07","MSDRG Base Rate"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10513.25","","","","","","","fee schedule","10207.04","37971.07","MSDRG Base Rate"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10207.04","","","","","","","fee schedule","10207.04","37971.07","Transplants-Case Rate"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10411.18","","","","","","","fee schedule","10207.04","37971.07","MSDRG Base Rate"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10717.39","","","","","","","fee schedule","10207.04","37971.07","MSDRG Base Rate"
"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","768","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10207.04","","","","","","","fee schedule","10207.04","37971.07","Psych-Case Rate"
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39380.79","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42118.27","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55192.25","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45763.16","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39497.39","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50481.09","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37701.13","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59876.37","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45031.48","","","","","","","fee schedule","15273.85","59876.37",""
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","46430.56","46430.56","46430.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","33207.66","33207.66","40384.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","29173.2","29173.2","29173.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","35850","35850","35850","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15999.36","","","","","","","fee schedule","15273.85","59876.37","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15732.07","","","","","","","fee schedule","15273.85","59876.37","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15273.85","","","","","","","fee schedule","15273.85","59876.37","Transplants-Case Rate"
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15579.33","","","","","","","fee schedule","15273.85","59876.37","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16037.54","","","","","","","fee schedule","15273.85","59876.37","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses With O.R. Procedures","769","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15273.85","","","","","","","fee schedule","15273.85","59876.37","Psych-Case Rate"
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23367.92","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24992.3","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32750.19","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27155.12","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23437.11","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29954.66","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22371.24","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35529.67","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26720.95","","","","","","","fee schedule","9642.34","35529.67",""
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","36418.13","36418.13","36418.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5161.25","5161.25","5405.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25432.31","25432.31","25432.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","23556.64","23556.64","23556.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","3384.23","2386.06","5405.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20307.17","20307.17","23121","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","17562.66","17562.66","17562.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","27656.06","27656.06","27656.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8714.15","8714.15","8714.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10100.35","","","","","","","fee schedule","9642.34","35529.67","MSDRG Base Rate"
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9931.61","","","","","","","fee schedule","9642.34","35529.67","MSDRG Base Rate"
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9642.34","","","","","","","fee schedule","9642.34","35529.67","Transplants-Case Rate"
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9835.19","","","","","","","fee schedule","9642.34","35529.67","MSDRG Base Rate"
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10124.46","","","","","","","fee schedule","9642.34","35529.67","MSDRG Base Rate"
"Abortion With D&C, Aspiration Curettage Or Hysterotomy","770","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9642.34","","","","","","","fee schedule","9642.34","35529.67","Psych-Case Rate"
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W Complicating Diagnoses","774","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery W/O Complicating Diagnoses","775","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15257.78","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16318.4","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21383.81","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17730.59","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15302.96","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19558.51","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14607.01","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23198.64","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17447.1","","","","","","","fee schedule","6790.11","23198.64",""
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","16098.92","16098.92","16098.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","40163.97","7860.29","41829.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6343.77","6110.9","6399.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","10243.66","10243.66","10243.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","14736.76","6987.35","22346.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","9519.13","9519.13","14698.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","7552.2","7552.2","7552.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6399.53","6110.9","10616.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15163","8408.21","15663","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","17852.78","17852.78","17852.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","18514.06","13957.68","19014.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5765","4440","7496.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7112.64","","","","","","","fee schedule","6790.11","23198.64","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6993.81","","","","","","","fee schedule","6790.11","23198.64","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6790.11","","","","","","","fee schedule","6790.11","23198.64","Transplants-Case Rate"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6925.91","","","","","","","fee schedule","6790.11","23198.64","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7129.62","","","","","","","fee schedule","6790.11","23198.64","MSDRG Base Rate"
"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","776","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6790.11","","","","","","","fee schedule","6790.11","23198.64","Psych-Case Rate"
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ectopic Pregnancy","777","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Threatened Abortion","778","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19606.5","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","20969.4","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27478.54","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","22784.09","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19664.55","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25133","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18770.24","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","29810.62","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22419.8","","","","","","","fee schedule","8319.49","29810.62",""
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17706.23","17706.23","17706.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","29015.48","29015.48","29015.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","20856.32","20856.32","20856.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20521","20521","20521","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8714.67","","","","","","","fee schedule","8319.49","29810.62","MSDRG Base Rate"
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8569.07","","","","","","","fee schedule","8319.49","29810.62","MSDRG Base Rate"
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8319.49","","","","","","","fee schedule","8319.49","29810.62","Transplants-Case Rate"
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8485.88","","","","","","","fee schedule","8319.49","29810.62","MSDRG Base Rate"
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8735.46","","","","","","","fee schedule","8319.49","29810.62","MSDRG Base Rate"
"Abortion Without D&C","779","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8319.49","","","","","","","fee schedule","8319.49","29810.62","Psych-Case Rate"
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"False Labor","780","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W Medical Complications","781","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses W/O Medical Complications","782","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","57216.11","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","61193.37","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","80188.48","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","66489.02","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","57385.51","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","73343.66","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54775.74","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","86994.01","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","65425.96","","","","","","","fee schedule","21546.29","86994.01",""
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","53555.23","53555.23","53555.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","32485.1","32485.1","32485.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","41480.45","40545.31","44024.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","53869.81","36048.17","89132.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","54425.74","54425.74","54425.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","175828.1","175828.1","175828.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39696.95","39585.54","39941","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","43350.81","43350.81","43350.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22569.74","","","","","","","fee schedule","21546.29","86994.01","MSDRG Base Rate"
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22192.68","","","","","","","fee schedule","21546.29","86994.01","MSDRG Base Rate"
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21546.29","","","","","","","fee schedule","21546.29","86994.01","Transplants-Case Rate"
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21977.22","","","","","","","fee schedule","21546.29","86994.01","MSDRG Base Rate"
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22623.6","","","","","","","fee schedule","21546.29","86994.01","MSDRG Base Rate"
"Cesarean Section With Sterilization With Mcc","783","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21546.29","","","","","","","fee schedule","21546.29","86994.01","Psych-Case Rate"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24705.63","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26422.99","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34624.99","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28709.63","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24778.78","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31669.43","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23651.89","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37563.58","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28250.6","","","","","","","fee schedule","10112.79","37563.58",""
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","26824.6","26824.6","26824.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23990.74","22119.09","25882.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33201.27","31560.87","33918.48","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10130.65","10130.65","10130.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","21746.52","21656.53","24162.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","52717.84","52717.84","52717.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","25337.71","25337.71","25337.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22774","21218.66","23277","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10071.96","10071.96","10071.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","31571.17","31571.17","31571.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","24093.94","22932.83","27942","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24957.83","24957.83","24957.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","28087.61","28087.61","28087.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10593.15","","","","","","","fee schedule","10112.79","37563.58","MSDRG Base Rate"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10416.17","","","","","","","fee schedule","10112.79","37563.58","MSDRG Base Rate"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10112.79","","","","","","","fee schedule","10112.79","37563.58","Transplants-Case Rate"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10315.05","","","","","","","fee schedule","10112.79","37563.58","MSDRG Base Rate"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10618.43","","","","","","","fee schedule","10112.79","37563.58","MSDRG Base Rate"
"Cesarean Section With Sterilization With Cc","784","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10112.79","","","","","","","fee schedule","10112.79","37563.58","Psych-Case Rate"
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22321.53","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23873.17","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31283.66","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25939.14","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22387.62","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28613.32","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21369.48","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33938.69","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25524.41","","","","","","","fee schedule","9274.33","33938.69",""
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","32642.63","32642.63","32642.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","26350.25","26350.25","26350.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20875.78","20875.78","20875.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25683.82","22788.19","27357.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","19333.63","19333.63","19333.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","17671.81","17671.81","17671.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","28335","28335","28335","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","22573","22573","22573","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","22654.22","22654.22","23685.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9714.86","","","","","","","fee schedule","9274.33","33938.69","MSDRG Base Rate"
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9552.56","","","","","","","fee schedule","9274.33","33938.69","MSDRG Base Rate"
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9274.33","","","","","","","fee schedule","9274.33","33938.69","Transplants-Case Rate"
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9459.82","","","","","","","fee schedule","9274.33","33938.69","MSDRG Base Rate"
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9738.05","","","","","","","fee schedule","9274.33","33938.69","MSDRG Base Rate"
"Cesarean Section With Sterilization Without Cc/Mcc","785","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9274.33","","","","","","","fee schedule","9274.33","33938.69","Psych-Case Rate"
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38441.6","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41113.79","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53875.97","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44671.76","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38555.41","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49277.16","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36801.99","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58448.38","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43957.53","","","","","","","fee schedule","14943.55","58448.38",""
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","43545.83","25232.77","58691.39","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","27375.68","27375.68","27375.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","31285.6","28700.84","36134.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","37849.49","35333.17","38618.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48192.6","34336.66","50608.37","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2998.26","2998.26","2998.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14512.35","14512.35","14512.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","34356.24","28370.25","36501.99","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","26813.99","26813.99","26813.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13057.62","13057.62","13057.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13685.69","13685.69","13685.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","33527.33","31169.37","36215","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","40487.4","36389.93","41689","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","37535.96","35585.3","43062.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","112716.51","112716.51","112716.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15653.37","","","","","","","fee schedule","14943.55","58448.38","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15391.86","","","","","","","fee schedule","14943.55","58448.38","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14943.55","","","","","","","fee schedule","14943.55","58448.38","Transplants-Case Rate"
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15242.42","","","","","","","fee schedule","14943.55","58448.38","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15690.73","","","","","","","fee schedule","14943.55","58448.38","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Mcc","786","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14943.55","","","","","","","fee schedule","14943.55","58448.38","Psych-Case Rate"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26027.02","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","27836.24","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","36476.92","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","30245.18","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26104.08","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","33363.28","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24916.92","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","39572.69","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","29761.6","","","","","","","fee schedule","10577.51","39572.69",""
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","25334","19184.34","49596.5","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","34071.13","34071.13","34071.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","30622.68","23707.16","31667.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","24376.8","22325.77","25375.96","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","32904.51","29372.21","34777.06","87","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2759.94","2759.94","2759.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9789.19","9789.19","9989.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","22948.9","19378.61","24916.92","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","37379.6","37379.6","37379.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","26652.36","26652.36","26652.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22812","18565.45","24019","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","914.14","914.14","8189.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","32071.19","32071.19","32071.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","27396","27396","27396","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8471.83","8471.83","8471.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","25544.65","21543.83","27808.58","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","20609.73","20609.73","20609.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","27537.78","27537.78","28295.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11079.94","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10894.84","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10577.51","","","","","","","fee schedule","10577.51","39572.69","Transplants-Case Rate"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10789.06","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11106.39","","","","","","","fee schedule","10577.51","39572.69","MSDRG Base Rate"
"Cesarean Section Without Sterilization With Cc","787","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10577.51","","","","","","","fee schedule","10577.51","39572.69","Psych-Case Rate"
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22344.83","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23898.09","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31316.33","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25966.22","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22410.99","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28643.19","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21391.79","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33974.12","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25551.06","","","","","","","fee schedule","9282.53","33974.12",""
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","23122.14","22950.7","28313.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","25959.45","25959.45","25959.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","14150.86","14150.86","22344.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","20421.43","19621.43","21621.43","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","27038.05","25154.32","28334.3","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2454.6","2454.6","2454.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","19252.6","17948.45","20638.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18602","15059.05","20550","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7725.77","7725.77","7725.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","32367","32367","32367","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","23036.35","22991.23","24738","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","20689.79","17463.46","23051.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","21863.81","21863.81","21863.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24109.35","24109.35","24109.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9723.45","","","","","","","fee schedule","9282.53","33974.12","MSDRG Base Rate"
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9561.01","","","","","","","fee schedule","9282.53","33974.12","MSDRG Base Rate"
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9282.53","","","","","","","fee schedule","9282.53","33974.12","Transplants-Case Rate"
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9468.18","","","","","","","fee schedule","9282.53","33974.12","MSDRG Base Rate"
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9746.66","","","","","","","fee schedule","9282.53","33974.12","MSDRG Base Rate"
"Cesarean Section Without Sterilization Without Cc/Mcc","788","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9282.53","","","","","","","fee schedule","9282.53","33974.12","Psych-Case Rate"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42000.27","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","44919.84","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","58863.46","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","48807.18","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42124.62","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","53838.92","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40208.88","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","63859.15","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48026.83","","","","","","","fee schedule","16195.08","63859.15",""
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","185453.43","8980.38","294673.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","6675","6675","13534.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","6797","2557","56455.63","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5847.94","5847.94","5847.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","2231.69","2231.69","2231.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","7690.74","7690.74","7690.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","40217.8","40217.8","40217.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","9793.42","5588.8","35427.44","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","89130.86","89130.86","89130.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","5489.6","4918.62","37004.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10231.55","10231.55","10231.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","10569.08","4563.8","15059.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16964.35","","","","","","","fee schedule","16195.08","63859.15","MSDRG Base Rate"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16680.93","","","","","","","fee schedule","16195.08","63859.15","MSDRG Base Rate"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16195.08","","","","","","","fee schedule","16195.08","63859.15","Transplants-Case Rate"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16518.98","","","","","","","fee schedule","16195.08","63859.15","MSDRG Base Rate"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17004.83","","","","","","","fee schedule","16195.08","63859.15","MSDRG Base Rate"
"Neonates, Died Or Transferred To Another Acute Care Facility","789","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16195.08","","","","","","","fee schedule","16195.08","63859.15","Psych-Case Rate"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","138513.27","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","148141.74","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","194126.6","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","160961.87","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","138923.37","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","177556.12","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","132605.43","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","210601.98","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","158388.33","","","","","","","fee schedule","50137.41","210601.98",""
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","29807.41","22878.88","214259.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","201753.75","201753.75","201753.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","23438.8","8094.71","82667.95","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","96656.3","96656.3","126664.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","121777.62","71524.43","142074.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","123258.4","44776.2","186185.19","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","23161.61","23161.61","23161.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","79228.72","58769.53","119256.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","60145.29","60145.29","60145.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","129180.27","69218.6","149384.27","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","23438.8","8094.71","78939.5","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","159349.52","159349.52","159349.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","72176.31","72176.31","148842.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","111086.89","67893.91","346086.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","16984.87","8400.17","85787.49","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5964.9","5964.9","5964.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","24800","24800","24800","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","23624.84","23624.84","23624.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","52518.94","","","","","","","fee schedule","50137.41","210601.98","MSDRG Base Rate"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51641.53","","","","","","","fee schedule","50137.41","210601.98","MSDRG Base Rate"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50137.41","","","","","","","fee schedule","50137.41","210601.98","Transplants-Case Rate"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","51140.16","","","","","","","fee schedule","50137.41","210601.98","MSDRG Base Rate"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","52644.28","","","","","","","fee schedule","50137.41","210601.98","MSDRG Base Rate"
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","790","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","50137.41","","","","","","","fee schedule","50137.41","210601.98","Psych-Case Rate"
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","94595","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","101170.58","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","132575.06","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","109925.84","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","94875.07","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","121258.57","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","90560.35","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","143826.61","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","108168.29","","","","","","","fee schedule","34691.94","143826.61",""
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9882.04","9882.04","9882.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","27660.97","27660.97","27660.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","95527.55","95527.55","96211.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","47684.27","26165.24","77511.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","41607.93","22381.69","78939.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","88639","43401.94","89139","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","62103.11","62103.11","62103.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","35622.68","27905.68","58655.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","28567.17","28567.17","28567.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","43607.48","43607.48","43607.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","36339.81","","","","","","","fee schedule","34691.94","143826.61","MSDRG Base Rate"
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35732.7","","","","","","","fee schedule","34691.94","143826.61","MSDRG Base Rate"
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34691.94","","","","","","","fee schedule","34691.94","143826.61","Transplants-Case Rate"
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","35385.78","","","","","","","fee schedule","34691.94","143826.61","MSDRG Base Rate"
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","36426.54","","","","","","","fee schedule","34691.94","143826.61","MSDRG Base Rate"
"Prematurity With Major Problems","791","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34691.94","","","","","","","fee schedule","34691.94","143826.61","Psych-Case Rate"
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","57078.61","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","61046.31","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","79995.77","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","66329.23","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","57247.6","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","73167.4","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54644.1","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","86784.95","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","65268.73","","","","","","","fee schedule","21497.93","86784.95",""
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","6515.8","3803.66","94865.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","11508.28","11508.28","11508.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","38121.41","19429.12","73929.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","55752.72","55140.28","55752.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","43892.98","8043.53","74472.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2548.45","2548.45","2548.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","6084.25","3120.44","52591.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","4839.12","4839.12","4839.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","9574.25","6766.87","53285","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19429.12","19429.12","39676.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","5441.09","5441.09","5441.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","31269.61","8438.08","37802.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22519.08","","","","","","","fee schedule","21497.93","86784.95","MSDRG Base Rate"
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22142.87","","","","","","","fee schedule","21497.93","86784.95","MSDRG Base Rate"
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21497.93","","","","","","","fee schedule","21497.93","86784.95","Transplants-Case Rate"
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","21927.89","","","","","","","fee schedule","21497.93","86784.95","MSDRG Base Rate"
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22572.83","","","","","","","fee schedule","21497.93","86784.95","MSDRG Base Rate"
"Prematurity Without Major Problems","792","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21497.93","","","","","","","fee schedule","21497.93","86784.95","Psych-Case Rate"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","97172.53","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","103927.28","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","136187.48","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","112921.11","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","97460.23","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","124562.63","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","93027.95","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","147745.61","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","111115.67","","","","","","","fee schedule","35598.43","147745.61",""
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","24916.7","24916.7","24916.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","15303.87","1855.11","27528.36","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21036.26","8633.87","64013.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3225.12","3225.12","3225.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","30608.36","4162.58","74079.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","31579.95","31579.95","31579.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","23481","16367.24","27842.21","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","12616.35","5536","32757.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","14131.9","14131.9","44733.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","15745.28","5950","28873","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","23226.28","23226.28","23226.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3289.62","3289.62","3289.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","15826.76","15826.76","15826.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37289.36","","","","","","","fee schedule","35598.43","147745.61","MSDRG Base Rate"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36666.38","","","","","","","fee schedule","35598.43","147745.61","MSDRG Base Rate"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35598.43","","","","","","","fee schedule","35598.43","147745.61","Transplants-Case Rate"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36310.4","","","","","","","fee schedule","35598.43","147745.61","MSDRG Base Rate"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37378.35","","","","","","","fee schedule","35598.43","147745.61","MSDRG Base Rate"
"Full Term Neonate With Major Problems","793","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35598.43","","","","","","","fee schedule","35598.43","147745.61","Psych-Case Rate"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34395.85","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36786.81","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48205.85","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39970.32","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34497.69","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44091.04","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32928.8","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52297.04","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39331.26","","","","","","","fee schedule","13520.71","52297.04",""
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","5660.48","2225.86","8711.43","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","4657.12","4657.12","18204.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","918.89","918.89","918.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4192.01","2209.89","9481","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","33953.36","33953.36","33953.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18786.76","6123.02","42789.84","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","900.87","900.87","900.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","6404.6","4927.1","20254.33","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9053.4","3559.14","27528.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","8056.35","5844.26","24279.72","45","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","14140.17","14140.17","16964.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","7526.53","5879.68","30938.13","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","8341.28","5760.9","19116.48","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6286.06","3526.88","16218.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","6859.16","6859.16","8216.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14162.94","","","","","","","fee schedule","13520.71","52297.04","MSDRG Base Rate"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13926.33","","","","","","","fee schedule","13520.71","52297.04","MSDRG Base Rate"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13520.71","","","","","","","fee schedule","13520.71","52297.04","Transplants-Case Rate"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13791.12","","","","","","","fee schedule","13520.71","52297.04","MSDRG Base Rate"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14196.75","","","","","","","fee schedule","13520.71","52297.04","MSDRG Base Rate"
"Neonate With Other Significant Problems","794","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13520.71","","","","","","","fee schedule","13520.71","52297.04","Psych-Case Rate"
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","4656.34","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","4980.02","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","6525.87","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","5410.98","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","4670.13","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","5968.83","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","4457.74","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","7079.71","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","5324.47","","","","","","","fee schedule","3061.72","7079.71",""
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","3519.91","1695.09","5233.83","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","3820.02","3820.02","3820.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","5006.07","4767.07","6257.54","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","644.21","571.03","644.21","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","3566.19","2882.92","4457.74","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","4011.97","4011.97","4011.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","4852.67","4852.67","4852.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","4382.35","3360.7","4387","76","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","4468.28","3463.62","5782.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","4639.33","3540.1","5155","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","3983.16","3186.53","5181.81","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","1948.58","1948.58","1948.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","5903.35","5903.35","5903.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","3207.15","","","","","","","fee schedule","3061.72","7079.71","MSDRG Base Rate"
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","3153.57","","","","","","","fee schedule","3061.72","7079.71","MSDRG Base Rate"
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","3061.72","","","","","","","fee schedule","3061.72","7079.71","Transplants-Case Rate"
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","3122.95","","","","","","","fee schedule","3061.72","7079.71","MSDRG Base Rate"
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3214.81","","","","","","","fee schedule","3061.72","7079.71","MSDRG Base Rate"
"Normal Newborn","795","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","3061.72","","","","","","","fee schedule","3061.72","7079.71","Psych-Case Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27196.94","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29087.48","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38116.55","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31604.69","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27277.46","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34862.96","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26036.94","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41351.48","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31099.38","","","","","","","fee schedule","10988.95","41351.48",""
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","38073.32","38073.32","38073.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7700.08","7700.08","7700.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","24707.53","24707.53","24707.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11510.93","","","","","","","fee schedule","10988.95","41351.48","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11318.62","","","","","","","fee schedule","10988.95","41351.48","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10988.95","","","","","","","fee schedule","10988.95","41351.48","Transplants-Case Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11208.73","","","","","","","fee schedule","10988.95","41351.48","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11538.4","","","","","","","fee schedule","10988.95","41351.48","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Mcc","796","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10988.95","","","","","","","fee schedule","10988.95","41351.48","Psych-Case Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23314.32","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24934.97","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32675.06","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27092.83","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23383.35","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29885.95","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22319.92","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35448.17","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26659.66","","","","","","","fee schedule","9623.49","35448.17",""
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10080.61","","","","","","","fee schedule","9623.49","35448.17","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9912.19","","","","","","","fee schedule","9623.49","35448.17","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9623.49","","","","","","","fee schedule","9623.49","35448.17","Transplants-Case Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9815.96","","","","","","","fee schedule","9623.49","35448.17","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10104.66","","","","","","","fee schedule","9623.49","35448.17","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C With Cc","797","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9623.49","","","","","","","fee schedule","9623.49","35448.17","Psych-Case Rate"
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22305.22","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23855.72","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31260.8","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25920.18","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22371.26","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28592.41","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21353.86","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33913.88","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25505.76","","","","","","","fee schedule","9268.6","33913.88",""
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9708.86","","","","","","","fee schedule","9268.6","33913.88","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9546.66","","","","","","","fee schedule","9268.6","33913.88","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9268.6","","","","","","","fee schedule","9268.6","33913.88","Transplants-Case Rate"
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9453.97","","","","","","","fee schedule","9268.6","33913.88","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9732.03","","","","","","","fee schedule","9268.6","33913.88","MSDRG Base Rate"
"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","798","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9268.6","","","","","","","fee schedule","9268.6","33913.88","Psych-Case Rate"
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","105546.01","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","112882.83","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","147922.93","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","122651.67","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","105858.51","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","135296.36","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","101044.29","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","160477.04","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","120690.66","","","","","","","fee schedule","38543.27","160477.04",""
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","38406.19","38406.19","38406.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","90288.87","90288.87","90288.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","38714.61","38714.61","38714.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40374.08","","","","","","","fee schedule","38543.27","160477.04","MSDRG Base Rate"
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39699.57","","","","","","","fee schedule","38543.27","160477.04","MSDRG Base Rate"
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38543.27","","","","","","","fee schedule","38543.27","160477.04","Transplants-Case Rate"
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39314.14","","","","","","","fee schedule","38543.27","160477.04","MSDRG Base Rate"
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40470.43","","","","","","","fee schedule","38543.27","160477.04","MSDRG Base Rate"
"Splenic Procedures With Mcc","799","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38543.27","","","","","","","fee schedule","38543.27","160477.04","Psych-Case Rate"
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","65473.07","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","70024.3","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","91760.62","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","76084.17","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","65666.92","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","83928.02","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","62680.52","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","99548.28","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","74867.7","","","","","","","fee schedule","24450.15","99548.28",""
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","22599.94","22599.94","22599.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","62768","62768","62768","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","73030.69","73030.69","73030.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","25611.53","","","","","","","fee schedule","24450.15","99548.28","MSDRG Base Rate"
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25183.65","","","","","","","fee schedule","24450.15","99548.28","MSDRG Base Rate"
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24450.15","","","","","","","fee schedule","24450.15","99548.28","Transplants-Case Rate"
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24939.15","","","","","","","fee schedule","24450.15","99548.28","MSDRG Base Rate"
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25672.66","","","","","","","fee schedule","24450.15","99548.28","MSDRG Base Rate"
"Splenic Procedures With Cc","800","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24450.15","","","","","","","fee schedule","24450.15","99548.28","Psych-Case Rate"
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44486.91","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47579.33","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","62348.49","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51696.83","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44618.63","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57026.48","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42589.47","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","67639.96","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","50870.28","","","","","","","fee schedule","17069.6","67639.96",""
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","1675.58","1675.58","1675.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17880.41","","","","","","","fee schedule","17069.6","67639.96","MSDRG Base Rate"
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17581.69","","","","","","","fee schedule","17069.6","67639.96","MSDRG Base Rate"
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17069.6","","","","","","","fee schedule","17069.6","67639.96","Transplants-Case Rate"
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17410.99","","","","","","","fee schedule","17069.6","67639.96","MSDRG Base Rate"
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17923.08","","","","","","","fee schedule","17069.6","67639.96","MSDRG Base Rate"
"Splenic Procedures Without Cc/Mcc","801","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17069.6","","","","","","","fee schedule","17069.6","67639.96","Psych-Case Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","92849.45","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","99303.69","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","130128.67","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","107897.4","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","93124.35","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","119021","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","88889.26","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","141172.6","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","106172.28","","","","","","","fee schedule","34078.06","141172.6",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","239311.87","239311.87","239311.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","35696.77","","","","","","","fee schedule","34078.06","141172.6","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35100.4","","","","","","","fee schedule","34078.06","141172.6","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34078.06","","","","","","","fee schedule","34078.06","141172.6","Transplants-Case Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34759.62","","","","","","","fee schedule","34078.06","141172.6","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35781.96","","","","","","","fee schedule","34078.06","141172.6","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","802","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34078.06","","","","","","","fee schedule","34078.06","141172.6","Psych-Case Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","43321.66","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","46333.08","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","60715.39","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","50342.73","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","43449.93","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","55532.78","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","41473.92","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","65868.26","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","49537.83","","","","","","","fee schedule","16659.8","65868.26",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15521.91","15521.91","15521.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17451.14","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17159.59","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16659.8","","","","","","","fee schedule","16659.8","65868.26","Transplants-Case Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16993","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17492.79","","","","","","","fee schedule","16659.8","65868.26","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","803","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16659.8","","","","","","","fee schedule","16659.8","65868.26","Psych-Case Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31601.58","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33798.3","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44289.67","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36723.19","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31695.14","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40509.14","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30253.72","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","48048.5","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","36136.04","","","","","","","fee schedule","12538","48048.5",""
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9216.06","9216.06","9216.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13133.56","","","","","","","fee schedule","12538","48048.5","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12914.14","","","","","","","fee schedule","12538","48048.5","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12538","","","","","","","fee schedule","12538","48048.5","Transplants-Case Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12788.76","","","","","","","fee schedule","12538","48048.5","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13164.9","","","","","","","fee schedule","12538","48048.5","MSDRG Base Rate"
"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","804","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12538","","","","","","","fee schedule","12538","48048.5","Psych-Case Rate"
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25150.76","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26899.06","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35248.83","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29226.89","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25225.22","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32240.02","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","24078.03","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38240.37","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28759.6","","","","","","","fee schedule","10269.33","38240.37",""
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","18073.42","10519.67","53562.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","21237.44","21237.44","21237.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","23627.58","22801.2","23812.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","29514.35","25456.3","33799.46","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2252.04","2252.04","2252.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","21154.96","17204.18","22116.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","29919.9","29919.9","29919.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7564.19","7564.19","7564.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20512","16885.07","23162.48","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","18988.65","18988.65","21491.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10590.12","10590.12","10590.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","25592.26","25592.26","25592.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","21815.31","21815.31","25809.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10757.12","","","","","","","fee schedule","10269.33","38240.37","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10577.41","","","","","","","fee schedule","10269.33","38240.37","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10269.33","","","","","","","fee schedule","10269.33","38240.37","Transplants-Case Rate"
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10474.72","","","","","","","fee schedule","10269.33","38240.37","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10782.8","","","","","","","fee schedule","10269.33","38240.37","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Mcc","805","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10269.33","","","","","","","fee schedule","10269.33","38240.37","Psych-Case Rate"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17571.97","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18793.45","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","24627.15","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","20419.83","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17624","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","22525","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16822.49","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","26717.24","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","20093.35","","","","","","","fee schedule","7603.98","26717.24",""
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","12797.08","8475.53","25336.5","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","16760.69","16760.69","16760.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","12732.63","12732.63","16848.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","16793.32","14504.31","18019.85","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21033.89","17044.46","22662.43","65","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1999.17","1773.69","1999.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6548.39","6548.39","6548.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","12751.24","11146.51","16144.24","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","13702.87","13702.87","13702.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6284","6284","6284","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","8332.55","8332.55","8332.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","14974.16","11932.33","15884","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5992.97","5361.01","6502.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","22497.49","22497.49","22497.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","18198.9","14933.6","19454","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6353.76","6353.76","6353.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","15913.8","11067.84","19283.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","18766.57","18766.57","18766.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7965.17","","","","","","","fee schedule","7603.98","26717.24","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7832.1","","","","","","","fee schedule","7603.98","26717.24","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7603.98","","","","","","","fee schedule","7603.98","26717.24","Transplants-Case Rate"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7756.06","","","","","","","fee schedule","7603.98","26717.24","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7984.18","","","","","","","fee schedule","7603.98","26717.24","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C With Cc","806","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7603.98","","","","","","","fee schedule","7603.98","26717.24","Psych-Case Rate"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15712.23","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16804.44","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22020.72","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18258.68","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15758.75","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20141.05","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15042.08","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23889.6","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17966.76","","","","","","","fee schedule","6949.93","23889.6",""
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","13196.99","9941.59","16566.26","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","12096.43","12096.43","12096.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","11621.22","10381.4","14240.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","14219.1","12184.66","15767.74","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18427.95","16634.33","19959.6","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6688.83","6688.83","6688.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1824.46","1824.46","1824.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","13018.8","11375.04","14218.8","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","13285.93","13285.93","13285.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","12401.76","12401.76","12401.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","12598","10158.95","13990","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6423.82","6423.82","6423.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","19662.28","19662.28","19662.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","13272.29","12008.44","16440","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","15073.86","10925.18","16998.81","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","8899.49","8899.49","8899.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","13811.46","13811.46","13811.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7280.05","","","","","","","fee schedule","6949.93","23889.6","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7158.43","","","","","","","fee schedule","6949.93","23889.6","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6949.93","","","","","","","fee schedule","6949.93","23889.6","Transplants-Case Rate"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7088.93","","","","","","","fee schedule","6949.93","23889.6","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7297.43","","","","","","","fee schedule","6949.93","23889.6","MSDRG Base Rate"
"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","807","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6949.93","","","","","","","fee schedule","6949.93","23889.6","Psych-Case Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51455.11","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","55031.91","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","72114.43","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59794.35","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51607.45","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","65958.8","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49260.46","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","78234.73","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58838.33","","","","","","","fee schedule","19520.22","78234.73",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","314907.34","314907.34","314907.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","20057.5","20057.5","20057.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","67110.88","67110.88","67110.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18582.3","18582.3","19728.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","19595.29","19595.29","37285.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","20133.31","20133.31","20133.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20447.43","","","","","","","fee schedule","19520.22","78234.73","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20105.83","","","","","","","fee schedule","19520.22","78234.73","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19520.22","","","","","","","fee schedule","19520.22","78234.73","Transplants-Case Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19910.62","","","","","","","fee schedule","19520.22","78234.73","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20496.23","","","","","","","fee schedule","19520.22","78234.73","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","808","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19520.22","","","","","","","fee schedule","19520.22","78234.73","Psych-Case Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29501.8","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31552.56","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","41346.83","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","34283.1","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29589.15","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37817.5","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28243.49","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","44855.9","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33734.97","","","","","","","fee schedule","11799.54","44855.9",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24714.6","24714.6","24714.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9418.7","8890.3","11236.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","172740.43","172740.43","172740.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","32935.67","32935.67","32935.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12360.02","","","","","","","fee schedule","11799.54","44855.9","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12153.53","","","","","","","fee schedule","11799.54","44855.9","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11799.54","","","","","","","fee schedule","11799.54","44855.9","Transplants-Case Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12035.53","","","","","","","fee schedule","11799.54","44855.9","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12389.52","","","","","","","fee schedule","11799.54","44855.9","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","809","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11799.54","","","","","","","fee schedule","11799.54","44855.9","Psych-Case Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24391.01","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26086.51","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34184.05","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","28344.02","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24463.23","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31266.13","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23350.69","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37085.22","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27890.84","","","","","","","fee schedule","10002.14","37085.22",""
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","13373.73","13373.73","13373.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","192623.41","192623.41","192623.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","11405.95","11405.95","11405.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12395.42","12395.42","12395.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10477.24","","","","","","","fee schedule","10002.14","37085.22","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10302.2","","","","","","","fee schedule","10002.14","37085.22","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10002.14","","","","","","","fee schedule","10002.14","37085.22","Transplants-Case Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10202.18","","","","","","","fee schedule","10002.14","37085.22","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10502.25","","","","","","","fee schedule","10002.14","37085.22","MSDRG Base Rate"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","810","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10002.14","","","","","","","fee schedule","10002.14","37085.22","Psych-Case Rate"
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32727.21","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35002.18","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45867.25","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38031.25","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32824.11","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41952.06","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31331.34","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49759.97","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37423.19","","","","","","","fee schedule","12933.87","49759.97",""
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","4624.54","4624.54","4624.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","33123.5","33123.5","33123.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","37084.61","37084.61","44062.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11126.01","11103.36","11202.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","31389.35","31389.35","31389.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11875.59","11875.59","11875.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10830.98","10830.98","10830.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8718.14","8718.14","8718.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","30886","30886","30886","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12252.64","11003.61","12854.91","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11492.94","11492.94","11492.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13548.23","","","","","","","fee schedule","12933.87","49759.97","MSDRG Base Rate"
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13321.89","","","","","","","fee schedule","12933.87","49759.97","MSDRG Base Rate"
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12933.87","","","","","","","fee schedule","12933.87","49759.97","Transplants-Case Rate"
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13192.55","","","","","","","fee schedule","12933.87","49759.97","MSDRG Base Rate"
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13580.56","","","","","","","fee schedule","12933.87","49759.97","MSDRG Base Rate"
"Red Blood Cell Disorders With Mcc","811","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12933.87","","","","","","","fee schedule","12933.87","49759.97","Psych-Case Rate"
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21398.65","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22886.14","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29990.25","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24866.69","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21462.01","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","27430.31","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20485.96","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","32535.5","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24469.11","","","","","","","fee schedule","8949.77","32535.5",""
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","27524.57","11153.97","28904.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2344.96","2344.96","2344.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8270.1","1657.64","8847.74","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","20590.82","20590.82","20590.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7113.31","1957.51","8685.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7782.45","4101.05","8988.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16650.52","15899.55","16650.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19843.22","15850.58","20262","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7353.56","7015.46","8822.35","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9374.88","","","","","","","fee schedule","8949.77","32535.5","MSDRG Base Rate"
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9218.26","","","","","","","fee schedule","8949.77","32535.5","MSDRG Base Rate"
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8949.77","","","","","","","fee schedule","8949.77","32535.5","Transplants-Case Rate"
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9128.77","","","","","","","fee schedule","8949.77","32535.5","MSDRG Base Rate"
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9397.26","","","","","","","fee schedule","8949.77","32535.5","MSDRG Base Rate"
"Red Blood Cell Disorders Without Mcc","812","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8949.77","","","","","","","fee schedule","8949.77","32535.5","Psych-Case Rate"
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35547.12","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38018.1","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49819.35","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41308.17","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35652.36","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45566.81","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34030.97","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54047.48","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40647.72","","","","","","","fee schedule","13925.6","54047.48",""
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","4101.75","4101.75","4101.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12347","11790.14","39409.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48131.81","48131.81","48131.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13935.57","13935.57","13935.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12179.1","12179.1","14113.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13622.68","13622.68","13631.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","9455.39","8001.58","41270.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","39937","39937","54123.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11803.91","11803.91","11803.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","12235.05","12235.05","12235.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14587.07","","","","","","","fee schedule","13925.6","54047.48","MSDRG Base Rate"
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14343.37","","","","","","","fee schedule","13925.6","54047.48","MSDRG Base Rate"
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13925.6","","","","","","","fee schedule","13925.6","54047.48","Transplants-Case Rate"
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14204.11","","","","","","","fee schedule","13925.6","54047.48","MSDRG Base Rate"
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14621.88","","","","","","","fee schedule","13925.6","54047.48","MSDRG Base Rate"
"Coagulation Disorders","813","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13925.6","","","","","","","fee schedule","13925.6","54047.48","Psych-Case Rate"
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49562.74","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53008","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69462.28","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57595.29","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","49709.49","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63533.04","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47448.8","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75357.49","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","56674.43","","","","","","","fee schedule","18854.7","75357.49",""
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","15932.92","15932.92","15932.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17954.24","17954.24","17954.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19750.3","","","","","","","fee schedule","18854.7","75357.49","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19420.34","","","","","","","fee schedule","18854.7","75357.49","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18854.7","","","","","","","fee schedule","18854.7","75357.49","Transplants-Case Rate"
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19231.79","","","","","","","fee schedule","18854.7","75357.49","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19797.44","","","","","","","fee schedule","18854.7","75357.49","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Mcc","814","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18854.7","","","","","","","fee schedule","18854.7","75357.49","Psych-Case Rate"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23631.27","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25273.95","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33119.27","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27461.15","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23701.24","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30292.24","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22623.35","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35930.08","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27022.09","","","","","","","fee schedule","9734.95","35930.08",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8976.22","8976.22","8976.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","136639.26","136639.26","136639.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8940.83","8940.83","8940.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","18244.92","18244.92","18244.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","19827.67","19827.67","19827.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","31008.87","31008.87","31008.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10197.36","","","","","","","fee schedule","9734.95","35930.08","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10027","","","","","","","fee schedule","9734.95","35930.08","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9734.95","","","","","","","fee schedule","9734.95","35930.08","Transplants-Case Rate"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9929.65","","","","","","","fee schedule","9734.95","35930.08","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10221.7","","","","","","","fee schedule","9734.95","35930.08","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9734.95","","","","","","","fee schedule","9734.95","35930.08","Psych-Case Rate"
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14728.76","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15752.6","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20642.38","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","17115.82","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14772.37","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18880.37","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14100.55","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22394.29","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16842.17","","","","","","","fee schedule","6604.06","22394.29",""
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","10519.81","10519.81","10519.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8807.44","8410.22","16810.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","16810.37","6616.51","17604.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","11110.03","11110.03","11110.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8727.59","8727.59","8727.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6917.75","","","","","","","fee schedule","6604.06","22394.29","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6802.18","","","","","","","fee schedule","6604.06","22394.29","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6604.06","","","","","","","fee schedule","6604.06","22394.29","Transplants-Case Rate"
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6736.14","","","","","","","fee schedule","6604.06","22394.29","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6934.26","","","","","","","fee schedule","6604.06","22394.29","MSDRG Base Rate"
"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","816","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6604.06","","","","","","","fee schedule","6604.06","22394.29","Psych-Case Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","53172.69","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","56868.88","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","74521.62","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","61790.29","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","53330.12","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","68160.52","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","50904.78","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","80846.21","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","60802.36","","","","","","","fee schedule","20124.27","80846.21",""
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","38110.51","38110.51","38110.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","234523.4","234523.4","234523.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5568.45","5568.45","5568.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45550.58","45550.58","45550.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7645.67","7300.85","11433.86","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","44585.51","44585.51","44585.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7934.19","7934.19","7934.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21080.17","","","","","","","fee schedule","20124.27","80846.21","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20728","","","","","","","fee schedule","20124.27","80846.21","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20124.27","","","","","","","fee schedule","20124.27","80846.21","Transplants-Case Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20526.76","","","","","","","fee schedule","20124.27","80846.21","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21130.48","","","","","","","fee schedule","20124.27","80846.21","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Mcc","817","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20124.27","","","","","","","fee schedule","20124.27","80846.21","Psych-Case Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27015.16","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28893.06","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37861.79","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31393.45","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27095.14","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34629.94","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25862.91","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41075.09","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30891.52","","","","","","","fee schedule","10925.02","41075.09",""
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","23814.02","23814.02","23814.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","11348.7","11348.7","11348.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","21461.61","21461.61","21461.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","24104.04","20370.67","25685.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","75632.44","75632.44","75632.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","26029.45","26029.45","26029.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11443.96","","","","","","","fee schedule","10925.02","41075.09","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11252.77","","","","","","","fee schedule","10925.02","41075.09","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10925.02","","","","","","","fee schedule","10925.02","41075.09","Transplants-Case Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11143.52","","","","","","","fee schedule","10925.02","41075.09","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11471.27","","","","","","","fee schedule","10925.02","41075.09","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures With Cc","818","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10925.02","","","","","","","fee schedule","10925.02","41075.09","Psych-Case Rate"
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20039.97","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21433.01","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28086.05","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23287.81","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20099.3","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25688.65","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19185.23","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30469.7","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22915.48","","","","","","","fee schedule","8471.94","30469.7",""
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25571.96","25571.96","25571.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17766.93","17766.93","17766.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","16283","16283","16283","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8874.36","","","","","","","fee schedule","8471.94","30469.7","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8726.1","","","","","","","fee schedule","8471.94","30469.7","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8471.94","","","","","","","fee schedule","8471.94","30469.7","Transplants-Case Rate"
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8641.38","","","","","","","fee schedule","8471.94","30469.7","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8895.54","","","","","","","fee schedule","8471.94","30469.7","MSDRG Base Rate"
"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","819","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8471.94","","","","","","","fee schedule","8471.94","30469.7","Psych-Case Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","136679.16","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","146180.14","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","191556.1","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","158830.51","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","137083.84","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","175205.04","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","130849.55","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","207813.32","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","156291.06","","","","","","","fee schedule","49492.38","207813.32",""
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","162990.64","162990.64","162990.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","45948.04","45948.04","45948.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","51843.27","","","","","","","fee schedule","49492.38","207813.32","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","50977.15","","","","","","","fee schedule","49492.38","207813.32","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","49492.38","","","","","","","fee schedule","49492.38","207813.32","Transplants-Case Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","50482.23","","","","","","","fee schedule","49492.38","207813.32","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51967","","","","","","","fee schedule","49492.38","207813.32","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","820","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","49492.38","","","","","","","fee schedule","49492.38","207813.32","Psych-Case Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","52170.57","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","55797.11","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","73117.15","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","60625.77","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","52325.04","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","66875.94","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49945.4","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","79322.55","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","59656.45","","","","","","","fee schedule","19771.84","79322.55",""
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","47605.09","47605.09","47605.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","52352.13","52352.13","52352.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","45764.59","45764.59","45764.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20711","","","","","","","fee schedule","19771.84","79322.55","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20365","","","","","","","fee schedule","19771.84","79322.55","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19771.84","","","","","","","fee schedule","19771.84","79322.55","Transplants-Case Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20167.28","","","","","","","fee schedule","19771.84","79322.55","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20760.43","","","","","","","fee schedule","19771.84","79322.55","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures With Cc","821","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19771.84","","","","","","","fee schedule","19771.84","79322.55","Psych-Case Rate"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28059.22","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30009.7","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39325.05","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32606.73","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28142.3","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35968.3","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26862.44","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42662.54","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32085.4","","","","","","","fee schedule","11292.2","42662.54",""
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","69733.4","69733.4","69733.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10092.32","10092.32","10092.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11828.58","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11630.97","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11292.2","","","","","","","fee schedule","11292.2","42662.54","Transplants-Case Rate"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11518.04","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11856.81","","","","","","","fee schedule","11292.2","42662.54","MSDRG Base Rate"
"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","822","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11292.2","","","","","","","fee schedule","11292.2","42662.54","Psych-Case Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","106848.76","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","114276.14","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","149748.74","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","124165.55","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","107165.12","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","136966.32","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","102291.47","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","162457.8","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","122180.34","","","","","","","fee schedule","39001.43","162457.8",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","102273.25","102273.25","102273.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","37379.79","37379.79","37379.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","100766.75","100766.75","100766.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","37194.35","37194.35","37789.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","39719.74","39719.74","39719.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40854","","","","","","","fee schedule","39001.43","162457.8","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40171.47","","","","","","","fee schedule","39001.43","162457.8","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39001.43","","","","","","","fee schedule","39001.43","162457.8","Transplants-Case Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39781.46","","","","","","","fee schedule","39001.43","162457.8","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40951.5","","","","","","","fee schedule","39001.43","162457.8","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","823","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39001.43","","","","","","","fee schedule","39001.43","162457.8","Psych-Case Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","52799.81","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","56470.08","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","73999.03","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","61356.98","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","52956.13","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","67682.53","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","50547.8","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","80279.27","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","60375.97","","","","","","","fee schedule","19993.14","80279.27",""
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17059.72","17059.72","17059.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","145597.73","145597.73","145597.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17064.02","17064.02","17064.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","20843.53","20843.53","20843.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","22443.86","22443.86","22443.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20942.81","","","","","","","fee schedule","19993.14","80279.27","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20592.93","","","","","","","fee schedule","19993.14","80279.27","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19993.14","","","","","","","fee schedule","19993.14","80279.27","Transplants-Case Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20393","","","","","","","fee schedule","19993.14","80279.27","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20992.8","","","","","","","fee schedule","19993.14","80279.27","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","824","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19993.14","","","","","","","fee schedule","19993.14","80279.27","Psych-Case Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","31447.77","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","33633.8","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","44074.1","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","36544.45","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","31540.88","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","40311.98","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","30106.46","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","47814.64","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","35960.16","","","","","","","fee schedule","12483.91","47814.64",""
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","36537.29","36537.29","36537.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","1522.16","1522.16","1522.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","14642.03","14642.03","14642.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13076.9","","","","","","","fee schedule","12483.91","47814.64","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12858.43","","","","","","","fee schedule","12483.91","47814.64","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12483.91","","","","","","","fee schedule","12483.91","47814.64","Transplants-Case Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12733.59","","","","","","","fee schedule","12483.91","47814.64","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13108.11","","","","","","","fee schedule","12483.91","47814.64","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","825","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12483.91","","","","","","","fee schedule","12483.91","47814.64","Psych-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","109016.13","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","116594.17","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","152786.3","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","126684.18","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","109338.9","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","139744.6","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","104366.4","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","165753.17","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","124658.69","","","","","","","fee schedule","39763.66","165753.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","128414.48","128414.48","128414.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","40491.73","40491.73","40491.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","34737.31","34737.31","34737.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","44520.57","44520.57","44520.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","37896.68","37896.68","37896.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41652.43","","","","","","","fee schedule","39763.66","165753.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40956.57","","","","","","","fee schedule","39763.66","165753.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39763.66","","","","","","","fee schedule","39763.66","165753.17","Transplants-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40558.93","","","","","","","fee schedule","39763.66","165753.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41751.84","","","","","","","fee schedule","39763.66","165753.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","826","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39763.66","","","","","","","fee schedule","39763.66","165753.17","Psych-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","53862.52","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","57606.66","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","75488.41","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","62591.92","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54021.99","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69044.79","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","51565.18","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","81895.06","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","61591.17","","","","","","","fee schedule","20366.88","81895.06",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","52806.56","52806.56","52806.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","73909.71","72184.47","129731.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","6533.8","6533.8","6533.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19525.93","19525.93","19525.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19547.63","19547.63","19547.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","49149.34","49149.34","49149.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","51513.71","51307","51807","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","19150.28","19150.28","20674.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","61591.17","61591.17","61591.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21334.31","","","","","","","fee schedule","20366.88","81895.06","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20977.89","","","","","","","fee schedule","20366.88","81895.06","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20366.88","","","","","","","fee schedule","20366.88","81895.06","Transplants-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20774.22","","","","","","","fee schedule","20366.88","81895.06","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21385.22","","","","","","","fee schedule","20366.88","81895.06","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20366.88","","","","","","","fee schedule","20366.88","81895.06","Psych-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39707.06","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42467.22","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55649.52","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46142.31","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39824.62","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50899.32","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38013.48","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","60372.45","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45404.57","","","","","","","fee schedule","15388.59","60372.45",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","67089.8","67089.8","67089.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","38307.71","38307.71","38307.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50201.23","50201.23","50201.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14822.62","14822.62","14822.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","99910.4","99910.4","99910.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","13894.46","13894.46","13894.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","40627.81","40627.81","40627.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","40885.01","40885.01","40885.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16119.55","","","","","","","fee schedule","15388.59","60372.45","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15850.25","","","","","","","fee schedule","15388.59","60372.45","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15388.59","","","","","","","fee schedule","15388.59","60372.45","Transplants-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15696.36","","","","","","","fee schedule","15388.59","60372.45","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16158.02","","","","","","","fee schedule","15388.59","60372.45","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","828","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15388.59","","","","","","","fee schedule","15388.59","60372.45","Psych-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","73643.8","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","78763","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","103211.92","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","85579.12","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","73861.84","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","94401.84","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","70502.76","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","111971.44","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","84210.84","","","","","","","fee schedule","27323.69","111971.44",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","73678.8","73678.8","73678.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","74251.83","74251.83","74251.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","14776.02","14776.02","14776.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","29734.4","29734.4","29734.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","26199.35","26199.35","26199.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","24278","24278","24278","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","67700","67700","68878","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","79560","79560","79560","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","24109.48","24109.48","24109.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","71621.32","71621.32","71621.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","28621.57","","","","","","","fee schedule","27323.69","111971.44","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28143.4","","","","","","","fee schedule","27323.69","111971.44","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27323.69","","","","","","","fee schedule","27323.69","111971.44","Transplants-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","27870.16","","","","","","","fee schedule","27323.69","111971.44","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","28689.87","","","","","","","fee schedule","27323.69","111971.44","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","829","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27323.69","","","","","","","fee schedule","27323.69","111971.44","Psych-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35074.03","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37512.13","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","49156.31","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40758.41","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35177.87","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44960.37","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33578.06","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53328.17","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40106.75","","","","","","","fee schedule","13759.22","53328.17",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","39537.25","39537.25","39537.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","29249.79","29249.79","29249.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14412.78","","","","","","","fee schedule","13759.22","53328.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14172","","","","","","","fee schedule","13759.22","53328.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13759.22","","","","","","","fee schedule","13759.22","53328.17","Transplants-Case Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14034.4","","","","","","","fee schedule","13759.22","53328.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14447.18","","","","","","","fee schedule","13759.22","53328.17","MSDRG Base Rate"
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","830","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13759.22","","","","","","","fee schedule","13759.22","53328.17","Psych-Case Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28024.26","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29972.31","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39276.06","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32566.11","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28107.24","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35923.49","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26828.98","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42609.39","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32045.42","","","","","","","fee schedule","11279.91","42609.39",""
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","15268.77","5863.66","22902.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","24347.09","24347.09","25256.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","28224.55","16209.85","36048.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9096.92","9096.92","9096.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","8376.35","8376.35","8376.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10441.49","10441.49","10441.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21680.17","15343.09","26401","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","10699.17","10699.17","11632.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","23643.26","23643.26","23643.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11815.71","","","","","","","fee schedule","11279.91","42609.39","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11618.31","","","","","","","fee schedule","11279.91","42609.39","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11279.91","","","","","","","fee schedule","11279.91","42609.39","Transplants-Case Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11505.51","","","","","","","fee schedule","11279.91","42609.39","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11843.91","","","","","","","fee schedule","11279.91","42609.39","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","831","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11279.91","","","","","","","fee schedule","11279.91","42609.39","Psych-Case Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16816.89","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17985.88","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23568.9","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19542.37","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16866.68","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21557.08","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16099.62","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25569.17","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19229.92","","","","","","","fee schedule","7338.42","25569.17",""
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","17412.83","10824.41","22966.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","15904.67","15904.67","15904.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","9000.52","5092.44","15025.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","17644.99","6627.86","23407.82","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1646.5","1646.5","1646.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","5776.08","5776.08","5822.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","16099.62","16099.62","16099.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","3897.65","3897.65","3897.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5543.43","5543.43","5726.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","621.79","621.79","621.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","12410.52","8239.25","15907","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","8963.08","8963.08","8963.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","14689.99","12418.85","18248.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5789.88","5789.88","5789.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","14222.1","9592.68","15417.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7686.99","","","","","","","fee schedule","7338.42","25569.17","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7558.57","","","","","","","fee schedule","7338.42","25569.17","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7338.42","","","","","","","fee schedule","7338.42","25569.17","Transplants-Case Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7485.19","","","","","","","fee schedule","7338.42","25569.17","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7705.34","","","","","","","fee schedule","7338.42","25569.17","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures With Cc","832","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7338.42","","","","","","","fee schedule","7338.42","25569.17","Psych-Case Rate"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","12186.18","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","13033.28","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","17078.96","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","14161.18","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","12222.26","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","15621.11","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","11666.42","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","18528.44","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","13934.76","","","","","","","fee schedule","5709.87","18528.44",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9035.85","9035.85","16681.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","8711.2","8711.2","8711.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","11822.7","11222.7","23625.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","13827.44","5783.24","16376.71","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","1494.51","1494.51","1494.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","3903.38","3903.38","3903.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","11097.26","9187.54","11566.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","2556.94","2556.94","2556.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","9051.08","5564.87","11412","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","11920.8","11920.8","11920.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","10792.8","10792.8","10792.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","9157.66","9157.66","9157.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","11904.49","11904.49","12434.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","5981.09","","","","","","","fee schedule","5709.87","18528.44","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","5881.17","","","","","","","fee schedule","5709.87","18528.44","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","5709.87","","","","","","","fee schedule","5709.87","18528.44","Transplants-Case Rate"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","5824.07","","","","","","","fee schedule","5709.87","18528.44","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5995.36","","","","","","","fee schedule","5709.87","18528.44","MSDRG Base Rate"
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","833","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5709.87","","","","","","","fee schedule","5709.87","18528.44","Psych-Case Rate"
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","127942.12","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","136835.76","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","179311.11","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","148677.47","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","128320.92","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","164005.27","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","122485.16","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","194529.12","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","146300.35","","","","","","","fee schedule","46419.68","194529.12",""
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","452963.76","452963.76","452963.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","373874.74","373874.74","373874.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","69065.56","69065.56","69065.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","46003.74","46003.74","110937.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","43155.65","43155.65","43155.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","48624.61","","","","","","","fee schedule","46419.68","194529.12","MSDRG Base Rate"
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","47812.27","","","","","","","fee schedule","46419.68","194529.12","MSDRG Base Rate"
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","46419.68","","","","","","","fee schedule","46419.68","194529.12","Transplants-Case Rate"
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","47348.07","","","","","","","fee schedule","46419.68","194529.12","MSDRG Base Rate"
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","48740.66","","","","","","","fee schedule","46419.68","194529.12","MSDRG Base Rate"
"Acute Leukemia With Mcc","834","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","46419.68","","","","","","","fee schedule","46419.68","194529.12","Psych-Case Rate"
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51988.57","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68126.4","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56487.64","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48609.57","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48753.49","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62311.19","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46536.28","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73908.24","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55584.48","","","","","","","fee schedule","18519.49","73908.24",""
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9812.4","9812.4","9812.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","12472.59","12472.59","12472.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","229244.57","229244.57","229244.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19399.17","","","","","","","fee schedule","18519.49","73908.24","MSDRG Base Rate"
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19075.07","","","","","","","fee schedule","18519.49","73908.24","MSDRG Base Rate"
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18519.49","","","","","","","fee schedule","18519.49","73908.24","Transplants-Case Rate"
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18889.88","","","","","","","fee schedule","18519.49","73908.24","MSDRG Base Rate"
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19445.46","","","","","","","fee schedule","18519.49","73908.24","MSDRG Base Rate"
"Acute Leukemia With Cc","835","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18519.49","","","","","","","fee schedule","18519.49","73908.24","Psych-Case Rate"
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30396.04","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39831.31","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","33026.5","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28420.45","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28504.59","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36431.34","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27208.26","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","43211.76","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32498.46","","","","","","","fee schedule","11419.24","43211.76",""
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11961.65","","","","","","","fee schedule","11419.24","43211.76","MSDRG Base Rate"
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11761.82","","","","","","","fee schedule","11419.24","43211.76","MSDRG Base Rate"
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11419.24","","","","","","","fee schedule","11419.24","43211.76","Transplants-Case Rate"
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11647.62","","","","","","","fee schedule","11419.24","43211.76","MSDRG Base Rate"
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11990.2","","","","","","","fee schedule","11419.24","43211.76","MSDRG Base Rate"
"Acute Leukemia Without Cc/Mcc","836","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11419.24","","","","","","","fee schedule","11419.24","43211.76","Psych-Case Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","119747.18","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","156918.05","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","130110.05","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","111964.21","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","112295.71","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","143523.66","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","107188.74","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","170235.57","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","128029.79","","","","","","","fee schedule","40800.47","170235.57",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","42536.78","42536.78","42536.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","135448.19","135448.19","135448.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","34889.94","34889.94","89136.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","40074.27","40074.27","40074.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","254610.26","254610.26","254610.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19359.27","19359.27","23841.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","18794.72","18794.72","169020","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","28991.59","28991.59","28991.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","257167.89","257167.89","257167.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","42738.49","","","","","","","fee schedule","40800.47","170235.57","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","42024.48","","","","","","","fee schedule","40800.47","170235.57","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","40800.47","","","","","","","fee schedule","40800.47","170235.57","Transplants-Case Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","41616.48","","","","","","","fee schedule","40800.47","170235.57","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","42840.49","","","","","","","fee schedule","40800.47","170235.57","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","837","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40800.47","","","","","","","fee schedule","40800.47","170235.57","Psych-Case Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52028.45","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68178.66","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56530.97","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48646.86","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48790.89","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62358.99","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46571.98","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73964.93","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55627.12","","","","","","","fee schedule","18532.6","73964.93",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","21159.4","21159.4","21159.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","63521.2","63521.2","63521.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","27008.8","27008.8","27008.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","63521.2","63521.2","63521.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","31553.06","31553.06","31553.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19412.9","","","","","","","fee schedule","18532.6","73964.93","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19088.58","","","","","","","fee schedule","18532.6","73964.93","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18532.6","","","","","","","fee schedule","18532.6","73964.93","Transplants-Case Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18903.25","","","","","","","fee schedule","18532.6","73964.93","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19459.23","","","","","","","fee schedule","18532.6","73964.93","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","838","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18532.6","","","","","","","fee schedule","18532.6","73964.93","Psych-Case Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35989.21","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","47160.66","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","39103.7","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","33650.09","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33749.72","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","43135.07","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","32214.85","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","51163.15","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","38478.49","","","","","","","fee schedule","13258.44","51163.15",""
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","32751.19","32751.19","32751.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","12607","12607","12607","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","9309.26","9309.26","9309.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","23666.89","23666.89","23666.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13888.22","","","","","","","fee schedule","13258.44","51163.15","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13656.19","","","","","","","fee schedule","13258.44","51163.15","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13258.44","","","","","","","fee schedule","13258.44","51163.15","Transplants-Case Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13523.61","","","","","","","fee schedule","13258.44","51163.15","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13921.36","","","","","","","fee schedule","13258.44","51163.15","MSDRG Base Rate"
"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","839","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13258.44","","","","","","","fee schedule","13258.44","51163.15","Psych-Case Rate"
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80629.88","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","105658.3","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","87607.56","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75389.34","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75612.55","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","96639.4","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","72173.85","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","114625.45","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","86206.85","","","","","","","fee schedule","27937.57","114625.45",""
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","67861.92","67861.92","67861.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","76213.91","76213.91","76213.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45691.9","45691.9","45691.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","22649.23","22649.23","22649.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25914.44","25914.44","25914.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","104697.87","104697.87","104697.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","26366.73","25518.76","28321.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","70023","70023","70023","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","89731.65","89731.65","89731.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","27579.63","27579.63","27579.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7008.47","7008.47","7008.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29264.6","","","","","","","fee schedule","27937.57","114625.45","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28775.7","","","","","","","fee schedule","27937.57","114625.45","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27937.57","","","","","","","fee schedule","27937.57","114625.45","Transplants-Case Rate"
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28496.32","","","","","","","fee schedule","27937.57","114625.45","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29334.45","","","","","","","fee schedule","27937.57","114625.45","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Mcc","840","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27937.57","","","","","","","fee schedule","27937.57","114625.45","Psych-Case Rate"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40662.65","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53284.79","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44181.57","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38019.78","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38132.34","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48736.44","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36398.17","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57807.03","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43475.18","","","","","","","fee schedule","14795.2","57807.03",""
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","103528.43","103528.43","103528.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18687.78","18687.78","18687.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","47238.32","47238.32","47238.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22649.23","22649.23","22649.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","34423","34423","34423","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","321526.04","321526.04","321526.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15497.97","","","","","","","fee schedule","14795.2","57807.03","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15239.06","","","","","","","fee schedule","14795.2","57807.03","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14795.2","","","","","","","fee schedule","14795.2","57807.03","Transplants-Case Rate"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15091.1","","","","","","","fee schedule","14795.2","57807.03","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15534.96","","","","","","","fee schedule","14795.2","57807.03","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia With Cc","841","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14795.2","","","","","","","fee schedule","14795.2","57807.03","Psych-Case Rate"
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25184.22","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33001.68","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27363.65","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23547.37","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23617.09","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30184.69","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22543.03","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35802.51","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26926.15","","","","","","","fee schedule","9705.45","35802.51",""
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","20859.06","20859.06","20859.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","53079.75","53079.75","53079.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","50685.78","19733.5","50685.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","8061.64","8061.64","30782.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10166.46","","","","","","","fee schedule","9705.45","35802.51","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9996.61","","","","","","","fee schedule","9705.45","35802.51","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9705.45","","","","","","","fee schedule","9705.45","35802.51","Transplants-Case Rate"
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9899.56","","","","","","","fee schedule","9705.45","35802.51","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10190.72","","","","","","","fee schedule","9705.45","35802.51","MSDRG Base Rate"
"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","842","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9705.45","","","","","","","fee schedule","9705.45","35802.51","Psych-Case Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49720.39","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65154.16","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54023.17","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46488.81","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46626.46","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59592.66","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44505.98","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","70683.74","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53159.43","","","","","","","fee schedule","17773.64","70683.74",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","56465.78","56465.78","56465.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14805.29","14805.29","14805.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15351.03","15351.03","15351.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18617.89","","","","","","","fee schedule","17773.64","70683.74","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18306.85","","","","","","","fee schedule","17773.64","70683.74","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17773.64","","","","","","","fee schedule","17773.64","70683.74","Transplants-Case Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18129.11","","","","","","","fee schedule","17773.64","70683.74","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18662.32","","","","","","","fee schedule","17773.64","70683.74","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","843","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17773.64","","","","","","","fee schedule","17773.64","70683.74","Psych-Case Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","30343.7","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39762.72","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32969.63","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","28371.51","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28455.51","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","36368.61","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","27161.41","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","43137.35","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","32442.49","","","","","","","fee schedule","11402.03","43137.35",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","41879.87","41879.87","41879.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","37337.84","37337.84","37337.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7995.82","7995.82","8135.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3354.17","3354.17","3354.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11943.63","","","","","","","fee schedule","11402.03","43137.35","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11744.09","","","","","","","fee schedule","11402.03","43137.35","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11402.03","","","","","","","fee schedule","11402.03","43137.35","Transplants-Case Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11630.07","","","","","","","fee schedule","11402.03","43137.35","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11972.13","","","","","","","fee schedule","11402.03","43137.35","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","844","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11402.03","","","","","","","fee schedule","11402.03","43137.35","Psych-Case Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21226.13","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27814.96","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23063.03","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19846.54","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19905.3","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25440.7","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19000.05","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30175.59","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22694.29","","","","","","","fee schedule","8403.91","30175.59",""
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8803.1","","","","","","","fee schedule","8403.91","30175.59","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8656.03","","","","","","","fee schedule","8403.91","30175.59","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8403.91","","","","","","","fee schedule","8403.91","30175.59","Transplants-Case Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8571.99","","","","","","","fee schedule","8403.91","30175.59","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8824.11","","","","","","","fee schedule","8403.91","30175.59","MSDRG Base Rate"
"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","845","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8403.91","","","","","","","fee schedule","8403.91","30175.59","Psych-Case Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","64618.06","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","84676.24","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","70210.09","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","60418.21","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","60597.1","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","77448.35","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","57841.27","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","91862.65","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","69087.53","","","","","","","fee schedule","22672.43","91862.65",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","15707.02","15707.02","15707.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","46955.17","46955.17","46955.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20636.93","20636.93","20636.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","21419.09","21419.09","21419.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","23749.37","","","","","","","fee schedule","22672.43","91862.65","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23352.6","","","","","","","fee schedule","22672.43","91862.65","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22672.43","","","","","","","fee schedule","22672.43","91862.65","Transplants-Case Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23125.88","","","","","","","fee schedule","22672.43","91862.65","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23806.05","","","","","","","fee schedule","22672.43","91862.65","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","846","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22672.43","","","","","","","fee schedule","22672.43","91862.65","Psych-Case Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32606.89","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42728.43","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35428.67","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30487.6","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30577.87","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39081.17","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29187.25","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46354.76","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34862.22","","","","","","","fee schedule","12146.23","46354.76",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","46828.87","46828.87","46828.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21723.04","15291.7","40971.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","11381.47","11381.47","11381.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","23369.24","23369.24","23369.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12723.18","","","","","","","fee schedule","12146.23","46354.76","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12510.62","","","","","","","fee schedule","12146.23","46354.76","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12146.23","","","","","","","fee schedule","12146.23","46354.76","Transplants-Case Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12389.15","","","","","","","fee schedule","12146.23","46354.76","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12753.54","","","","","","","fee schedule","12146.23","46354.76","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","847","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12146.23","","","","","","","fee schedule","12146.23","46354.76","Psych-Case Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21171.3","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27743.1","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23003.45","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19795.27","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","19853.88","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25374.98","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","18950.96","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30097.64","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22635.66","","","","","","","fee schedule","8385.88","30097.64",""
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8784.21","","","","","","","fee schedule","8385.88","30097.64","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8637.46","","","","","","","fee schedule","8385.88","30097.64","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8385.88","","","","","","","fee schedule","8385.88","30097.64","Transplants-Case Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8553.6","","","","","","","fee schedule","8385.88","30097.64","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8805.17","","","","","","","fee schedule","8385.88","30097.64","MSDRG Base Rate"
"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","848","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8385.88","","","","","","","fee schedule","8385.88","30097.64","Psych-Case Rate"
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","67534.29","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","88497.69","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","73378.68","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","63144.9","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","63331.85","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","80943.6","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","60451.65","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","96008.42","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","72205.47","","","","","","","fee schedule","23631.37","96008.42",""
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24753.86","","","","","","","fee schedule","23631.37","96008.42","MSDRG Base Rate"
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24340.31","","","","","","","fee schedule","23631.37","96008.42","MSDRG Base Rate"
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23631.37","","","","","","","fee schedule","23631.37","96008.42","Transplants-Case Rate"
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24104","","","","","","","fee schedule","23631.37","96008.42","MSDRG Base Rate"
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24812.94","","","","","","","fee schedule","23631.37","96008.42","MSDRG Base Rate"
"Radiotherapy","849","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23631.37","","","","","","","fee schedule","23631.37","96008.42","Psych-Case Rate"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","215838.04","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","282836.59","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","234516.58","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","201809.65","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","202407.15","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","258693.9","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","193202.1","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","306840.72","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","230767.02","","","","","","","fee schedule","72397.9","306840.72",""
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","32734.38","32734.38","32734.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","74537.08","74537.08","74537.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","6950.34","6950.34","6950.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","769610.63","769610.63","769610.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","7909.98","7909.98","7909.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","75836.8","","","","","","","fee schedule","72397.9","306840.72","MSDRG Base Rate"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","74569.84","","","","","","","fee schedule","72397.9","306840.72","MSDRG Base Rate"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","72397.9","","","","","","","fee schedule","72397.9","306840.72","Transplants-Case Rate"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","73845.86","","","","","","","fee schedule","72397.9","306840.72","MSDRG Base Rate"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","76017.8","","","","","","","fee schedule","72397.9","306840.72","MSDRG Base Rate"
"Acute Leukemia With Other Procedures","850","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","72397.9","","","","","","","fee schedule","72397.9","306840.72","Psych-Case Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","123094.61","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","161304.55","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","133747.17","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","115094.07","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","115434.84","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","147535.74","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","110185.1","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","174994.35","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","131608.75","","","","","","","fee schedule","41901.2","174994.35",""
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","111831.69","111831.69","158485.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","28101.21","28101.21","28101.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","110353.02","110353.02","110353.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","119526.07","119526.07","149158.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","148617.54","90153.51","278389.93","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","16718.68","16718.68","16718.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","42288.74","25297.64","65761.72","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","122236.33","122236.33","122236.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","39937.35","38200.65","67287.15","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","41291.57","39336.47","42110.43","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13218.93","13218.93","29428.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","108706.74","66543.2","122582.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","98918.56","98918.56","98918.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","40724.14","38107.57","45452.8","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","78382.02","51820.72","248658.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","129708.72","129708.72","129708.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","43891.51","","","","","","","fee schedule","41901.2","174994.35","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","43158.24","","","","","","","fee schedule","41901.2","174994.35","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41901.2","","","","","","","fee schedule","41901.2","174994.35","Transplants-Case Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","42739.22","","","","","","","fee schedule","41901.2","174994.35","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","43996.26","","","","","","","fee schedule","41901.2","174994.35","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","853","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41901.2","","","","","","","fee schedule","41901.2","174994.35","Psych-Case Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49802.64","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65261.94","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54112.54","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46565.72","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46703.59","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59691.24","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44579.61","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","70800.68","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53247.37","","","","","","","fee schedule","17800.69","70800.68",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","42138.45","42138.45","42138.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8936.85","8936.85","8936.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","42519.57","42519.57","42519.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","49329.86","42155.91","61201.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","62497.53","62497.53","62497.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17143.94","16082.72","20584.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15513.32","15513.32","15513.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15836.38","15836.38","15836.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","13218.93","13218.93","13218.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","41073","41073","41073","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16550.36","16550.36","16550.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18646.22","","","","","","","fee schedule","17800.69","70800.68","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18334.71","","","","","","","fee schedule","17800.69","70800.68","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17800.69","","","","","","","fee schedule","17800.69","70800.68","Transplants-Case Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18156.7","","","","","","","fee schedule","17800.69","70800.68","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18690.72","","","","","","","fee schedule","17800.69","70800.68","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17800.69","","","","","","","fee schedule","17800.69","70800.68","Psych-Case Rate"
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37317.71","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48901.55","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40547.17","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34892.25","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34995.55","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44727.35","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33404.03","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53051.78","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39898.88","","","","","","","fee schedule","13695.29","53051.78",""
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","34742.69","34742.69","34742.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14345.82","","","","","","","fee schedule","13695.29","53051.78","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14106.15","","","","","","","fee schedule","13695.29","53051.78","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13695.29","","","","","","","fee schedule","13695.29","53051.78","Transplants-Case Rate"
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13969.2","","","","","","","fee schedule","13695.29","53051.78","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14380.05","","","","","","","fee schedule","13695.29","53051.78","MSDRG Base Rate"
"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","855","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13695.29","","","","","","","fee schedule","13695.29","53051.78","Psych-Case Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","113376.35","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","148569.64","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","123187.89","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","106007.45","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","106321.31","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","135887.86","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","101486.05","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","161178.64","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","121218.31","","","","","","","fee schedule","38705.55","161178.64",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","84677.85","84677.85","84677.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","102679.5","102679.5","102679.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","113177.03","53215.47","174181.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","38268.1","38268.1","38268.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","36998.87","34904.34","55854.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","38807.42","37491.31","56546.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","57184.66","57184.66","57184.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","84564.7","84564.7","99046","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","334540.62","334540.62","334540.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","36708.93","36708.93","36708.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","40544.06","","","","","","","fee schedule","38705.55","161178.64","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39866.72","","","","","","","fee schedule","38705.55","161178.64","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","38705.55","","","","","","","fee schedule","38705.55","161178.64","Transplants-Case Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","39479.66","","","","","","","fee schedule","38705.55","161178.64","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","40640.83","","","","","","","fee schedule","38705.55","161178.64","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","856","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","38705.55","","","","","","","fee schedule","38705.55","161178.64","Psych-Case Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","49907.66","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","53376.89","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","69945.67","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","57996.1","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","50055.42","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","63975.17","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","47779.01","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","75881.91","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","57068.83","","","","","","","fee schedule","18976.01","75881.91",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","29928.07","29928.07","29928.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","129066.81","129066.81","129066.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","52073.53","52073.53","52073.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19153.85","19153.85","19153.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","89538.9","89538.9","89538.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","18847.95","16481.45","18853.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17910.52","17910.52","30064.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","47838","47838","47838","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","18038.22","17401.4","19470.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","58065.51","58065.51","58065.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19877.37","","","","","","","fee schedule","18976.01","75881.91","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19545.29","","","","","","","fee schedule","18976.01","75881.91","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18976.01","","","","","","","fee schedule","18976.01","75881.91","Transplants-Case Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19355.53","","","","","","","fee schedule","18976.01","75881.91","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19924.81","","","","","","","fee schedule","18976.01","75881.91","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18976.01","","","","","","","fee schedule","18976.01","75881.91","Psych-Case Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32461.53","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34718.03","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45494.9","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37722.52","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32557.64","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41611.49","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31076.99","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49356.02","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37119.39","","","","","","","fee schedule","12840.44","49356.02",""
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","28745.49","28745.49","28745.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10467.53","10467.53","10467.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13450.36","","","","","","","fee schedule","12840.44","49356.02","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13225.65","","","","","","","fee schedule","12840.44","49356.02","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12840.44","","","","","","","fee schedule","12840.44","49356.02","Transplants-Case Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13097.25","","","","","","","fee schedule","12840.44","49356.02","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13482.46","","","","","","","fee schedule","12840.44","49356.02","MSDRG Base Rate"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","858","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12840.44","","","","","","","fee schedule","12840.44","49356.02","Psych-Case Rate"
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42501.33","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45455.72","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59565.69","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49389.44","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42627.16","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54481.21","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40688.57","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64620.99","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48599.78","","","","","","","fee schedule","16371.3","64620.99",""
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","18689.26","18689.26","18689.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","19998.12","19998.12","19998.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","55902.87","55902.87","56435.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","21197.54","21197.54","21197.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16848.5","16848.5","16848.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13748.62","13748.62","15534","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15956.75","15956.75","15956.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","17846.35","12163.09","33091.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","39616","28915.98","40366","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","49250.18","49250.18","49250.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","42910.48","42910.48","42910.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15654","15654","16379.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","19102.11","19102.11","19102.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","3890.72","3890.72","3890.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","31158.63","31158.63","31158.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17148.94","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16862.44","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16371.3","","","","","","","fee schedule","16371.3","64620.99","Transplants-Case Rate"
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16698.73","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17189.87","","","","","","","fee schedule","16371.3","64620.99","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections With Mcc","862","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16371.3","","","","","","","fee schedule","16371.3","64620.99","Psych-Case Rate"
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23256.06","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24872.66","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32593.41","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27025.13","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23324.91","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29811.26","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22264.15","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35359.59","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26593.04","","","","","","","fee schedule","9603","35359.59",""
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","17487.31","17487.31","17487.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","31064.18","15327.78","31315.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","22308.77","22308.77","22308.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7728.11","7398.57","7739.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9227.43","9227.43","9644.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10656.33","8275.54","29191.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21548.64","21548.64","21909","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","15727.57","15727.57","15727.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","26593.04","26593.04","26593.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10059.14","","","","","","","fee schedule","9603","35359.59","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9891.09","","","","","","","fee schedule","9603","35359.59","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9603","","","","","","","fee schedule","9603","35359.59","Transplants-Case Rate"
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9795.06","","","","","","","fee schedule","9603","35359.59","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10083.15","","","","","","","fee schedule","9603","35359.59","MSDRG Base Rate"
"Postoperative And Post-Traumatic Infections Without Mcc","863","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9603","","","","","","","fee schedule","9603","35359.59","Psych-Case Rate"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20687.85","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22125.92","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28994.06","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24040.69","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20749.1","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26519.15","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19805.47","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31454.76","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23656.32","","","","","","","fee schedule","8699.79","31454.76",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","28767.49","28767.49","28767.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","21461.3","21461.3","21461.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8951.49","8951.49","8951.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7250.88","7250.88","7250.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9113.03","","","","","","","fee schedule","8699.79","31454.76","MSDRG Base Rate"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8960.78","","","","","","","fee schedule","8699.79","31454.76","MSDRG Base Rate"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8699.79","","","","","","","fee schedule","8699.79","31454.76","Transplants-Case Rate"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8873.79","","","","","","","fee schedule","8699.79","31454.76","MSDRG Base Rate"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9134.78","","","","","","","fee schedule","8699.79","31454.76","MSDRG Base Rate"
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8699.79","","","","","","","fee schedule","8699.79","31454.76","Psych-Case Rate"
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34917.88","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","37345.13","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48937.47","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40576.96","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35021.26","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44760.21","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33428.57","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","53090.76","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39928.2","","","","","","","fee schedule","13704.3","53090.76",""
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","13410.2","13410.2","13410.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12205.89","12205.89","12205.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14355.25","","","","","","","fee schedule","13704.3","53090.76","MSDRG Base Rate"
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14115.43","","","","","","","fee schedule","13704.3","53090.76","MSDRG Base Rate"
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13704.3","","","","","","","fee schedule","13704.3","53090.76","Transplants-Case Rate"
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13978.39","","","","","","","fee schedule","13704.3","53090.76","MSDRG Base Rate"
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14389.52","","","","","","","fee schedule","13704.3","53090.76","MSDRG Base Rate"
"Viral Illness With Mcc","865","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13704.3","","","","","","","fee schedule","13704.3","53090.76","Psych-Case Rate"
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20266.03","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21674.78","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28402.88","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23550.51","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20326.03","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25978.43","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19401.65","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30813.41","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23173.97","","","","","","","fee schedule","8551.44","30813.41",""
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","26531.1","26531.1","26531.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","18623.73","18623.73","18623.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18820.66","18820.66","18820.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8500.96","8500.96","8500.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8361.3","8361.3","8361.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","18064.13","18064.13","18064.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","18767.91","18767.91","18767.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8957.63","","","","","","","fee schedule","8551.44","30813.41","MSDRG Base Rate"
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8807.98","","","","","","","fee schedule","8551.44","30813.41","MSDRG Base Rate"
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8551.44","","","","","","","fee schedule","8551.44","30813.41","Transplants-Case Rate"
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8722.47","","","","","","","fee schedule","8551.44","30813.41","MSDRG Base Rate"
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8979.01","","","","","","","fee schedule","8551.44","30813.41","MSDRG Base Rate"
"Viral Illness Without Mcc","866","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8551.44","","","","","","","fee schedule","8551.44","30813.41","Psych-Case Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48782.03","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","52173.01","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","68368.1","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56688.04","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48926.46","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","62532.26","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46701.39","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","74170.45","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55781.69","","","","","","","fee schedule","18580.14","74170.45",""
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18857.03","18857.03","18857.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","16676.01","16676.01","18833.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","28101.21","28101.21","28101.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","55323","55323","55323","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19462.7","","","","","","","fee schedule","18580.14","74170.45","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19137.54","","","","","","","fee schedule","18580.14","74170.45","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18580.14","","","","","","","fee schedule","18580.14","74170.45","Transplants-Case Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18951.74","","","","","","","fee schedule","18580.14","74170.45","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19509.15","","","","","","","fee schedule","18580.14","74170.45","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Mcc","867","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18580.14","","","","","","","fee schedule","18580.14","74170.45","Psych-Case Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24029.79","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25700.17","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33677.79","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27924.25","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","24100.93","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30803.08","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23004.87","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36536","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27477.78","","","","","","","fee schedule","9875.1","36536",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7170.88","7170.88","7170.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8525.66","8525.66","8525.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10344.17","","","","","","","fee schedule","9875.1","36536","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10171.35","","","","","","","fee schedule","9875.1","36536","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9875.1","","","","","","","fee schedule","9875.1","36536","Transplants-Case Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10072.6","","","","","","","fee schedule","9875.1","36536","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10368.86","","","","","","","fee schedule","9875.1","36536","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9875.1","","","","","","","fee schedule","9875.1","36536","Psych-Case Rate"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","17005.66","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","18187.77","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","23833.46","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","19761.74","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","17056.01","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","21799.06","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","16280.34","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","25856.19","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","19445.78","","","","","","","fee schedule","7404.81","25856.19",""
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7756.54","","","","","","","fee schedule","7404.81","25856.19","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7626.95","","","","","","","fee schedule","7404.81","25856.19","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7404.81","","","","","","","fee schedule","7404.81","25856.19","Transplants-Case Rate"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7552.91","","","","","","","fee schedule","7404.81","25856.19","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7775.05","","","","","","","fee schedule","7404.81","25856.19","MSDRG Base Rate"
"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","869","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7404.81","","","","","","","fee schedule","7404.81","25856.19","Psych-Case Rate"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","161079.5","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","172276.62","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","225753.21","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","187185.37","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","161556.41","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","206483.11","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","154209.17","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","244912.72","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","184192.56","","","","","","","fee schedule","58073.66","244912.72",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","28101.21","28101.21","45599.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","157822.98","157822.98","157822.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","134853.54","134853.54","134853.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","58424.72","58424.72","66946.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","51408.23","51408.23","51408.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","57086.36","57086.36","57882.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","46451.79","29428.47","125760.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","519831.03","519831.03","519831.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","60832.16","","","","","","","fee schedule","58073.66","244912.72","MSDRG Base Rate"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","59815.87","","","","","","","fee schedule","58073.66","244912.72","MSDRG Base Rate"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","58073.66","","","","","","","fee schedule","58073.66","244912.72","Transplants-Case Rate"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","59235.13","","","","","","","fee schedule","58073.66","244912.72","MSDRG Base Rate"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60977.34","","","","","","","fee schedule","58073.66","244912.72","MSDRG Base Rate"
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","58073.66","","","","","","","fee schedule","58073.66","244912.72","Psych-Case Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45269.96","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48416.81","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","63445.94","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","52606.79","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45404","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58030.25","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43339.12","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","68830.55","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51765.68","","","","","","","fee schedule","17344.99","68830.55",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","34454.78","17614.01","52016.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","28101.21","13218.93","29428.47","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","43001.89","41753.49","43405.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","43969.68","20448.35","48621.76","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","59701.01","31998.21","61451.01","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5725.43","5725.43","5725.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","16094.76","15036.31","17514.46","90","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","37634.4","27384.24","101256.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","80616.58","80616.58","80616.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15659.99","14559.64","17905.1","100","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","111603.45","111603.45","111603.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","16924.77","15305.06","17426.96","75","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","28101.21","9358.95","29428.47","76","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","40335","27370.18","43082","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","65302.86","45388.2","66243","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","49566","44302.06","50629","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","15622.51","7322.38","17372.88","64","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","48788","26694.9","371137.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","13725.23","7309.07","30538.98","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","52288","47361.59","52288","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18168.88","","","","","","","fee schedule","17344.99","68830.55","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17865.34","","","","","","","fee schedule","17344.99","68830.55","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17344.99","","","","","","","fee schedule","17344.99","68830.55","Transplants-Case Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17691.89","","","","","","","fee schedule","17344.99","68830.55","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18212.24","","","","","","","fee schedule","17344.99","68830.55","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","871","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17344.99","","","","","","","fee schedule","17344.99","68830.55","Psych-Case Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23848.01","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25505.75","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33423.02","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27713.01","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23918.61","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30570.06","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22830.85","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36259.61","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27269.92","","","","","","","fee schedule","9811.17","36259.61",""
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","25934.17","25934.17","25934.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","9358.95","8936.85","13843.29","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","23037.7","23037.7","23037.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","17044.39","9224.54","24639.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","25505.8","16421.25","31939.89","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8766.48","8233.07","10095.53","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","21752.64","12580.02","22830.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8370.66","7209.68","8888.74","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8771.71","8075.15","9471.65","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","8936.85","8936.85","13843.29","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","20716.21","12417.16","22636","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","24886.65","24886.65","24886.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","22522.22","22522.22","24061.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","7438.81","6441.36","8441.59","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","18714.37","14372.53","22182.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","10892.68","6277.29","14365.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","23733.5","23733.5","23733.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10277.2","","","","","","","fee schedule","9811.17","36259.61","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10105.51","","","","","","","fee schedule","9811.17","36259.61","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9811.17","","","","","","","fee schedule","9811.17","36259.61","Transplants-Case Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10007.39","","","","","","","fee schedule","9811.17","36259.61","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10301.73","","","","","","","fee schedule","9811.17","36259.61","MSDRG Base Rate"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","872","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9811.17","","","","","","","fee schedule","9811.17","36259.61","Psych-Case Rate"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","90071.49","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","96332.63","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","126235.36","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","104669.22","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","90338.17","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","115460.02","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","86229.78","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","136948.87","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","102995.72","","","","","","","fee schedule","33101.09","136948.87",""
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","33371","33371","33371","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","65503.33","65503.33","65503.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","85252.11","85252.11","85252.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","60815.22","60815.22","60815.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34673.39","","","","","","","fee schedule","33101.09","136948.87","MSDRG Base Rate"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34094.12","","","","","","","fee schedule","33101.09","136948.87","MSDRG Base Rate"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33101.09","","","","","","","fee schedule","33101.09","136948.87","Transplants-Case Rate"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33763.11","","","","","","","fee schedule","33101.09","136948.87","MSDRG Base Rate"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34756.14","","","","","","","fee schedule","33101.09","136948.87","MSDRG Base Rate"
"O.R. Procedures With Principal Diagnosis Of Mental Illness","876","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33101.09","","","","","","","fee schedule","33101.09","136948.87","Psych-Case Rate"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","22377.46","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23932.99","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","31362.05","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","26004.14","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","22443.71","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28685.01","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","21423.02","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","34023.73","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25588.37","","","","","","","fee schedule","9294","34023.73",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","68819.56","68819.56","68819.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","1611.47","1611.47","1611.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","3054","3054","4581","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","21337.32","21337.32","21337.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","11027.99","11027.99","11027.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","19704","17633.6","21081","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8144.21","8144.21","8144.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9735.46","","","","","","","fee schedule","9294","34023.73","MSDRG Base Rate"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9572.82","","","","","","","fee schedule","9294","34023.73","MSDRG Base Rate"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9294","","","","","","","fee schedule","9294","34023.73","Transplants-Case Rate"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9479.88","","","","","","","fee schedule","9294","34023.73","MSDRG Base Rate"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9758.7","","","","","","","fee schedule","9294","34023.73","MSDRG Base Rate"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9294","","","","","","","fee schedule","9294","34023.73","Psych-Case Rate"
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21927.67","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23451.93","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30731.68","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25481.45","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21992.6","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28108.45","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20992.42","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33339.85","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25074.04","","","","","","","fee schedule","9135.82","33339.85",""
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","10689","10689","10689","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7458.84","7458.84","7954.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","3377.98","3377.98","3377.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","3824.89","3613.07","5528.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","4095.16","4095.16","4095.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","543.33","543.33","543.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6017.9","6017.9","6017.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9569.77","","","","","","","fee schedule","9135.82","33339.85","MSDRG Base Rate"
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9409.89","","","","","","","fee schedule","9135.82","33339.85","MSDRG Base Rate"
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9135.82","","","","","","","fee schedule","9135.82","33339.85","Transplants-Case Rate"
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9318.54","","","","","","","fee schedule","9135.82","33339.85","MSDRG Base Rate"
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9592.61","","","","","","","fee schedule","9135.82","33339.85","MSDRG Base Rate"
"Depressive Neuroses","881","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9135.82","","","","","","","fee schedule","9135.82","33339.85","Psych-Case Rate"
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","25024.91","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26764.47","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","35072.46","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29080.65","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25099","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","32078.7","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23957.55","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","38049.03","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28615.7","","","","","","","fee schedule","10225.08","38049.03",""
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","2440","2440","16797","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","4231","4231","7152","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7493.25","6665.02","8294.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5804.85","5804.85","6816.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","1500.26","1500.26","3789.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","6892.74","6892.74","6892.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6422.64","6422.64","8521.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","3870","3870","3870","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10710.77","","","","","","","fee schedule","10225.08","38049.03","MSDRG Base Rate"
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10531.83","","","","","","","fee schedule","10225.08","38049.03","MSDRG Base Rate"
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10225.08","","","","","","","fee schedule","10225.08","38049.03","Transplants-Case Rate"
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10429.58","","","","","","","fee schedule","10225.08","38049.03","MSDRG Base Rate"
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10736.33","","","","","","","fee schedule","10225.08","38049.03","MSDRG Base Rate"
"Neuroses Except Depressive","882","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10225.08","","","","","","","fee schedule","10225.08","38049.03","Psych-Case Rate"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45824.62","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49010.03","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","64223.29","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","53251.34","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45960.3","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58741.25","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43870.12","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","69673.87","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","52399.93","","","","","","","fee schedule","17540.06","69673.87",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10748.76","10748.76","10748.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","2648.69","2648.69","5297.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","7158.17","7158.17","7158.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18373.21","","","","","","","fee schedule","17540.06","69673.87","MSDRG Base Rate"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18066.26","","","","","","","fee schedule","17540.06","69673.87","MSDRG Base Rate"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17540.06","","","","","","","fee schedule","17540.06","69673.87","Transplants-Case Rate"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17890.86","","","","","","","fee schedule","17540.06","69673.87","MSDRG Base Rate"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18417.06","","","","","","","fee schedule","17540.06","69673.87","MSDRG Base Rate"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17540.06","","","","","","","fee schedule","17540.06","69673.87","Psych-Case Rate"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","37495.41","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40101.83","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","52549.89","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","43572.23","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","37606.43","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48064.28","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","35896.17","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57009.76","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","42875.58","","","","","","","fee schedule","14610.79","57009.76",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","45813.2","45813.2","45813.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","26840","26840","26840","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13797.5","13797.5","13797.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12777.82","3914.31","12929.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12961.36","12607.05","14584.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","2441.74","2441.74","2441.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","12385.69","12385.69","12385.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15304.8","","","","","","","fee schedule","14610.79","57009.76","MSDRG Base Rate"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15049.11","","","","","","","fee schedule","14610.79","57009.76","MSDRG Base Rate"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14610.79","","","","","","","fee schedule","14610.79","57009.76","Transplants-Case Rate"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14903.01","","","","","","","fee schedule","14610.79","57009.76","MSDRG Base Rate"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15341.33","","","","","","","fee schedule","14610.79","57009.76","MSDRG Base Rate"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14610.79","","","","","","","fee schedule","14610.79","57009.76","Psych-Case Rate"
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32552.42","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","34815.24","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","45622.28","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","37828.14","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","32648.8","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","41728","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31164","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","49494.21","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37223.32","","","","","","","fee schedule","12872.4","49494.21",""
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","17074.36","11022.41","42397.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","6621.7","2648.69","17704.53","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","8503.22","6954","17080","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","6652.96","4418","23481","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","7412","4281","13077","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","2087.8","2087.8","2087.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","9993.19","5940.91","11602.47","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","2789.1","2479.2","7835.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","4940.81","1642.4","12023.26","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","10980","10980","10980","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9932.65","4622.64","35986.29","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","7587.66","3793.82","11381.49","71","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","4195.16","1075.53","25849.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","9733.63","9733.63","9733.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","15224.81","15224.81","15224.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","9672.4","2045.95","16530.24","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","2702.76","1109","27755.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","5965.14","3330","8351.2","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","4296","4296","4296","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13483.84","","","","","","","fee schedule","12872.4","49494.21","MSDRG Base Rate"
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13258.57","","","","","","","fee schedule","12872.4","49494.21","MSDRG Base Rate"
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12872.4","","","","","","","fee schedule","12872.4","49494.21","Transplants-Case Rate"
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13129.85","","","","","","","fee schedule","12872.4","49494.21","MSDRG Base Rate"
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13516.02","","","","","","","fee schedule","12872.4","49494.21","MSDRG Base Rate"
"Psychoses","885","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12872.4","","","","","","","fee schedule","12872.4","49494.21","Psych-Case Rate"
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48364.87","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51726.85","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","67783.45","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","56203.27","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48508.06","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","61997.51","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","46302.02","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","73536.18","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","55304.67","","","","","","","fee schedule","18433.43","73536.18",""
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19309.02","","","","","","","fee schedule","18433.43","73536.18","MSDRG Base Rate"
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18986.43","","","","","","","fee schedule","18433.43","73536.18","MSDRG Base Rate"
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18433.43","","","","","","","fee schedule","18433.43","73536.18","Transplants-Case Rate"
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18802.1","","","","","","","fee schedule","18433.43","73536.18","MSDRG Base Rate"
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19355.1","","","","","","","fee schedule","18433.43","73536.18","MSDRG Base Rate"
"Behavioral And Developmental Disorders","886","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18433.43","","","","","","","fee schedule","18433.43","73536.18","Psych-Case Rate"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","24957.32","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","26692.18","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","34977.74","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","29002.11","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","25031.22","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","31992.07","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","23892.85","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","37946.27","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","28538.41","","","","","","","fee schedule","10201.31","37946.27",""
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10685.87","","","","","","","fee schedule","10201.31","37946.27","MSDRG Base Rate"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10507.35","","","","","","","fee schedule","10201.31","37946.27","MSDRG Base Rate"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10201.31","","","","","","","fee schedule","10201.31","37946.27","Transplants-Case Rate"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","10405.34","","","","","","","fee schedule","10201.31","37946.27","MSDRG Base Rate"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10711.38","","","","","","","fee schedule","10201.31","37946.27","MSDRG Base Rate"
"Other Mental Disorder Diagnoses","887","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10201.31","","","","","","","fee schedule","10201.31","37946.27","Psych-Case Rate"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14376.85","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15376.23","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20149.19","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16706.89","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14419.42","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18429.27","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","13763.66","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","21859.23","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16439.77","","","","","","","fee schedule","6480.3","21859.23",""
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","10667.81","10667.81","10667.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","4880","4880","4880","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","1527","1527","4581","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","4177.6","4177.6","4177.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6263.63","6263.63","6263.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12764.41","12764.41","12764.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","1424.44","1424.44","1424.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","422.86","422.86","422.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","15686.03","15686.03","15686.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","11070.37","11070.37","11070.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6788.11","","","","","","","fee schedule","6480.3","21859.23","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6674.71","","","","","","","fee schedule","6480.3","21859.23","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6480.3","","","","","","","fee schedule","6480.3","21859.23","Transplants-Case Rate"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6609.91","","","","","","","fee schedule","6480.3","21859.23","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6804.32","","","","","","","fee schedule","6480.3","21859.23","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6480.3","","","","","","","fee schedule","6480.3","21859.23","Psych-Case Rate"
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","32990.56","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","35283.83","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","46236.33","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","38337.28","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","33088.23","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","42289.63","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","31583.45","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","50160.37","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","37724.32","","","","","","","fee schedule","13026.49","50160.37",""
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5807.76","5807.76","5807.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5205.85","3579.08","8450.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","13645.25","","","","","","","fee schedule","13026.49","50160.37","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13417.28","","","","","","","fee schedule","13026.49","50160.37","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13026.49","","","","","","","fee schedule","13026.49","50160.37","Transplants-Case Rate"
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13287.02","","","","","","","fee schedule","13026.49","50160.37","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13677.81","","","","","","","fee schedule","13026.49","50160.37","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","895","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13026.49","","","","","","","fee schedule","13026.49","50160.37","Psych-Case Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40669.56","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43496.62","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","56998.46","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47260.8","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40789.97","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52133.12","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38934.93","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61835.87","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46505.17","","","","","","","fee schedule","15727.09","61835.87",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","11627.54","11627.54","28989.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","10645","10645","28699","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","10689","10689","10689","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14278.9","14278.9","14278.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","23823.44","23823.44","23823.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15491.88","15491.88","15491.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5224.55","3748.14","13743.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","37562.62","37562.62","38597","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14850.1","14850.1","14850.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16474.13","","","","","","","fee schedule","15727.09","61835.87","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16198.9","","","","","","","fee schedule","15727.09","61835.87","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15727.09","","","","","","","fee schedule","15727.09","61835.87","Transplants-Case Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16041.63","","","","","","","fee schedule","15727.09","61835.87","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16513.44","","","","","","","fee schedule","15727.09","61835.87","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","896","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15727.09","","","","","","","fee schedule","15727.09","61835.87","Psych-Case Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20573.65","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22003.79","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28834.01","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23907.99","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20634.57","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26372.77","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19696.15","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31281.14","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23525.74","","","","","","","fee schedule","8659.63","31281.14",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","44526.86","44526.86","44526.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5451.73","5161.25","6987.19","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","11884.08","4880","16226","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","4718","4718","8244.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","4581","1527","10171","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6578.19","6049.28","8135.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","16264.85","16264.85","16264.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6380.95","1521.17","8924.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","4378.98","3626.17","8276.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","5224.55","2063.18","8745.66","91","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","4595.16","3125.89","17634","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","4247.47","3415.42","22762","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5338.22","2937.83","7764.73","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","3296","3296","3296","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6923.84","4928.82","6923.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9070.96","","","","","","","fee schedule","8659.63","31281.14","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8919.42","","","","","","","fee schedule","8659.63","31281.14","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8659.63","","","","","","","fee schedule","8659.63","31281.14","Transplants-Case Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8832.82","","","","","","","fee schedule","8659.63","31281.14","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9092.61","","","","","","","fee schedule","8659.63","31281.14","MSDRG Base Rate"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","897","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8659.63","","","","","","","fee schedule","8659.63","31281.14","Psych-Case Rate"
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","97801.76","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","104600.26","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","137069.35","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","113652.32","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","98091.33","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","125369.23","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","93630.34","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","148702.32","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","111835.19","","","","","","","fee schedule","35819.72","148702.32",""
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37521.16","","","","","","","fee schedule","35819.72","148702.32","MSDRG Base Rate"
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","36894.31","","","","","","","fee schedule","35819.72","148702.32","MSDRG Base Rate"
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35819.72","","","","","","","fee schedule","35819.72","148702.32","Transplants-Case Rate"
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36536.11","","","","","","","fee schedule","35819.72","148702.32","MSDRG Base Rate"
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37610.71","","","","","","","fee schedule","35819.72","148702.32","MSDRG Base Rate"
"Wound Debridements For Injuries With Mcc","901","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35819.72","","","","","","","fee schedule","35819.72","148702.32","Psych-Case Rate"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","44617.42","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","47718.91","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","62531.4","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","51848.49","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","44749.52","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","57193.77","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","42714.41","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","67838.39","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","51019.51","","","","","","","fee schedule","17115.5","67838.39",""
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","70246.42","70246.42","70246.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17683.92","17683.92","17683.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","64652.06","64652.06","64652.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17928.49","","","","","","","fee schedule","17115.5","67838.39","MSDRG Base Rate"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17628.96","","","","","","","fee schedule","17115.5","67838.39","MSDRG Base Rate"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17115.5","","","","","","","fee schedule","17115.5","67838.39","Transplants-Case Rate"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17457.81","","","","","","","fee schedule","17115.5","67838.39","MSDRG Base Rate"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17971.28","","","","","","","fee schedule","17115.5","67838.39","MSDRG Base Rate"
"Wound Debridements For Injuries With Cc","902","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17115.5","","","","","","","fee schedule","17115.5","67838.39","Psych-Case Rate"
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27257.53","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29152.28","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38201.48","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31675.11","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27338.23","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34940.63","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26094.95","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","41443.61","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31168.67","","","","","","","fee schedule","11010.26","41443.61",""
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","10692.85","10692.85","10692.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","10423.33","10423.33","10423.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11533.25","","","","","","","fee schedule","11010.26","41443.61","MSDRG Base Rate"
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11340.57","","","","","","","fee schedule","11010.26","41443.61","MSDRG Base Rate"
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11010.26","","","","","","","fee schedule","11010.26","41443.61","Transplants-Case Rate"
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11230.47","","","","","","","fee schedule","11010.26","41443.61","MSDRG Base Rate"
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11560.77","","","","","","","fee schedule","11010.26","41443.61","MSDRG Base Rate"
"Wound Debridements For Injuries Without Cc/Mcc","903","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11010.26","","","","","","","fee schedule","11010.26","41443.61","Psych-Case Rate"
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","85601.6","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","91552.02","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","119970.79","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","99474.89","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","85855.04","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","109730.19","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","81950.53","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","130152.63","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","97884.44","","","","","","","fee schedule","31529.09","130152.63",""
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","156369.77","156369.77","156369.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","93056.24","93056.24","93056.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33026.72","","","","","","","fee schedule","31529.09","130152.63","MSDRG Base Rate"
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32474.96","","","","","","","fee schedule","31529.09","130152.63","MSDRG Base Rate"
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31529.09","","","","","","","fee schedule","31529.09","130152.63","Transplants-Case Rate"
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32159.67","","","","","","","fee schedule","31529.09","130152.63","MSDRG Base Rate"
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33105.54","","","","","","","fee schedule","31529.09","130152.63","MSDRG Base Rate"
"Skin Grafts For Injuries With Cc/Mcc","904","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31529.09","","","","","","","fee schedule","31529.09","130152.63","Psych-Case Rate"
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","34570.64","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","36973.75","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","48450.81","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","40173.44","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","34672.99","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","44315.09","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","33096.14","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","52562.8","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","39531.13","","","","","","","fee schedule","13582.18","52562.8",""
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14227.33","","","","","","","fee schedule","13582.18","52562.8","MSDRG Base Rate"
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13989.65","","","","","","","fee schedule","13582.18","52562.8","MSDRG Base Rate"
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13582.18","","","","","","","fee schedule","13582.18","52562.8","Transplants-Case Rate"
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","13853.82","","","","","","","fee schedule","13582.18","52562.8","MSDRG Base Rate"
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14261.29","","","","","","","fee schedule","13582.18","52562.8","MSDRG Base Rate"
"Skin Grafts For Injuries Without Cc/Mcc","905","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13582.18","","","","","","","fee schedule","13582.18","52562.8","Psych-Case Rate"
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","45778.01","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","48960.18","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","64157.97","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","53197.17","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","45913.55","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","58681.5","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","43825.5","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","69603.01","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","52346.63","","","","","","","fee schedule","17523.66","69603.01",""
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","59686.24","59686.24","59686.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","24753.28","24753.28","24753.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18356.03","","","","","","","fee schedule","17523.66","69603.01","MSDRG Base Rate"
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18049.37","","","","","","","fee schedule","17523.66","69603.01","MSDRG Base Rate"
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17523.66","","","","","","","fee schedule","17523.66","69603.01","Transplants-Case Rate"
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","17874.13","","","","","","","fee schedule","17523.66","69603.01","MSDRG Base Rate"
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18399.84","","","","","","","fee schedule","17523.66","69603.01","MSDRG Base Rate"
"Hand Procedures For Injuries","906","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17523.66","","","","","","","fee schedule","17523.66","69603.01","Psych-Case Rate"
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","89474.89","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","95694.55","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","125399.22","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","103975.92","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","89739.8","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","114695.25","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","85658.62","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","136041.76","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","102313.51","","","","","","","fee schedule","32891.27","136041.76",""
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","97823.73","97823.73","97823.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","93880.57","55282.72","123177.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","32819.98","31611.21","33854.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","75390.48","75390.48","75390.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","31532.39","31078.07","33020.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","33053.81","31975.81","44586.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","58639.24","58639.24","86270.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","31639.17","3429.73","32202.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","103317.26","103317.26","103317.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34453.61","","","","","","","fee schedule","32891.27","136041.76","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33878.01","","","","","","","fee schedule","32891.27","136041.76","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32891.27","","","","","","","fee schedule","32891.27","136041.76","Transplants-Case Rate"
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","33549.1","","","","","","","fee schedule","32891.27","136041.76","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","34535.83","","","","","","","fee schedule","32891.27","136041.76","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Mcc","907","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32891.27","","","","","","","fee schedule","32891.27","136041.76","Psych-Case Rate"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","46498.14","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","49730.36","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","65167.22","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54034.01","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","46635.8","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","59604.6","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","44514.91","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","70697.92","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","53170.08","","","","","","","fee schedule","17776.92","70697.92",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50989.81","32970.98","60119.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","47683.28","47683.28","47683.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","5195.89","5195.89","5195.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","17288.09","17288.09","18295.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","39476.48","39476.48","39476.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17542.6","17542.6","17542.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17861.12","17861.12","17861.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","16698.34","16698.34","16698.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","71360.55","71360.55","71360.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18621.32","","","","","","","fee schedule","17776.92","70697.92","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18310.23","","","","","","","fee schedule","17776.92","70697.92","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","17776.92","","","","","","","fee schedule","17776.92","70697.92","Transplants-Case Rate"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18132.46","","","","","","","fee schedule","17776.92","70697.92","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18665.77","","","","","","","fee schedule","17776.92","70697.92","MSDRG Base Rate"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17776.92","","","","","","","fee schedule","17776.92","70697.92","Psych-Case Rate"
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30592.47","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32719.05","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42875.41","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35550.54","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30683.05","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","39215.6","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","29287.65","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","46514.21","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34982.14","","","","","","","fee schedule","12183.11","46514.21",""
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","39971.77","39971.77","39971.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","39721.89","39721.89","39721.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11316.14","11316.14","11316.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","32721","32721","32721","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12761.81","","","","","","","fee schedule","12183.11","46514.21","MSDRG Base Rate"
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12548.6","","","","","","","fee schedule","12183.11","46514.21","MSDRG Base Rate"
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12183.11","","","","","","","fee schedule","12183.11","46514.21","Transplants-Case Rate"
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12426.77","","","","","","","fee schedule","12183.11","46514.21","MSDRG Base Rate"
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12792.27","","","","","","","fee schedule","12183.11","46514.21","MSDRG Base Rate"
"Other O.R. Procedures For Injuries Without Cc/Mcc","909","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12183.11","","","","","","","fee schedule","12183.11","46514.21","Psych-Case Rate"
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38094.35","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40742.41","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53389.31","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44268.24","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38207.14","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","48832.04","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36469.56","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","57920.42","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43560.46","","","","","","","fee schedule","14821.42","57920.42",""
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15525.44","","","","","","","fee schedule","14821.42","57920.42","MSDRG Base Rate"
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15266.06","","","","","","","fee schedule","14821.42","57920.42","MSDRG Base Rate"
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14821.42","","","","","","","fee schedule","14821.42","57920.42","Transplants-Case Rate"
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15117.85","","","","","","","fee schedule","14821.42","57920.42","MSDRG Base Rate"
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15562.49","","","","","","","fee schedule","14821.42","57920.42","MSDRG Base Rate"
"Traumatic Injury With Mcc","913","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14821.42","","","","","","","fee schedule","14821.42","57920.42","Psych-Case Rate"
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","20636.58","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22071.09","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","28922.2","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23981.11","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20697.68","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26453.43","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19756.39","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31376.81","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","23597.69","","","","","","","fee schedule","8681.76","31376.81",""
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","23880.35","23880.35","23880.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","6904.32","6904.32","6904.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","9009.09","9009.09","9009.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9094.14","","","","","","","fee schedule","8681.76","31376.81","MSDRG Base Rate"
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8942.21","","","","","","","fee schedule","8681.76","31376.81","MSDRG Base Rate"
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8681.76","","","","","","","fee schedule","8681.76","31376.81","Transplants-Case Rate"
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8855.4","","","","","","","fee schedule","8681.76","31376.81","MSDRG Base Rate"
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9115.85","","","","","","","fee schedule","8681.76","31376.81","MSDRG Base Rate"
"Traumatic Injury Without Mcc","914","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8681.76","","","","","","","fee schedule","8681.76","31376.81","Psych-Case Rate"
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39189.69","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","41913.88","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","54924.42","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","45541.09","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","39305.72","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","50236.12","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","37518.18","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","59585.81","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","44812.96","","","","","","","fee schedule","15206.64","59585.81",""
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","15206.76","15206.76","15206.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12937.08","12937.08","12937.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15928.96","","","","","","","fee schedule","15206.64","59585.81","MSDRG Base Rate"
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15662.84","","","","","","","fee schedule","15206.64","59585.81","MSDRG Base Rate"
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15206.64","","","","","","","fee schedule","15206.64","59585.81","Transplants-Case Rate"
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15510.77","","","","","","","fee schedule","15206.64","59585.81","MSDRG Base Rate"
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15966.97","","","","","","","fee schedule","15206.64","59585.81","MSDRG Base Rate"
"Allergic Reactions With Mcc","915","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15206.64","","","","","","","fee schedule","15206.64","59585.81","Psych-Case Rate"
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","15528.12","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","16607.53","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","21762.69","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18044.74","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","15574.1","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","19905.05","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14865.82","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","23609.67","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","17756.23","","","","","","","fee schedule","6885.18","23609.67",""
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","35005.97","35005.97","35005.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","12697.06","12697.06","12697.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","5671.99","5671.99","5671.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","3826.1","3826.1","3826.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7212.23","","","","","","","fee schedule","6885.18","23609.67","MSDRG Base Rate"
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7091.74","","","","","","","fee schedule","6885.18","23609.67","MSDRG Base Rate"
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6885.18","","","","","","","fee schedule","6885.18","23609.67","Transplants-Case Rate"
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7022.88","","","","","","","fee schedule","6885.18","23609.67","MSDRG Base Rate"
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7229.44","","","","","","","fee schedule","6885.18","23609.67","MSDRG Base Rate"
"Allergic Reactions Without Mcc","916","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6885.18","","","","","","","fee schedule","6885.18","23609.67","Psych-Case Rate"
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36551.56","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","39092.37","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","51227.08","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","42475.41","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36659.78","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46854.38","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34992.57","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","55574.69","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41796.29","","","","","","","fee schedule","14278.85","55574.69",""
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","18761.84","18761.84","18761.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","45698.39","33570.14","49693.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","13571.23","13546.73","14741.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","32975.9","32975.9","32975.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12902.6","12120.56","14215","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","6494.15","6494.15","6494.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","13566.1","13566.1","13566.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","30651.47","30651.47","30651.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14957.1","","","","","","","fee schedule","14278.85","55574.69","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14707.22","","","","","","","fee schedule","14278.85","55574.69","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14278.85","","","","","","","fee schedule","14278.85","55574.69","Transplants-Case Rate"
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14564.43","","","","","","","fee schedule","14278.85","55574.69","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14992.79","","","","","","","fee schedule","14278.85","55574.69","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs With Mcc","917","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14278.85","","","","","","","fee schedule","14278.85","55574.69","Psych-Case Rate"
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","19974.72","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","21363.22","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","27994.6","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","23211.98","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","20033.86","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","25605.01","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","19122.76","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","30370.48","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","22840.86","","","","","","","fee schedule","8448.99","30370.48",""
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","14813.27","14813.27","14813.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","15428.78","15428.78","26382.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","12856.71","12856.71","12856.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8499.32","8499.32","8499.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","9060.79","9060.79","9060.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7979.02","7979.02","7979.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","8285.91","8285.91","8484.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","18917","18917","18917","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6870.62","6870.62","6870.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8850.32","","","","","","","fee schedule","8448.99","30370.48","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8702.46","","","","","","","fee schedule","8448.99","30370.48","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8448.99","","","","","","","fee schedule","8448.99","30370.48","Transplants-Case Rate"
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8617.97","","","","","","","fee schedule","8448.99","30370.48","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8871.44","","","","","","","fee schedule","8448.99","30370.48","MSDRG Base Rate"
"Poisoning And Toxic Effects Of Drugs Without Mcc","918","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8448.99","","","","","","","fee schedule","8448.99","30370.48","Psych-Case Rate"
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","42666.79","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","45632.69","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","59797.59","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","49581.73","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","42793.12","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","54693.32","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","40846.98","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","64872.57","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","48788.99","","","","","","","fee schedule","16429.49","64872.57",""
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","48398.96","48398.96","48398.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","20427.41","17722.9","30657.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","14675.92","14501.59","16230.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","15975.37","14411.29","38857.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","15835.51","15835.51","15835.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","37480","37480","37480","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","33091.59","33091.59","33091.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","47865.01","47865.01","47865.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","17209.89","","","","","","","fee schedule","16429.49","64872.57","MSDRG Base Rate"
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16922.37","","","","","","","fee schedule","16429.49","64872.57","MSDRG Base Rate"
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16429.49","","","","","","","fee schedule","16429.49","64872.57","Transplants-Case Rate"
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16758.08","","","","","","","fee schedule","16429.49","64872.57","MSDRG Base Rate"
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","17250.96","","","","","","","fee schedule","16429.49","64872.57","MSDRG Base Rate"
"Complications Of Treatment With Mcc","919","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16429.49","","","","","","","fee schedule","16429.49","64872.57","Psych-Case Rate"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23358.6","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","24982.33","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","32737.12","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27144.29","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23427.76","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","29942.71","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22362.32","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","35515.5","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","26710.29","","","","","","","fee schedule","9639.06","35515.5",""
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","9539.51","9539.51","9539.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","18019.88","18019.88","30298.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8482.15","8482.15","8482.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","16822.2","16822.2","16822.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","7963.51","7963.51","8639.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","9069.13","9069.13","9069.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21505","21505","22302","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","26209","26209","26209","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","8865.3","8865.3","8865.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","15385.17","15385.17","15385.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10096.92","","","","","","","fee schedule","9639.06","35515.5","MSDRG Base Rate"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9928.23","","","","","","","fee schedule","9639.06","35515.5","MSDRG Base Rate"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9639.06","","","","","","","fee schedule","9639.06","35515.5","Transplants-Case Rate"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9831.84","","","","","","","fee schedule","9639.06","35515.5","MSDRG Base Rate"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10121.01","","","","","","","fee schedule","9639.06","35515.5","MSDRG Base Rate"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9639.06","","","","","","","fee schedule","9639.06","35515.5","Psych-Case Rate"
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","16043.16","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","17158.37","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","22484.52","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","18643.25","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","16090.66","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","20565.26","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","15358.89","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","24392.77","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","18345.17","","","","","","","fee schedule","7066.32","24392.77",""
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","21560","21560","21560","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","10190.97","10190.97","10190.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","4645.8","4645.8","4645.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","15114","15114","15114","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","7401.97","","","","","","","fee schedule","7066.32","24392.77","MSDRG Base Rate"
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7278.31","","","","","","","fee schedule","7066.32","24392.77","MSDRG Base Rate"
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7066.32","","","","","","","fee schedule","7066.32","24392.77","Transplants-Case Rate"
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","7207.65","","","","","","","fee schedule","7066.32","24392.77","MSDRG Base Rate"
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7419.64","","","","","","","fee schedule","7066.32","24392.77","MSDRG Base Rate"
"Complications Of Treatment Without Cc/Mcc","921","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7066.32","","","","","","","fee schedule","7066.32","24392.77","Psych-Case Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","40769.77","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","43603.8","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","57138.9","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","47377.25","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40890.48","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","52261.58","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","39030.86","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","61988.24","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","46619.76","","","","","","","fee schedule","15762.33","61988.24",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","27430.29","27430.29","27430.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","14086.6","14086.6","14086.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","22516.43","22516.43","22516.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","14776.88","14776.88","14776.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16511.04","","","","","","","fee schedule","15762.33","61988.24","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","16235.2","","","","","","","fee schedule","15762.33","61988.24","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15762.33","","","","","","","fee schedule","15762.33","61988.24","Transplants-Case Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","16077.58","","","","","","","fee schedule","15762.33","61988.24","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16550.45","","","","","","","fee schedule","15762.33","61988.24","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","922","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15762.33","","","","","","","fee schedule","15762.33","61988.24","Psych-Case Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","23717.5","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","25366.17","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","33240.12","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","27561.35","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","23787.72","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","30402.77","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","22705.9","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","36061.18","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","27120.69","","","","","","","fee schedule","9765.28","36061.18",""
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","8355.22","8355.22","8355.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","8438.35","8438.35","8438.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2532.01","2532.01","2532.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","34426","34426","34426","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","10229.13","","","","","","","fee schedule","9765.28","36061.18","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10058.24","","","","","","","fee schedule","9765.28","36061.18","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9765.28","","","","","","","fee schedule","9765.28","36061.18","Transplants-Case Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9960.59","","","","","","","fee schedule","9765.28","36061.18","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10253.54","","","","","","","fee schedule","9765.28","36061.18","MSDRG Base Rate"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","923","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9765.28","","","","","","","fee schedule","9765.28","36061.18","Psych-Case Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","497573.4","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","532161.21","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","697350.03","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","578214.24","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","499046.59","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","637824.84","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","476351.01","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","756533.62","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","568969.47","","","","","","","fee schedule","176414.06","756533.62",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","647296.18","647296.18","647296.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","184793.73","","","","","","","fee schedule","176414.06","756533.62","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","181706.48","","","","","","","fee schedule","176414.06","756533.62","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","176414.06","","","","","","","fee schedule","176414.06","756533.62","Transplants-Case Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","179942.34","","","","","","","fee schedule","176414.06","756533.62","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","185234.76","","","","","","","fee schedule","176414.06","756533.62","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","927","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","176414.06","","","","","","","fee schedule","176414.06","756533.62","Psych-Case Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","167159.77","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","178779.55","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","234274.73","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","194251.06","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","167654.69","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","214277.24","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","160030.11","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","254157.45","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","191145.28","","","","","","","fee schedule","60212.01","254157.45",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","94012.28","94012.28","94012.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","146626","146626","146626","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","50805.91","50805.91","50805.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","42207.58","42207.58","42207.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","63072.08","","","","","","","fee schedule","60212.01","254157.45","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","62018.37","","","","","","","fee schedule","60212.01","254157.45","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","60212.01","","","","","","","fee schedule","60212.01","254157.45","Transplants-Case Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","61416.25","","","","","","","fee schedule","60212.01","254157.45","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63222.61","","","","","","","fee schedule","60212.01","254157.45","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","928","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","60212.01","","","","","","","fee schedule","60212.01","254157.45","Psych-Case Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","75060.74","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","80278.44","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","105197.77","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","87225.71","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","75282.98","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","96218.18","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","71859.27","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","114125.83","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","85831.1","","","","","","","fee schedule","27822.01","114125.83",""
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","29143.56","","","","","","","fee schedule","27822.01","114125.83","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","28656.67","","","","","","","fee schedule","27822.01","114125.83","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","27822.01","","","","","","","fee schedule","27822.01","114125.83","Transplants-Case Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","28378.45","","","","","","","fee schedule","27822.01","114125.83","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29213.11","","","","","","","fee schedule","27822.01","114125.83","MSDRG Base Rate"
"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","929","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","27822.01","","","","","","","fee schedule","27822.01","114125.83","Psych-Case Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","90754.33","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","97062.94","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","127192.36","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","105462.72","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","91023.03","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","116335.33","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","86883.5","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","137987.08","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","103776.54","","","","","","","fee schedule","33341.23","137987.08",""
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","34924.94","","","","","","","fee schedule","33341.23","137987.08","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","34341.47","","","","","","","fee schedule","33341.23","137987.08","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33341.23","","","","","","","fee schedule","33341.23","137987.08","Transplants-Case Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","34008.05","","","","","","","fee schedule","33341.23","137987.08","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35008.29","","","","","","","fee schedule","33341.23","137987.08","MSDRG Base Rate"
"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","933","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33341.23","","","","","","","fee schedule","33341.23","137987.08","Psych-Case Rate"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","51518.03","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","55099.21","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","72202.62","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","59867.47","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","51670.56","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","66039.46","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","49320.7","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","78330.4","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","58910.28","","","","","","","fee schedule","19542.35","78330.4",""
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","50536.48","50536.48","50536.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18167.6","18167.6","18167.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","2736.32","2736.32","2736.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","20470.61","","","","","","","fee schedule","19542.35","78330.4","MSDRG Base Rate"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20128.62","","","","","","","fee schedule","19542.35","78330.4","MSDRG Base Rate"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","19542.35","","","","","","","fee schedule","19542.35","78330.4","Transplants-Case Rate"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","19933.2","","","","","","","fee schedule","19542.35","78330.4","MSDRG Base Rate"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20519.47","","","","","","","fee schedule","19542.35","78330.4","MSDRG Base Rate"
"Full Thickness Burn Without Skin Graft Or Inhalation Injury","934","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19542.35","","","","","","","fee schedule","19542.35","78330.4","Psych-Case Rate"
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","48008.3","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","51345.5","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","67283.72","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","55788.92","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","48150.44","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","61540.44","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","45960.66","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","72994.04","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","54896.94","","","","","","","fee schedule","18308.03","72994.04",""
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","284768.26","284768.26","284768.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","31195.04","15138.52","203659.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","18097.95","18097.95","18097.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","43626.75","43626.75","43626.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","17107.08","16648.7","17405","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","17186.28","17186.28","17186.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","21435.74","21435.74","21435.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","29647.96","29647.96","29647.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","17320.65","17320.65","17320.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","19177.66","","","","","","","fee schedule","18308.03","72994.04","MSDRG Base Rate"
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18857.27","","","","","","","fee schedule","18308.03","72994.04","MSDRG Base Rate"
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18308.03","","","","","","","fee schedule","18308.03","72994.04","Transplants-Case Rate"
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18674.19","","","","","","","fee schedule","18308.03","72994.04","MSDRG Base Rate"
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","19223.43","","","","","","","fee schedule","18308.03","72994.04","MSDRG Base Rate"
"Non-Extensive Burns","935","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18308.03","","","","","","","fee schedule","18308.03","72994.04","Psych-Case Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","84562.19","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","90440.36","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","118514.07","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","98267.04","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","84812.56","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","108397.81","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","80955.46","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","128572.27","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","96695.9","","","","","","","fee schedule","31163.54","128572.27",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","158833.39","158833.39","503480.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","2732.62","2732.62","2732.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","32643.81","","","","","","","fee schedule","31163.54","128572.27","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32098.45","","","","","","","fee schedule","31163.54","128572.27","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","31163.54","","","","","","","fee schedule","31163.54","128572.27","Transplants-Case Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","31786.81","","","","","","","fee schedule","31163.54","128572.27","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32721.72","","","","","","","fee schedule","31163.54","128572.27","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","939","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","31163.54","","","","","","","fee schedule","31163.54","128572.27","Psych-Case Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","54461.45","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","58247.23","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","76327.83","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","63287.93","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","54622.7","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","69812.55","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","52138.58","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","82805.71","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","62276.05","","","","","","","fee schedule","20577.52","82805.71",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","50460.35","50460.35","50460.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","66126.94","66126.94","71843.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12315.36","12315.36","12315.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","21554.95","","","","","","","fee schedule","20577.52","82805.71","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21194.85","","","","","","","fee schedule","20577.52","82805.71","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","20577.52","","","","","","","fee schedule","20577.52","82805.71","Transplants-Case Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","20989.07","","","","","","","fee schedule","20577.52","82805.71","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21606.4","","","","","","","fee schedule","20577.52","82805.71","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","940","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","20577.52","","","","","","","fee schedule","20577.52","82805.71","Psych-Case Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","47255.55","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","50540.42","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","66228.74","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","54914.17","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","47395.46","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","60575.51","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","45240.01","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","71849.52","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","54036.18","","","","","","","fee schedule","18043.29","71849.52",""
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","18900.35","","","","","","","fee schedule","18043.29","71849.52","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18584.59","","","","","","","fee schedule","18043.29","71849.52","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","18043.29","","","","","","","fee schedule","18043.29","71849.52","Transplants-Case Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","18404.16","","","","","","","fee schedule","18043.29","71849.52","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18945.45","","","","","","","fee schedule","18043.29","71849.52","MSDRG Base Rate"
"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","941","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","18043.29","","","","","","","fee schedule","18043.29","71849.52","Psych-Case Rate"
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","36090.12","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38598.86","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50580.37","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41939.19","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","36196.98","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","46262.88","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34550.81","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54873.09","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","41268.64","","","","","","","fee schedule","14116.56","54873.09",""
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","16592.14","16592.14","16592.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","34741.61","34741.61","34741.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","47808.45","37989.85","47808.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","50649.33","31755.7","54605.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","34057.74","34057.74","34057.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","51757.15","51757.15","51757.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","20851.01","20851.01","28249.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19113.42","15638.25","23228.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","33512","29478.97","33512","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","37397","37397","37397","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","70707.86","70707.86","70707.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","6887.32","6887.32","6887.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","40679.7","40679.7","40679.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14787.1","","","","","","","fee schedule","14116.56","54873.09","MSDRG Base Rate"
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14540.06","","","","","","","fee schedule","14116.56","54873.09","MSDRG Base Rate"
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14116.56","","","","","","","fee schedule","14116.56","54873.09","Transplants-Case Rate"
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14398.89","","","","","","","fee schedule","14116.56","54873.09","MSDRG Base Rate"
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14822.39","","","","","","","fee schedule","14116.56","54873.09","MSDRG Base Rate"
"Rehabilitation With Cc/Mcc","945","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14116.56","","","","","","","fee schedule","14116.56","54873.09","Psych-Case Rate"
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","26726.17","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","28583.99","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","37456.78","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","31057.64","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","26805.3","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","34259.5","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","25586.25","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","40635.71","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","30561.07","","","","","","","fee schedule","10823.39","40635.71",""
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8296.07","8296.07","8296.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","34967.66","34967.66","34967.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11337.5","","","","","","","fee schedule","10823.39","40635.71","MSDRG Base Rate"
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11148.09","","","","","","","fee schedule","10823.39","40635.71","MSDRG Base Rate"
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","10823.39","","","","","","","fee schedule","10823.39","40635.71","Transplants-Case Rate"
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11039.86","","","","","","","fee schedule","10823.39","40635.71","MSDRG Base Rate"
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11364.56","","","","","","","fee schedule","10823.39","40635.71","MSDRG Base Rate"
"Rehabilitation Without Cc/Mcc","946","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","10823.39","","","","","","","fee schedule","10823.39","40635.71","Psych-Case Rate"
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","29583.37","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","31639.8","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","41461.14","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","34377.89","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","29670.96","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","37922.06","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28321.58","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","44979.92","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","33828.24","","","","","","","fee schedule","11828.22","44979.92",""
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","11569.53","11569.53","11569.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","40282.5","40282.5","40282.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","12315.36","12315.36","12315.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11808.69","11808.69","11808.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","22681.71","22681.71","22681.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","9276.64","9276.64","9276.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","26603.34","26603.34","26603.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","43416","43416","43416","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11826.95","11826.95","11826.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12390.06","","","","","","","fee schedule","11828.22","44979.92","MSDRG Base Rate"
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12183.07","","","","","","","fee schedule","11828.22","44979.92","MSDRG Base Rate"
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11828.22","","","","","","","fee schedule","11828.22","44979.92","Transplants-Case Rate"
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12064.78","","","","","","","fee schedule","11828.22","44979.92","MSDRG Base Rate"
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12419.63","","","","","","","fee schedule","11828.22","44979.92","MSDRG Base Rate"
"Signs And Symptoms With Mcc","947","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11828.22","","","","","","","fee schedule","11828.22","44979.92","Psych-Case Rate"
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","18655.65","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","19952.46","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","26145.93","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","21679.14","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","18710.89","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","23914.14","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","17859.96","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","28364.92","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","21332.52","","","","","","","fee schedule","7985.09","28364.92",""
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","8097.99","8097.99","8097.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","16332.38","16332.38","16332.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","17726.09","17726.09","17726.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","6457.92","6457.92","6457.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","7563.54","7563.54","7563.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12315.36","8097.99","32587.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","6449.35","6449.35","6449.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","20605.36","20605.36","20605.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","8364.38","","","","","","","fee schedule","7985.09","28364.92","MSDRG Base Rate"
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8224.64","","","","","","","fee schedule","7985.09","28364.92","MSDRG Base Rate"
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","7985.09","","","","","","","fee schedule","7985.09","28364.92","Transplants-Case Rate"
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8144.79","","","","","","","fee schedule","7985.09","28364.92","MSDRG Base Rate"
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8384.34","","","","","","","fee schedule","7985.09","28364.92","MSDRG Base Rate"
"Signs And Symptoms Without Mcc","948","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","7985.09","","","","","","","fee schedule","7985.09","28364.92","Psych-Case Rate"
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27725.96","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29653.27","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","38857.98","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32219.46","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","27808.05","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35541.1","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26543.4","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42155.83","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31704.32","","","","","","","fee schedule","11175","42155.83",""
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","112692.67","112692.67","112692.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","25787.02","25787.02","25787.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","78569.37","78569.37","78569.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","66809.66","66809.66","66809.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","8604.52","8604.52","8604.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","25420.24","25291.76","40650.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","23687","23687","23687","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","47004.37","47004.37","47004.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11705.81","","","","","","","fee schedule","11175","42155.83","MSDRG Base Rate"
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11510.25","","","","","","","fee schedule","11175","42155.83","MSDRG Base Rate"
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11175","","","","","","","fee schedule","11175","42155.83","Transplants-Case Rate"
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11398.5","","","","","","","fee schedule","11175","42155.83","MSDRG Base Rate"
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11733.75","","","","","","","fee schedule","11175","42155.83","MSDRG Base Rate"
"Aftercare With Cc/Mcc","949","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11175","","","","","","","fee schedule","11175","42155.83","Psych-Case Rate"
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","14628.55","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","15645.42","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","20501.94","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","16999.37","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","14671.86","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","18751.91","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","14004.61","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","22241.92","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","16727.58","","","","","","","fee schedule","6568.81","22241.92",""
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","88794.36","23768.8","88794.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","38266.06","22696.79","111566.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","39710.07","39710.07","39710.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12458.84","12458.84","12458.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6880.83","","","","","","","fee schedule","6568.81","22241.92","MSDRG Base Rate"
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6765.87","","","","","","","fee schedule","6568.81","22241.92","MSDRG Base Rate"
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6568.81","","","","","","","fee schedule","6568.81","22241.92","Transplants-Case Rate"
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6700.19","","","","","","","fee schedule","6568.81","22241.92","MSDRG Base Rate"
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6897.25","","","","","","","fee schedule","6568.81","22241.92","MSDRG Base Rate"
"Aftercare Without Cc/Mcc","950","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6568.81","","","","","","","fee schedule","6568.81","22241.92","Psych-Case Rate"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","12957.58","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","13858.3","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","18160.07","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","15057.59","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","12995.94","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","16609.94","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","12404.92","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","19701.3","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","14816.84","","","","","","","fee schedule","5981.16","19701.3",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","29801.96","18144.2","68470.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","6698.19","6698.19","6698.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","5386.3","5386.3","5800.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","5749.28","5749.28","5749.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","29801.96","12342.66","65382.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","5636.61","5636.61","5900.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","67849.69","67849.69","67849.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","6265.27","","","","","","","fee schedule","5981.16","19701.3","MSDRG Base Rate"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","6160.59","","","","","","","fee schedule","5981.16","19701.3","MSDRG Base Rate"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","5981.16","","","","","","","fee schedule","5981.16","19701.3","Transplants-Case Rate"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","6100.78","","","","","","","fee schedule","5981.16","19701.3","MSDRG Base Rate"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","6280.22","","","","","","","fee schedule","5981.16","19701.3","MSDRG Base Rate"
"Other Factors Influencing Health Status","951","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","5981.16","","","","","","","fee schedule","5981.16","19701.3","Psych-Case Rate"
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","156868.29","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","167772.67","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","219851.19","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","182291.65","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","157332.73","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","201084.88","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","150177.57","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","238509.8","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","179377.08","","","","","","","fee schedule","56592.63","238509.8",""
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","121007.3","121007.3","121007.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","59280.78","","","","","","","fee schedule","56592.63","238509.8","MSDRG Base Rate"
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","58290.41","","","","","","","fee schedule","56592.63","238509.8","MSDRG Base Rate"
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","56592.63","","","","","","","fee schedule","56592.63","238509.8","Transplants-Case Rate"
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","57724.48","","","","","","","fee schedule","56592.63","238509.8","MSDRG Base Rate"
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","59422.26","","","","","","","fee schedule","56592.63","238509.8","MSDRG Base Rate"
"Craniotomy For Multiple Significant Trauma","955","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","56592.63","","","","","","","fee schedule","56592.63","238509.8","Psych-Case Rate"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","87696.72","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","93792.78","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","122907.11","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","101909.57","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","87956.36","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","112415.86","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","83956.29","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","133338.14","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","100280.19","","","","","","","fee schedule","32265.91","133338.14",""
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","43669.83","43669.83","80779.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","115847.58","115847.58","115847.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","138503.73","119713.75","298634.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","32889.65","32889.65","32889.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","29928.99","29928.99","29928.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","49336.62","48101.09","90829.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","27660.84","27660.84","27660.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","29967.7","29967.7","29967.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","207216.4","207216.4","207216.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","14267.7","14267.7","14267.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","56620.3","56620.3","56620.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","33798.54","","","","","","","fee schedule","32265.91","133338.14","MSDRG Base Rate"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","33233.89","","","","","","","fee schedule","32265.91","133338.14","MSDRG Base Rate"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","32265.91","","","","","","","fee schedule","32265.91","133338.14","Transplants-Case Rate"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","32911.23","","","","","","","fee schedule","32265.91","133338.14","MSDRG Base Rate"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","33879.21","","","","","","","fee schedule","32265.91","133338.14","MSDRG Base Rate"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","32265.91","","","","","","","fee schedule","32265.91","133338.14","Psych-Case Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","177581.77","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","189926.01","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","248881.17","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","206362.13","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","178107.54","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","227636.89","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","170007.59","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","270003.54","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","203062.72","","","","","","","fee schedule","63877.28","270003.54",""
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","82735.27","82735.27","82735.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","66715.57","66715.57","66715.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","85772.03","85772.03","85772.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","153240.66","153240.66","153240.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","239664.98","134333.76","515488.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","20549.6","20549.6","20549.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","61104.72","60999.86","62599.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","166845.62","166845.62","166845.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","62247.35","62247.35","62247.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","60585.51","60585.51","60585.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","77136.6","53234.95","81903.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","273032.16","273032.16","273032.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","192202.25","192202.25","192202.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","59967.08","59967.08","61419.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","20960.59","20960.59","20960.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","66911.45","","","","","","","fee schedule","63877.28","270003.54","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","65793.6","","","","","","","fee schedule","63877.28","270003.54","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","63877.28","","","","","","","fee schedule","63877.28","270003.54","Transplants-Case Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","65154.83","","","","","","","fee schedule","63877.28","270003.54","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","67071.14","","","","","","","fee schedule","63877.28","270003.54","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Mcc","957","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","63877.28","","","","","","","fee schedule","63877.28","270003.54","Psych-Case Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","98204.94","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","105031.46","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","137634.4","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","114120.84","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","98495.7","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","125886.05","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","94016.32","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","149315.33","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","112296.22","","","","","","","fee schedule","35961.51","149315.33",""
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","51428.08","43669.83","85772.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","78100.13","78100.13","78100.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","80384.24","80384.24","80384.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","75023.84","73556.5","167499.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","10219.36","10219.36","10219.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","157550.3","157550.3","157550.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","34209.67","32666.76","53153.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","90224","89724","92516","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","33407.55","33407.55","33407.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","197016.79","197016.79","197016.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","49811.44","49811.44","49811.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","37669.68","","","","","","","fee schedule","35961.51","149315.33","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","37040.36","","","","","","","fee schedule","35961.51","149315.33","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","35961.51","","","","","","","fee schedule","35961.51","149315.33","Transplants-Case Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","36680.74","","","","","","","fee schedule","35961.51","149315.33","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","37759.59","","","","","","","fee schedule","35961.51","149315.33","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","35961.51","","","","","","","fee schedule","35961.51","149315.33","Psych-Case Rate"
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","68612.25","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","73381.69","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","96160.19","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","79732.12","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","68815.39","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","87952.04","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","65685.82","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","104321.24","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","78457.32","","","","","","","fee schedule","25554.16","104321.24",""
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","78551.67","78551.67","78551.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","20260.83","20260.83","20260.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","34209.67","34209.67","34209.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26767.98","","","","","","","fee schedule","25554.16","104321.24","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","26320.78","","","","","","","fee schedule","25554.16","104321.24","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25554.16","","","","","","","fee schedule","25554.16","104321.24","Transplants-Case Rate"
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","26065.24","","","","","","","fee schedule","25554.16","104321.24","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26831.87","","","","","","","fee schedule","25554.16","104321.24","MSDRG Base Rate"
"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","959","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25554.16","","","","","","","fee schedule","25554.16","104321.24","Psych-Case Rate"
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","63711.21","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","68139.97","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","89291.38","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","74036.77","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","63899.84","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","81669.54","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","60993.81","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","96869.47","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","72853.04","","","","","","","fee schedule","23830.53","96869.47",""
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","33522.2","33522.2","33522.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","73570.65","73570.65","73570.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","38224.38","38224.38","38224.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","22885.92","22527.84","23220.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","46069.16","46069.16","46069.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","53234.95","53234.95","64486.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","83624.69","83624.69","83624.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","21527.41","21527.41","21527.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24962.48","","","","","","","fee schedule","23830.53","96869.47","MSDRG Base Rate"
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","24545.45","","","","","","","fee schedule","23830.53","96869.47","MSDRG Base Rate"
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23830.53","","","","","","","fee schedule","23830.53","96869.47","Transplants-Case Rate"
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","24307.14","","","","","","","fee schedule","23830.53","96869.47","MSDRG Base Rate"
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25022.06","","","","","","","fee schedule","23830.53","96869.47","MSDRG Base Rate"
"Other Multiple Significant Trauma With Mcc","963","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23830.53","","","","","","","fee schedule","23830.53","96869.47","Psych-Case Rate"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","35717.24","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","38200.06","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","50057.78","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","41505.87","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","35822.99","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","45784.89","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","34193.84","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","54306.15","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","40842.26","","","","","","","fee schedule","13985.43","54306.15",""
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","97409.22","97409.22","97409.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","20744.59","20744.59","20744.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","36127.61","36127.61","36127.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11949.8","11949.8","11949.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","31039.82","31039.82","31039.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","12236.55","11213.91","12736.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","12951.19","12951.19","12951.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","19808.98","19808.98","19808.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","33148","33148","33148","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11840.16","11840.16","11840.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","17993.82","17993.82","17993.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","21527.41","21527.41","21527.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","14649.74","","","","","","","fee schedule","13985.43","54306.15","MSDRG Base Rate"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14404.99","","","","","","","fee schedule","13985.43","54306.15","MSDRG Base Rate"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","13985.43","","","","","","","fee schedule","13985.43","54306.15","Transplants-Case Rate"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","14265.14","","","","","","","fee schedule","13985.43","54306.15","MSDRG Base Rate"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14684.7","","","","","","","fee schedule","13985.43","54306.15","MSDRG Base Rate"
"Other Multiple Significant Trauma With Cc","964","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","13985.43","","","","","","","fee schedule","13985.43","54306.15","Psych-Case Rate"
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21918.35","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","23441.96","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","30718.61","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","25470.62","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21983.25","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","28096.5","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20983.5","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","33325.68","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","25063.38","","","","","","","fee schedule","9132.54","33325.68",""
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","7248.67","7248.67","7248.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","9540.11","9540.11","9540.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9566.34","","","","","","","fee schedule","9132.54","33325.68","MSDRG Base Rate"
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9406.52","","","","","","","fee schedule","9132.54","33325.68","MSDRG Base Rate"
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9132.54","","","","","","","fee schedule","9132.54","33325.68","Transplants-Case Rate"
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","9315.19","","","","","","","fee schedule","9132.54","33325.68","MSDRG Base Rate"
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9589.17","","","","","","","fee schedule","9132.54","33325.68","MSDRG Base Rate"
"Other Multiple Significant Trauma Without Cc/Mcc","965","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9132.54","","","","","","","fee schedule","9132.54","33325.68","Psych-Case Rate"
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","142656.9","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","152573.4","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","199933.9","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","165777.05","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","143079.27","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","182867.72","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","136572.32","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","216902.14","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","163126.52","","","","","","","fee schedule","51594.67","216902.14",""
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","141316.48","141316.48","141316.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","178221.37","178221.37","178221.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","108793.85","108793.85","108793.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","54045.42","","","","","","","fee schedule","51594.67","216902.14","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","53142.51","","","","","","","fee schedule","51594.67","216902.14","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","51594.67","","","","","","","fee schedule","51594.67","216902.14","Transplants-Case Rate"
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","52626.56","","","","","","","fee schedule","51594.67","216902.14","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","54174.4","","","","","","","fee schedule","51594.67","216902.14","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures With Mcc","969","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","51594.67","","","","","","","fee schedule","51594.67","216902.14","Psych-Case Rate"
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","61464.61","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","65737.2","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","86142.76","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","71426.07","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","61646.59","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","78789.69","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","58843.03","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","93453.63","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","70284.07","","","","","","","fee schedule","23040.43","93453.63",""
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","24134.85","","","","","","","fee schedule","23040.43","93453.63","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23731.64","","","","","","","fee schedule","23040.43","93453.63","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","23040.43","","","","","","","fee schedule","23040.43","93453.63","Transplants-Case Rate"
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","23501.24","","","","","","","fee schedule","23040.43","93453.63","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","24192.45","","","","","","","fee schedule","23040.43","93453.63","MSDRG Base Rate"
"Hiv With Extensive O.R. Procedures Without Mcc","970","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","23040.43","","","","","","","fee schedule","23040.43","93453.63","Psych-Case Rate"
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","67258.23","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","71933.55","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","94262.53","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","78158.65","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","67457.36","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","86216.36","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","64389.55","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","102262.52","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","76909.01","","","","","","","fee schedule","25077.97","102262.52",""
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","97319.68","97319.68","101916.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","46486.98","46486.98","46486.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","67538.64","67538.64","67538.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","90627.75","90627.75","90627.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","25779.45","25743.87","70167.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","24640.17","24640.17","24640.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","47469.9","13495.21","97319.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","22795.56","22795.56","22795.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","105762.15","105762.15","105762.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","26269.17","","","","","","","fee schedule","25077.97","102262.52","MSDRG Base Rate"
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25830.31","","","","","","","fee schedule","25077.97","102262.52","MSDRG Base Rate"
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","25077.97","","","","","","","fee schedule","25077.97","102262.52","Transplants-Case Rate"
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","25579.53","","","","","","","fee schedule","25077.97","102262.52","MSDRG Base Rate"
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","26331.87","","","","","","","fee schedule","25077.97","102262.52","MSDRG Base Rate"
"Hiv With Major Related Condition With Mcc","974","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","25077.97","","","","","","","fee schedule","25077.97","102262.52","Psych-Case Rate"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30179.98","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32277.88","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42297.29","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35071.19","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30269.33","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38686.83","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28892.75","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45887.03","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34510.46","","","","","","","fee schedule","12038.04","45887.03",""
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","47469.9","12886.56","47469.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","18314.24","18314.24","18314.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","39319.57","39319.57","39319.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","12886.56","12886.56","47469.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12609.85","","","","","","","fee schedule","12038.04","45887.03","MSDRG Base Rate"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12399.18","","","","","","","fee schedule","12038.04","45887.03","MSDRG Base Rate"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12038.04","","","","","","","fee schedule","12038.04","45887.03","Transplants-Case Rate"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12278.8","","","","","","","fee schedule","12038.04","45887.03","MSDRG Base Rate"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12639.94","","","","","","","fee schedule","12038.04","45887.03","MSDRG Base Rate"
"Hiv With Major Related Condition With Cc","975","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12038.04","","","","","","","fee schedule","12038.04","45887.03","Psych-Case Rate"
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","21037.42","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","22499.8","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","29483.99","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","24446.92","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","21099.71","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","26967.26","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","20140.14","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","31986.27","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","24056.05","","","","","","","fee schedule","8822.73","31986.27",""
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","10066.36","10066.36","10066.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","9241.81","","","","","","","fee schedule","8822.73","31986.27","MSDRG Base Rate"
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","9087.41","","","","","","","fee schedule","8822.73","31986.27","MSDRG Base Rate"
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","8822.73","","","","","","","fee schedule","8822.73","31986.27","Transplants-Case Rate"
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","8999.18","","","","","","","fee schedule","8822.73","31986.27","MSDRG Base Rate"
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","9263.87","","","","","","","fee schedule","8822.73","31986.27","MSDRG Base Rate"
"Hiv With Major Related Condition Without Cc/Mcc","976","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","8822.73","","","","","","","fee schedule","8822.73","31986.27","Psych-Case Rate"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","30242.9","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","32345.17","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","42385.48","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","35144.31","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","30332.44","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","38767.49","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","28952.98","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","45982.7","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","34582.41","","","","","","","fee schedule","12060.17","45982.7",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","19003.13","19003.13","19003.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","11905.64","11905.64","11905.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","69497.02","69497.02","69497.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","49711.98","49711.98","49711.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","11572.51","11572.51","11572.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","12633.03","","","","","","","fee schedule","12060.17","45982.7","MSDRG Base Rate"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12421.98","","","","","","","fee schedule","12060.17","45982.7","MSDRG Base Rate"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","12060.17","","","","","","","fee schedule","12060.17","45982.7","Transplants-Case Rate"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","12301.37","","","","","","","fee schedule","12060.17","45982.7","MSDRG Base Rate"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12663.18","","","","","","","fee schedule","12060.17","45982.7","MSDRG Base Rate"
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","12060.17","","","","","","","fee schedule","12060.17","45982.7","Psych-Case Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","109342.4","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","116943.12","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","153243.57","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","127063.33","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","109666.13","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","140162.83","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","104678.75","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","166249.24","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","125031.78","","","","","","","fee schedule","39878.41","166249.24",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","109980.35","109980.35","109980.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","103850.68","103850.68","103850.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","112129.33","112129.33","113613.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","148887.39","75550.92","209454.06","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","40314.12","38291.72","61639.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","111538.81","111538.81","239562.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","37765.57","30822.22","39709","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","40077.17","40077.17","40077.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","54744.84","54744.84","54744.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","104381","104381","104381","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","118045.48","118045.48","118045.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","37564.42","25821.67","116451.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","126686.68","126686.68","126686.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","41772.63","","","","","","","fee schedule","39878.41","166249.24","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","41074.76","","","","","","","fee schedule","39878.41","166249.24","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","39878.41","","","","","","","fee schedule","39878.41","166249.24","Transplants-Case Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","40675.98","","","","","","","fee schedule","39878.41","166249.24","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","41872.33","","","","","","","fee schedule","39878.41","166249.24","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","981","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","39878.41","","","","","","","fee schedule","39878.41","166249.24","Psych-Case Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","57295.34","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","61278.11","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","80299.53","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","66581.1","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","57464.98","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","73445.23","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","54851.59","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","87114.49","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","65516.57","","","","","","","fee schedule","21574.16","87114.49",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","121968.19","121968.19","121968.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","18291.88","18291.88","18291.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","74928.31","74872.4","75023.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","19764.15","19764.15","19764.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","63028.32","63028.32","63028.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","19615.4","19442.3","19661.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","18896.21","18896.21","18896.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","46914.39","46914.39","46914.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","63174","63174","63174","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","19736.74","19628.79","19884.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","63496.66","63496.66","65516.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","22598.93","","","","","","","fee schedule","21574.16","87114.49","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","22221.38","","","","","","","fee schedule","21574.16","87114.49","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","21574.16","","","","","","","fee schedule","21574.16","87114.49","Transplants-Case Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","22005.64","","","","","","","fee schedule","21574.16","87114.49","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","22652.87","","","","","","","fee schedule","21574.16","87114.49","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","21574.16","","","","","","","fee schedule","21574.16","87114.49","Psych-Case Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","39944.77","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","42721.45","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","55982.67","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","46418.55","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","40063.04","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","51204.04","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","38241.05","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","60733.88","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","45676.39","","","","","","","fee schedule","15472.19","60733.88",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","99865.83","99865.83","99865.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","51896.36","51896.36","51896.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","42857.03","42857.03","42857.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","34288","34288","34288","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","45676.39","45676.39","45676.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","16207.12","","","","","","","fee schedule","15472.19","60733.88","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15936.36","","","","","","","fee schedule","15472.19","60733.88","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15472.19","","","","","","","fee schedule","15472.19","60733.88","Transplants-Case Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15781.63","","","","","","","fee schedule","15472.19","60733.88","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","16245.8","","","","","","","fee schedule","15472.19","60733.88","MSDRG Base Rate"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","983","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15472.19","","","","","","","fee schedule","15472.19","60733.88","Psych-Case Rate"
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","984","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","985","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","986","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","79898.86","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","85452.87","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","111978.4","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","92847.93","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","80135.42","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","102420.02","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","76491.03","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","121481.93","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","91363.43","","","","","","","fee schedule","29523.51","121481.93",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","12322.34","12322.34","12322.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","65691.18","65691.18","65691.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","34563.04","34563.04","34563.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","131294.21","131294.21","131294.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","27771.87","27228.94","28565.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","76908","76908","76908","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","27409.25","27409.25","28454.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","30925.88","","","","","","","fee schedule","29523.51","121481.93","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","30409.22","","","","","","","fee schedule","29523.51","121481.93","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","29523.51","","","","","","","fee schedule","29523.51","121481.93","Transplants-Case Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","30113.98","","","","","","","fee schedule","29523.51","121481.93","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","30999.69","","","","","","","fee schedule","29523.51","121481.93","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","987","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","29523.51","","","","","","","fee schedule","29523.51","121481.93","Psych-Case Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","38304.1","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","40966.73","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","53683.26","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","44511.98","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","38417.51","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","49100.91","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","36670.36","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","58239.32","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","43800.3","","","","","","","fee schedule","14895.19","58239.32",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","48597.71","48597.71","48597.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","24107.05","24107.05","24107.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","2906.99","2906.99","2906.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","14643.66","14643.66","14643.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","22567.86","14703.85","43669.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","15854.75","15854.75","15854.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","15602.71","","","","","","","fee schedule","14895.19","58239.32","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","15342.05","","","","","","","fee schedule","14895.19","58239.32","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","14895.19","","","","","","","fee schedule","14895.19","58239.32","Transplants-Case Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","15193.09","","","","","","","fee schedule","14895.19","58239.32","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","15639.95","","","","","","","fee schedule","14895.19","58239.32","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","14895.19","","","","","","","fee schedule","14895.19","58239.32","Psych-Case Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","27947.36","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","29890.06","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","39168.27","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","32476.73","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","28030.1","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","35824.9","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","26755.35","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","42492.45","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","31957.48","","","","","","","fee schedule","11252.86","42492.45",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","14145.46","14145.46","14145.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","5948.31","5948.31","5948.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","10080.23","10080.23","11403.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","11787.37","","","","","","","fee schedule","11252.86","42492.45","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11590.45","","","","","","","fee schedule","11252.86","42492.45","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","11252.86","","","","","","","fee schedule","11252.86","42492.45","Transplants-Case Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","11477.92","","","","","","","fee schedule","11252.86","42492.45","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11815.5","","","","","","","fee schedule","11252.86","42492.45","MSDRG Base Rate"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","989","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","11252.86","","","","","","","fee schedule","11252.86","42492.45","Psych-Case Rate"
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Principal Diagnosis Invalid As Discharge Diagnosis","998","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","All Commercial Plans","","","[All IP services (%BC): 75] [IP High Cost Drugs (%BC): 75] [IP Prosthetics/Implants/Devices (%BC): 75] [All Other IP (%BC): 75]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Aetna","Va Preferred Other Commercial Plan","","","[All IP services (%BC): 75.4] [All Other IP (%BC): 75.4]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Amerihealth Caritas","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Exchange","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 60.60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2544] [Psych-Per Diem: 2544] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $37,049 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 207805 Charge Threshold 336234.01 (%BC): 60.60]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Hmo","","","[Stop Loss: Total Charges > 336234.01 | Excess % of Charge: 64.70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2722] [Psych-Per Diem: 2722] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $39,625 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 222258 Charge Threshold 336234.01 (%BC): 64.70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Ppo","","","[Stop Loss: Total Charges > 224154.01 | Excess % of Charge: 54.80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1591] [Psych-Per Diem: 1591] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: Non-Kidney transplants = MSDRG base rate of $41,161 * CMS MSDRG relative weights] [Kidney Transplant-Case Rate: 221630 Charge Threshold 336300.01 (%BC): 54.80]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Healthy Blue Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Bcbs","Anthem Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Ppo/Pos","","","[Stop Loss: Total Charges > 90969 | Total % of Charge: 72.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [IP Prosthetics/Implants/Devices (%BC): 71]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Cigna","Open Access Plus B Other Commercial Plan","","","[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1033] [Psych-Per Diem: 1033] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","First Health","Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Transplants-Case Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Link Other Commercial Plan","","","[All IP services (%BC): 93] [All Other IP (%BC): 93]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Ultra Ppo","","","[Transplants (%BC): 90] [All Other IP (%BC): 74.7]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Standard Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Medcost","Virginia Plus Ppo","","","[All IP services (%BC): 74] [All Other IP (%BC): 74]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Multiplan","Phcs Ppo","","","[All IP services (%BC): 85] [All Other IP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Optum","Transplant","","","[Transplants: Pre/Post Transplant Services = Lessor of billed charges or 350% of Medicare; Multiple Organ Rates:  Heart/Kidney = $428,758 and Heart/Kidney/Pancreas = $509,903] [Heart Transplant-Case Rate: 342792] [Heart Transplant: Lessor of 80% of billed charges or $342,792 for 25 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.] [Kidney Transplant: Lessor of 80% of billed charges or living donor case rate of $119,977 for 15 days and cadaveric case rate of $114,621 for 10days; additonal per diem of $5,356 for ICU or $4,285 for Non-ICU.] [Kidney Transplant-Live Donor-Case Rate: 119977] [Kidney Transplant-Cadaveric Donor-Case Rate: 114621] [Kidney/Pancreas Simul. Transplant-Case Rate: 198444] [Pancreas Transplant-Case Rate: 112479] [Pancrease Transplant: Lessor of 80% of billed charges or $112,479 for 10 days and then an additonal per diem of $5,356 for ICU and $4,285 for Non-ICU.]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Hmo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 53] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1223.06] [SNF-Per Diem: 944] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 98.6%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 98.6]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicare Managed Care Plan","","","[MSDRG Base Rate: FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Psych-Per Diem: 994.29] [SNF-Per Diem: 778]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Ppo","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 69.5] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1193.52] [SNF-Per Diem: 921] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 80.8%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 80.8]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Sentara Health Plan","Exchange","","","[Stop Loss: Total Charges > 369383 | Excess % of Charge: 71.1] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1188.89] [SNF-Per Diem: 1094] [Transplants-Case Rate: FEE SCHEDULE] [Transplants: BMT paid 95.9%; See Optum transplant agreement for all other transplants] [Bone Marrow Transplant (%BC): 95.9]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Dsnp Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Case Rate: FEE SCHEDULE] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 9402] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Va Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://www.dmas.virginia.gov/] [Transplants: See Optum transplant agreement for transplant rates]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Community Plan - Nc Medicaid Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Onenet Workers Compensation Plan","","","[All Other IP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Qnbr Other Commercial Plan","","","[All Other IP (%BC): 57]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Unitedhealthcare","Options Ppo","","","[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 10365] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1124] [Burn  (%BC): 76.2] [Trauma  (%BC): 76.2]","","","","0","other","","","No services performed during 15-month lookback period."
"Ungroupable","999","MS-DRG","","","","","facility","inpatient","","","","","","Wellcare","Medicaid Managed Care Plan","","","[Inpatient Services: Payer leverages state specific Medicaid payment methodology.  Available, referenceable algorithm logic found here: https://medicaid.ncdhhs.gov/providers]","","","","0","other","","","No services performed during 15-month lookback period."
"PRISMASATE BKGK42.5 SOL 5000ML","0000-1069-57","NDC","","","","","facility","both","1","EA","","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PRISMASATE BKGK42.5 SOL 5000ML","0000-1069-57","NDC","","","","","facility","both","1","EA","UD","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRISMASATE B22GK4/0 SOL 5000ML","0000-1075-01","NDC","","","","","facility","both","1","EA","UD","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRISMASATE B22GK4/0 SOL 5000ML","0000-1075-01","NDC","","","","","facility","both","1","EA","","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PRISMASATE BK2/0 SOL 5000ML","0000-1075-80","NDC","","","","","facility","both","1","EA","UD","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRISMASATE BK2/0 SOL 5000ML","0000-1075-80","NDC","","","","","facility","both","1","EA","","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PRISMASATE BK2/0 SOL 5000ML","0000-1139-18","NDC","","","","","facility","both","1","EA","","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PRISMASATE BK2/0 SOL 5000ML","0000-1139-18","NDC","","","","","facility","both","1","EA","UD","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN REGULAR 100 UNIT/ML SOLN","0002-0213-01","NDC","","","","","facility","both","1","EA","","11.84","5.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN REGULAR 100 UNIT/ML SOLN","0002-0213-01","NDC","","","","","facility","both","1","EA","UD","11.92","5.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRASUGREL 10 MG TABS","0002-5123-01","NDC","","","","","facility","both","1","EA","","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRASUGREL 10 MG TABS","0002-5123-01","NDC","","","","","facility","both","1","EA","UD","5.59","2.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN LISPRO 100 UNIT/ML SOLN","0002-7510-01","NDC","","","","","facility","both","1","EA","","11.56","5.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN LISPRO 100 UNIT/ML SOLN","0002-7510-01","NDC","","","","","facility","both","1","EA","UD","11.64","5.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN LISPRO 100 UNIT/ML SOLN","0002-7510-17","NDC","","","","","facility","both","1","EA","UD","11.56","5.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN LISPRO 100 UNIT/ML SOLN","0002-7510-17","NDC","","","","","facility","both","1","EA","","11.56","5.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN LISPRO 100 UNIT/ML SOLN","0002-7533-01","NDC","","","","","facility","both","1","EA","UD","11.87","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN LISPRO 100 UNIT/ML SOLN","0002-7533-01","NDC","","","","","facility","both","1","EA","","11.87","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN REGULAR 100 UNIT/ML SOLN","0002-8215-01","NDC","","","","","facility","both","1","EA","","11.62","5.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN REGULAR 100 UNIT/ML SOLN","0002-8215-01","NDC","","","","","facility","both","1","EA","UD","11.62","5.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN REGULAR FOR PUMP- PHARMACY SUPPLIED","0002-8215-17","NDC","","","","","facility","both","1","EA","","126.54","63.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN NPH 100 UNIT/ML SUSPENSION","0002-8315-01","NDC","","","","","facility","both","1","EA","","11.75","5.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN NPH 100 UNIT/ML SUSPENSION","0002-8315-01","NDC","","","","","facility","both","1","EA","UD","12.14","6.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN NPH & REGULAR 70/30 100 UNIT/ML (70-30) SUSPENSION","0002-8715-01","NDC","","","","","facility","both","1","EA","UD","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN NPH & REGULAR 70/30 100 UNIT/ML (70-30) SUSPENSION","0002-8715-01","NDC","","","","","facility","both","1","EA","","12.14","6.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN U-500 REGULAR FOR PUMP- PHARMACY SUPPLIED","0002-8824-01","NDC","","","","","facility","both","1","EA","UD","359.57","179.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN U-500 REGULAR FOR PUMP- PHARMACY SUPPLIED","0002-8824-01","NDC","","","","","facility","both","1","EA","","486.65","243.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KENALOG PER 10 MG","0003-0293-05","NDC","","","","","facility","both","1","EA","PN","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"KENALOG PER 10 MG","0003-0293-20","NDC","","","","","facility","both","1","EA","PN","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"KENALOG PER 10 MG","0003-0293-28","NDC","","","","","facility","both","1","EA","PN","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"KENALOG PER 10 MG","0003-0293-28","NDC","","","","","facility","both","1","EA","50,PN","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"KENALOG PER 10 MG","0003-0293-28","NDC","","","","","facility","both","1","EA","RT,PN","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier RT: Right side (used to identify procedures performed on the right side of the body) | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","JG","2864.5","1432.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","TB","3795.58","1897.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","","3795.58","1897.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","UD","4493.89","2246.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","JG,UD","4493.89","2246.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","JG,UD,TB","4959.44","2479.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","JG,TB","6123.29","3061.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BELATACEPT 250 MG SOLR 1 EACH VIAL","0003-0371-13","NDC","","","","","facility","both","1","EA","UD,TB","6123.29","3061.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION","0003-0494-20","NDC","","","","","facility","both","1","EA","UD","78.06","39.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION","0003-0494-20","NDC","","","","","facility","both","1","EA","","78.06","39.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"APIXABAN 2.5 MG TABS","0003-0893-31","NDC","","","","","facility","both","1","EA","UD","22.95","11.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"APIXABAN 2.5 MG TABS","0003-0893-31","NDC","","","","","facility","both","1","EA","","22.95","11.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"APIXABAN 5 MG TABS","0003-0894-21","NDC","","","","","facility","both","1","EA","","22.95","11.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"APIXABAN 5 MG TABS","0003-0894-21","NDC","","","","","facility","both","1","EA","UD","22.95","11.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"APIXABAN 5 MG TABS","0003-0894-31","NDC","","","","","facility","both","1","EA","UD","22.95","11.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"APIXABAN 5 MG TABS","0003-0894-31","NDC","","","","","facility","both","1","EA","","22.95","11.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZTREONAM 1 GRAM SOLR 1 EACH VIAL","0003-2560-16","NDC","","","","","facility","both","1","EA","","173.19","86.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AZTREONAM 2 GRAM SOLR 1 EACH VIAL","0003-2570-16","NDC","","","","","facility","both","1","EA","UD","333.42","166.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZTREONAM 2 GRAM SOLR 1 EACH VIAL","0003-2570-16","NDC","","","","","facility","both","1","EA","","333.42","166.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"MYCOPHENOLATE 200 MG/ML SUSR","0004-0261-29","NDC","","","","","facility","both","1","EA","","11.61","5.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MYCOPHENOLATE 200 MG/ML SUSR","0004-0261-29","NDC","","","","","facility","both","1","EA","UD","11.61","5.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML SYRG","0005-0100-01","NDC","","","","","facility","both","1","EA","","930.22","465.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML SYRG","0005-0100-01","NDC","","","","","facility","both","1","EA","UD","930.22","465.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PNEUMOCOCCAL 13-VAL CONJ (PREVNAR 13) VACC 0.5 ML SYRG","0005-1971-01","NDC","","","","","facility","both","1","EA","UD","1154.51","577.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PNEUMOCOCCAL 13-VAL CONJ (PREVNAR 13) VACC 0.5 ML SYRG","0005-1971-01","NDC","","","","","facility","both","1","EA","","1154.51","577.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PNEUMOCOCCAL 13-VAL CONJ (PREVNAR 13) VACC 0.5 ML SYRG","0005-1971-05","NDC","","","","","facility","both","1","EA","","1154.51","577.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML SYRG","0005-2000-01","NDC","","","","","facility","both","1","EA","UD","1286.67","643.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML SYRG","0005-2000-01","NDC","","","","","facility","both","1","EA","","1286.67","643.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML SYRG","0005-2000-01","NDC","","","","","facility","both","1","EA","PN","1291","645.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML SYRG","0005-2000-02","NDC","","","","","facility","both","1","EA","","1286.67","643.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PCV20 VACCINE IM","0005-2000-10","NDC","","","","","facility","both","1","EA","","1291","645.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MULTIVITAMIN WITH MINERAL LIQD","0005-4344-15","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMIN WITH MINERAL LIQD","0005-4344-15","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SITAGLIPTIN PHOSPHATE 50 MG TABS","0006-0112-01","NDC","","","","","facility","both","1","EA","","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SITAGLIPTIN PHOSPHATE 50 MG TABS","0006-0112-01","NDC","","","","","facility","both","1","EA","UD","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SITAGLIPTIN PHOSPHATE 25 MG TABS","0006-0221-01","NDC","","","","","facility","both","1","EA","UD","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SITAGLIPTIN PHOSPHATE 25 MG TABS","0006-0221-01","NDC","","","","","facility","both","1","EA","","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RALTEGRAVIR 400 MG TABS","0006-0227-61","NDC","","","","","facility","both","1","EA","","58.94","29.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RALTEGRAVIR 400 MG TABS","0006-0227-61","NDC","","","","","facility","both","1","EA","UD","58.94","29.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SITAGLIPTIN PHOSPHATE 100 MG TABS","0006-0277-01","NDC","","","","","facility","both","1","EA","UD","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SITAGLIPTIN PHOSPHATE 100 MG TABS","0006-0277-01","NDC","","","","","facility","both","1","EA","","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SITAGLIPTIN PHOSPHATE 100 MG TABS","0006-0277-28","NDC","","","","","facility","both","1","EA","","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SITAGLIPTIN PHOSPHATE 100 MG TABS","0006-0277-28","NDC","","","","","facility","both","1","EA","UD","38.56","19.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SITAGLIPTIN PHOSPHATE 100 MG TABS","0006-0277-54","NDC","","","","","facility","both","1","EA","UD","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SITAGLIPTIN PHOSPHATE 100 MG TABS","0006-0277-54","NDC","","","","","facility","both","1","EA","","37.18","18.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BEZLOTOXUMAB 25 MG/ML SOLN 40 ML VIAL","0006-3025-00","NDC","","","","","facility","both","1","EA","JG","11653.64","5826.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BEZLOTOXUMAB 25 MG/ML SOLN 40 ML VIAL","0006-3025-00","NDC","","","","","facility","both","1","EA","","15210.44","7605.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DORAVIRINE 100 MG TABS","0006-3069-01","NDC","","","","","facility","both","1","EA","","96.69","48.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DORAVIRINE 100 MG TABS","0006-3069-01","NDC","","","","","facility","both","1","EA","UD","96.69","48.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LETERMOVIR 480 MG TABS","0006-3076-03","NDC","","","","","facility","both","1","EA","","286.87","143.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HEP B VACCINE ADULT IM","0006-4094-01","NDC","","","","","facility","both","1","EA","","201","100.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEP A VACCINE ADULT IM","0006-4096-01","NDC","","","","","facility","both","1","EA","","230","115","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML SUSPENSION","0006-4119-01","NDC","","","","","facility","both","1","EA","","1447.81","723.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML SYRG","0006-4121-02","NDC","","","","","facility","both","1","EA","","1544.17","772.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MEASLES, MUMPS AND RUBELLA VACCINE 1,000-12,500 TCID50/0.5 ML SOLR","0006-4681-01","NDC","","","","","facility","both","1","EA","UD","504.41","252.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEASLES, MUMPS AND RUBELLA VACCINE 1,000-12,500 TCID50/0.5 ML SOLR","0006-4681-01","NDC","","","","","facility","both","1","EA","","504.41","252.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VARICELLA VIRUS VACC LIVE (PF) 1,350 UNIT/0.5 ML SUSR","0006-4827-01","NDC","","","","","facility","both","1","EA","","904.39","452.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VARICELLA VIRUS VACC LIVE (PF) 1,350 UNIT/0.5 ML SUSR","0006-4827-01","NDC","","","","","facility","both","1","EA","UD","904.39","452.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LETERMOVIR 480 MG/24 ML SOLN 24 ML VIAL","0006-5004-01","NDC","","","","","facility","both","1","EA","","1078.75","539.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LETERMOVIR 480 MG/24 ML SOLN 24 ML VIAL","0006-5004-01","NDC","","","","","facility","both","1","EA","UD","2155","1077.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LETERMOVIR 480 MG/24 ML SOLN 24 ML VIAL","0006-5004-02","NDC","","","","","facility","both","1","EA","","1078.75","539.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SUGAMMADEX 100 MG/ML SOLN","0006-5423-12","NDC","","","","","facility","both","1","EA","UD","664.04","332.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUGAMMADEX 100 MG/ML SOLN","0006-5423-12","NDC","","","","","facility","both","1","EA","","664.04","332.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SUGAMMADEX 100 MG/ML SOLN","0006-5425-05","NDC","","","","","facility","both","1","EA","","1416.25","708.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SUGAMMADEX 100 MG/ML SOLN","0006-5425-05","NDC","","","","","facility","both","1","EA","UD","1416.25","708.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOPRAZOLE 40 MG SOLR 1 EACH VIAL","0008-0923-51","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"PANTOPRAZOLE 40 MG SOLR 1 EACH VIAL","0008-0923-51","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIGECYCLINE 50 MG SOLR 1 EACH VIAL","0008-4990-19","NDC","","","","","facility","both","1","EA","","359.24","179.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIGECYCLINE 50 MG SOLR 1 EACH VIAL","0008-4990-20","NDC","","","","","facility","both","1","EA","","359.24","179.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML SOLR 1 EACH VIAL","0009-0003-02","NDC","","","","","facility","both","1","EA","UD","298.63","149.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML SOLR 1 EACH VIAL","0009-0003-02","NDC","","","","","facility","both","1","EA","","298.63","149.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE SOD SUCC (PF) 1,000 MG/8 ML SOLR 1 EACH VIAL","0009-0005-01","NDC","","","","","facility","both","1","EA","","761.62","380.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML SOLR","0009001103","NDC","","","","","facility","both","1","EA","UD","4.84","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML SOLR","0009001103","NDC","","","","","facility","both","1","EA","","118.2","59.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML SOLR","0009-0011-04","NDC","","","","","facility","both","1","EA","UD","118.2","59.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML SOLR","0009-0011-04","NDC","","","","","facility","both","1","EA","","118.2","59.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"HYDROCORTISONE SOD SUCC (PF) 500 MG/4 ML SOLR 1 EACH VIAL","0009-0016-12","NDC","","","","","facility","both","1","EA","UD","832.62","416.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML SOLR 1 EACH VIAL","0009-0018-20","NDC","","","","","facility","both","1","EA","UD","380.41","190.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML SOLR 1 EACH VIAL","0009-0018-20","NDC","","","","","facility","both","1","EA","","380.41","190.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLR","0009-0039-28","NDC","","","","","facility","both","1","EA","UD","40.29","20.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLR","0009-0039-28","NDC","","","","","facility","both","1","EA","","40.29","20.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLR","0009-0039-30","NDC","","","","","facility","both","1","EA","UD","40.29","20.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLR","0009-0039-30","NDC","","","","","facility","both","1","EA","","40.29","20.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLR","0009-0047-22","NDC","","","","","facility","both","1","EA","UD","63.35","31.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLR","0009-0047-22","NDC","","","","","facility","both","1","EA","","63.35","31.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLR","0009-0047-25","NDC","","","","","facility","both","1","EA","","63.35","31.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLR","0009-0047-25","NDC","","","","","facility","both","1","EA","UD","63.35","31.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GELATIN ADSORBABLE SPONGE 100 SPGE","0009-0342-01","NDC","","","","","facility","both","1","EA","","51.87","25.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC 1,000 MG SOLR 1 EACH VIAL","0009-0698-01","NDC","","","","","facility","both","1","EA","UD","205.63","102.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLR","0009-0825-01","NDC","","","","","facility","both","1","EA","","20.95","10.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLR","0009-0825-01","NDC","","","","","facility","both","1","EA","UD","21.9","10.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPROST 250 MCG/ML SOLN","0009-0856-05","NDC","","","","","facility","both","1","EA","","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPROST 250 MCG/ML SOLN","0009-0856-05","NDC","","","","","facility","both","1","EA","UD","431.24","215.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPROST 250 MCG/ML SOLN","0009-0856-08","NDC","","","","","facility","both","1","EA","UD","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPROST 250 MCG/ML SOLN","0009-0856-08","NDC","","","","","facility","both","1","EA","","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CLINDAMYCIN 150 MG/ML SOLN","0009-0902-11","NDC","","","","","facility","both","1","EA","","25.15","12.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INJ, METHYLPRED ACETATE 1 MG","0009-3073-01","NDC","","","","","facility","both","1","EA","PN","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION","0009-3073-03","NDC","","","","","facility","both","1","EA","","56.88","28.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION","0009-3073-03","NDC","","","","","facility","both","1","EA","UD","56.88","28.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IDARUBICIN 1 MG/ML SOLN 5 ML VIAL","0013-2576-91","NDC","","","","","facility","both","1","EA","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IDARUBICIN 1 MG/ML SOLN 10 ML VIAL","0013-2586-10","NDC","","","","","facility","both","1","EA","","528.4","264.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IDARUBICIN 1 MG/ML SOLN 10 ML VIAL","0013-2586-91","NDC","","","","","facility","both","1","EA","","524.4","262.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IDARUBICIN 1 MG/ML SOLN 20 ML VIAL","0013-2596-91","NDC","","","","","facility","both","1","EA","","390.4","195.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IOTHALAMATE MEGLUMINE 17.2 % SOLN","0019-0862-07","NDC","","","","","facility","both","1","EA","","800","400","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0023-0403-50","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0023-0403-50","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0023-0403-70","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0023-0403-70","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM-MINERAL OIL 57.3-42.5 % OINT 3.5 G TUBE","0023066704","NDC","","","","","facility","both","1","EA","UD","11.46","5.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM-MINERAL OIL 57.3-42.5 % OINT 3.5 G TUBE","0023066704","NDC","","","","","facility","both","1","EA","","11.46","5.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BALANCED SALT SOLN 500 ML PLAS CONT","0023-0850-50","NDC","","","","","facility","both","1","EA","","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INJECTION,ONABOTULINUMTOXINA","0023-1145-01","NDC","","","","","facility","both","1","EA","PN","638","319","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BIMATOPROST 0.01 % DROP 2.5 ML DROP BTL","0023-3205-03","NDC","","","","","facility","both","1","EA","","433.09","216.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INJECTION,ONABOTULINUMTOXINA","0023-3921-02","NDC","","","","","facility","both","1","EA","","29","14.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INJECTION,ONABOTULINUMTOXINA","0023-3921-02","NDC","","","","","facility","both","1","EA","PN","3480","1740","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0023-5487-50","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0023-5487-50","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVONORGESTREL 20.4 MCG/24 HR (8 YRS) 52 MG IUD","0023-5858-01","NDC","","","","","facility","both","1","EA","","883.1","441.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVONORGESTREL 20.4 MCG/24 HR (8 YRS) 52 MG IUD","0023-5858-01","NDC","","","","","facility","both","1","EA","UD","883.1","441.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRON DEXTRAN COMPLEX 50 MG/ML SOLN 2 ML VIAL","0023-6082-01","NDC","","","","","facility","both","1","EA","UD","55.34","27.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRON DEXTRAN COMPLEX 50 MG/ML SOLN 2 ML VIAL","0023-6082-10","NDC","","","","","facility","both","1","EA","","55.34","27.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IRON DEXTRAN COMPLEX 50 MG/ML SOLN 2 ML VIAL","0023-6082-10","NDC","","","","","facility","both","1","EA","UD","57.98","28.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOXYMETHYLCELLULOSE 1 % DLGL 15 ML DROP BTL","0023-9205-15","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INJECTION,ONABOTULINUMTOXINA","0023-9232-01","NDC","","","","","facility","both","1","EA","PN","1160","580","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DRONEDARONE 400 MG TABS","0024-4142-60","NDC","","","","","facility","both","1","EA","UD","25.56","12.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DRONEDARONE 400 MG TABS","0024-4142-60","NDC","","","","","facility","both","1","EA","","25.56","12.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RASBURICASE 7.5 MG SOLR 1 EACH VIAL","0024-5151-75","NDC","","","","","facility","both","1","EA","JG","17542.7","8771.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"INSULIN LISPRO 100 UNIT/ML SOLN","0024-5926-05","NDC","","","","","facility","both","1","EA","UD","11.64","5.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN LISPRO 100 UNIT/ML SOLN","0024-5926-05","NDC","","","","","facility","both","1","EA","","11.68","5.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SPIRONOLACTONE-HCTZ","0025-1011-31","NDC","","","","","facility","both","1","EA","UD","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIPASE-PROTEASE-AMYLASE 12,000-38,000 -60,000 UNIT CPDR","0032-0047-70","NDC","","","","","facility","both","1","EA","","12.46","6.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIPASE-PROTEASE-AMYLASE 12,000-38,000 -60,000 UNIT CPDR","0032-0047-70","NDC","","","","","facility","both","1","EA","UD","12.87","6.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIPASE-PROTEASE-AMYLASE 12,000-38,000 -60,000 UNIT CPDR","0032-1212-01","NDC","","","","","facility","both","1","EA","","11.87","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIPASE-PROTEASE-AMYLASE 12,000-38,000 -60,000 UNIT CPDR","0032-1212-01","NDC","","","","","facility","both","1","EA","UD","12.87","6.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIPASE-PROTEASE-AMYLASE 12,000-38,000 -60,000 UNIT CPDR","0032-1212-07","NDC","","","","","facility","both","1","EA","","12.87","6.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIPASE-PROTEASE-AMYLASE 24,000-76,000 -120,000 UNIT CPDR","0032-1224-01","NDC","","","","","facility","both","1","EA","UD","20.34","10.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIPASE-PROTEASE-AMYLASE 24,000-76,000 -120,000 UNIT CPDR","0032-1224-01","NDC","","","","","facility","both","1","EA","","20.34","10.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIPASE-PROTEASE-AMYLASE 24,000-76,000 -120,000 UNIT CPDR","0032-1224-07","NDC","","","","","facility","both","1","EA","","20.96","10.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIPASE-PROTEASE-AMYLASE 24,000-76,000 -120,000 UNIT CPDR","0032-1224-07","NDC","","","","","facility","both","1","EA","UD","33.92","16.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIPASE-PROTEASE-AMYLASE 24,000-76,000 -120,000 UNIT CPDR","0032-2636-01","NDC","","","","","facility","both","1","EA","","20.34","10.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIPASE-PROTEASE-AMYLASE 24,000-76,000 -120,000 UNIT CPDR","0032-2636-01","NDC","","","","","facility","both","1","EA","UD","20.34","10.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN G","00338-1021-04","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PENICILLIN G","00338-1021-04","NDC","","","","","facility","both","1","EA","UD","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE-PRAMOXINE 1-1 % FOAM 10 G CAN","0037-6822-10","NDC","","","","","facility","both","1","EA","UD","446.75","223.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE-PRAMOXINE 1-1 % FOAM 10 G CAN","0037-6822-10","NDC","","","","","facility","both","1","EA","","446.75","223.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ESTROGENS (CONJUGATED) 25 MG SOLR","0046-0749-05","NDC","","","","","facility","both","1","EA","UD","1786.42","893.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTROGENS (CONJUGATED) 25 MG SOLR","0046-0749-05","NDC","","","","","facility","both","1","EA","","1786.42","893.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESTROGENS (CONJUGATED) 0.45 MG TABS","0046-1101-81","NDC","","","","","facility","both","1","EA","","30.1","15.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESTROGENS (CONJUGATED) 0.625 MG TABS","0046-1102-81","NDC","","","","","facility","both","1","EA","UD","4.35","2.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTROGENS (CONJUGATED) 0.625 MG TABS","0046-1102-81","NDC","","","","","facility","both","1","EA","","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PENICILLIN","0049-0420-05","NDC","","","","","facility","both","1","EA","UD","73.7","36.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN G POTASSIUM 5 MILLION UNIT SOLR 1 EACH VIAL","0049-0520-22","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN G POTASSIUM 5 MILLION UNIT SOLR 1 EACH VIAL","0049-0520-22","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"PENICILLIN G POTASSIUM 5 MILLION UNIT SOLR","0049-0520-84","NDC","","","","","facility","both","1","EA","","2.98","1.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PENICILLIN G POTASSIUM 5 MILLION UNIT SOLR","0049-0520-84","NDC","","","","","facility","both","1","EA","UD","3.16","1.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN G POTASSIUM 20 MILLION UNIT SOLR 1 EACH VIAL","0049-0530-28","NDC","","","","","facility","both","1","EA","","33.74","16.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PENICILLIN G POTASSIUM 20 MILLION UNIT SOLR 1 EACH VIAL","0049-0530-28","NDC","","","","","facility","both","1","EA","UD","49.37","24.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG SOLR 1 EACH VIAL","0049-3190-01","NDC","","","","","facility","both","1","EA","","145.69","72.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VORICONAZOLE 200 MG SOLR 1 EACH VIAL","0049-3190-01","NDC","","","","","facility","both","1","EA","UD","163.59","81.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG SOLR","0049-3190-28","NDC","","","","","facility","both","1","EA","UD","145.69","72.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG SOLR","0049-3190-28","NDC","","","","","facility","both","1","EA","","143.19","71.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ETONOGESTREL 68 MG IMPL","0052-4330-01","NDC","","","","","facility","both","1","EA","","1601.96","800.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISMUTH SUBSALICYLATE 262 MG/15 ML SUSPENSION","00536-1286-30","NDC","","","","","facility","both","1","EA","UD","14.41","7.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISMUTH SUBSALICYLATE 262 MG/15 ML SUSPENSION","00536-1286-30","NDC","","","","","facility","both","1","EA","","4.96","2.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG SOLR","0053-7201-02","NDC","","","","","facility","both","1","EA","JG","12089.48","6044.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"FLECAINIDE 50 MG TABS","0054-0010-20","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLECAINIDE 50 MG TABS","0054-0010-20","NDC","","","","","facility","both","1","EA","UD","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLECAINIDE 100 MG TABS","0054-0011-20","NDC","","","","","facility","both","1","EA","","0.42","0.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLECAINIDE 100 MG TABS","0054-0011-20","NDC","","","","","facility","both","1","EA","UD","1.42","0.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 10 MG TABS","0054-0017-20","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 10 MG TABS","0054-0017-20","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","0054-0018-20","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 20 MG TABS","0054-0018-20","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IPRATROPIUM 21 MCG (0.03 %) SPRY 30 ML CANISTER","0054-0045-44","NDC","","","","","facility","both","1","EA","UD","103.9","51.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IPRATROPIUM 21 MCG (0.03 %) SPRY 30 ML CANISTER","0054-0045-44","NDC","","","","","facility","both","1","EA","","103.9","51.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IPRATROPIUM 42 MCG (0.06 %) SPRY 15 ML CANISTER","0054-0046-41","NDC","","","","","facility","both","1","EA","","103.9","51.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CITALOPRAM 10 MG/5 ML SOLN","0054-0062-58","NDC","","","","","facility","both","1","EA","","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CITALOPRAM 10 MG/5 ML SOLN","0054-0062-58","NDC","","","","","facility","both","1","EA","UD","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 1 MG/ML SOLN","0054-0063-44","NDC","","","","","facility","both","1","EA","UD","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 1 MG/ML SOLN","0054-0063-44","NDC","","","","","facility","both","1","EA","","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 15 MG TABS","0054-0235-24","NDC","","","","","facility","both","1","EA","UD","2.15","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 15 MG TABS","0054-0235-24","NDC","","","","","facility","both","1","EA","","2.15","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CODEINE SULFATE 15 MG TABS","0054-0243-24","NDC","","","","","facility","both","1","EA","","3.16","1.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 1 MG/ML LIQD","0054-0386-05","NDC","","","","","facility","both","1","EA","","31","15.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 1 MG/ML LIQD","0054-0386-63","NDC","","","","","facility","both","1","EA","UD","2.59","1.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 1 MG/ML LIQD","0054-0386-63","NDC","","","","","facility","both","1","EA","","2.59","1.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 100 MG/5 ML (20 MG/ML) SOLN","0054051755","NDC","","","","","facility","both","1","EA","UD","9.88","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 100 MG/5 ML (20 MG/ML) SOLN","0054051755","NDC","","","","","facility","both","1","EA","","9.88","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHADONE 10 MG TABS","0054-0710-20","NDC","","","","","facility","both","1","EA","","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHADONE 10 MG TABS","0054-0710-20","NDC","","","","","facility","both","1","EA","UD","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITRIOL 1 MCG/ML SOLN","0054-3120-01","NDC","","","","","facility","both","1","EA","UD","22.51","11.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITRIOL 1 MCG/ML SOLN","0054-3120-01","NDC","","","","","facility","both","1","EA","","22.51","11.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCITRIOL 1 MCG/ML SOLN","0054-3120-41","NDC","","","","","facility","both","1","EA","UD","22.51","11.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITRIOL 1 MCG/ML SOLN","0054-3120-41","NDC","","","","","facility","both","1","EA","","22.51","11.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE 1 MG/ML DROP","0054-3176-44","NDC","","","","","facility","both","1","EA","","3.45","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE 1 MG/ML DROP","0054-3176-44","NDC","","","","","facility","both","1","EA","UD","84.48","42.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 0.5 MG/5 ML SOLN","0054-3177-57","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 0.5 MG/5 ML SOLN","0054-3177-57","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE 0.5 MG/5 ML SOLN","0054-3177-63","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 0.5 MG/5 ML SOLN","0054-3177-63","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION SPSN 16 G AER W/ADAP","0054-3270-99","NDC","","","","","facility","both","1","EA","UD","12.54","6.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION SPSN 16 G AER W/ADAP","0054-3270-99","NDC","","","","","facility","both","1","EA","","12.54","6.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"FUROSEMIDE 60 ML BOTTLE","0054-3294-46","NDC","","","","","facility","both","1","EA","UD","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 60 ML BOTTLE","0054-3294-46","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","0054-3505-47","NDC","","","","","facility","both","1","EA","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","0054-3505-47","NDC","","","","","facility","both","1","EA","UD","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG/ML CONC","0054-3553-44","NDC","","","","","facility","both","1","EA","UD","5.06","2.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG/ML CONC","0054-3553-44","NDC","","","","","facility","both","1","EA","","7.08","3.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHADONE 1MG/ML","0054-3555-63","NDC","","","","","facility","both","1","EA","","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHADONE 1MG/ML","0054-3555-63","NDC","","","","","facility","both","1","EA","UD","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 5 MG/5 ML SOLN","0054-3722-50","NDC","","","","","facility","both","1","EA","","11.41","5.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PREDNISONE 5 MG/5 ML SOLN","0054-3722-50","NDC","","","","","facility","both","1","EA","UD","56.8","28.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 20 MG/5 ML (4 MG/ML) SOLN","0054-3727-63","NDC","","","","","facility","both","1","EA","UD","2.68","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 20 MG/5 ML (4 MG/ML) SOLN","0054-3727-63","NDC","","","","","facility","both","1","EA","","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MERCAPTOPURINE 50 MG TABS","0054-4581-11","NDC","","","","","facility","both","1","EA","","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOTRIMAZOLE 10 MG TROC","0054-8146-22","NDC","","","","","facility","both","1","EA","UD","3.97","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 10 MG TROC","0054-8146-22","NDC","","","","","facility","both","1","EA","","3.97","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXAMETHASONE 4 MG TABS","0054-8175-25","NDC","","","","","facility","both","1","EA","","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXAMETHASONE 4 MG TABS","0054-8175-25","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 2 MG TABS","0054-8176-25","NDC","","","","","facility","both","1","EA","UD","2.17","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 2 MG TABS","0054-8176-25","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXAMETHASONE 0.5 MG TABS","0054-8179-25","NDC","","","","","facility","both","1","EA","UD","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 0.5 MG TABS","0054-8179-25","NDC","","","","","facility","both","1","EA","","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FUROSEMIDE 20 MG TABS","0054-8297-25","NDC","","","","","facility","both","1","EA","","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FUROSEMIDE 20 MG TABS","0054-8297-25","NDC","","","","","facility","both","1","EA","UD","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 40 MG TABS","0054-8299-25","NDC","","","","","facility","both","1","EA","UD","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 40 MG TABS","0054-8299-25","NDC","","","","","facility","both","1","EA","","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN 5 MG TABS","0054-8496-19","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LITHIUM 150 MG CAPS","0054-8526-25","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LITHIUM 150 MG CAPS","0054-8526-25","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LITHIUM 300 MG CAPS","0054-8527-25","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LITHIUM 300 MG CAPS","0054-8527-25","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOTREXATE 2.5 MG TABS 100 EACH BLIST PACK","0054-8550-25","NDC","","","","","facility","both","1","EA","","7.02","3.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 5 MG TABS","0054-8724-25","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 5 MG TABS","0054-8724-25","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 2.5 MG TABS","0054-8740-25","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 2.5 MG TABS","0054-8740-25","NDC","","","","","facility","both","1","EA","","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 10 MG TABS","0054-9817-25","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBACHOL 0.01 % SOLN","0065-0023-15","NDC","","","","","facility","both","1","EA","","111.38","55.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"CARBACHOL 0.01 % SOLN","0065-0023-15","NDC","","","","","facility","both","1","EA","UD","111.38","55.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUORESCEIN 500 MG/5 ML (10 %) SOLN","0065-0092-65","NDC","","","","","facility","both","1","EA","","325","162.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % DROP 2 ML DROP BTL","0065-0359-02","NDC","","","","","facility","both","1","EA","","89.15","44.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % DROP 2 ML DROP BTL","0065-0359-02","NDC","","","","","facility","both","1","EA","UD","89.15","44.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPENTOLATE 1 % DROP","0065-0396-02","NDC","","","","","facility","both","1","EA","UD","6.74","3.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPENTOLATE 1 % DROP","0065-0396-02","NDC","","","","","facility","both","1","EA","","6.74","3.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ARTIFICIAL TEAR 0.5 % DROP 15 ML DROP BTL","0065-0408-72","NDC","","","","","facility","both","1","EA","UD","84.88","42.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARTIFICIAL TEAR 0.5 % DROP 15 ML DROP BTL","0065-0408-72","NDC","","","","","facility","both","1","EA","","84.88","42.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROVIDONE-IODINE 5% 5 % SOLN","0065-0411-30","NDC","","","","","facility","both","1","EA","","1.94","0.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROVIDONE-IODINE 5% 5 % SOLN","0065-0411-30","NDC","","","","","facility","both","1","EA","UD","1.94","0.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FORTIFIED TOBRAMYCIN EYE DROPS 15 MG/ML DROP 5 ML DROP BTL","0065-0643-05","NDC","","","","","facility","both","1","EA","","49","24.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FORTIFIED TOBRAMYCIN EYE DROPS 15 MG/ML DROP 5 ML DROP BTL","0065-0643-05","NDC","","","","","facility","both","1","EA","UD","49","24.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TETRACAINE 0.5 % DROP","0065-0741-14","NDC","","","","","facility","both","1","EA","","44.65","22.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"TETRACAINE 0.5 % DROP","0065-0741-14","NDC","","","","","facility","both","1","EA","UD","44.65","22.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BALANCED SALT SOLN 15 ML BOTTLE","0065-0795-15","NDC","","","","","facility","both","1","EA","","47.9","23.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 36 ML"
"BALANCED SALT SOLN 15 ML BOTTLE","0065-0795-15","NDC","","","","","facility","both","1","EA","UD","47.9","23.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 36 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BALANCED SALT PLUS SOLN 500 ML BOTTLE","0065-0800-50","NDC","","","","","facility","both","1","EA","UD","561.88","280.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BALANCED SALT PLUS SOLN 500 ML BOTTLE","0065-0800-50","NDC","","","","","facility","both","1","EA","","561.88","280.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","0067-0333-22","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","0067-0333-22","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFAMPIN 600 MG SOLR 1 EACH VIAL","0068-0597-01","NDC","","","","","facility","both","1","EA","","227.24","113.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RITUXIMAB-PVVR 10 MG/ML SOLN 10 ML VIAL","0069-0238-01","NDC","","","","","facility","both","1","EA","UD","13833.8","6916.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RITUXIMAB-PVVR 10 MG/ML SOLN 10 ML VIAL","0069-0238-01","NDC","","","","","facility","both","1","EA","","13833.8","6916.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RITUXIMAB-PVVR 10 MG/ML SOLN 50 ML VIAL","0069-0249-01","NDC","","","","","facility","both","1","EA","UD","31037","15518.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RITUXIMAB-PVVR 10 MG/ML SOLN 50 ML VIAL","0069-0249-01","NDC","","","","","facility","both","1","EA","","31037","15518.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRASTUZUMAB-QYYP 420 MG SOLR 1 EACH VIAL","0069-0305-01","NDC","","","","","facility","both","1","EA","JG,TB","11337.94","5668.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML SOLN","0069-0338-01","NDC","","","","","facility","both","1","EA","","4627.5","2313.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPOETIN ALFA-EPBX (ESRD) 10,000 UNIT/ML SOLN","0069-1308-01","NDC","","","","","facility","both","1","EA","UD","600.68","300.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA-EPBX (ESRD) 10,000 UNIT/ML SOLN","0069-1308-01","NDC","","","","","facility","both","1","EA","UD,JB","600.68","300.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier JB: Administered subcutaneously"
"EPOETIN ALFA-EPBX (ESRD) 10,000 UNIT/ML SOLN","0069-1308-01","NDC","","","","","facility","both","1","EA","","812.46","406.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","JB","1130.12","565.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","EC,JB","1130.12","565.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier JB: Administered subcutaneously"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","JG,EC,JB","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier JB: Administered subcutaneously"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","JG,UD","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","TB","268.14","134.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","JG","578.51","289.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","","268.14","134.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","UD","268.14","134.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA-EPBX (ESRD) 20,000 UNIT/ML SOLN","0069-1311-01","NDC","","","","","facility","both","1","EA","UD,TB","268.14","134.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"EPOETIN ALFA-EPBX (NON-ESRD) 20,000 UNIT/ML SOLN","0069-1311-10","NDC","","","","","facility","both","1","EA","JG","578.51","289.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"EPOETIN ALFA-EPBX (NON-ESRD) 20,000 UNIT/ML SOLN","0069-1311-10","NDC","","","","","facility","both","1","EA","TB","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"EPOETIN ALFA-EPBX (NON-ESRD) 20,000 UNIT/ML SOLN","0069-1311-10","NDC","","","","","facility","both","1","EA","UD","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA-EPBX (NON-ESRD) 20,000 UNIT/ML SOLN","0069-1311-10","NDC","","","","","facility","both","1","EA","JG,UD","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA-EPBX (NON-ESRD) 20,000 UNIT/ML SOLN","0069-1311-10","NDC","","","","","facility","both","1","EA","","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"EPOETIN ALFA-EPBX (NON-ESRD) 20,000 UNIT/ML SOLN","0069-1311-10","NDC","","","","","facility","both","1","EA","JG,EC,JB","826.45","413.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier JB: Administered subcutaneously"
"COVID VAC23-24(12UP)(RAXT)(PF) 30 MCG/0.3 ML SYRG","0069-2377-01","NDC","","","","","facility","both","1","EA","UD","647.24","323.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COVID VAC23-24(12UP)(RAXT)(PF) 30 MCG/0.3 ML SYRG","0069-2377-01","NDC","","","","","facility","both","1","EA","","647.24","323.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SARSCOV2 VACC 30MCG/0.3ML TRIS-SUCROSE IM USE (PFIZER)","0069-2432-01","NDC","","","","","facility","both","1","EA","","131.1","65.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ELRANATAMAB-BCMM 40 MG/ML SOLN","0069-2522-02","NDC","","","","","facility","both","1","EA","TB","8982.73","4491.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL","0069-3034-20","NDC","","","","","facility","both","1","EA","","59.2","29.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL","0069-3034-20","NDC","","","","","facility","both","1","EA","UD","59.2","29.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 250 MG TABS","0069-4061-89","NDC","","","","","facility","both","1","EA","","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","0069-4061-89","NDC","","","","","facility","both","1","EA","UD","2.33","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILDENAFIL 10 MG TABS","0069-4190-68","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILDENAFIL 10 MG TABS","0069-4190-68","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOSPHENYTOIN 500 MG PE/10 ML SOLN 10 ML VIAL","0069-6001-21","NDC","","","","","facility","both","1","EA","","33.31","16.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PHENYTOIN 50 MG CHEW","0071-0007-40","NDC","","","","","facility","both","1","EA","UD","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYTOIN ER 100 MG CAPS","0071-0369-40","NDC","","","","","facility","both","1","EA","","0.38","0.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN ER 100 MG CAPS","0071-0369-40","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 0.4 MG SUBL","0071-0418-13","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 0.4 MG SUBL","0071-0418-13","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH"
"VENETOCLAX 100 MG TABS","0074-0576-11","NDC","","","","","facility","both","1","EA","UD","2075.32","1037.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENETOCLAX 100 MG TABS","0074-0576-11","NDC","","","","","facility","both","1","EA","","596.08","298.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PARICALCITOL 5 MCG/ML SOLN","0074-1658-01","NDC","","","","","facility","both","1","EA","UD","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 20 MEQ TBSR","0074-3023-13","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE, MODIFIED 25 MG CAPS","0074-3108-32","NDC","","","","","facility","both","1","EA","","2.31","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOSPORINE, MODIFIED 25 MG CAPS","0074-3108-32","NDC","","","","","facility","both","1","EA","UD","3.31","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE, MODIFIED 100 MG CAPS","0074-3109-32","NDC","","","","","facility","both","1","EA","UD","10.23","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE, MODIFIED 100 MG CAPS","0074-3109-32","NDC","","","","","facility","both","1","EA","","10.23","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 50 MCG TABS","0074-4552-11","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 50 MCG TABS","0074-4552-11","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 150 MCG TABS","0074-7069-90","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOSPORINE, MODIFIED-NEORAL 100 MG/ML SOLN","0074-7269-50","NDC","","","","","facility","both","1","EA","","14.79","7.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOSPORINE-SANDIMMUNE 250 MG/5 ML SOLN 5 ML AMPUL","0078-0109-01","NDC","","","","","facility","both","1","EA","UD","246.91","123.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE-SANDIMMUNE 250 MG/5 ML SOLN 5 ML AMPUL","0078-0109-01","NDC","","","","","facility","both","1","EA","","246.91","123.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CYCLOSPORINE-SANDIMMUNE 250 MG/5 ML SOLN 5 ML AMPUL","0078-0109-61","NDC","","","","","facility","both","1","EA","","246.91","123.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOSPORINE-SANDIMMUNE 250 MG/5 ML SOLN 5 ML AMPUL","0078-0109-61","NDC","","","","","facility","both","1","EA","UD","246.91","123.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE-SANDIMMUNE 25 MG CAPS","0078-0240-15","NDC","","","","","facility","both","1","EA","","28.7","14.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOSPORINE-SANDIMMUNE 25 MG CAPS","0078-0240-61","NDC","","","","","facility","both","1","EA","","28.7","14.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BASILIXIMAB 20 MG SOLR 1 EACH VIAL","0078-0331-84","NDC","","","","","facility","both","1","EA","JG","17701.45","8850.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BASILIXIMAB 20 MG SOLR 1 EACH VIAL","0078-0331-84","NDC","","","","","facility","both","1","EA","JG,UD","18378.33","9189.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"BASILIXIMAB 20 MG SOLR 1 EACH VIAL","0078-0331-84","NDC","","","","","facility","both","1","EA","","18378.33","9189.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BASILIXIMAB 20 MG SOLR 1 EACH VIAL","0078-0331-84","NDC","","","","","facility","both","1","EA","TB","18378.33","9189.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"CARBAMAZEPINE 20 MG/ML SUSPENSION","0078-0508-83","NDC","","","","","facility","both","1","EA","","3.99","2.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ARTEMETHER-LUMEFANTRINE 20-120 MG TABS","0078-0568-45","NDC","","","","","facility","both","1","EA","UD","115.3","57.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACUBITRIL-VALSARTAN 12-13 MG TABS","0078-0659-20","NDC","","","","","facility","both","1","EA","UD","15.73","7.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACUBITRIL-VALSARTAN 12-13 MG TABS","0078-0659-20","NDC","","","","","facility","both","1","EA","","15.73","7.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SACUBITRIL-VALSARTAN 24-26 MG TABS","0078-0659-67","NDC","","","","","facility","both","1","EA","","26.35","13.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SACUBITRIL-VALSARTAN 24-26 MG TABS","0078-0659-67","NDC","","","","","facility","both","1","EA","UD","26.35","13.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACUBITRIL-VALSARTAN 97-103 MG TABS","0078-0696-20","NDC","","","","","facility","both","1","EA","","25.81","12.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SACUBITRIL-VALSARTAN 97-103 MG TABS","0078-0696-20","NDC","","","","","facility","both","1","EA","UD","25.81","12.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACUBITRIL-VALSARTAN 97-103 MG TABS","0078-0696-67","NDC","","","","","facility","both","1","EA","UD","26.35","13.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACUBITRIL-VALSARTAN 97-103 MG TABS","0078-0696-67","NDC","","","","","facility","both","1","EA","","25.81","12.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BRINZOLAMIDE 1 % DRPS 10 ML DROP BTL","0078-0722-10","NDC","","","","","facility","both","1","EA","","738.03","369.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SACUBITRIL-VALSARTAN 49-51 MG TABS","0078-0777-20","NDC","","","","","facility","both","1","EA","UD","25.81","12.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACUBITRIL-VALSARTAN 49-51 MG TABS","0078-0777-20","NDC","","","","","facility","both","1","EA","","25.81","12.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TOBRAMYCIN 0.3 % OINT 3.5 G TUBE","0078-0813-01","NDC","","","","","facility","both","1","EA","","377.54","188.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"OCTREOTIDE 20 MG SSRR","0078-0818-81","NDC","","","","","facility","both","1","EA","JG,UD","18250.69","9125.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 20 MG SSRR","0078-0818-81","NDC","","","","","facility","both","1","EA","JG","18250.69","9125.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"OCTREOTIDE 20 MG SSRR","0078-0818-81","NDC","","","","","facility","both","1","EA","UD","18949.8","9474.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 30 MG SSRR","0078-0825-81","NDC","","","","","facility","both","1","EA","JG","26858.38","13429.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CIPROFLOXACIN HCL 0.3 % OINT 3.5 G TUBE","0078-0841-01","NDC","","","","","facility","both","1","EA","UD","377.54","188.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN HCL 0.3 % OINT 3.5 G TUBE","0078-0841-01","NDC","","","","","facility","both","1","EA","","463.77","231.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CIPROFLOX-HYDROCORTISONE 0.2-1 % DRPS 10 ML DROP BTL","0078-0855-26","NDC","","","","","facility","both","1","EA","","231.38","115.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOX-HYDROCORTISONE 0.2-1 % DRPS 10 ML DROP BTL","0078-0855-26","NDC","","","","","facility","both","1","EA","UD","231.38","115.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OINT 3.5 G TUBE","0078-0876-01","NDC","","","","","facility","both","1","EA","","462.86","231.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"INCLISIRAN 284 MG/1.5 ML SYRG","0078-1000-60","NDC","","","","","facility","both","1","EA","TB","13940.09","6970.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"INCLISIRAN 284 MG/1.5 ML SYRG","0078-1000-60","NDC","","","","","facility","both","1","EA","","13940.09","6970.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INCLISIRAN 284 MG/1.5 ML SYRG","0078-1000-60","NDC","","","","","facility","both","1","EA","UD,TB","13940.09","6970.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"INCLISIRAN 284 MG/1.5 ML SYRG","0078-1000-60","NDC","","","","","facility","both","1","EA","UD","14266.99","7133.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PSEUDOEPHEDRINE SR 120 MG TBSR","0081067020","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG TABS","0084-2083-14","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG TABS","0084-2083-14","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG- 10 MCG/ML DROP","0087-040201","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PEDI MV NO.189-FERROUS SULFATE 11 MG IRON/ML DROP","0087-0405-89","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PEDI MV NO.189-FERROUS SULFATE 11 MG IRON/ML DROP","0087-0405-89","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN GLARGINE 100 UNIT/ML SOLN","0088-2220-33","NDC","","","","","facility","both","1","EA","UD","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN GLARGINE 100 UNIT/ML SOLN","0088-2220-33","NDC","","","","","facility","both","1","EA","","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZOLPIDEM 5 MG TABS","0093-0073-01","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLPIDEM 5 MG TABS","0093-0073-01","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"KETOROLAC 10 MG TABS","0093-0314-01","NDC","","","","","facility","both","1","EA","UD","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 10 MG TABS","0093-0314-01","NDC","","","","","facility","both","1","EA","","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 30 MG TABS","0093-0318-01","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 60 MG TABS","0093-0319-01","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 60 MG TABS","0093-0319-01","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATENOLOL 25 MG TABS","0093-0787-01","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.5 MG TABS","0093-0832-05","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.5 MG TABS","0093-0832-05","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 500,000 UNIT TABS","0093-0983-01","NDC","","","","","facility","both","1","EA","","3.37","1.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NEOMYCIN 500 MG TABS","0093-1177-01","NDC","","","","","facility","both","1","EA","","4.06","2.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 0.5 MG TABS","0093-1712-10","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 0.5 MG TABS","0093-1712-10","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RASAGILINE 0.5 MG TABS","0093-3060-56","NDC","","","","","facility","both","1","EA","","5.5","2.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEPHALEXIN 250 MG CAPS","0093-3145-01","NDC","","","","","facility","both","1","EA","UD","1.63","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUTEROL 90 MCG/ACTUATION HFAA 8.5 G CANISTER","0093-3174-31","NDC","","","","","facility","both","1","EA","","126.93","63.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ALBUTEROL 90 MCG/ACTUATION HFAA 8.5 G CANISTER","0093-3174-31","NDC","","","","","facility","both","1","EA","UD","126.93","63.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 2 MG TABS","0093-3213-01","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 2 MG TABS","0093-3213-01","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 2 MG TABS","0093-3427-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG TABS","0093-3427-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PENICILLIN V POTASSIUM 250 MG/5 ML SOLR","0093-4127-73","NDC","","","","","facility","both","1","EA","UD","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEPHALEXIN 250 MG/5 ML SUSR","0093-4177-73","NDC","","","","","facility","both","1","EA","","5.03","2.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEPHALEXIN 250 MG/5 ML SUSR","0093-4177-73","NDC","","","","","facility","both","1","EA","UD","9.05","4.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARVEDILOL 12.5 MG TABS","0093-7295-05","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","0093-7295-05","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LETROZOLE 2.5 MG TABS","0093-7620-56","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG TABS","0093-7704-56","NDC","","","","","facility","both","1","EA","UD","3.5","1.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ELETRIPTAN 20 MG TABS","0093-8310-19","NDC","","","","","facility","both","1","EA","","46.24","23.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLYBURIDE 5 MG TABS","0093-8344-98","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 200 MG CAPS","0093-8740-01","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 200 MG CAPS","0093-8740-01","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 250 MG CAPS","0093-8741-01","NDC","","","","","facility","both","1","EA","UD","3.07","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 250 MG CAPS","0093-8741-01","NDC","","","","","facility","both","1","EA","","3.07","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.125 MG ODT.","0093-9290-67","NDC","","","","","facility","both","1","EA","","3.77","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.25 MG ODT.","0093-9291-19","NDC","","","","","facility","both","1","EA","","2.77","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE 1 % LOTN 120 ML BOTTLE","0096-0732-04","NDC","","","","","facility","both","1","EA","","120","60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCORTISONE 1 % LOTN 120 ML BOTTLE","0096-0732-04","NDC","","","","","facility","both","1","EA","UD","120","60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","0113-0065-10","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","0113-0065-10","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % SUPP","0113-0279-53","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24","0115-1487-01","NDC","","","","","facility","both","1","EA","","1.7","0.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24","0115-1487-01","NDC","","","","","facility","both","1","EA","UD","1.7","0.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","0121-0431-30","NDC","","","","","facility","both","1","EA","","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","0121-0431-30","NDC","","","","","facility","both","1","EA","UD","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 12.5 MG/5 ML ELIX","0121-0489-05","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIPHENHYDRAMINE 12.5 MG/5 ML ELIX","0121-0489-05","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERROUS SULFATE 300 MG (60 MG IRON)/5 ML LIQD","0121053005","NDC","","","","","facility","both","1","EA","UD","7.54","3.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERROUS SULFATE 300 MG (60 MG IRON)/5 ML LIQD","0121053005","NDC","","","","","facility","both","1","EA","","7.54","3.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"HALOPERIDOL 2 MG/ML CONC","0121-0581-05","NDC","","","","","facility","both","1","EA","","13.22","6.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"HALOPERIDOL 2 MG/ML CONC","0121-0581-05","NDC","","","","","facility","both","1","EA","UD","13.22","6.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML SOLN","0121059515","NDC","","","","","facility","both","1","EA","","12.97","6.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 160 MG/5 ML (5 ML) SOLN","0121-0657-05","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 160 MG/5 ML (5 ML) SOLN","0121-0657-05","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA LEAF EXTRACT 176 MG/5 ML SYRP","0121072208","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA LEAF EXTRACT 176 MG/5 ML SYRP","0121072208","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) SOLN","0121-0759-08","NDC","","","","","facility","both","1","EA","","6.08","3.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) SOLN","0121-0759-08","NDC","","","","","facility","both","1","EA","UD","6.08","3.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML CONC 0.5 ML ORAL SYRINGE","0121-0770-55","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","0121-0853-20","NDC","","","","","facility","both","1","EA","UD","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","0121-0853-20","NDC","","","","","facility","both","1","EA","","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","0121-0853-40","NDC","","","","","facility","both","1","EA","UD","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 125 MG CAPS","0121-0867-20","NDC","","","","","facility","both","1","EA","UD","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 125 MG CAPS","0121-0867-20","NDC","","","","","facility","both","1","EA","","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","0121-0868-05","NDC","","","","","facility","both","1","EA","UD","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","0121-0868-05","NDC","","","","","facility","both","1","EA","","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHLORHEXIDINE 0.12 % MWSH","0121-0893-15","NDC","","","","","facility","both","1","EA","UD","4.83","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORHEXIDINE 0.12 % MWSH","0121-0893-15","NDC","","","","","facility","both","1","EA","","4.83","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIAZEPAM 5 MG/5 ML SOLN","0121-0905-05","NDC","","","","","facility","both","1","EA","","5.41","2.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIAZEPAM 5 MG/5 ML SOLN","0121-0905-05","NDC","","","","","facility","both","1","EA","UD","5.41","2.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 100 MG/5 ML SUSPENSION","0121-0914-00","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"IBUPROFEN 100 MG/5 ML SUSPENSION","0121-0914-05","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 100 MG/5 ML SUSPENSION","0121-0914-05","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ELIX","0121-0942-05","NDC","","","","","facility","both","1","EA","UD","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEGESTROL 400 MG/10 ML SUSPENSION","0121-0945-00","NDC","","","","","facility","both","1","EA","UD","10.27","5.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEGESTROL 400 MG/10 ML SUSPENSION","0121-0945-00","NDC","","","","","facility","both","1","EA","","10.66","5.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","0121-0972-51","NDC","","","","","facility","both","1","EA","UD","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","0121-0972-51","NDC","","","","","facility","both","1","EA","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIPHENHYDRAMINE 12.5 MG/5 ML ELIX","0121-0978-10","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 12.5 MG/5 ML ELIX","0121-0978-10","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","0121-1016-05","NDC","","","","","facility","both","1","EA","","54.18","27.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","0121-1016-05","NDC","","","","","facility","both","1","EA","UD","54.18","27.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 20 GRAM/30 ML SOLN","0121-1154-30","NDC","","","","","facility","both","1","EA","UD","3.42","1.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 20 GRAM/30 ML SOLN","0121-1154-30","NDC","","","","","facility","both","1","EA","","3.42","1.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LACTULOSE 10 GRAM/15 ML SOLN","0121-1154-40","NDC","","","","","facility","both","1","EA","UD","3.42","1.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 10 GRAM/15 ML SOLN","0121-1154-40","NDC","","","","","facility","both","1","EA","","3.42","1.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML SOLN","0121119030","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML SOLN","0121119030","NDC","","","","","facility","both","1","EA","UD","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML SYRP","0121-1276-10","NDC","","","","","facility","both","1","EA","UD","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML SYRP","0121-1276-10","NDC","","","","","facility","both","1","EA","","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","0121-1488-10","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","0121-1488-10","NDC","","","","","facility","both","1","EA","UD","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CODEINE-GUAIFENESIN 10-100 MG/5 ML LIQD","0121-1550-10","NDC","","","","","facility","both","1","EA","","2.95","1.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CODEINE-GUAIFENESIN 10-100 MG/5 ML LIQD","0121-1550-10","NDC","","","","","facility","both","1","EA","UD","2.95","1.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 5 MG/5 ML SOLN","0121-1576-10","NDC","","","","","facility","both","1","EA","UD","5.17","2.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 5 MG/5 ML SOLN","0121-1576-10","NDC","","","","","facility","both","1","EA","","5.17","2.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","0121-1744-05","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","0121-1744-05","NDC","","","","","facility","both","1","EA","UD","3.7","1.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","0121-1762-30","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","0121-1762-30","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML 10-100 MG/5 ML","0121-1775-05","NDC","","","","","facility","both","1","EA","","2.95","1.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML 10-100 MG/5 ML","0121-1775-05","NDC","","","","","facility","both","1","EA","UD","2.95","1.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 100 MG/5 ML SUSPENSION","0121-1828-10","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 100 MG/5 ML SUSPENSION","0121-1828-10","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOCUSATE SODIUM 50 MG/5 ML LIQD","0121-1870-10","NDC","","","","","facility","both","1","EA","","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOCUSATE SODIUM 50 MG/5 ML LIQD","0121-1870-10","NDC","","","","","facility","both","1","EA","UD","2.62","1.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE 20 MG/ML SUSPENSION","0121-1894-10","NDC","","","","","facility","both","1","EA","UD","12.37","6.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 650 MG/20.3 ML SOLN","0121-1971-21","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 650 MG/20.3 ML SOLN","0121-1971-21","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUAIFENESIN 100 MG/5 ML LIQD","0121-2232-15","NDC","","","","","facility","both","1","EA","UD","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUAIFENESIN 100 MG/5 ML LIQD","0121-2232-15","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML SOLN","0121-2316-15","NDC","","","","","facility","both","1","EA","UD","13.29","6.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML SOLN","0121-2316-15","NDC","","","","","facility","both","1","EA","","13.29","6.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) SOLN","0121-4675-00","NDC","","","","","facility","both","1","EA","UD","2.86","1.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) SOLN","0121-4675-00","NDC","","","","","facility","both","1","EA","","2.86","1.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) SOLN","0121-4675-05","NDC","","","","","facility","both","1","EA","","2.86","1.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) SOLN","0121-4675-05","NDC","","","","","facility","both","1","EA","UD","2.86","1.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG/5 ML (4 MG/ML) SOLN","0121-4721-05","NDC","","","","","facility","both","1","EA","UD","17.68","8.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG/5 ML (4 MG/ML) SOLN","0121-4721-05","NDC","","","","","facility","both","1","EA","","17.68","8.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"SENNA LEAF EXTRACT 176 MG/5 ML SYRP","0121472215","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA LEAF EXTRACT 176 MG/5 ML SYRP","0121472215","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"CALCIUM CARBONATE 500 MG/5 ML (1,250 MG/5 ML) SUSPENSION","0121-4766-05","NDC","","","","","facility","both","1","EA","UD","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CARBONATE 500 MG/5 ML (1,250 MG/5 ML) SUSPENSION","0121-4766-05","NDC","","","","","facility","both","1","EA","","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","0121-4799-05","NDC","","","","","facility","both","1","EA","UD","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","0121-4799-05","NDC","","","","","facility","both","1","EA","","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 5 MG/5 ML SOLN","0121-4827-05","NDC","","","","","facility","both","1","EA","UD","13.16","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG/5 ML SOLN","0121-4827-05","NDC","","","","","facility","both","1","EA","","13.16","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 5 MG/5 ML SOLN","0121-4827-40","NDC","","","","","facility","both","1","EA","","14.16","7.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"OXYCODONE 5 MG/5 ML SOLN","0121-4827-40","NDC","","","","","facility","both","1","EA","UD","14.16","7.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","0121-4950-15","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 2 % SOLN","0121-4950-15","NDC","","","","","facility","both","1","EA","UD","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","0121-4950-40","NDC","","","","","facility","both","1","EA","UD","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","0121-4950-40","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"MINERAL OIL OIL 240 ML BOTTLE","0127303612","NDC","","","","","facility","both","1","EA","","7.48","3.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINERAL OIL OIL 240 ML BOTTLE","0127303612","NDC","","","","","facility","both","1","EA","UD","7.48","3.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 200 MG/20 ML SOLN","0131-1810-67","NDC","","","","","facility","both","1","EA","","208.75","104.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LACOSAMIDE 200 MG/20 ML SOLN","0131-1810-67","NDC","","","","","facility","both","1","EA","UD","208.75","104.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 50 MG TABS","0131-2477-60","NDC","","","","","facility","both","1","EA","","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 50 MG TABS","0131-2477-60","NDC","","","","","facility","both","1","EA","UD","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 100 MG TABS","0131-2478-60","NDC","","","","","facility","both","1","EA","","1.95","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 100 MG TABS","0131-2478-60","NDC","","","","","facility","both","1","EA","UD","1.95","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCERIN (ADULT) SUPP","0132007900","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLYCERIN (ADULT) SUPP","0132007900","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCERIN (ADULT) SUPP","0132-0079-50","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLYCERIN (ADULT) SUPP","0132-0079-50","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCERIN (CHILD) SUPP","0132-0081-12","NDC","","","","","facility","both","1","EA","UD","1.01","0.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCERIN (CHILD) SUPP","0132-0081-12","NDC","","","","","facility","both","1","EA","","1.01","0.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 EACH"
"SODIUM PHOSPHATES 19-7 GRAM/118 ML ENEM 133 ML SQUEEZ BTL","0132-0201-40","NDC","","","","","facility","both","1","EA","","3.39","1.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM PHOSPHATES 9.5-3.5 GRAM/59 ML ENEM","0132-0202-20","NDC","","","","","facility","both","1","EA","","4.36","2.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINERAL OIL ENEM 133 ML SQUEEZ BTL","0132030140","NDC","","","","","facility","both","1","EA","UD","7.05","3.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINERAL OIL ENEM 133 ML SQUEEZ BTL","0132030140","NDC","","","","","facility","both","1","EA","","7.05","3.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINERAL OIL ENEM 133 ML SQUEEZ BTL","0132-0301-40","NDC","","","","","facility","both","1","EA","UD","7.05","3.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINERAL OIL ENEM 133 ML SQUEEZ BTL","0132-0301-40","NDC","","","","","facility","both","1","EA","","7.05","3.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DICYCLOMINE 20 MG TABS","0143-1227-01","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXORUBICIN 10 MG SOLR 1 EACH VIAL","0143-9092-01","NDC","","","","","facility","both","1","EA","","2012.65","1006.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXORUBICIN 50 MG SOLR 1 EACH VIAL","0143-9093-01","NDC","","","","","facility","both","1","EA","","1050.91","525.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXORUBICIN 50 MG SOLR 1 EACH VIAL","0143-9093-01","NDC","","","","","facility","both","1","EA","UD","1524.36","762.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BORTEZOMIB 3.5 MG SOLR","0143-9098-01","NDC","","","","","facility","both","1","EA","JG,UD","108.88","54.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 2 GRAM SOLR 1 EACH VIAL","0143-9139-01","NDC","","","","","facility","both","1","EA","59","33","16.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier 59: Distinct Procedural Service"
"CEFAZOLIN 2 GRAM SOLR 1 EACH VIAL","0143-9139-01","NDC","","","","","facility","both","1","EA","UD","33","16.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 2 GRAM SOLR 1 EACH VIAL","0143-9139-01","NDC","","","","","facility","both","1","EA","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFAZOLIN 3 GRAM SOLR 1 EACH VIAL","0143-9140-01","NDC","","","","","facility","both","1","EA","UD","39.38","19.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 3 GRAM SOLR 1 EACH VIAL","0143-9140-01","NDC","","","","","facility","both","1","EA","","39.38","19.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","0143-9141-10","NDC","","","","","facility","both","1","EA","UD","105.68","52.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","0143-9141-10","NDC","","","","","facility","both","1","EA","","53.84","26.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL","0143-9152-01","NDC","","","","","facility","both","1","EA","UD","128.13","64.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL","0143-9152-01","NDC","","","","","facility","both","1","EA","","128.13","64.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL","0143-9162-01","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL","0143-9162-01","NDC","","","","","facility","both","1","EA","","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 1,000 MG SOLR","0143-9162-10","NDC","","","","","facility","both","1","EA","","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 50 ML VIAL","0143-9184-01","NDC","","","","","facility","both","1","EA","UD","120.08","60.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 50 ML VIAL","0143-9184-01","NDC","","","","","facility","both","1","EA","","120.08","60.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHLOROPROCAINE (PF) 20 MG/ML (2 %) SOLN","0143-9209-10","NDC","","","","","facility","both","1","EA","UD","15.83","7.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLOROPROCAINE (PF) 20 MG/ML (2 %) SOLN","0143-9209-10","NDC","","","","","facility","both","1","EA","","169.06","84.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CHLOROPROCAINE 30 MG/ML (3 %) SOLN","0143-9210-10","NDC","","","","","facility","both","1","EA","UD","16.49","8.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLOROPROCAINE 30 MG/ML (3 %) SOLN","0143-9210-10","NDC","","","","","facility","both","1","EA","","37.47","18.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IDARUBICIN 1 MG/ML SOLN 10 ML VIAL","0143-9218-01","NDC","","","","","facility","both","1","EA","","556","278","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IDARUBICIN 1 MG/ML SOLN 20 ML VIAL","0143-9219-01","NDC","","","","","facility","both","1","EA","","556","278","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IDARUBICIN 1 MG/ML SOLN 20 ML VIAL","0143-9219-01","NDC","","","","","facility","both","1","EA","UD","556","278","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROCURONIUM 10 MG/ML SOLN","0143-9250-01","NDC","","","","","facility","both","1","EA","","12.19","6.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROCURONIUM 10 MG/ML SOLN","0143-9250-01","NDC","","","","","facility","both","1","EA","UD","12.19","6.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 1 GRAM SOLR","0143-9262-25","NDC","","","","","facility","both","1","EA","","12.2","6.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"DOXORUBICIN 50 MG SOLR 1 EACH VIAL","0143-9277-01","NDC","","","","","facility","both","1","EA","","1050.91","525.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PANTOPRAZOLE 40 MG SOLR","0143-9284-01","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PANTOPRAZOLE 40 MG SOLR","0143-9284-01","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN 875 MG TABS","0143-9285-01","NDC","","","","","facility","both","1","EA","UD","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN 875 MG TABS","0143-9285-01","NDC","","","","","facility","both","1","EA","","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOFLOXACIN 750 MG/150 ML PGBK","0143-9317-01","NDC","","","","","facility","both","1","EA","UD","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","0143-9317-01","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL","0143-9318-01","NDC","","","","","facility","both","1","EA","","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE (MARCAINE) 0.5% SOLN","0143-9329-01","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE (MARCAINE) 0.5% SOLN","0143-9329-01","NDC","","","","","facility","both","1","EA","","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE HCL INJECTION 0.5%, PER ML","0143-9334-10","NDC","","","","","facility","both","1","EA","PN","0.84","0.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"VANCOMYCIN 750 MG SOLR 1 EACH VIAL","0143-9355-01","NDC","","","","","facility","both","1","EA","UD","44.26","22.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 750 MG SOLR 1 EACH VIAL","0143-9355-01","NDC","","","","","facility","both","1","EA","","44.26","22.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","0143-9378-01","NDC","","","","","facility","both","1","EA","","153.54","76.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","0143-9378-01","NDC","","","","","facility","both","1","EA","UD","107.07","53.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","0143-9379-01","NDC","","","","","facility","both","1","EA","","8.24","4.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","0143-9379-01","NDC","","","","","facility","both","1","EA","UD","86","43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","0143-9380-01","NDC","","","","","facility","both","1","EA","UD","167","83.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","0143-9380-01","NDC","","","","","facility","both","1","EA","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FOSAPREPITANT 150 MG SOLR 1 EACH VIAL","0143-9384-01","NDC","","","","","facility","both","1","EA","","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOSAPREPITANT 150 MG SOLR 1 EACH VIAL","0143-9384-01","NDC","","","","","facility","both","1","EA","UD","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DECITABINE 50 MG SOLR 1 EACH VIAL","0143-9385-01","NDC","","","","","facility","both","1","EA","","377.6","188.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DECITABINE 50 MG SOLR 1 EACH VIAL","0143-9385-01","NDC","","","","","facility","both","1","EA","UD","384.8","192.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","0143-9398-01","NDC","","","","","facility","both","1","EA","UD","190","95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","0143-9398-01","NDC","","","","","facility","both","1","EA","","190","95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE 500 MG SOLR","0143-9503-01","NDC","","","","","facility","both","1","EA","UD","146.25","73.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAZOLAMIDE 500 MG SOLR","0143-9503-01","NDC","","","","","facility","both","1","EA","","146.25","73.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ETOMIDATE 2 MG/ML SOLN","0143-9506-01","NDC","","","","","facility","both","1","EA","","16.69","8.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOMIDATE 2 MG/ML SOLN","0143-9506-01","NDC","","","","","facility","both","1","EA","UD","16.69","8.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOMIDATE 2 MG/ML SOLN","0143-9507-01","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOMIDATE 2 MG/ML SOLN","0143-9507-01","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 50 MG/ML SOLN","0143-9508-01","NDC","","","","","facility","both","1","EA","UD","25.13","12.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 50 MG/ML SOLN","0143-9508-01","NDC","","","","","facility","both","1","EA","","25.13","12.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETAMINE 100 MG/ML SOLN 5 ML VIAL","0143-9509-01","NDC","","","","","facility","both","1","EA","","54.47","27.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL","0143-9510-01","NDC","","","","","facility","both","1","EA","","18.95","9.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHOTREXATE 25 MG/ML SOLN 2 ML VIAL","0143-9519-01","NDC","","","","","facility","both","1","EA","","8.64","4.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHOTREXATE 25 MG/ML SOLN 2 ML VIAL","0143-9519-10","NDC","","","","","facility","both","1","EA","","7.71","3.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"METHOTREXATE 25 MG/ML SOLN 2 ML VIAL","0143-9519-10","NDC","","","","","facility","both","1","EA","UD","7.71","3.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IFOSFAMIDE 1 GRAM/20 ML SOLN 20 ML VIAL","0143-9531-01","NDC","","","","","facility","both","1","EA","","163.24","81.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXMEDETOMIDINE 100 MCG/ML SOLN","0143-9532-01","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE 100 MCG/ML SOLN","0143-9532-01","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","0143-9542-10","NDC","","","","","facility","both","1","EA","","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"DAUNORUBICIN 5 MG/ML 5 MG/ML SOLN 4 ML VIAL","0143-9551-10","NDC","","","","","facility","both","1","EA","","1092.77","546.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LEUCOVORIN CALCIUM 350 MG SOLR 1 EACH VIAL","0143-9552-01","NDC","","","","","facility","both","1","EA","UD","106.23","53.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEUCOVORIN CALCIUM 350 MG SOLR 1 EACH VIAL","0143-9552-01","NDC","","","","","facility","both","1","EA","","106.23","53.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 200 MG SOLR 1 EACH VIAL","0143-9553-01","NDC","","","","","facility","both","1","EA","","47.7","23.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 100 MG SOLR 1 EACH VIAL","0143-9554-01","NDC","","","","","facility","both","1","EA","","57.5","28.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENTOLAMINE MESYLATE 5 MG SOLR","0143-9564-01","NDC","","","","","facility","both","1","EA","JG,UD","2006.4","1003.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENTOLAMINE MESYLATE 5 MG SOLR","0143-9564-01","NDC","","","","","facility","both","1","EA","UD,TB","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"PHENTOLAMINE MESYLATE 5 MG SOLR","0143-9564-01","NDC","","","","","facility","both","1","EA","TB","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"PHENTOLAMINE MESYLATE 5 MG SOLR","0143-9564-01","NDC","","","","","facility","both","1","EA","JG","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"PHENTOLAMINE MESYLATE 5 MG SOLR","0143-9564-01","NDC","","","","","facility","both","1","EA","","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZATHIOPRINE 100 MG SOLR 1 EACH VIAL","0143-9566-01","NDC","","","","","facility","both","1","EA","JG","371.24","185.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"SODIUM IRON GLUC 62.5 MG/5 ML SOLN 5 ML VIAL","0143-9570-01","NDC","","","","","facility","both","1","EA","UD","53.75","26.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM IRON GLUC 62.5 MG/5 ML SOLN 5 ML VIAL","0143-9570-01","NDC","","","","","facility","both","1","EA","","53.75","26.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM IRON GLUC 62.5 MG/5 ML SOLN 5 ML VIAL","0143-9570-10","NDC","","","","","facility","both","1","EA","","53.75","26.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SODIUM IRON GLUC 62.5 MG/5 ML SOLN 5 ML VIAL","0143-9570-10","NDC","","","","","facility","both","1","EA","UD","102.5","51.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"XYLOCAINE MPF INJECTION 1%, PER ML","0143-9577-01","NDC","","","","","facility","both","1","EA","PN","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0143-9595-01","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0143-9595-01","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LABETALOL 5 MG/ML SOLN 20 ML VIAL","0143-9622-01","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN 20 ML VIAL","0143-9622-01","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TESTOSTERONE CYPIONATE 200 MG/ML OIL","0143-9659-01","NDC","","","","","facility","both","1","EA","","43.75","21.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GLYCOPYRROLATE 0.2 MG/ML SOLN","0143-9681-01","NDC","","","","","facility","both","1","EA","UD","10.31","5.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE 0.2 MG/ML SOLN","0143-9681-01","NDC","","","","","facility","both","1","EA","","10.31","5.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GLYCOPYRROLATE 0.2 MG/ML SOLN","0143-9682-01","NDC","","","","","facility","both","1","EA","","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GLYCOPYRROLATE 0.2 MG/ML SOLN","0143-9682-01","NDC","","","","","facility","both","1","EA","UD","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICARDIPINE 25 MG/10 ML SOLN","0143-9689-01","NDC","","","","","facility","both","1","EA","","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NICARDIPINE 25 MG/10 ML SOLN","0143-9689-01","NDC","","","","","facility","both","1","EA","UD","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","0143-9689-10","NDC","","","","","facility","both","1","EA","UD","221.25","110.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","0143-9689-10","NDC","","","","","facility","both","1","EA","","221.25","110.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IRINOTECAN 100 MG/5 ML SOLN 5 ML VIAL","0143-9701-01","NDC","","","","","facility","both","1","EA","","52.3","26.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","0143-9702-01","NDC","","","","","facility","both","1","EA","","38.5","19.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","0143-9702-01","NDC","","","","","facility","both","1","EA","UD","38.5","19.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MILRINONE 1 MG/ML SOLN 50 ML VIAL","0143-9708-01","NDC","","","","","facility","both","1","EA","UD","88.44","44.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MILRINONE 1 MG/ML SOLN 50 ML VIAL","0143-9708-01","NDC","","","","","facility","both","1","EA","","88.44","44.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MILRINONE 1 MG/ML SOLN 10 ML VIAL","0143-9710-01","NDC","","","","","facility","both","1","EA","","125.94","62.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MILRINONE 1 MG/ML SOLN 10 ML VIAL","0143-9710-01","NDC","","","","","facility","both","1","EA","UD","125.94","62.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MILRINONE 20 MG/100 ML (200 MCG/ML) PGBK","0143-9719-01","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MILRINONE 20 MG/100 ML (200 MCG/ML) PGBK","0143-9719-01","NDC","","","","","facility","both","1","EA","","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MILRINONE 20 MG/100 ML (200 MCG/ML) PGBK","0143-9719-10","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MILRINONE 20 MG/100 ML (200 MCG/ML) PGBK","0143-9719-10","NDC","","","","","facility","both","1","EA","UD","9.89","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","0143-9720-01","NDC","","","","","facility","both","1","EA","UD","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","0143-9720-01","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVOFLOXACIN 500 MG/100 ML PGBK","0143-9721-01","NDC","","","","","facility","both","1","EA","","10.4","5.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVOFLOXACIN 500 MG/100 ML PGBK","0143-9721-01","NDC","","","","","facility","both","1","EA","UD","10.4","5.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 250 MG/50 ML PGBK","0143-9722-01","NDC","","","","","facility","both","1","EA","","8.2","4.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVOFLOXACIN 250 MG/50 ML PGBK","0143-9722-01","NDC","","","","","facility","both","1","EA","UD","20.6","10.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE (0.01MG/ML) 0.01 MG/ML SOLN","0143-9724-01","NDC","","","","","facility","both","1","EA","UD","9.08","4.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE (0.01MG/ML) 0.01 MG/ML SOLN","0143-9724-01","NDC","","","","","facility","both","1","EA","","9.08","4.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BENZTROPINE 1 MG/ML SOLN","0143-9729-01","NDC","","","","","facility","both","1","EA","UD","283.75","141.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZTROPINE 1 MG/ML SOLN","0143-9729-01","NDC","","","","","facility","both","1","EA","","283.75","141.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TERBUTALINE 1 MG/ML SOLN","0143-9746-01","NDC","","","","","facility","both","1","EA","","10.63","5.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TERBUTALINE 1 MG/ML SOLN","0143-9746-01","NDC","","","","","facility","both","1","EA","UD","10.63","5.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR","0143-9754-01","NDC","","","","","facility","both","1","EA","UD","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR","0143-9754-01","NDC","","","","","facility","both","1","EA","","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUMAZENIL 0.1 MG/ML SOLN","0143-9784-01","NDC","","","","","facility","both","1","EA","","43.13","21.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUMAZENIL 0.1 MG/ML SOLN","0143-9784-01","NDC","","","","","facility","both","1","EA","UD","43.13","21.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","0143-9785-01","NDC","","","","","facility","both","1","EA","","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","0143-9785-01","NDC","","","","","facility","both","1","EA","UD","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","0143-9785-10","NDC","","","","","facility","both","1","EA","","12.88","6.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","0143-9785-10","NDC","","","","","facility","both","1","EA","UD","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRILAT 1.25 MG/ML SOLN","0143-9787-01","NDC","","","","","facility","both","1","EA","UD","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRILAT 1.25 MG/ML SOLN","0143-9787-01","NDC","","","","","facility","both","1","EA","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVOCARNITINE 200 MG/ML SOLN 5 ML VIAL","0143-9852-01","NDC","","","","","facility","both","1","EA","UD","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOCARNITINE 200 MG/ML SOLN 5 ML VIAL","0143-9852-01","NDC","","","","","facility","both","1","EA","","4.86","2.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFTRIAXONE 2 GRAM SOLR","0143-9856-01","NDC","","","","","facility","both","1","EA","UD","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 2 GRAM SOLR","0143-9856-01","NDC","","","","","facility","both","1","EA","","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTRIAXONE 1 GRAM SOLR","0143-9857-01","NDC","","","","","facility","both","1","EA","","8.88","4.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTRIAXONE 1 GRAM SOLR","0143-9857-01","NDC","","","","","facility","both","1","EA","UD","8.88","4.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIODARONE 50 MG/ML SOLN","0143-9875-01","NDC","","","","","facility","both","1","EA","UD","13.43","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIODARONE 50 MG/ML SOLN","0143-9875-01","NDC","","","","","facility","both","1","EA","","13.43","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMOXICILLIN 200 MG/5 ML SUSR 100 ML BOTTLE","0143-9886-01","NDC","","","","","facility","both","1","EA","UD","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN 250 MG/5 ML SUSR","0143-9889-80","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMOXICILLIN 250 MG/5 ML SUSR","0143-9889-80","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 1 GRAM SOLR","0143-9924-90","NDC","","","","","facility","both","1","EA","UD","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 1 GRAM SOLR","0143-9924-90","NDC","","","","","facility","both","1","EA","","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"CIPROFLOXACIN HCL 250 MG TABS","0143-9927-01","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN HCL 250 MG TABS","0143-9927-01","NDC","","","","","facility","both","1","EA","","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 15 G TUBE","0168-0004-15","NDC","","","","","facility","both","1","EA","","11.29","5.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 453.6 G JAR","0168-0004-16","NDC","","","","","facility","both","1","EA","","62.92","31.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 15 G TUBE","0168-0006-15","NDC","","","","","facility","both","1","EA","UD","8.72","4.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 15 G TUBE","0168-0006-15","NDC","","","","","facility","both","1","EA","","8.72","4.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 453.6 G JAR","0168-0006-16","NDC","","","","","facility","both","1","EA","UD","87.32","43.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 453.6 G JAR","0168-0006-16","NDC","","","","","facility","both","1","EA","","87.32","43.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 80 G TUBE","0168-0006-80","NDC","","","","","facility","both","1","EA","","24.52","12.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 1 % CREA 28.35 G TUBE","0168-0015-31","NDC","","","","","facility","both","1","EA","","28.35","14.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 1 % CREA 28.35 G TUBE","0168-0015-31","NDC","","","","","facility","both","1","EA","UD","28.35","14.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 1 % OINT 28.35 G TUBE","0168-0020-31","NDC","","","","","facility","both","1","EA","","28.35","14.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BETAMETHASONE DIPROPIONATE 0.05 % OINT 15 G TUBE","0168-0056-15","NDC","","","","","facility","both","1","EA","","63.74","31.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BETAMETHASONE DIPROPIONATE 0.05 % OINT 15 G TUBE","0168-0056-15","NDC","","","","","facility","both","1","EA","UD","63.74","31.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 2.5 % CREA 30 G TUBE","0168-0080-31","NDC","","","","","facility","both","1","EA","","10.9","5.45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 2.5 % CREA 30 G TUBE","0168-0080-31","NDC","","","","","facility","both","1","EA","UD","10.9","5.45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 2.5 % OINT 28.35 G TUBE","0168-0146-30","NDC","","","","","facility","both","1","EA","UD","10.87","5.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 2.5 % OINT 28.35 G TUBE","0168-0146-30","NDC","","","","","facility","both","1","EA","","10.87","5.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOBETASOL 0.05 % CREA 15 G TUBE","0168-0163-15","NDC","","","","","facility","both","1","EA","","8.51","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLINDAMYCIN 1 % GEL 30 G TUBE","0168-0202-30","NDC","","","","","facility","both","1","EA","UD","25.47","12.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 1 % GEL 30 G TUBE","0168-0202-30","NDC","","","","","facility","both","1","EA","","25.47","12.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLINDAMYCIN 2 % CREA 40 G TUBE/KIT","0168-0277-40","NDC","","","","","facility","both","1","EA","","254.4","127.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"INSULIN NPH 100 UNIT/ML SUSPENSION","0169-1834-11","NDC","","","","","facility","both","1","EA","UD","12.27","6.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN NPH 100 UNIT/ML SUSPENSION","0169-1834-11","NDC","","","","","facility","both","1","EA","","12.78","6.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN NPH & REGULAR 70/30 100 UNIT/ML (70-30) SUSPENSION","0169-1837-02","NDC","","","","","facility","both","1","EA","","20.28","10.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN ASPART PROTAMINE & ASPART 70/30 100 UNIT/ML SOLN","0169-3685-12","NDC","","","","","facility","both","1","EA","","13.17","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN ASPART PROTAMINE & ASPART 70/30 100 UNIT/ML SOLN","0169-3685-12","NDC","","","","","facility","both","1","EA","UD","13.59","6.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTRADIOL 10 MCG TABS","0169-5176-03","NDC","","","","","facility","both","1","EA","","18.64","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLUCAGON 1 MG SOLR","0169-7065-15","NDC","","","","","facility","both","1","EA","","1415.24","707.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) SOLR","0169-7201-01","NDC","","","","","facility","both","1","EA","TB","2680","1340","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) SOLR","0169-7201-01","NDC","","","","","facility","both","1","EA","","2680","1340","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG"
"COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) SOLR","0169-7201-01","NDC","","","","","facility","both","1","EA","JG","12000","6000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) SOLR","0169-7202-01","NDC","","","","","facility","both","1","EA","","24","12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG"
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) SOLR","0169-7202-01","NDC","","","","","facility","both","1","EA","TB","5360","2680","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) SOLR","0169-7202-01","NDC","","","","","facility","both","1","EA","UD","24000","12000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) SOLR","0169-7202-01","NDC","","","","","facility","both","1","EA","JG","24000","12000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) SOLR","0169-7205-01","NDC","","","","","facility","both","1","EA","","60","30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG"
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) SOLR","0169-7205-01","NDC","","","","","facility","both","1","EA","JG","60000","30000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) SOLR","0169-7205-01","NDC","","","","","facility","both","1","EA","TB","60000","30000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) SOLR","0169-7205-01","NDC","","","","","facility","both","1","EA","UD","60000","30000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 MCG | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INSULIN ASPART 100 UNIT/ML SOLN","0169-7501-11","NDC","","","","","facility","both","1","EA","","11.91","5.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INSULIN ASPART 100 UNIT/ML SOLN","0169-7501-11","NDC","","","","","facility","both","1","EA","UD","88.81","44.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE, MODIFIED-NEORAL 100 MG/ML SOLN","0172-7313-20","NDC","","","","","facility","both","1","EA","","14.79","7.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","0173-0547-00","NDC","","","","","facility","both","1","EA","UD","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 42 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","0173-0547-00","NDC","","","","","facility","both","1","EA","","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 42 ML"
"ALBUTEROL 90 MCG/ACTUATION HFAA 8 G CANISTER","0173-0682-24","NDC","","","","","facility","both","1","EA","","80.52","40.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ALBUTEROL 90 MCG/ACTUATION HFAA 8 G CANISTER","0173-0682-24","NDC","","","","","facility","both","1","EA","UD","80.52","40.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMOTRIGINE ER 200 MG TR24","0173-0757-00","NDC","","","","","facility","both","1","EA","","4.81","2.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUTICASONE FUROATE-VILANTEROL 100-25 MCG/DOSE DSDV 28 EACH BLIST PACK","0173-0859-14","NDC","","","","","facility","both","1","EA","","408.48","204.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUTICASONE FUROATE-VILANTEROL 100-25 MCG/DOSE DSDV 28 EACH BLIST PACK","0173-0859-14","NDC","","","","","facility","both","1","EA","UD","408.48","204.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUTICASONE FUROATE 100 MCG/ACTUATION DSDV 14 EACH BLIST PACK","0173-0874-14","NDC","","","","","facility","both","1","EA","UD","249.22","124.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUTICASONE FUROATE 100 MCG/ACTUATION DSDV 14 EACH BLIST PACK","0173-0874-14","NDC","","","","","facility","both","1","EA","","249.22","124.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INJECTION, MEPOLIZUMAB, 1 MG","0173-0881-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/DOSE DSDV 28 EACH BLIST PACK","0173-0882-14","NDC","","","","","facility","both","1","EA","","408.48","204.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/DOSE DSDV 28 EACH BLIST PACK","0173-0882-14","NDC","","","","","facility","both","1","EA","UD","408.48","204.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUTICASONE-UMECLIDIN-VILANTER 100-62.5-25 MCG DSDV 28 EACH BLIST PACK","0173-0887-14","NDC","","","","","facility","both","1","EA","","749.96","374.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THERAPEUTIC MULTIVITAMIN TABS","0178055001","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THERAPEUTIC MULTIVITAMIN TABS","0178055001","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 EACH"
"TICAGRELOR 60 MG TABS","0186-0776-60","NDC","","","","","facility","both","1","EA","","19.68","9.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TICAGRELOR 90 MG TABS","0186-0777-39","NDC","","","","","facility","both","1","EA","UD","19.34","9.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TICAGRELOR 90 MG TABS","0186-0777-39","NDC","","","","","facility","both","1","EA","","19.34","9.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUDESONIDE 180 MCG/ACTUATION AEPB 1 EACH CANISTER","0186-0916-12","NDC","","","","","facility","both","1","EA","","452.9","226.45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION 300 MG TB24","0187-0731-30","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHYTONADIONE (VITAMIN K1)(5MG/5ML) 5 MG SYRG","0187-1704-05","NDC","","","","","facility","both","1","EA","","42.47","21.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NS NASAL GEL GEL 14.1 G JAR","0225052547","NDC","","","","","facility","both","1","EA","","10.28","5.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NS NASAL GEL GEL 14.1 G JAR","0225052547","NDC","","","","","facility","both","1","EA","UD","10.28","5.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 0.5 % SPRY 15 ML SQUEEZ BTL","0225-0805-47","NDC","","","","","facility","both","1","EA","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 0.5 % SPRY 15 ML SQUEEZ BTL","0225-0805-47","NDC","","","","","facility","both","1","EA","UD","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMOTRIGINE ER 25 MG TR24","0228-1410-03","NDC","","","","","facility","both","1","EA","","5.21","2.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMAZEPAM 15 MG CAPS","0228-2076-10","NDC","","","","","facility","both","1","EA","","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMAZEPAM 15 MG CAPS","0228-2076-10","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE HCL 0.1 MG TABS","0228-2127-10","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE HCL 0.1 MG TABS","0228-2127-10","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INDAPAMIDE 1.25 MG TABS","0228-2597-96","NDC","","","","","facility","both","1","EA","UD","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE MONONITRATE 20 MG TABS","0228-2620-11","NDC","","","","","facility","both","1","EA","","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE MONONITRATE 20 MG TABS","0228-2620-11","NDC","","","","","facility","both","1","EA","UD","2.52","1.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE MONONITRATE 10 MG TABS","0228-2631-11","NDC","","","","","facility","both","1","EA","","2.46","1.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE MONONITRATE 10 MG TABS","0228-2631-11","NDC","","","","","facility","both","1","EA","UD","2.46","1.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERROUS SULFATE 325 MG 325 MG (65 MG IRON) TBEC","0245010810","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FERROUS SULFATE 325 MG 325 MG (65 MG IRON) TBEC","0245010889","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERROUS SULFATE 325 MG 325 MG (65 MG IRON) TBEC","0245010889","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIODARONE 100 MG TABS","0245-0144-89","NDC","","","","","facility","both","1","EA","","3.18","1.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIODARONE 200 MG TABS","0245-0147-89","NDC","","","","","facility","both","1","EA","UD","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIODARONE 200 MG TABS","0245-0147-89","NDC","","","","","facility","both","1","EA","","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 20 MEQ PACK","0245-0360-01","NDC","","","","","facility","both","1","EA","","4.88","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 20 MEQ PACK","0245-0360-01","NDC","","","","","facility","both","1","EA","UD","4.88","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 20 MEQ PACK","0245-0360-89","NDC","","","","","facility","both","1","EA","UD","4.88","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERROUS SULFATE 325 MG (65 MG IRON) TABS","0245-1088-94","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FERROUS SULFATE 325 MG (65 MG IRON) TABS","0245-1088-94","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 8 MEQ TBSR","0245-5315-89","NDC","","","","","facility","both","1","EA","","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 10 MEQ TBSR","0245-5316-89","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 10 MEQ TBSR","0245-5316-89","NDC","","","","","facility","both","1","EA","","0.57","0.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE ER 10 MEQ TBTQ","0245-5317-01","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 10 MEQ TBTQ","0245-5317-01","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","0245-5319-89","NDC","","","","","facility","both","1","EA","","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","0245-5319-89","NDC","","","","","facility","both","1","EA","UD","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LUBIPROSTONE 8 MCG CAPS","0254-3028-02","NDC","","","","","facility","both","1","EA","UD","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LUBIPROSTONE 8 MCG CAPS","0254-3028-02","NDC","","","","","facility","both","1","EA","","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LUBIPROSTONE 24 MCG CAPS","0254-3029-02","NDC","","","","","facility","both","1","EA","","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LUBIPROSTONE 24 MCG CAPS","0254-3029-02","NDC","","","","","facility","both","1","EA","UD","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM OINT 30 G TUBE","0263-5085-01","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"WHITE PETROLATUM OINT 30 G TUBE","0263-5085-01","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN","0264-1944-20","NDC","","","","","facility","both","1","EA","UD","5.09","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN","0264-1944-20","NDC","","","","","facility","both","1","EA","","5.09","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CEFTRIAXONE 1 GRAM/50 ML PGBK","0264-3153-11","NDC","","","","","facility","both","1","EA","","115.6","57.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CEFTRIAXONE 1 GRAM/50 ML PGBK","0264-3153-11","NDC","","","","","facility","both","1","EA","UD","58.8","29.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0264-4400-54","NDC","","","","","facility","both","1","EA","UD","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0264-4400-54","NDC","","","","","facility","both","1","EA","","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML FLEX CONT","0264-5600-52","NDC","","","","","facility","both","1","EA","","306.25","153.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML FLEX CONT","0264-5600-52","NDC","","","","","facility","both","1","EA","UD","306.25","153.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","0264-9587-20","NDC","","","","","facility","both","1","EA","UD","2.33","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","0264-9587-20","NDC","","","","","facility","both","1","EA","","2.33","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"LIDOCAINE 4 MG/ML (0.4 %) SOLP","0264-9594-10","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 MG/ML (0.4 %) SOLP","0264-9594-10","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"HEPARIN 1,000 UNIT/500 ML SOLP","0264-9872-10","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"HEPARIN 1,000 UNIT/500 ML SOLP","0264-9872-10","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % SOLN","0270-0445-35","NDC","","","","","facility","both","1","EA","","51.04","25.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % SOLN","0270-0445-35","NDC","","","","","facility","both","1","EA","UD","51.04","25.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SINCALIDE 5 MCG SOLR","0270-0556-15","NDC","","","","","facility","both","1","EA","UD","667.06","333.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SINCALIDE 5 MCG SOLR","0270-0556-15","NDC","","","","","facility","both","1","EA","","180","90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) SOLN","0270-5164-12","NDC","","","","","facility","both","1","EA","","75","37.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) SOLN","0270-5164-13","NDC","","","","","facility","both","1","EA","","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) SOLN","0270-5164-14","NDC","","","","","facility","both","1","EA","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) SOLN","0270-5164-15","NDC","","","","","facility","both","1","EA","","240","120","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"SULFUR HEXAFLUORIDE MICROSPHR 25 MG SUSR","0270-7099-16","NDC","","","","","facility","both","1","EA","","275.86","137.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 EACH"
"NITROGLYCERIN 2 % OINT","0281-0326-08","NDC","","","","","facility","both","1","EA","UD","7.61","3.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 48 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 2 % OINT","0281-0326-08","NDC","","","","","facility","both","1","EA","","7.61","3.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 48 G"
"BENZOCAINE 20 % SPRA","0283-0679-02","NDC","","","","","facility","both","1","EA","","1.72","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SKIN CLEANSER COMB NO.42 CLSR 473 ML BOTTLE","0299011022","NDC","","","","","facility","both","1","EA","","39.08","19.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"QUETIAPINE SR 200 MG TB24","0310-0282-60","NDC","","","","","facility","both","1","EA","UD","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE SR 200 MG TB24","0310-0282-60","NDC","","","","","facility","both","1","EA","","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM PWPK","0310-1105-01","NDC","","","","","facility","both","1","EA","","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM PWPK","0310-1105-01","NDC","","","","","facility","both","1","EA","UD","49.68","24.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM PWPK","0310-1110-01","NDC","","","","","facility","both","1","EA","","41.68","20.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM PWPK","0310-1110-01","NDC","","","","","facility","both","1","EA","UD","41.68","20.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREMELIMUMAB-ACTL 20 MG/ML SOLN 15 ML VIAL","0310-4535-30","NDC","","","","","facility","both","1","EA","","153046.23","76523.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DAPAGLIFLOZIN PROPANEDIOL 5 MG TABS","0310-6205-30","NDC","","","","","facility","both","1","EA","UD","38.15","19.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPAGLIFLOZIN PROPANEDIOL 5 MG TABS","0310-6205-30","NDC","","","","","facility","both","1","EA","","38.15","19.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPAGLIFLOZIN PROPANEDIOL 10 MG TABS","0310-6210-39","NDC","","","","","facility","both","1","EA","UD","28.18","14.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPAGLIFLOZIN PROPANEDIOL 10 MG TABS","0310-6210-39","NDC","","","","","facility","both","1","EA","","28.18","14.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CAMPHOR-MENTHOL 0.5-0.5 % LOTN 222 ML BOTTLE","0316-0229-75","NDC","","","","","facility","both","1","EA","UD","16.54","8.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAMPHOR-MENTHOL 0.5-0.5 % LOTN 222 ML BOTTLE","0316-0229-75","NDC","","","","","facility","both","1","EA","","16.54","8.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"D10W% PARENTERAL NUTRITION COCKTAIL 500ML","0338-0023-04","NDC","","","","","facility","both","1","EA","","69.53","34.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 14 ML"
"D10W% PARENTERAL NUTRITION COCKTAIL 500ML","0338-0023-04","NDC","","","","","facility","both","1","EA","UD","69.53","34.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 14 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 15 MG/ML SOLN","0338-0069-10","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"KETOROLAC 15 MG/ML SOLN","0338-0069-10","NDC","","","","","facility","both","1","EA","UD","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 30 MG/ML SOLN","0338-0072-25","NDC","","","","","facility","both","1","EA","","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"KETOROLAC 30 MG/ML SOLN","0338-0072-25","NDC","","","","","facility","both","1","EA","UD","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) SOLN","0338-0112-20","NDC","","","","","facility","both","1","EA","UD","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) SOLN","0338-0112-20","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"PLASMALYTE-A SOLP","0338-0221-03","NDC","","","","","facility","both","1","EA","UD","56","28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PLASMALYTE-A SOLP","0338-0221-03","NDC","","","","","facility","both","1","EA","","56","28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CARDIOPLEGIC 16 MEQ/L (= K+) SOLN","0338-0341-04","NDC","","","","","facility","both","1","EA","","315","157.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 14 ML"
"CARDIOPLEGIC 16 MEQ/L (= K+) SOLN","0338-0341-04","NDC","","","","","facility","both","1","EA","UD","315","157.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 14 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MANNITOL 20 % SOLP","0338-0357-02","NDC","","","","","facility","both","1","EA","UD","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 36 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MANNITOL 20 % SOLP","0338-0357-02","NDC","","","","","facility","both","1","EA","","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 36 ML"
"MANNITOL 20 % SOLP","0338-0357-03","NDC","","","","","facility","both","1","EA","","78","39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MANNITOL 20 % SOLP","0338-0357-03","NDC","","","","","facility","both","1","EA","UD","78","39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 MG/ML (0.4 %) SOLP","0338-0409-03","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML"
"LIDOCAINE 4 MG/ML (0.4 %) SOLP","0338-0409-03","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 8 MG/ML (0.8 %) SOLP","0338-0411-02","NDC","","","","","facility","both","1","EA","UD","33","16.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 8 MG/ML (0.8 %) SOLP","0338-0411-02","NDC","","","","","facility","both","1","EA","","33","16.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"HEPARIN 1,000 UNIT/500 ML SOLP","0338-0424-18","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML"
"HEPARIN 2,000 UNIT/1,000 ML SOLP","0338-0433-04","NDC","","","","","facility","both","1","EA","","26","13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"GENTAMICIN 80 MG/100 ML PGBK","0338-0503-48","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 80 MG/100 ML PGBK","0338-0503-48","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"GENTAMICIN 100 MG/100 ML PGBK","0338-0505-48","NDC","","","","","facility","both","1","EA","UD","19.2","9.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 120 MG/100 ML PGBK","0338-0507-48","NDC","","","","","facility","both","1","EA","UD","18.8","9.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 120 MG/100 ML PGBK","0338-0507-48","NDC","","","","","facility","both","1","EA","","18.8","9.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"FAT EMULSION 20 % SYRG","0338-0519-09","NDC","","","","","facility","both","1","EA","","33.03","16.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FAT EMULSION 20 % SYRG","0338-0519-09","NDC","","","","","facility","both","1","EA","UD","33.03","16.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION 20 % EMUL 100 ML BAG","0338-0519-58","NDC","","","","","facility","both","1","EA","UD","378.8","189.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION 20 % EMUL 100 ML BAG","0338-0519-58","NDC","","","","","facility","both","1","EA","","378.8","189.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"AMINO ACID 10 % SOLP 2,000 ML BAG","0338-0644-06","NDC","","","","","facility","both","1","EA","","46.8","23.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"AMINO ACID 10 % SOLP 2,000 ML BAG","0338-0644-06","NDC","","","","","facility","both","1","EA","UD","41.2","20.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETIC ACID 0.25 % SOLN 1,000 ML BOTTLE","0338-0656-04","NDC","","","","","facility","both","1","EA","UD","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK","0338-0703-41","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK","0338-0703-41","NDC","","","","","facility","both","1","EA","UD","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML PGBK","0338-0705-41","NDC","","","","","facility","both","1","EA","","16.2","8.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML PGBK","0338-0705-41","NDC","","","","","facility","both","1","EA","UD","16.2","8.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK","0338-0705-48","NDC","","","","","facility","both","1","EA","","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK","0338-0705-48","NDC","","","","","facility","both","1","EA","UD","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/100 ML PGBK","0338-0709-48","NDC","","","","","facility","both","1","EA","UD","14.8","7.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/100 ML PGBK","0338-0709-48","NDC","","","","","facility","both","1","EA","","14.8","7.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"DEXTROSE 70 % SOLP","0338-0719-06","NDC","","","","","facility","both","1","EA","UD","5.62","2.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROSE 70 % SOLP","0338-0719-06","NDC","","","","","facility","both","1","EA","","5.62","2.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"DOPAMINE IN D5W 400 MG/250 ML (1,600 MCG/ML) SOLN","0338-1007-02","NDC","","","","","facility","both","1","EA","UD","57","28.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOPAMINE IN D5W 400 MG/250 ML (1,600 MCG/ML) SOLN","0338-1007-02","NDC","","","","","facility","both","1","EA","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML"
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) SOLN","0338-1009-02","NDC","","","","","facility","both","1","EA","UD","81","40.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) SOLN","0338-1009-02","NDC","","","","","facility","both","1","EA","","81","40.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML"
"NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) SOLN","0338-1051-02","NDC","","","","","facility","both","1","EA","","2.01","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) SOLN","0338-1051-02","NDC","","","","","facility","both","1","EA","UD","2.04","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 500 MG/100 ML PGBK","0338-1055-48","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"METRONIDAZOLE 500 MG/100 ML PGBK","0338-1055-48","NDC","","","","","facility","both","1","EA","UD","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOBUTAMINE 1,000 MG/250 ML (4,000 MCG/ML) SOLP","0338-1077-02","NDC","","","","","facility","both","1","EA","","2.19","1.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML"
"DOBUTAMINE 1,000 MG/250 ML (4,000 MCG/ML) SOLP","0338-1077-02","NDC","","","","","facility","both","1","EA","UD","3.99","2.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 18 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 4.25% IN D10W W/LYTES 4.25 % SOLP","0338-1115-04","NDC","","","","","facility","both","1","EA","","330","165","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"AMINO ACIDS 4.25% IN D10W W/LYTES 4.25 % SOLP","0338-1115-04","NDC","","","","","facility","both","1","EA","UD","330","165","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 5% IN D15W W/LYTES 5 % SOLP","0338-1123-04","NDC","","","","","facility","both","1","EA","UD","346","173","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 5% IN D15W W/LYTES 5 % SOLP","0338-1123-04","NDC","","","","","facility","both","1","EA","","346","173","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"AMINO ACID (PREMASOL) 10 % SOLP 500 ML FLEX CONT","0338-1130-03","NDC","","","","","facility","both","1","EA","UD","10.52","5.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACID (PREMASOL) 10 % SOLP 500 ML FLEX CONT","0338-1130-03","NDC","","","","","facility","both","1","EA","","16.96","8.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"AMINO ACID (PREMASOL) 10 % SOLP","0338-1130-04","NDC","","","","","facility","both","1","EA","","117.34","58.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"AMINO ACID (PREMASOL) 10 % SOLP","0338-1130-04","NDC","","","","","facility","both","1","EA","UD","117.34","58.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 4.25% IN D10W W/LYTES 4.25 % SOLP","0338-1145-03","NDC","","","","","facility","both","1","EA","","194","97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"AMINO ACIDS 4.25% IN D10W W/LYTES 4.25 % SOLP","0338-1145-03","NDC","","","","","facility","both","1","EA","UD","194","97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 5% IN D15W W/LYTES 5 % SOLP 1,000 ML BAG","0338-1147-03","NDC","","","","","facility","both","1","EA","","137","68.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"AMINO ACIDS 5% IN D15W W/LYTES 5 % SOLP 1,000 ML BAG","0338-1147-03","NDC","","","","","facility","both","1","EA","UD","182","91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MESNA 100 MG/ML SOLN 10 ML VIAL","0338-1305-01","NDC","","","","","facility","both","1","EA","UD","25.25","12.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MESNA 100 MG/ML SOLN 10 ML VIAL","0338-1305-01","NDC","","","","","facility","both","1","EA","","32.34","16.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0338-1709-40","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0338-1709-40","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 600 MG/50 ML PGBK","0338-3612-50","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 600 MG/50 ML PGBK","0338-3612-50","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLINDAMYCIN 900 MG/50 ML PGBK","0338-3814-50","NDC","","","","","facility","both","1","EA","UD","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 900 MG/50 ML PGBK","0338-3814-50","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUCONAZOLE 400 MG/200 ML PGBK","0338-6045-37","NDC","","","","","facility","both","1","EA","","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FLUCONAZOLE 400 MG/200 ML PGBK","0338-6045-37","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 5% IN D15W W/LYTES 5 % SOLP 2,000 ML BAG","0338-7032-01","NDC","","","","","facility","both","1","EA","UD","346","173","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS 5% IN D15W W/LYTES 5 % SOLP 2,000 ML BAG","0338-7032-01","NDC","","","","","facility","both","1","EA","","346","173","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLINDAMYCIN IN 0.9 % SOD CHLOR 600 MG/50 ML PGBK","0338-9549-50","NDC","","","","","facility","both","1","EA","","44.8","22.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLINDAMYCIN IN 0.9 % SOD CHLOR 600 MG/50 ML PGBK","0338-9549-50","NDC","","","","","facility","both","1","EA","UD","44.8","22.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) SOLN","0338-9555-24","NDC","","","","","facility","both","1","EA","UD","57.6","28.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) SOLN","0338-9555-24","NDC","","","","","facility","both","1","EA","","57.6","28.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","0338-9557-12","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","0338-9557-12","NDC","","","","","facility","both","1","EA","UD","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 CARTRIDGE","0362-0557-05","NDC","","","","","facility","both","1","EA","","12.75","6.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 CARTRIDGE","0362-0557-05","NDC","","","","","facility","both","1","EA","UD","12.75","6.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 CARTRIDGE","0362-9011-50","NDC","","","","","facility","both","1","EA","","12.75","6.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"METOPROLOL 12.5 MG TABS","0378-0018-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 12.5 MG TABS","0378-0018-01","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","0378-0085-01","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","0378-0085-01","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE 0.1 MG/24 HR PTWK","0378-0871-16","NDC","","","","","facility","both","1","EA","UD","21.16","10.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE 0.1 MG/24 HR PTWK","0378-0871-16","NDC","","","","","facility","both","1","EA","","21.16","10.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONIDINE 0.2 MG/24 HR PTWK","0378-0872-16","NDC","","","","","facility","both","1","EA","UD","30.15","15.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE 0.2 MG/24 HR PTWK","0378-0872-16","NDC","","","","","facility","both","1","EA","","30.15","15.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONIDINE 0.3 MG/24 HR PTWK","0378-0873-16","NDC","","","","","facility","both","1","EA","","38.73","19.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONIDINE 0.3 MG/24 HR PTWK","0378-0873-16","NDC","","","","","facility","both","1","EA","UD","38.73","19.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE TABS","0378-2146-01","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE TABS","0378-2146-01","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESTRADIOL 0.05 MG/24 HR PTWK","0378-3350-16","NDC","","","","","facility","both","1","EA","UD","37.7","18.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARMODAFINIL 50 MG TABS","0378-3431-93","NDC","","","","","facility","both","1","EA","","3.18","1.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ABACAVIR 300 MG TABS","0378-4105-91","NDC","","","","","facility","both","1","EA","UD","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ABACAVIR 300 MG TABS","0378-4105-91","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 12HR 60 MG CP12","0378-6060-01","NDC","","","","","facility","both","1","EA","","8.5","4.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 12HR 60 MG CP12","0378-6060-01","NDC","","","","","facility","both","1","EA","UD","8.5","4.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CITALOPRAM 20 MG TABS","0378-6232-01","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CITALOPRAM 20 MG TABS","0378-6232-01","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 24HR 240 MG C24P","0378-6440-01","NDC","","","","","facility","both","1","EA","","6.16","3.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 24HR 240 MG C24P","0378-6440-01","NDC","","","","","facility","both","1","EA","UD","6.16","3.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 5 % OINT 15 G TUBE","0378-8700-06","NDC","","","","","facility","both","1","EA","","39.27","19.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"RIVASTIGMINE 9.5 MG/24 HOUR PT24","0378-9071-16","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVASTIGMINE 13.3 MG/24 HOUR PT24","0378-9072-16","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.1 MG/HR PT24","0378-9102-16","NDC","","","","","facility","both","1","EA","","2.83","1.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.1 MG/HR PT24","0378-9102-16","NDC","","","","","facility","both","1","EA","UD","2.83","1.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 0.2 MG/HR PT24","0378-9104-16","NDC","","","","","facility","both","1","EA","UD","3.03","1.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 0.2 MG/HR PT24","0378-9104-16","NDC","","","","","facility","both","1","EA","","3.03","1.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.2 MG/HR PT24","0378-9104-93","NDC","","","","","facility","both","1","EA","","3.03","1.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.4 MG/HR PT24","0378-9112-16","NDC","","","","","facility","both","1","EA","","3.45","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.6 MG/HR PT24","0378-9116-16","NDC","","","","","facility","both","1","EA","UD","3.83","1.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 12 MCG/HR PT72","0378-9119-16","NDC","","","","","facility","both","1","EA","UD","38.48","19.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 12 MCG/HR PT72","0378-9119-16","NDC","","","","","facility","both","1","EA","","38.48","19.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 25 MCG/HR PT72","0378-9121-16","NDC","","","","","facility","both","1","EA","","10.54","5.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 25 MCG/HR PT72","0378-9121-16","NDC","","","","","facility","both","1","EA","UD","10.54","5.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 25 MCG/HR PT72 5 EACH BOX","0378-9121-98","NDC","","","","","facility","both","1","EA","","9.54","4.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 25 MCG/HR PT72 5 EACH BOX","0378-9121-98","NDC","","","","","facility","both","1","EA","UD","10.54","5.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 50 MCG/HR PT72","0378-9122-16","NDC","","","","","facility","both","1","EA","","17.66","8.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 50 MCG/HR PT72","0378-9122-16","NDC","","","","","facility","both","1","EA","UD","17.66","8.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 50 MCG/HR PT72","0378-9122-98","NDC","","","","","facility","both","1","EA","UD","17.66","8.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 100 MCG/HR PT72","0378-9124-16","NDC","","","","","facility","both","1","EA","UD","29.61","14.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 100 MCG/HR PT72","0378-9124-16","NDC","","","","","facility","both","1","EA","","29.61","14.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLYCERIN SOLN 473 ML BOTTLE","0395-1031-16","NDC","","","","","facility","both","1","EA","UD","62.5","31.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCERIN SOLN 473 ML BOTTLE","0395-1031-16","NDC","","","","","facility","both","1","EA","","62.5","31.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POVIDONE-IODINE 10 % SOLN","0395-2325-16","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POVIDONE-IODINE 10 % SOLN","0395-2325-16","NDC","","","","","facility","both","1","EA","UD","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODINE, STRONG 5 % SOLN 473 ML BOTTLE","0395-2775-16","NDC","","","","","facility","both","1","EA","","250.98","125.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINERAL OIL OIL 473 ML BOTTLE","0395-4219-16","NDC","","","","","facility","both","1","EA","","13.77","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0123-23","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0123-23","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0123-62","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0123-62","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0406-0124-23","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0406-0124-23","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0406-0124-62","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","0406-0125-01","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","0406-0125-23","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","0406-0125-23","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN-CODEINE 300-30 MG TABS","0406-0484-23","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN-CODEINE 300-30 MG TABS","0406-0484-23","NDC","","","","","facility","both","1","EA","UD","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0512-23","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0512-23","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0512-62","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 5-325 MG TABS","0406-0512-62","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0406-0522-23","NDC","","","","","facility","both","1","EA","UD","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0406-0522-23","NDC","","","","","facility","both","1","EA","","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","0406-0523-23","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","0406-0523-23","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHADONE 10 MG/ML CONC","0406-0527-10","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG/ML CONC","0406-0527-10","NDC","","","","","facility","both","1","EA","","2.91","1.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 5 MG TABS","0406-0552-23","NDC","","","","","facility","both","1","EA","UD","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG TABS","0406-0552-23","NDC","","","","","facility","both","1","EA","","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALTREXONE 50 MG TABS","0406-1170-03","NDC","","","","","facility","both","1","EA","UD","3.35","1.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALTREXONE 50 MG TABS","0406-1170-03","NDC","","","","","facility","both","1","EA","","3.35","1.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS","0406-1236-01","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS","0406-1236-01","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG TABS","0406-3243-01","NDC","","","","","facility","both","1","EA","UD","0.27","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG TABS","0406-3243-01","NDC","","","","","facility","both","1","EA","","0.27","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 4 MG TABS","0406-3244-01","NDC","","","","","facility","both","1","EA","UD","0.31","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 4 MG TABS","0406-3244-01","NDC","","","","","facility","both","1","EA","","0.31","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHADONE 5 MG TABS","0406-5755-23","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHADONE 5 MG TABS","0406-5755-23","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG TABS","0406-5771-23","NDC","","","","","facility","both","1","EA","UD","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG TABS","0406-5771-23","NDC","","","","","facility","both","1","EA","","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE SR 15 MG TBSR","0406-8315-23","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE SR 15 MG TBSR","0406-8315-23","NDC","","","","","facility","both","1","EA","UD","0.55","0.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE SR 100 MG TBSR","0406-8390-01","NDC","","","","","facility","both","1","EA","UD","3.17","1.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE SR 100 MG TBSR","0406-8390-01","NDC","","","","","facility","both","1","EA","","5.33","2.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE SR 100 MG TBSR","0406-8390-23","NDC","","","","","facility","both","1","EA","UD","2.17","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE SR 100 MG TBSR","0406-8390-23","NDC","","","","","facility","both","1","EA","","5.33","2.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE 20 MG/1 ML SYRG","0406-8557-01","NDC","","","","","facility","both","1","EA","","94.36","47.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 20 MG/ML CONC 30 ML BOTTLE","0406-8557-30","NDC","","","","","facility","both","1","EA","","50.18","25.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 20 MG/ML CONC 30 ML BOTTLE","0406-8557-30","NDC","","","","","facility","both","1","EA","UD","50.18","25.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 100 MCG/HR PT72","0406-9000-76","NDC","","","","","facility","both","1","EA","","29.61","14.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IOHEXOL (OMNIPAQUE) 180 MG/ML SOLN","0407-1411-10","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL (OMNIPAQUE) 180 MG/ML SOLN","0407-1411-10","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL (OMNIPAQUE) 180 MG/ML SOLN","0407-1411-20","NDC","","","","","facility","both","1","EA","","128","64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL (OMNIPAQUE) 180 MG/ML SOLN","0407-1411-20","NDC","","","","","facility","both","1","EA","UD","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-10","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-10","NDC","","","","","facility","both","1","EA","","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-20","NDC","","","","","facility","both","1","EA","","48","24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-20","NDC","","","","","facility","both","1","EA","UD","88","44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-30","NDC","","","","","facility","both","1","EA","UD","3.33","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-30","NDC","","","","","facility","both","1","EA","","3.33","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-33","NDC","","","","","facility","both","1","EA","","672","336","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 240 MG IODINE/ML SOLN","0407-1412-33","NDC","","","","","facility","both","1","EA","UD","720","360","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-10","NDC","","","","","facility","both","1","EA","UD","0.8","0.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-10","NDC","","","","","facility","both","1","EA","","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-58","NDC","","","","","facility","both","1","EA","UD","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-58","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-59","NDC","","","","","facility","both","1","EA","UD","240","120","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-59","NDC","","","","","facility","both","1","EA","","120","60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-61","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-61","NDC","","","","","facility","both","1","EA","","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-63","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-63","NDC","","","","","facility","both","1","EA","UD","32","16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-65","NDC","","","","","facility","both","1","EA","","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 300 MG IODINE/ML SOLN","0407-1413-65","NDC","","","","","facility","both","1","EA","UD","720","360","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-08","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-08","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-89","NDC","","","","","facility","both","1","EA","","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-89","NDC","","","","","facility","both","1","EA","UD","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-90","NDC","","","","","facility","both","1","EA","","400","200","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-91","NDC","","","","","facility","both","1","EA","UD","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-93","NDC","","","","","facility","both","1","EA","","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IOHEXOL 350 MG IODINE/ML SOLN","0407-1414-93","NDC","","","","","facility","both","1","EA","UD","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 270 MG IODINE/ML SOLN","0407-2222-17","NDC","","","","","facility","both","1","EA","UD","96","48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 270 MG IODINE/ML SOLN","0407-2222-17","NDC","","","","","facility","both","1","EA","","400","200","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-04","NDC","","","","","facility","both","1","EA","","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-04","NDC","","","","","facility","both","1","EA","UD","400","200","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-16","NDC","","","","","facility","both","1","EA","","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-16","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-17","NDC","","","","","facility","both","1","EA","","24","12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-17","NDC","","","","","facility","both","1","EA","UD","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-19","NDC","","","","","facility","both","1","EA","","64","32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-19","NDC","","","","","facility","both","1","EA","UD","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-21","NDC","","","","","facility","both","1","EA","UD","256","128","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODIXANOL 320 MG IODINE/ML SOLN","0407-2223-21","NDC","","","","","facility","both","1","EA","","400","200","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CARBOPROST 250 MCG/ML SOLN","0409-0064-01","NDC","","","","","facility","both","1","EA","","431.24","215.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPROST 250 MCG/ML SOLN","0409-0064-01","NDC","","","","","facility","both","1","EA","UD","431.24","215.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN 20 ML VIAL","0409-0125-01","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METRONIDAZOLE 500 MG/100 ML PGBK","0409-0152-01","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METRONIDAZOLE 500 MG/100 ML PGBK","0409-0152-01","NDC","","","","","facility","both","1","EA","UD","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 500 MG/100 ML PGBK","0409-0152-24","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"METRONIDAZOLE 500 MG/100 ML PGBK","0409-0152-24","NDC","","","","","facility","both","1","EA","UD","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) SOLN 26.3 ML VIAL","0409-0181-01","NDC","","","","","facility","both","1","EA","","100.54","50.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) SOLN 26.3 ML VIAL","0409-0181-01","NDC","","","","","facility","both","1","EA","UD","197.09","98.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) SOLN 52.6 ML VIAL","0409-0182-01","NDC","","","","","facility","both","1","EA","UD","264.84","132.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) SOLN 52.6 ML VIAL","0409-0182-01","NDC","","","","","facility","both","1","EA","","264.84","132.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MILRINONE 1 MG/ML SOLN 50 ML VIAL","0409-0212-03","NDC","","","","","facility","both","1","EA","UD","36.88","18.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MILRINONE 1 MG/ML SOLN 50 ML VIAL","0409-0212-03","NDC","","","","","facility","both","1","EA","","88.44","44.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AZTREONAM 1 GRAM SOLR 1 EACH VIAL","0409-0829-11","NDC","","","","","facility","both","1","EA","","173.19","86.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZTREONAM 2 GRAM SOLR 1 EACH VIAL","0409-0830-11","NDC","","","","","facility","both","1","EA","","333.42","166.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZTREONAM 2 GRAM SOLR 1 EACH VIAL","0409-0830-11","NDC","","","","","facility","both","1","EA","UD","333.42","166.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/500 ML SOLP","0409-1005-01","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CISATRACURIUM 10 MG/ML CONC. (ICU USE ONLY) SOLN 20 ML VIAL","0409-1103-11","NDC","","","","","facility","both","1","EA","","590","295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE","0409-1134-03","NDC","","","","","facility","both","1","EA","","4.74","2.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE","0409-1134-03","NDC","","","","","facility","both","1","EA","UD","103.28","51.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF","0409-1159-02","NDC","","","","","facility","both","1","EA","UD","8.05","4.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF","0409-1159-02","NDC","","","","","facility","both","1","EA","","8.05","4.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","0409-1159-18","NDC","","","","","facility","both","1","EA","UD","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","0409-1159-18","NDC","","","","","facility","both","1","EA","","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE (MARCAINE) 0.25% 0.25% SOLN","0409-1160-01","NDC","","","","","facility","both","1","EA","UD","22.81","11.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE (MARCAINE) 0.25% 0.25% SOLN","0409-1160-01","NDC","","","","","facility","both","1","EA","","22.81","11.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE HCL INJECTION 0.5%, PER ML","0409-1162-02","NDC","","","","","facility","both","1","EA","PN","0.42","0.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BUPIVACAINE","0409-1162-09","NDC","","","","","facility","both","1","EA","","64.67","32.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE PF (MARCAINE-PF) 0.5% 0.5% SOLN 10 ML VIAL","0409-1162-18","NDC","","","","","facility","both","1","EA","","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE PF (MARCAINE-PF) 0.5% 0.5% SOLN 10 ML VIAL","0409-1162-18","NDC","","","","","facility","both","1","EA","UD","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE HCL INJECTION 0.5%, PER ML","0409-1162-19","NDC","","","","","facility","both","1","EA","PN","0.42","0.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BUPIVACAINE (MARCAINE) 0.5% SOLN","0409-1163-18","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE (MARCAINE) 0.5% SOLN","0409-1163-18","NDC","","","","","facility","both","1","EA","","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE PF 0.75% 0.75 % (7.5 MG/ML) SOLN","0409-1165-01","NDC","","","","","facility","both","1","EA","UD","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF 0.75% 0.75 % (7.5 MG/ML) SOLN","0409-1165-01","NDC","","","","","facility","both","1","EA","","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MEPERIDINE","0409-1176-03","NDC","","","","","facility","both","1","EA","UD","12.61","6.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEPERIDINE","0409-1176-03","NDC","","","","","facility","both","1","EA","","12.61","6.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GENTAMICIN 40 MG/ML SOLN","0409-1207-13","NDC","","","","","facility","both","1","EA","UD","19.26","9.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 40 MG/ML SOLN","0409-1207-13","NDC","","","","","facility","both","1","EA","","19.26","9.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-EPINEPHRINE 1.5 %-1:200,000 SOLN","0409-1209-01","NDC","","","","","facility","both","1","EA","UD","17.63","8.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-EPINEPHRINE 1.5 %-1:200,000 SOLN","0409-1209-01","NDC","","","","","facility","both","1","EA","","17.63","8.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"DIAZEPAM 5 MG/ML SYRG","0409-1273-03","NDC","","","","","facility","both","1","EA","UD","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 5 MG/ML SYRG","0409-1273-03","NDC","","","","","facility","both","1","EA","","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 1 MG/ML SYRG","0409-1283-03","NDC","","","","","facility","both","1","EA","","15.59","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 1 MG/ML SYRG","0409-1283-03","NDC","","","","","facility","both","1","EA","UD","15.59","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 1 MG/ML SYRG","0409-1283-17","NDC","","","","","facility","both","1","EA","","15.59","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 1 MG/ML SYRG","0409-1283-17","NDC","","","","","facility","both","1","EA","UD","20.59","10.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG/ML SYRG","0409-1312-03","NDC","","","","","facility","both","1","EA","UD","25.2","12.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG/ML SYRG","0409-1312-03","NDC","","","","","facility","both","1","EA","","25.2","12.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN 10 GRAM SOLR","0409-1319-01","NDC","","","","","facility","both","1","EA","","33.11","16.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 10 GRAM SOLR","0409-1319-01","NDC","","","","","facility","both","1","EA","UD","33.11","16.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 100 MG/5 ML (2 %) SYRG","0409-1323-15","NDC","","","","","facility","both","1","EA","","33.53","16.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NALBUPHINE 10 MG/ML SOLN","0409-1463-01","NDC","","","","","facility","both","1","EA","UD","29.1","14.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALBUPHINE 10 MG/ML SOLN","0409-1463-01","NDC","","","","","facility","both","1","EA","","31.51","15.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"NALBUPHINE 10 MG/ML SOLN","0409-1463-71","NDC","","","","","facility","both","1","EA","UD","29.1","14.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALBUPHINE 10 MG/ML SOLN","0409-1463-71","NDC","","","","","facility","both","1","EA","","29.1","14.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","0409-1596-01","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","0409-1596-01","NDC","","","","","facility","both","1","EA","UD","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUTORPHANOL 2 MG/ML SOLN","0409-1626-01","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUTORPHANOL 2 MG/ML SOLN","0409-1626-21","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUTORPHANOL 2 MG/ML SOLN","0409-1626-21","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 0.1 MG/ML SYRG","0409-1630-15","NDC","","","","","facility","both","1","EA","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SYRG","0409-1631-40","NDC","","","","","facility","both","1","EA","","58.75","29.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VECURONIUM 10 MG SOLR","0409-1632-21","NDC","","","","","facility","both","1","EA","UD","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VECURONIUM 10 MG SOLR","0409-1632-21","NDC","","","","","facility","both","1","EA","","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) SOLN","0409-1660-50","NDC","","","","","facility","both","1","EA","UD","57.6","28.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) SOLN","0409-1660-50","NDC","","","","","facility","both","1","EA","","57.6","28.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"BUPIVACAINE 0.25%-EPINEPHRINE 1:200,000 (PF) 0.25 %-1:200,000 SOLN","0409-1746-10","NDC","","","","","facility","both","1","EA","UD","28.81","14.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.25%-EPINEPHRINE 1:200,000 (PF) 0.25 %-1:200,000 SOLN","0409-1746-10","NDC","","","","","facility","both","1","EA","","28.81","14.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"BUPIVACAINE 0.25%-EPINEPHRINE 1:200,000 (PF) 0.25 %-1:200,000 SOLN","0409-1746-30","NDC","","","","","facility","both","1","EA","UD","24.25","12.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.25%-EPINEPHRINE 1:200,000 (PF) 0.25 %-1:200,000 SOLN","0409-1746-30","NDC","","","","","facility","both","1","EA","","24.25","12.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"METOPROLOL 5 MG/5 ML SOLN","0409-1778-05","NDC","","","","","facility","both","1","EA","UD","7.56","3.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 5 MG/5 ML SOLN","0409-1778-05","NDC","","","","","facility","both","1","EA","","7.56","3.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"METOPROLOL 5 MG/5 ML SOLN","0409-1778-15","NDC","","","","","facility","both","1","EA","UD","7.56","3.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 5 MG/5 ML SOLN","0409-1778-15","NDC","","","","","facility","both","1","EA","","7.56","3.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVETIRACETAM 500 MG/5 ML SOLN","0409-1886-02","NDC","","","","","facility","both","1","EA","UD","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML SOLN","0409-1886-02","NDC","","","","","facility","both","1","EA","","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LEVETIRACETAM 500 MG/5 ML SOLN","0409-1886-22","NDC","","","","","facility","both","1","EA","UD","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML SOLN","0409-1886-22","NDC","","","","","facility","both","1","EA","","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 2 MG/ML SYRG","0409-1890-03","NDC","","","","","facility","both","1","EA","","5.51","2.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 2 MG/ML SYRG","0409-1890-03","NDC","","","","","facility","both","1","EA","UD","8.19","4.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 4 MG/ML SYRG","0409-1891-03","NDC","","","","","facility","both","1","EA","UD","7.92","3.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 4 MG/ML SYRG","0409-1891-03","NDC","","","","","facility","both","1","EA","","7.92","3.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCAINAMIDE 100 MG/ML SOLN 10 ML VIAL","0409-1902-01","NDC","","","","","facility","both","1","EA","","550.5","275.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LORAZEPAM 2 MG/ML SYRG","0409-1985-03","NDC","","","","","facility","both","1","EA","UD","7.51","3.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML SYRG","0409-1985-03","NDC","","","","","facility","both","1","EA","","6.25","3.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) SOLP","0409-2050-01","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) SOLP","0409-2050-01","NDC","","","","","facility","both","1","EA","UD","24","12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM PF 1 MG/ML SOLN","0409-2305-04","NDC","","","","","facility","both","1","EA","UD","10.88","5.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM PF 1 MG/ML SOLN","0409-2305-04","NDC","","","","","facility","both","1","EA","","10.88","5.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM PF 1 MG/ML SOLN","0409-2305-16","NDC","","","","","facility","both","1","EA","UD","6.8","3.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM PF 1 MG/ML SOLN","0409-2305-16","NDC","","","","","facility","both","1","EA","","6.8","3.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM (PF) 5 MG/ML SOLN 1 ML VIAL","0409-2308-21","NDC","","","","","facility","both","1","EA","","8.37","4.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LABETALOL 20 MG/4 ML (5 MG/ML) SYRG","0409-2339-24","NDC","","","","","facility","both","1","EA","UD","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 20 MG/4 ML (5 MG/ML) SYRG","0409-2339-24","NDC","","","","","facility","both","1","EA","","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LABETALOL 20 MG/4 ML (5 MG/ML) SYRG","0409-2339-24","NDC","","","","","facility","both","1","EA","59","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier 59: Distinct Procedural Service"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","0409-2344-02","NDC","","","","","facility","both","1","EA","","51.84","25.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","0409-2344-02","NDC","","","","","facility","both","1","EA","UD","77.76","38.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","0409-2344-62","NDC","","","","","facility","both","1","EA","","105.68","52.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","0409-2344-62","NDC","","","","","facility","both","1","EA","UD","27.92","13.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 1 GRAM SOLR","0409-2585-01","NDC","","","","","facility","both","1","EA","","19.58","9.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"CEFAZOLIN 1 GRAM SOLR","0409-2585-01","NDC","","","","","facility","both","1","EA","UD","36.65","18.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 5 ML VIAL","0409-2634-05","NDC","","","","","facility","both","1","EA","UD","272.04","136.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 5 ML VIAL","0409-2634-05","NDC","","","","","facility","both","1","EA","","272.04","136.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HYDROMORPHONE 0.01MG/ML BUPIV 0.125% (PF) 100ML NS","0409-2634-25","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 0.01MG/ML BUPIV 0.125% (PF) 100ML NS","0409-2634-25","NDC","","","","","facility","both","1","EA","UD","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN","0409-2720-30","NDC","","","","","facility","both","1","EA","","6.39","3.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1,000 UNIT/ML SOLN","0409-2720-30","NDC","","","","","facility","both","1","EA","UD","9.69","4.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 5,000 UNIT/ML SOLN","0409-2723-01","NDC","","","","","facility","both","1","EA","","10.06","5.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN 5,000 UNIT/ML SOLN","0409-2723-30","NDC","","","","","facility","both","1","EA","UD","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 5,000 UNIT/ML SOLN","0409-2723-30","NDC","","","","","facility","both","1","EA","","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DAPTOMYCIN 50 MG/ML SOLR","0409-2757-01","NDC","","","","","facility","both","1","EA","UD","109.55","54.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPTOMYCIN 50 MG/ML SOLR","0409-2757-01","NDC","","","","","facility","both","1","EA","","109.55","54.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 SOLN","0409-3177-01","NDC","","","","","facility","both","1","EA","UD","26.56","13.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 SOLN","0409-3177-01","NDC","","","","","facility","both","1","EA","","26.56","13.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","0409-3178-02","NDC","","","","","facility","both","1","EA","UD","37.94","18.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","0409-3178-02","NDC","","","","","facility","both","1","EA","","37.94","18.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","0409-3178-03","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","0409-3178-03","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 2%-EPINEPHRINE 1:100,000 2 %-1:100,000 SOLN","0409-3182-01","NDC","","","","","facility","both","1","EA","","23.38","11.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 2%-EPINEPHRINE 1:100,000 2 %-1:100,000 SOLN","0409-3182-01","NDC","","","","","facility","both","1","EA","UD","23.38","11.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2%-EPINEPHRINE 1:100,000 2 %-1:100,000 SOLN","0409-3182-11","NDC","","","","","facility","both","1","EA","","23.38","11.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-EPINEPHRINE PF 2 %-1:200,000 SOLN","0409-3183-01","NDC","","","","","facility","both","1","EA","UD","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-EPINEPHRINE PF 2 %-1:200,000 SOLN","0409-3183-01","NDC","","","","","facility","both","1","EA","","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL","0409-3299-15","NDC","","","","","facility","both","1","EA","UD","6.05","3.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL","0409-3299-15","NDC","","","","","facility","both","1","EA","","6.05","3.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM ACETATE 2 MEQ/ML SOLN 100 ML VIAL","0409-3299-16","NDC","","","","","facility","both","1","EA","","6.05","3.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM ACETATE 2 MEQ/ML SOLN 100 ML VIAL","0409-3299-16","NDC","","","","","facility","both","1","EA","UD","6.05","3.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN 400 MG/200 ML PGBK","0409-3300-01","NDC","","","","","facility","both","1","EA","UD","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN 400 MG/200 ML PGBK","0409-3300-01","NDC","","","","","facility","both","1","EA","","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOXACIN 400 MG/200 ML PGBK","0409-3300-24","NDC","","","","","facility","both","1","EA","","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CIPROFLOXACIN 400 MG/200 ML PGBK","0409-3300-24","NDC","","","","","facility","both","1","EA","UD","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0409-3308-03","NDC","","","","","facility","both","1","EA","","20.71","10.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 3 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0409-3308-11","NDC","","","","","facility","both","1","EA","UD","20.71","10.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0409-3308-11","NDC","","","","","facility","both","1","EA","","20.71","10.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","0409-3385-11","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-01","NDC","","","","","facility","both","1","EA","UD","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-01","NDC","","","","","facility","both","1","EA","","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-11","NDC","","","","","facility","both","1","EA","","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-11","NDC","","","","","facility","both","1","EA","UD","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-18","NDC","","","","","facility","both","1","EA","","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-18","NDC","","","","","facility","both","1","EA","UD","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-21","NDC","","","","","facility","both","1","EA","","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METOCLOPRAMIDE 5 MG/ML SOLN","0409-3414-21","NDC","","","","","facility","both","1","EA","UD","9.9","4.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","0409-3510-21","NDC","","","","","facility","both","1","EA","UD","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1.5 GRAM SOLR 1 EACH VIAL","0409-3515-11","NDC","","","","","facility","both","1","EA","UD","153.25","76.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1.5 GRAM SOLR 1 EACH VIAL","0409-3515-11","NDC","","","","","facility","both","1","EA","","153.25","76.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TOBRAMYCIN 300 MG","0409-3578-01","NDC","","","","","facility","both","1","EA","UD","223.26","111.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN 300 MG","0409-3578-01","NDC","","","","","facility","both","1","EA","","223.26","111.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75 % (7.5 MG/ML) SOLN","0409-3613-01","NDC","","","","","facility","both","1","EA","UD","10.78","5.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.75% IN DEXTROSE 8.25% (INTRATHECAL) 0.75 % (7.5 MG/ML) SOLN","0409-3613-01","NDC","","","","","facility","both","1","EA","","10.78","5.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"AMPICILLIN 500 MG SOLR","0409-3718-10","NDC","","","","","facility","both","1","EA","","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"KETOROLAC 15 MG/ML SOLN","0409-3793-01","NDC","","","","","facility","both","1","EA","UD","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 15 MG/ML SOLN","0409-3793-01","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"KETOROLAC 15 MG/ML SOLN","0409-3793-19","NDC","","","","","facility","both","1","EA","UD","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 15 MG/ML SOLN","0409-3793-19","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 30 MG/ML SOLN","0409-3795-19","NDC","","","","","facility","both","1","EA","","7.94","3.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 30 MG/ML SOLN","0409-3795-19","NDC","","","","","facility","both","1","EA","UD","7.94","3.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 60 MG/2 ML SOLN","0409-3796-19","NDC","","","","","facility","both","1","EA","UD","8.94","4.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 0.5 MG/ML SOLN","0409-3814-11","NDC","","","","","facility","both","1","EA","","54.38","27.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 10 ML VIAL","0409-3815-12","NDC","","","","","facility","both","1","EA","","27.86","13.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"MORPHINE 10 ML VIAL","0409-3815-12","NDC","","","","","facility","both","1","EA","UD","27.86","13.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MANNITOL 25 % SOLN 50 ML VIAL","0409-4031-16","NDC","","","","","facility","both","1","EA","","4.37","2.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MANNITOL 25 % SOLN 50 ML VIAL","0409-4031-16","NDC","","","","","facility","both","1","EA","UD","4.37","2.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL","0409-4090-11","NDC","","","","","facility","both","1","EA","","150.31","75.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZINC CHLORIDE 1 MG/ML SOLN 10 ML VIAL","0409-4090-11","NDC","","","","","facility","both","1","EA","UD","150.31","75.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CUPERIC CHLORIDE (COPPER) 0.4 MG/ML SOLN 10 ML VIAL","0409-4092-11","NDC","","","","","facility","both","1","EA","","83.75","41.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","0409-4264-01","NDC","","","","","facility","both","1","EA","UD","25.9","12.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","0409-4264-01","NDC","","","","","facility","both","1","EA","","25.9","12.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","0409-4264-11","NDC","","","","","facility","both","1","EA","UD","25.9","12.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","0409-4264-11","NDC","","","","","facility","both","1","EA","","25.9","12.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 0.5% SOLN","0409-4275-16","NDC","","","","","facility","both","1","EA","UD","32.19","16.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4276-01","NDC","","","","","facility","both","1","EA","UD","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4276-01","NDC","","","","","facility","both","1","EA","","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4276-02","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4276-02","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"XYLOCAINE MPF INJECTION 1%, PER ML","0409-4276-16","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"XYLOCAINE MPF INJECTION 1%, PER ML","0409-4276-16","NDC","","","","","facility","both","1","EA","UD","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4276-17","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4276-17","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (XYLOCAINE) 2% SOLN","0409-4277-16","NDC","","","","","facility","both","1","EA","UD","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 2% SOLN","0409-4277-16","NDC","","","","","facility","both","1","EA","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 5 MG/ML (0.5 %) SOLN","0409-4278-01","NDC","","","","","facility","both","1","EA","","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 5 MG/ML (0.5 %) SOLN","0409-4278-16","NDC","","","","","facility","both","1","EA","UD","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4279-02","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4279-02","NDC","","","","","facility","both","1","EA","","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4279-16","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4279-16","NDC","","","","","facility","both","1","EA","","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (PF) 20 MG/ML (2 %) SOLN","0409-4282-12","NDC","","","","","facility","both","1","EA","","29.06","14.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (PF) 20 MG/ML (2 %) SOLN","0409-4282-12","NDC","","","","","facility","both","1","EA","UD","29.06","14.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4% 40 MG/ML (4 %) SOLN","0409-4283-01","NDC","","","","","facility","both","1","EA","UD","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4% 40 MG/ML (4 %) SOLN","0409-4283-01","NDC","","","","","facility","both","1","EA","","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 4% 40 MG/ML (4 %) SOLN","0409-4283-11","NDC","","","","","facility","both","1","EA","","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN 125MG/5ML SOLN","0409-4332-01","NDC","","","","","facility","both","1","EA","","5.52","2.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"VANCOMYCIN 125MG/5ML SOLN","0409-4332-01","NDC","","","","","facility","both","1","EA","UD","5.52","2.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 500 MG SOLR","0409-4332-11","NDC","","","","","facility","both","1","EA","UD","3.12","1.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 500 MG SOLR","0409-4332-11","NDC","","","","","facility","both","1","EA","","2.81","1.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 100 MG SOLR","0409-4350-13","NDC","","","","","facility","both","1","EA","","73.82","36.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 100 MG SOLR","0409-4350-13","NDC","","","","","facility","both","1","EA","UD","73.82","36.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","0409-4444-01","NDC","","","","","facility","both","1","EA","UD","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","0409-4444-01","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","0409-4520-02","NDC","","","","","facility","both","1","EA","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","0409-4520-02","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","0409-4699-33","NDC","","","","","facility","both","1","EA","UD","39.69","19.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","0409-4699-33","NDC","","","","","facility","both","1","EA","","39.69","19.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"PROPOFOL 10 MG/ML EMUL","0409-4699-50","NDC","","","","","facility","both","1","EA","","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROPOFOL 10 MG/ML EMUL","0409-4699-50","NDC","","","","","facility","both","1","EA","UD","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4713-02","NDC","","","","","facility","both","1","EA","","3.2","1.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","0409-4713-02","NDC","","","","","facility","both","1","EA","UD","4.25","2.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4713-12","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4713-12","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4713-75","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","0409-4713-75","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ONDANSETRON 2 MG/ML SOLN","0409-4759-01","NDC","","","","","facility","both","1","EA","","4.38","2.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPINEPHRINE 0.1 MG/ML SYRG","0409-4933-11","NDC","","","","","facility","both","1","EA","UD","35.25","17.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 0.1 MG/ML SYRG","0409-4933-11","NDC","","","","","facility","both","1","EA","","35.25","17.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN 10 GRAM SOLR","0409-5017-01","NDC","","","","","facility","both","1","EA","","33.11","16.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 10 GRAM SOLR","0409-5017-01","NDC","","","","","facility","both","1","EA","UD","33.11","16.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTAZIDIME 6.75MG/0.3ML","0409-5082-11","NDC","","","","","facility","both","1","EA","","14.96","7.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTAZIDIME 6MG/0.3ML","0409-5092-16","NDC","","","","","facility","both","1","EA","","17.5","8.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) SYRG","0409-5534-14","NDC","","","","","facility","both","1","EA","UD","70.06","35.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) SYRG","0409-5534-14","NDC","","","","","facility","both","1","EA","","678.13","339.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"AMINOPHYLLINE 250 MG/10 ML SOLN","0409-5921-16","NDC","","","","","facility","both","1","EA","UD","91.94","45.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINOPHYLLINE 250 MG/10 ML SOLN","0409-5921-16","NDC","","","","","facility","both","1","EA","","91.94","45.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-04","NDC","","","","","facility","both","1","EA","","8.75","4.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-04","NDC","","","","","facility","both","1","EA","UD","8.75","4.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-18","NDC","","","","","facility","both","1","EA","UD","6.25","3.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-18","NDC","","","","","facility","both","1","EA","","8.75","4.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-19","NDC","","","","","facility","both","1","EA","","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-19","NDC","","","","","facility","both","1","EA","UD","8.13","4.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-20","NDC","","","","","facility","both","1","EA","UD","12.06","6.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-20","NDC","","","","","facility","both","1","EA","","12.06","6.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-35","NDC","","","","","facility","both","1","EA","","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 10 MG/ML SOLN","0409-6102-35","NDC","","","","","facility","both","1","EA","UD","8.13","4.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERYTHROMYCIN LACTOBIONATE 500 MG SOLR 1 EACH VIAL","0409-6482-01","NDC","","","","","facility","both","1","EA","","274.12","137.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"ERYTHROMYCIN LACTOBIONATE 500 MG SOLR 1 EACH VIAL","0409-6482-01","NDC","","","","","facility","both","1","EA","UD","477.01","238.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERYTHROMYCIN LACTOBIONATE 500 MG SOLR 1 EACH VIAL","0409-6482-11","NDC","","","","","facility","both","1","EA","JG","172.68","86.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ERYTHROMYCIN LACTOBIONATE 500 MG SOLR 1 EACH VIAL","0409-6482-11","NDC","","","","","facility","both","1","EA","","274.12","137.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERYTHROMYCIN LACTOBIONATE 500 MG SOLR 1 EACH VIAL","0409-6482-11","NDC","","","","","facility","both","1","EA","UD","172.68","86.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 5 GRAM SOLR","0409-6509-01","NDC","","","","","facility","both","1","EA","UD","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 5 GRAM SOLR","0409-6509-01","NDC","","","","","facility","both","1","EA","","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 750 MG SOLR 1 EACH VIAL","0409-6531-12","NDC","","","","","facility","both","1","EA","UD","44.26","22.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 750 MG SOLR 1 EACH VIAL","0409-6531-12","NDC","","","","","facility","both","1","EA","","44.26","22.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 1,000 MG SOLR","0409-6533-11","NDC","","","","","facility","both","1","EA","UD","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1,000 MG SOLR","0409-6533-11","NDC","","","","","facility","both","1","EA","","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 1,000 MG SOLR","0409-6533-31","NDC","","","","","facility","both","1","EA","","2.54","1.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"VANCOMYCIN 1,000 MG SOLR","0409-6533-31","NDC","","","","","facility","both","1","EA","UD","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TESTOSTERONE CYPIONATE 200 MG/ML OIL","0409-6562-01","NDC","","","","","facility","both","1","EA","","43.75","21.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN","0409-6625-14","NDC","","","","","facility","both","1","EA","","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN","0409-6625-14","NDC","","","","","facility","both","1","EA","UD","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN","0409-6625-22","NDC","","","","","facility","both","1","EA","UD","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN","0409-6625-22","NDC","","","","","facility","both","1","EA","","39.38","19.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL","0409-6635-01","NDC","","","","","facility","both","1","EA","UD","20.5","10.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 5 ML VIAL","0409-6635-01","NDC","","","","","facility","both","1","EA","","20.5","10.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SYRG","0409-6637-24","NDC","","","","","facility","both","1","EA","UD","70.31","35.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SYRG","0409-6637-24","NDC","","","","","facility","both","1","EA","","70.31","35.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"D50W SOLP","0409-6648-02","NDC","","","","","facility","both","1","EA","UD","26.88","13.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SOLP","0409-6648-02","NDC","","","","","facility","both","1","EA","","26.88","13.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL","0409-6651-06","NDC","","","","","facility","both","1","EA","","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL","0409-6651-06","NDC","","","","","facility","both","1","EA","UD","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL","0409-6651-19","NDC","","","","","facility","both","1","EA","UD","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 10 ML VIAL","0409-6651-19","NDC","","","","","facility","both","1","EA","","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN","0409-6653-18","NDC","","","","","facility","both","1","EA","UD","6.09","3.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN","0409-6653-18","NDC","","","","","facility","both","1","EA","","6.09","3.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOMIDATE 2 MG/ML SOLN","0409-6695-02","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOMIDATE 2 MG/ML SOLN","0409-6695-02","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ETOMIDATE 2 MG/ML SOLN","0409-6695-12","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOMIDATE 2 MG/ML SOLN","0409-6695-12","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0409-6727-11","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0409-6727-55","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","0409-6727-55","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","0409-6729-11","NDC","","","","","facility","both","1","EA","","10.8","5.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","0409-6729-11","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 15 ML VIAL","0409-7295-11","NDC","","","","","facility","both","1","EA","","14.83","7.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 15 ML VIAL","0409-7295-11","NDC","","","","","facility","both","1","EA","UD","14.83","7.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL","0409-7299-83","NDC","","","","","facility","both","1","EA","UD","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL","0409-7299-83","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFTRIAXONE 1 GRAM SOLR","0409-7333-04","NDC","","","","","facility","both","1","EA","UD","54.28","27.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 1 GRAM SOLR","0409-7333-04","NDC","","","","","facility","both","1","EA","","28.39","14.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFTRIAXONE 2 GRAM SOLR 1 EACH VIAL","0409-7335-13","NDC","","","","","facility","both","1","EA","UD","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 2 GRAM SOLR 1 EACH VIAL","0409-7335-13","NDC","","","","","facility","both","1","EA","","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTRIAXONE 250 MG SOLR 1 EACH VIAL","0409-7337-11","NDC","","","","","facility","both","1","EA","UD","7.26","3.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 500 MG SOLR 1 EACH VIAL","0409-7338-11","NDC","","","","","facility","both","1","EA","UD","8.53","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 500 MG SOLR 1 EACH VIAL","0409-7338-11","NDC","","","","","facility","both","1","EA","","8.53","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL","0409-7391-72","NDC","","","","","facility","both","1","EA","","116.69","58.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL","0409-7391-72","NDC","","","","","facility","both","1","EA","UD","116.69","58.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTRAN 40 IN DEXTROSE 5% 10 % SOLP","0409-7418-13","NDC","","","","","facility","both","1","EA","UD","144","72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SYRG","0409-7517-16","NDC","","","","","facility","both","1","EA","UD","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SYRG","0409-7517-16","NDC","","","","","facility","both","1","EA","","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"D50W SYRG","0409-7517-66","NDC","","","","","facility","both","1","EA","UD","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SYRG","0409-7517-66","NDC","","","","","facility","both","1","EA","","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN (PORCINE)-0.45% NACL 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","0409-7650-05","NDC","","","","","facility","both","1","EA","UD","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN (PORCINE)-0.45% NACL 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","0409-7650-05","NDC","","","","","facility","both","1","EA","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MANNITOL 20 % SOLP","0409-7715-13","NDC","","","","","facility","both","1","EA","","78","39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOPAMINE IN D5W 400 MG/250 ML (1,600 MCG/ML) SOLN","0409-7809-11","NDC","","","","","facility","both","1","EA","UD","57","28.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOPAMINE IN D5W 400 MG/250 ML (1,600 MCG/ML) SOLN","0409-7809-11","NDC","","","","","facility","both","1","EA","","57","28.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOPAMINE 800 MG/250 ML (3,200 MCG/ML) SOLN","0409-7810-11","NDC","","","","","facility","both","1","EA","","81","40.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"D12.5% SOLN 500 ML BAG","0409-7922-30","NDC","","","","","facility","both","1","EA","UD","0.01","0.005","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D12.5% SOLN 500 ML BAG","0409-7922-30","NDC","","","","","facility","both","1","EA","","0.01","0.005","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL","0409-8183-01","NDC","","","","","facility","both","1","EA","","23.5","11.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"POTASSIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL","0409-8183-01","NDC","","","","","facility","both","1","EA","UD","23.5","11.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BIVALIRUDIN 0.1MG/ML FLUSH 0.1 MG/ML 1 EACH VIAL","0409-8300-10","NDC","","","","","facility","both","1","EA","","9.48","4.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 2 ML AMPUL","0409-9093-32","NDC","","","","","facility","both","1","EA","UD","16.7","8.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 2 ML AMPUL","0409-9093-32","NDC","","","","","facility","both","1","EA","","16.7","8.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0409-9094-12","NDC","","","","","facility","both","1","EA","","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0409-9094-12","NDC","","","","","facility","both","1","EA","UD","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 20 ML VIAL","0409-9094-16","NDC","","","","","facility","both","1","EA","","18.97","9.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 20 ML VIAL","0409-9094-16","NDC","","","","","facility","both","1","EA","UD","18.97","9.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 2 ML VIAL","0409-9094-22","NDC","","","","","facility","both","1","EA","","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 2 ML VIAL","0409-9094-22","NDC","","","","","facility","both","1","EA","UD","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 5 ML VIAL","0409-9094-25","NDC","","","","","facility","both","1","EA","","18.86","9.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 5 ML VIAL","0409-9094-25","NDC","","","","","facility","both","1","EA","UD","18.86","9.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0409-9094-41","NDC","","","","","facility","both","1","EA","UD","15.13","7.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0409-9094-41","NDC","","","","","facility","both","1","EA","","15.37","7.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML SYRG","0409-9157-31","NDC","","","","","facility","both","1","EA","UD","32.16","16.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML SYRG","0409-9157-31","NDC","","","","","facility","both","1","EA","","32.16","16.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROPIVACAINE/CLONIDINE","0409-9300-10","NDC","","","","","facility","both","1","EA","UD","126.51","63.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROPIVACAINE/CLONIDINE","0409-9300-10","NDC","","","","","facility","both","1","EA","","126.51","63.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","0409-9566-01","NDC","","","","","facility","both","1","EA","UD","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","0409-9566-01","NDC","","","","","facility","both","1","EA","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","0409-9566-10","NDC","","","","","facility","both","1","EA","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","0409-9735-01","NDC","","","","","facility","both","1","EA","UD","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","0409-9735-01","NDC","","","","","facility","both","1","EA","","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AEROCHAMBER SPCR","0435150012","NDC","","","","","facility","both","1","EA","UD","161.9","80.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYPOCHLORITE 0.125 % SOLN 473 ML BOTTLE","0436-0672-16","NDC","","","","","facility","both","1","EA","UD","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYPOCHLORITE 0.125 % SOLN 473 ML BOTTLE","0436-0672-16","NDC","","","","","facility","both","1","EA","","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM HYPOCHLORITE 0.25 % SOLN 473 ML BOTTLE","0436-0936-16","NDC","","","","","facility","both","1","EA","UD","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYPOCHLORITE 0.25 % SOLN 473 ML BOTTLE","0436-0936-16","NDC","","","","","facility","both","1","EA","","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM HYPOCHLORITE 0.5 % SOLN 473 ML BOTTLE","0436-0946-16","NDC","","","","","facility","both","1","EA","UD","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYPOCHLORITE 0.5 % SOLN 473 ML BOTTLE","0436-0946-16","NDC","","","","","facility","both","1","EA","","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFTAROLINE FOSAMIL 400 MG SOLR 1 EACH VIAL","0456-0400-01","NDC","","","","","facility","both","1","EA","","659.72","329.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THYROID (PORK) 30 MG TABS","0456-0458-01","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THYROID (PORK) 30 MG TABS","0456-0458-01","NDC","","","","","facility","both","1","EA","UD","2.82","1.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINACLOTIDE 145 MCG CAPS","0456-1201-30","NDC","","","","","facility","both","1","EA","","35.48","17.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINACLOTIDE 145 MCG CAPS","0456-1201-30","NDC","","","","","facility","both","1","EA","UD","35.48","17.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINACLOTIDE 290 MCG CAPS","0456-1202-30","NDC","","","","","facility","both","1","EA","","35.48","17.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINACLOTIDE 290 MCG CAPS","0456-1202-30","NDC","","","","","facility","both","1","EA","UD","35.48","17.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINACLOTIDE 72 MCG CAPS","0456-1203-30","NDC","","","","","facility","both","1","EA","","35.48","17.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINACLOTIDE 72 MCG CAPS","0456-1203-30","NDC","","","","","facility","both","1","EA","UD","35.48","17.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MILNACIPRAN 12.5 MG TABS","0456-1512-60","NDC","","","","","facility","both","1","EA","UD","20.38","10.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTAZIDIME-AVIBACTAM 2.5 GRAM SOLR 1 EACH VIAL","0456-2700-01","NDC","","","","","facility","both","1","EA","","751.2","375.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISAVUCONAZONIUM SULFATE 186 MG CAPS","0469-0520-01","NDC","","","","","facility","both","1","EA","UD","910.74","455.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISAVUCONAZONIUM SULFATE 186 MG CAPS","0469-0520-02","NDC","","","","","facility","both","1","EA","UD","910.74","455.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 5 MG/ML SOLN 1 ML AMPUL","0469-3016-01","NDC","","","","","facility","both","1","EA","UD","1225.11","612.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 5 MG/ML SOLN 1 ML AMPUL","0469-3016-01","NDC","","","","","facility","both","1","EA","JG,UD","1259.72","629.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 5 MG/ML SOLN 1 ML AMPUL","0469-3016-01","NDC","","","","","facility","both","1","EA","JG","1259.72","629.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TACROLIMUS 5 MG/ML SOLN 1 ML AMPUL","0469-3016-01","NDC","","","","","facility","both","1","EA","UD,TB","1259.72","629.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"AMPHOTERICIN B LIPOSOMAL 50 MG SUSR 1 EACH VIAL","0469-3051-30","NDC","","","","","facility","both","1","EA","","3057","1528.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","0469-3211-10","NDC","","","","","facility","both","1","EA","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","0469-3250-10","NDC","","","","","facility","both","1","EA","","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"REGADENOSON 0.4 MG/5 ML SYRG","0469-6501-89","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"REGADENOSON 0.4 MG/5 ML SYRG","0469-6501-89","NDC","","","","","facility","both","1","EA","UD","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 200 MG/5 ML SUSPENSION","0472-0082-16","NDC","","","","","facility","both","1","EA","","12.3","6.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACYCLOVIR 200 MG/5 ML SUSPENSION","0472-0082-16","NDC","","","","","facility","both","1","EA","UD","23.59","11.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICONAZOLE 200 MG SUPP","0472-1738-03","NDC","","","","","facility","both","1","EA","UD","33.47","16.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICONAZOLE 200 MG SUPP","0472-1738-03","NDC","","","","","facility","both","1","EA","","33.47","16.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THEOPHYLLINE CR (12 HOUR) 300 MG TB12","0480-3310-01","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM PHOSPHATE 500 MG TBSO","0486-1111-01","NDC","","","","","facility","both","1","EA","","2.33","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML NEBU","0487-0201-01","NDC","","","","","facility","both","1","EA","","1.9","0.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML NEBU","0487-0201-01","NDC","","","","","facility","both","1","EA","UD","1.9","0.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RACEPINEPHRINE 2.25 % NEBU","0487-5901-99","NDC","","","","","facility","both","1","EA","","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 EACH"
"RACEPINEPHRINE 2.25 % NEBU","0487-5901-99","NDC","","","","","facility","both","1","EA","UD","3.5","1.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 3 % NEBU","0487900330","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"SODIUM CHLORIDE 3 % NEBU","0487900330","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 3 % NEBU","0487900360","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 3 % NEBU","0487900360","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"SODIUM CHLORIDE 7 % NEBU","0487900730","NDC","","","","","facility","both","1","EA","UD","1.76","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 7 % NEBU","0487900730","NDC","","","","","facility","both","1","EA","","1.76","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"SODIUM CHLORIDE 7 % NEBU","0487900760","NDC","","","","","facility","both","1","EA","UD","1.76","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 7 % NEBU","0487900760","NDC","","","","","facility","both","1","EA","","1.76","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"SODIUM CHLORIDE 0.9 % NEBU","0487-9301-33","NDC","","","","","facility","both","1","EA","","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"ALBUTEROL 2.5 MG /3 ML (0.083 %) NEBU","0487-9501-01","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUTEROL 2.5 MG /3 ML (0.083 %) NEBU","0487-9501-01","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"BUDESONIDE 0.25 MG/2 ML NBSP","0487-9601-01","NDC","","","","","facility","both","1","EA","UD","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUDESONIDE 0.25 MG/2 ML NBSP","0487-9601-01","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"BUDESONIDE 0.5 MG/2 ML NBSP","0487-9701-01","NDC","","","","","facility","both","1","EA","","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"BUDESONIDE 0.5 MG/2 ML NBSP","0487-9701-01","NDC","","","","","facility","both","1","EA","UD","3.5","1.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IPRATROPIUM 0.02 % SOLN","0487-9801-01","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IPRATROPIUM 0.02 % SOLN","0487-9801-01","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"ALBUTEROL 2.5 MG/0.5 ML NEBU","0487-9901-30","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUTEROL 2.5 MG/0.5 ML NEBU","0487-9901-30","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 EACH"
"ALBUTEROL 1.25 MG/3 ML NEBU","0487-9904-01","NDC","","","","","facility","both","1","EA","UD","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUTEROL 1.25 MG/3 ML NEBU","0487-9904-01","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"ALBUTEROL 1.25 MG/3 ML NEBU","0487-9904-25","NDC","","","","","facility","both","1","EA","UD","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUTEROL 1.25 MG/3 ML NEBU","0487-9904-25","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 4 % CREA 5 G TUBE","0496-0882-05","NDC","","","","","facility","both","1","EA","UD","9.05","4.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % CREA 5 G TUBE","0496-0882-05","NDC","","","","","facility","both","1","EA","","9.05","4.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"LIDOCAINE 4 % CREA 5 G TUBE","0496-0882-06","NDC","","","","","facility","both","1","EA","","9.05","4.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 G"
"LIDOCAINE 4 % CREA 5 G TUBE","0496-0882-06","NDC","","","","","facility","both","1","EA","UD","9.05","4.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 1,000 MCG/ML SOLN","0517-0031-01","NDC","","","","","facility","both","1","EA","","8.81","4.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYANOCOBALAMIN 1,000 MCG/ML SOLN","0517-0031-01","NDC","","","","","facility","both","1","EA","UD","8.81","4.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 1,000 MCG/ML SOLN","0517-0031-25","NDC","","","","","facility","both","1","EA","","19.5","9.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CYANOCOBALAMIN 1,000 MCG/ML SOLN","0517-0031-25","NDC","","","","","facility","both","1","EA","UD","19.5","9.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLENE BLUE 5 MG/ML SOLN 10 ML AMPUL","0517-0374-01","NDC","","","","","facility","both","1","EA","JG","1467.44","733.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"METHYLENE BLUE 5 MG/ML SOLN 10 ML AMPUL","0517-0374-01","NDC","","","","","facility","both","1","EA","","1467.44","733.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHYLENE BLUE 5 MG/ML SOLN 10 ML AMPUL","0517-0374-01","NDC","","","","","facility","both","1","EA","TB","1467.44","733.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"METHYLENE BLUE 5 MG/ML SOLN 10 ML AMPUL","0517-0374-01","NDC","","","","","facility","both","1","EA","UD","1467.44","733.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERRIC CARBOXYMALTOSE 50 MG IRON/ML SOLN 15 ML VIAL","0517-0650-01","NDC","","","","","facility","both","1","EA","","6526.93","3263.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BETAMETHASONE ACETATE & SODIUM PHOSPHATE (CELESTONE) 6 MG/ML SUSPENSION","0517-0720-01","NDC","","","","","facility","both","1","EA","","236.25","118.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BETAMETHASONE ACETATE & SODIUM PHOSPHATE (CELESTONE) 6 MG/ML SUSPENSION","0517-0720-01","NDC","","","","","facility","both","1","EA","UD","236.25","118.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLERGONOVINE 0.2 MG/ML (1 ML) SOLN","0517-0740-01","NDC","","","","","facility","both","1","EA","UD","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLERGONOVINE 0.2 MG/ML (1 ML) SOLN","0517-0740-01","NDC","","","","","facility","both","1","EA","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDRALAZINE 20 MG/ML SOLN","0517-0901-01","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDRALAZINE 20 MG/ML SOLN","0517-0901-01","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG/2ML SOLR","0517-0955-01","NDC","","","","","facility","both","1","EA","UD","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG/2ML SOLR","0517-0955-01","NDC","","","","","facility","both","1","EA","","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATROPINE 1 MG/ML SOLN","0517-1001-01","NDC","","","","","facility","both","1","EA","","54.28","27.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATROPINE 1 MG/ML SOLN","0517-1001-25","NDC","","","","","facility","both","1","EA","UD","106.06","53.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 0.4 MG/ML SOLN","0517-1004-01","NDC","","","","","facility","both","1","EA","","52.5","26.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATROPINE 0.4 MG/ML SOLN","0517-1004-25","NDC","","","","","facility","both","1","EA","","52.5","26.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ATROPINE 0.4 MG/ML SOLN","0517-1004-25","NDC","","","","","facility","both","1","EA","UD","65","32.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 1 MG/ML SOLN","0517-1010-25","NDC","","","","","facility","both","1","EA","","57.45","28.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","0517-1820-01","NDC","","","","","facility","both","1","EA","","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","0517-1820-01","NDC","","","","","facility","both","1","EA","UD","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICYCLOMINE 10 MG/ML SOLN","0517-1980-01","NDC","","","","","facility","both","1","EA","UD","78.25","39.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICYCLOMINE 10 MG/ML SOLN","0517-1980-01","NDC","","","","","facility","both","1","EA","","78.25","39.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 15 ML VIAL","0517-2102-01","NDC","","","","","facility","both","1","EA","UD","14.83","7.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 15 ML VIAL","0517-2102-01","NDC","","","","","facility","both","1","EA","","14.83","7.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRON SUCROSE 200 MG IRON/10 ML SOLN 10 ML VIAL","0517-2310-01","NDC","","","","","facility","both","1","EA","UD","765.19","382.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRON SUCROSE 200 MG IRON/10 ML SOLN 10 ML VIAL","0517-2310-01","NDC","","","","","facility","both","1","EA","","765.19","382.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRON SUCROSE 50 MG IRON/2.5 ML SOLN 2.5 ML VIAL","0517-2325-01","NDC","","","","","facility","both","1","EA","","227.5","113.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRON SUCROSE 50 MG IRON/2.5 ML SOLN 2.5 ML VIAL","0517-2325-10","NDC","","","","","facility","both","1","EA","","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IRON SUCROSE 100 MG IRON/5 ML SOLN","0517-2340-01","NDC","","","","","facility","both","1","EA","UD","115","57.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRON SUCROSE 100 MG IRON/5 ML SOLN","0517-2340-01","NDC","","","","","facility","both","1","EA","","225","112.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRON SUCROSE 100 MG IRON/5 ML SOLN 5 ML VIAL","0517-2340-10","NDC","","","","","facility","both","1","EA","UD","227.5","113.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRON SUCROSE 100 MG IRON/5 ML SOLN 5 ML VIAL","0517-2340-10","NDC","","","","","facility","both","1","EA","","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IRON SUCROSE 100 MG IRON/5 ML SOLN 5 ML VIAL","0517-2340-25","NDC","","","","","facility","both","1","EA","UD","225","112.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRON SUCROSE 100 MG IRON/5 ML SOLN 5 ML VIAL","0517-2340-25","NDC","","","","","facility","both","1","EA","","227.5","113.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PAPAVERINE 30 MG/ML SOLN","0517-4002-25","NDC","","","","","facility","both","1","EA","","145","72.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PAPAVERINE 30 MG/ML SOLN","0517-4002-25","NDC","","","","","facility","both","1","EA","UD","145","72.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE 0.2 MG/ML SOLN","0517-4605-25","NDC","","","","","facility","both","1","EA","","19.75","9.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"NITROGLYCERIN 50 MG/10 ML (5 MG/ML) SOLN","0517-4810-01","NDC","","","","","facility","both","1","EA","","2.55","1.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NITROGLYCERIN 50 MG/10 ML (5 MG/ML) SOLN","0517-4810-01","NDC","","","","","facility","both","1","EA","UD","2.6","1.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 50 MG/10 ML (5 MG/ML) SOLN","0517-4810-25","NDC","","","","","facility","both","1","EA","UD","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 50 MG/10 ML (5 MG/ML) SOLN","0517-4810-25","NDC","","","","","facility","both","1","EA","","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HYDROXYZINE 50 MG/ML SOLN","0517-5601-25","NDC","","","","","facility","both","1","EA","UD","178.31","89.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 50 MG/ML SOLN","0517-5601-25","NDC","","","","","facility","both","1","EA","","178.31","89.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SOLN 10 ML VIAL","0517-6710-01","NDC","","","","","facility","both","1","EA","","49.06","24.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SOLN 10 ML VIAL","0517-6710-01","NDC","","","","","facility","both","1","EA","UD","49.06","24.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SOLN","0517-6710-10","NDC","","","","","facility","both","1","EA","UD","49.06","24.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SOLN","0517-6710-10","NDC","","","","","facility","both","1","EA","","49.06","24.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ACETYLCYSTEINE 100 MG/ML (10 %) SOLN","0517-7504-01","NDC","","","","","facility","both","1","EA","","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETYLCYSTEINE 100 MG/ML (10 %) SOLN","0517-7504-01","NDC","","","","","facility","both","1","EA","UD","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0517-7604-01","NDC","","","","","facility","both","1","EA","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0517-7604-01","NDC","","","","","facility","both","1","EA","UD","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0517-7604-25","NDC","","","","","facility","both","1","EA","UD","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","0517-7604-25","NDC","","","","","facility","both","1","EA","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"AMINOCAPROIC ACID 250 MG/ML SOLN 20 ML VIAL","0517-9120-01","NDC","","","","","facility","both","1","EA","","34.63","17.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMINOCAPROIC ACID 250 MG/ML SOLN 20 ML VIAL","0517-9120-01","NDC","","","","","facility","both","1","EA","UD","37.13","18.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINOCAPROIC ACID 250 MG/ML SOLN 20 ML VIAL","0517-9191-01","NDC","","","","","facility","both","1","EA","","37.13","18.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMINOCAPROIC ACID 250 MG/ML SOLN 20 ML VIAL","0517-9191-01","NDC","","","","","facility","both","1","EA","UD","71.75","35.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRACE ELEMENTS (MULTRYS) ZN-CU-MN-SE 1,000MCG-60MCG- 3 MCG-6 MCG/ML SOLN 1 ML VIAL","0517-9302-01","NDC","","","","","facility","both","1","EA","UD","40.58","20.29","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRACE ELEMENTS (MULTRYS) ZN-CU-MN-SE 1,000MCG-60MCG- 3 MCG-6 MCG/ML SOLN 1 ML VIAL","0517-9302-01","NDC","","","","","facility","both","1","EA","","43.2","21.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRACE ELEMENTS ZN-CU-MN-SE 3 MG-0.3 MG-55 MCG-60 MCG/ML SOLN 1 ML VIAL","0517-9305-01","NDC","","","","","facility","both","1","EA","","75.88","37.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRACE ELEMENTS ZN-CU-MN-SE 3 MG-0.3 MG-55 MCG-60 MCG/ML SOLN 1 ML VIAL","0517-9305-01","NDC","","","","","facility","both","1","EA","UD","149.25","74.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRACE ELEMENTS ZN-CU-MN-SE 3 MG-0.3 MG-55 MCG-60 MCG/ML SOLN 1 ML VIAL","0517-9305-25","NDC","","","","","facility","both","1","EA","","83.19","41.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"TRACE ELEMENTS ZN-CU-MN-SE 3 MG-0.3 MG-55 MCG-60 MCG/ML SOLN 1 ML VIAL","0517-9305-25","NDC","","","","","facility","both","1","EA","UD","149.25","74.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DROPERIDOL 2.5 MG/ML SOLN","0517-9702-01","NDC","","","","","facility","both","1","EA","","58.44","29.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DROPERIDOL 2.5 MG/ML SOLN","0517-9702-01","NDC","","","","","facility","both","1","EA","UD","58.44","29.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DROPERIDOL 2.5 MG/ML SOLN","0517-9702-25","NDC","","","","","facility","both","1","EA","","58.44","29.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"DROPERIDOL 2.5 MG/ML SOLN","0517-9702-25","NDC","","","","","facility","both","1","EA","UD","58.44","29.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM GEL 52.5 G TUBE","0521-2311-00","NDC","","","","","facility","both","1","EA","","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 G"
"BUTALBITAL-ASPIRIN-CAFFEINE 50-325-40 MG CAPS","0527-1552-01","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE 2.5 MG TABS","0527-1789-01","NDC","","","","","facility","both","1","EA","UD","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE 2.5 MG TABS","0527-1789-01","NDC","","","","","facility","both","1","EA","","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SUMATRIPTAN 5 MG/ACTUATION SPRY 6 EACH AER W/ADAP","0527-1818-43","NDC","","","","","facility","both","1","EA","","100.58","50.29","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SUMATRIPTAN 5 MG/ACTUATION SPRY 6 EACH AER W/ADAP","0527-1818-43","NDC","","","","","facility","both","1","EA","UD","100.58","50.29","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL LA 80 MG CS24","0527-4117-37","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL LA 80 MG CS24","0527-4117-37","NDC","","","","","facility","both","1","EA","UD","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 10 GRAM/15 ML SOLN 473 ML BOTTLE","0527-5125-70","NDC","","","","","facility","both","1","EA","UD","14.65","7.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","0527-6004-80","NDC","","","","","facility","both","1","EA","UD","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALUMINUM HYDROXIDE GEL 320 MG/5 ML SUSPENSION","0536-0091-85","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","0536-1048-15","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","0536-1048-15","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOYL PEROXIDE 5 % GEL 42.5 G TUBE","0536-1055-56","NDC","","","","","facility","both","1","EA","UD","7.69","3.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 14 MG/24 HR PT24","0536-1107-88","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 14 MG/24 HR PT24","0536-1107-88","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"UREA 20 % CREA 85 G TUBE","0536110945","NDC","","","","","facility","both","1","EA","UD","26.29","13.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"UREA 20 % CREA 85 G TUBE","0536110945","NDC","","","","","facility","both","1","EA","","26.29","13.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"LEVONORGESTREL 1.5 MG TABS","0536-1142-63","NDC","","","","","facility","both","1","EA","UD","19.2","9.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVONORGESTREL 1.5 MG TABS","0536-1142-63","NDC","","","","","facility","both","1","EA","","19.2","9.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12","0536-1161-37","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12","0536-1161-37","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % SUPP","0536-1186-12","NDC","","","","","facility","both","1","EA","UD","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % SUPP","0536-1186-12","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE 4 % PTMD","0536-1202-07","NDC","","","","","facility","both","1","EA","UD","2.76","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % PTMD","0536-1202-07","NDC","","","","","facility","both","1","EA","","2.76","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE 4 % PTMD","0536-1202-15","NDC","","","","","facility","both","1","EA","","3.68","1.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE 4 % PTMD","0536-1202-15","NDC","","","","","facility","both","1","EA","UD","3.68","1.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TETRAHYDROZOLINE 0.05 % DROP 15 ML DROP BTL","0536-1217-94","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TETRAHYDROZOLINE 0.05 % DROP 15 ML DROP BTL","0536-1217-94","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 325 MG TBEC","0536-1232-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 325 MG TBEC","0536-1232-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SENNA-DOCUSATE 8.6-50 MG TABS","0536-1248-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SENNA-DOCUSATE 8.6-50 MG TABS","0536-1248-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA-DOCUSATE 8.6-50 MG TABS","0536-1248-10","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA-DOCUSATE 8.6-50 MG TABS","0536-1248-10","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"KETOTIFEN 0.025 % (0.035 %) DROP","0536-1252-40","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOTIFEN 0.025 % (0.035 %) DROP","0536-1252-40","NDC","","","","","facility","both","1","EA","UD","11.68","5.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 5 % OINT 3.5 G TUBE","0536-1253-91","NDC","","","","","facility","both","1","EA","UD","25.54","12.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 5 % OINT 3.5 G TUBE","0536-1253-91","NDC","","","","","facility","both","1","EA","","25.54","12.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SODIUM CHLORIDE 5 % DROP 15 ML DROP BTL","0536-1254-94","NDC","","","","","facility","both","1","EA","UD","15.28","7.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 5 % DROP 15 ML DROP BTL","0536-1254-94","NDC","","","","","facility","both","1","EA","","16.33","8.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BACITRACIN 500 UNIT/GRAM OINT 30 G TUBE","0536-1256-28","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OINT 30 G TUBE","0536-1256-28","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN 500 UNIT/GRAM OINT 28 G TUBE","0536-1263-28","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OINT 28 G TUBE","0536-1263-28","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOTRIMAZOLE 1 % CREA 14.17 G TUBE","0536-1265-11","NDC","","","","","facility","both","1","EA","","14.17","7.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOTRIMAZOLE 1 % CREA 14.17 G TUBE","0536-1265-11","NDC","","","","","facility","both","1","EA","UD","14.17","7.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAMPHOR-MENTHOL 0.5-0.5 % LOTN 222 ML BOTTLE","0536-1268-12","NDC","","","","","facility","both","1","EA","","16.54","8.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CAMPHOR-MENTHOL 0.5-0.5 % LOTN 222 ML BOTTLE","0536-1268-12","NDC","","","","","facility","both","1","EA","UD","16.54","8.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POVIDONE-IODINE 10 % OINT 28.4 G TUBE","0536-1271-80","NDC","","","","","facility","both","1","EA","","6.27","3.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"POVIDONE-IODINE 10 % OINT 28.4 G TUBE","0536-1271-80","NDC","","","","","facility","both","1","EA","UD","6.27","3.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","0536-1294-97","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","0536-1294-97","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SIMETHICONE 40 MG/0.6 ML DRPS 30 ML DROP BTL","0536-1303-75","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SIMETHICONE 40 MG/0.6 ML DRPS 30 ML DROP BTL","0536-1303-75","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC OXIDE 20 % OINT 60 G TUBE","0536-1316-25","NDC","","","","","facility","both","1","EA","","60","30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ZINC OXIDE 20 % OINT 60 G TUBE","0536-1316-25","NDC","","","","","facility","both","1","EA","UD","60","30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC OXIDE 20 % OINT 30 G TUBE","0536-1316-28","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC OXIDE 20 % OINT 30 G TUBE","0536-1316-28","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ASPIRIN-ACETAMINOPHEN-CAFFEINE 250-250-65 MG TABS","0536-1326-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN-ACETAMINOPHEN-CAFFEINE 250-250-65 MG TABS","0536-1326-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COENZYME 10 30 MG CAPS","0536135807","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COENZYME 10 30 MG CAPS","0536135807","NDC","","","","","facility","both","1","EA","UD","1.84","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICONAZOLE 2 % CREA 30 G TUBE","0536-1375-75","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MICONAZOLE 2 % CREA 30 G TUBE","0536-1375-75","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SELENIUM SULFIDE 1 % SHAM 207 ML BOTTLE","0536-1995-53","NDC","","","","","facility","both","1","EA","UD","207","103.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAPSAICIN 0.025 % CREA 60 G TUBE","0536-2525-25","NDC","","","","","facility","both","1","EA","","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CAPSAICIN 0.025 % CREA 60 G TUBE","0536-2525-25","NDC","","","","","facility","both","1","EA","UD","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOXINE (VITAMIN B6) 25 MG TABS","0536440601","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOXINE (VITAMIN B6) 25 MG TABS","0536440601","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 7 MG/24 HR PT24","0536-5894-88","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 7 MG/24 HR PT24","0536-5894-88","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 21 MG/24 HR PT24","0536-5896-53","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 21 MG/24 HR PT24","0536-5896-53","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABS","0536730001","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM PHOSPHATES 19-7 GRAM/118 ML ENEM 133 ML SQUEEZ BTL","0536-7415-51","NDC","","","","","facility","both","1","EA","UD","3.39","1.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM PHOSPHATES 19-7 GRAM/118 ML ENEM 133 ML SQUEEZ BTL","0536-7415-51","NDC","","","","","facility","both","1","EA","","3.39","1.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) CAPS","0538800924","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPS","0538800927","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEDROXYPROGESTERONE 150 MG/ML SUSPENSION","0548-5400-00","NDC","","","","","facility","both","1","EA","UD","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEDROXYPROGESTERONE 150 MG/ML SUSPENSION","0548-5400-00","NDC","","","","","facility","both","1","EA","","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COSYNTROPIN 0.25 MG SOLR","0548-5900-00","NDC","","","","","facility","both","1","EA","UD","456.2","228.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COSYNTROPIN 0.25 MG SOLR","0548-5900-00","NDC","","","","","facility","both","1","EA","","389","194.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"HYALURONIDASE 150 UNIT/ML SOLN","0548-9090-10","NDC","","","","","facility","both","1","EA","","98.02","49.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HYALURONIDASE 150 UNIT/ML SOLN","0548-9090-10","NDC","","","","","facility","both","1","EA","UD","98.02","49.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOPROTERENOL 0.2 MG/ML SOLN 5 ML VIAL","0548-9502-00","NDC","","","","","facility","both","1","EA","","877.5","438.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CHLORDIAZEPOXIDE 25 MG CAPS","0555-0159-02","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORDIAZEPOXIDE 25 MG CAPS","0555-0159-02","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DANAZOL 200 MG CAPS","0555-0635-09","NDC","","","","","facility","both","1","EA","","25.99","13.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEDROXYPROGESTERONE 10 MG TABS","0555-0779-02","NDC","","","","","facility","both","1","EA","UD","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEDROXYPROGESTERONE 10 MG TABS","0555-0779-02","NDC","","","","","facility","both","1","EA","","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEDROXYPROGESTERONE 2.5 MG TABS","0555-0872-02","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEDROXYPROGESTERONE 2.5 MG TABS","0555-0872-02","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESTRADIOL 0.5 MG TABS","0555-0899-02","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROSE 40 % GEL","0574006915","NDC","","","","","facility","both","1","EA","UD","3.7","1.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROSE 40 % GEL","0574006915","NDC","","","","","facility","both","1","EA","","3.7","1.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"DEXTROSE 40 % GEL 37.5 G TUBE","0574007015","NDC","","","","","facility","both","1","EA","UD","3.7","1.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROSE 40 % GEL 37.5 G TUBE","0574007015","NDC","","","","","facility","both","1","EA","","3.7","1.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BROMOCRIPTINE 2.5 MG TABS","0574-0106-01","NDC","","","","","facility","both","1","EA","","9.01","4.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BROMOCRIPTINE 2.5 MG TABS","0574-0106-01","NDC","","","","","facility","both","1","EA","UD","10.01","5.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 10 MG TROC","0574-0107-14","NDC","","","","","facility","both","1","EA","UD","3.97","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 10 MG TROC","0574-0107-14","NDC","","","","","facility","both","1","EA","","3.97","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOTRIMAZOLE 10 MG TROC","0574-0107-70","NDC","","","","","facility","both","1","EA","UD","3.97","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 10 MG TROC","0574-0107-70","NDC","","","","","facility","both","1","EA","","3.97","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 10 MEQ TBSR","0574-0275-00","NDC","","","","","facility","both","1","EA","","0.57","0.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 10 MEQ TBSR","0574-0275-00","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMILORIDE 5 MG TABS","0574-0292-01","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMILORIDE 5 MG TABS","0574-0292-01","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FERROUS GLUCONATE 324 MG (37.5 MG IRON) TABS","0574050811","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FERROUS GLUCONATE 324 MG (37.5 MG IRON) TABS","0574050811","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION","0574-0520-74","NDC","","","","","facility","both","1","EA","UD","40.96","20.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION","0574-0520-74","NDC","","","","","facility","both","1","EA","","40.96","20.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACTIVATED CHARCOAL 25 GRAM/120 ML SUSPENSION","0574-0521-74","NDC","","","","","facility","both","1","EA","UD","40.96","20.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACTIVATED CHARCOAL 25 GRAM/120 ML SUSPENSION","0574-0521-74","NDC","","","","","facility","both","1","EA","","40.96","20.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIHYDROERGOTAMINE 1 MG/ML SOLN","0574-0850-10","NDC","","","","","facility","both","1","EA","","389.48","194.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"BACITRACIN 500 UNIT/GRAM OINT 3.5 G TUBE","0574-4022-35","NDC","","","","","facility","both","1","EA","UD","276.2","138.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OINT 3.5 G TUBE","0574-4022-35","NDC","","","","","facility","both","1","EA","","276.2","138.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","0574-4024-11","NDC","","","","","facility","both","1","EA","","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","0574-4024-50","NDC","","","","","facility","both","1","EA","","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 G"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","0574-4024-50","NDC","","","","","facility","both","1","EA","UD","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN 300 MG SUPP","0574-7034-12","NDC","","","","","facility","both","1","EA","","4.5","2.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN 300 MG SUPP","0574-7034-12","NDC","","","","","facility","both","1","EA","UD","4.5","2.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISACODYL 10 MG SUPP","0574-7050-12","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISACODYL 10 MG SUPP","0574-7050-12","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISACODYL 10 MG SUPP","0574-7050-50","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISACODYL 10 MG SUPP","0574-7050-50","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 80 MG TABS","0591-0343-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCHLOROTHIAZIDE 12.5 MG CAPS","0591-0347-01","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCHLOROTHIAZIDE 12.5 MG CAPS","0591-0347-01","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 40 MG TABS","0591-0404-01","NDC","","","","","facility","both","1","EA","","1.47","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIPIZIDE XL 2.5 MG TR24","0591-0900-30","NDC","","","","","facility","both","1","EA","","2.01","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","0591-2258-54","NDC","","","","","facility","both","1","EA","","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","0591-2258-54","NDC","","","","","facility","both","1","EA","UD","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORZOXAZONE 500 MG TABS","0591-2520-01","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORZOXAZONE 500 MG TABS","0591-2520-01","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALGANCICLOVIR 50 MG/ML SOLR","0591-2579-20","NDC","","","","","facility","both","1","EA","UD","182.01","91.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 24HR 180 MG C24P","0591-2882-01","NDC","","","","","facility","both","1","EA","UD","5.57","2.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 24HR 180 MG C24P","0591-2882-01","NDC","","","","","facility","both","1","EA","","5.57","2.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL","0591-2998-01","NDC","","","","","facility","both","1","EA","UD","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"URSODIOL","0591-2998-01","NDC","","","","","facility","both","1","EA","","2.43","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 300 MG CAPS","0591-3159-01","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TESTOSTERONE 1% GLPK 5 G PACKET","0591-3217-26","NDC","","","","","facility","both","1","EA","","830.5","415.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BUPROPION SR 150 MG SR12","0591-3541-60","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPROPION SR 150 MG SR12","0591-3541-60","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALPROIC ACID 250 MG CAPS","0591-4012-01","NDC","","","","","facility","both","1","EA","","1.79","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PERPHENAZINE 2 MG TABS","0591-4101-01","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROBENECID 500 MG TABS","0591-5347-01","NDC","","","","","facility","both","1","EA","UD","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROBENECID 500 MG TABS","0591-5347-01","NDC","","","","","facility","both","1","EA","","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINOCYCLINE 50 MG CAPS","0591-5694-60","NDC","","","","","facility","both","1","EA","UD","2.36","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINOCYCLINE 50 MG CAPS","0591-5694-60","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0024-02","NDC","","","","","facility","both","1","EA","","768.64","384.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFAA 12.9 G AER W/ADAP","0597-0087-17","NDC","","","","","facility","both","1","EA","UD","1186.16","593.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0100-51","NDC","","","","","facility","both","1","EA","","193.5","96.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0100-51","NDC","","","","","facility","both","1","EA","UD","193.5","96.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0100-61","NDC","","","","","facility","both","1","EA","","193.5","96.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TIOTROPIUM-OLODATEROL 2.5-2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0155-70","NDC","","","","","facility","both","1","EA","UD","193.5","96.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIOTROPIUM-OLODATEROL 2.5-2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0155-70","NDC","","","","","facility","both","1","EA","","193.5","96.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"OLODATEROL 2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0192-61","NDC","","","","","facility","both","1","EA","UD","434.87","217.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLODATEROL 2.5 MCG/ACTUATION MIST 4 G AER W/ADAP","0597-0192-61","NDC","","","","","facility","both","1","EA","","434.87","217.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"DABIGATRAN 75 MG CAPS","0597-0355-56","NDC","","","","","facility","both","1","EA","UD","9.95","4.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DABIGATRAN 75 MG CAPS","0597-0355-56","NDC","","","","","facility","both","1","EA","","18.08","9.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DABIGATRAN 150 MG CAPS","0597-0360-82","NDC","","","","","facility","both","1","EA","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DABIGATRAN 150 MG CAPS","0597-0360-82","NDC","","","","","facility","both","1","EA","UD","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUAIFENESIN 100 MG/5 ML LIQD","0603-0857-05","NDC","","","","","facility","both","1","EA","","5.05","2.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FELODIPINE 2.5 MG TB24","0603-3581-21","NDC","","","","","facility","both","1","EA","UD","2.28","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FELODIPINE 2.5 MG TB24","0603-3581-21","NDC","","","","","facility","both","1","EA","","3.57","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 10 MG TABS","0603-5338-21","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 10 MG TABS","0603-5338-21","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 10 MG/ML SOLN","0641-0367-21","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 10 MG/ML SOLN","0641-0367-21","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"DEXAMETHASONE 10 MG/ML SOLN","0641-0367-25","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 10 MG/ML SOLN","0641-0367-25","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"DIPHENHYDRAMINE 50 MG/ML SOLN","0641-0376-21","NDC","","","","","facility","both","1","EA","UD","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 50 MG/ML SOLN","0641-0376-21","NDC","","","","","facility","both","1","EA","","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIPHENHYDRAMINE 50 MG/ML SOLN","0641-0376-25","NDC","","","","","facility","both","1","EA","UD","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 50 MG/ML SOLN","0641-0376-25","NDC","","","","","facility","both","1","EA","","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN 1,000 UNIT/ML SOLN","0641-0391-12","NDC","","","","","facility","both","1","EA","UD","6.39","3.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN","0641-0391-12","NDC","","","","","facility","both","1","EA","","6.39","3.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN 5,000 UNIT/ML SOLN","0641-0400-37","NDC","","","","","facility","both","1","EA","","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN","0641-0400-37","NDC","","","","","facility","both","1","EA","UD","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 65 MG/ML SOLN","0641-0476-21","NDC","","","","","facility","both","1","EA","","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENOBARBITAL 65 MG/ML SOLN","0641-0476-21","NDC","","","","","facility","both","1","EA","UD","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL","0641-0477-21","NDC","","","","","facility","both","1","EA","UD","445.15","222.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL","0641-0477-21","NDC","","","","","facility","both","1","EA","","679.32","339.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYTOIN 50 MG/ML SOLN","0641-0493-21","NDC","","","","","facility","both","1","EA","UD","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYTOIN 50 MG/ML SOLN","0641-0493-25","NDC","","","","","facility","both","1","EA","UD","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG/ML SOLN","0641-0928-21","NDC","","","","","facility","both","1","EA","UD","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG/ML SOLN","0641-0928-21","NDC","","","","","facility","both","1","EA","","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHLORPROMAZINE 25 MG/ML SOLN","0641-1397-31","NDC","","","","","facility","both","1","EA","UD","20.56","10.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 25 MG/ML SOLN","0641-1397-31","NDC","","","","","facility","both","1","EA","","92.78","46.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHLORPROMAZINE 25 MG/ML SOLN","0641-1397-35","NDC","","","","","facility","both","1","EA","","80.5","40.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CHLORPROMAZINE 25 MG/ML SOLN","0641-1397-35","NDC","","","","","facility","both","1","EA","UD","80.5","40.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 250 MCG/ML (0.25 MG/ML) SOLN","0641-1410-31","NDC","","","","","facility","both","1","EA","UD","36.88","18.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 250 MCG/ML (0.25 MG/ML) SOLN","0641-1410-31","NDC","","","","","facility","both","1","EA","","36.88","18.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROMETHAZINE 25 MG/ML SOLN","0641-1495-31","NDC","","","","","facility","both","1","EA","","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROMETHAZINE 25 MG/ML SOLN","0641-1495-31","NDC","","","","","facility","both","1","EA","UD","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNITS/ML SYRINGE (CRRT ONLY)","0641-2440-41","NDC","","","","","facility","both","1","EA","UD","16.81","8.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML SOLN","0641-6001-01","NDC","","","","","facility","both","1","EA","UD","11.36","5.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML SOLN","0641-6001-01","NDC","","","","","facility","both","1","EA","","11.36","5.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUMETANIDE 0.25 MG/ML SOLN 10 ML VIAL","0641-6007-01","NDC","","","","","facility","both","1","EA","UD","15.44","7.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 0.25 MG/ML SOLN 10 ML VIAL","0641-6007-01","NDC","","","","","facility","both","1","EA","","17.94","8.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUMETANIDE 0.25 MG/ML SOLN 10 ML VIAL","0641-6007-10","NDC","","","","","facility","both","1","EA","UD","48.81","24.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 0.25 MG/ML SOLN 10 ML VIAL","0641-6007-10","NDC","","","","","facility","both","1","EA","","61.75","30.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"BUMETANIDE 0.25 MG/ML SOLN","0641-6008-01","NDC","","","","","facility","both","1","EA","","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUMETANIDE 0.25 MG/ML SOLN","0641-6008-01","NDC","","","","","facility","both","1","EA","UD","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 5 MG/ML SOLN","0641-6013-01","NDC","","","","","facility","both","1","EA","UD","15.81","7.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 5 MG/ML SOLN","0641-6013-01","NDC","","","","","facility","both","1","EA","","15.81","7.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 0.5 MG/ML SOLN","0641-6020-01","NDC","","","","","facility","both","1","EA","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 0.5 MG/ML SOLN","0641-6020-01","NDC","","","","","facility","both","1","EA","UD","5.15","2.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE (PF) 10 MG/ML SOLN","0641-6022-01","NDC","","","","","facility","both","1","EA","UD","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE (PF) 10 MG/ML SOLN","0641-6022-01","NDC","","","","","facility","both","1","EA","","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FAMOTIDINE (PF) 10 MG/ML SOLN","0641-6022-25","NDC","","","","","facility","both","1","EA","","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"FAMOTIDINE (PF) 10 MG/ML SOLN","0641-6022-25","NDC","","","","","facility","both","1","EA","UD","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE 10 MG/ML SOLN 4 ML VIAL","0641-6023-25","NDC","","","","","facility","both","1","EA","","13.63","6.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0641-6027-01","NDC","","","","","facility","both","1","EA","","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0641-6027-01","NDC","","","","","facility","both","1","EA","UD","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 20 ML VIAL","0641-6029-01","NDC","","","","","facility","both","1","EA","","51.56","25.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 20 ML VIAL","0641-6029-01","NDC","","","","","facility","both","1","EA","UD","51.56","25.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE 2500MCG IN 50ML 50 MCG/ML SOLN","0641-6030-01","NDC","","","","","facility","both","1","EA","UD","131.6","65.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE 2500MCG IN 50ML 50 MCG/ML SOLN","0641-6030-01","NDC","","","","","facility","both","1","EA","","131.6","65.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LORAZEPAM 2 MG/ML SOLN","0641-6044-01","NDC","","","","","facility","both","1","EA","UD","11.36","5.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML SOLN","0641-6044-01","NDC","","","","","facility","both","1","EA","","11.36","5.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LORAZEPAM 2 MG/ML SOLN","0641-6048-01","NDC","","","","","facility","both","1","EA","UD","11.36","5.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML SOLN","0641-6048-01","NDC","","","","","facility","both","1","EA","","11.36","5.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MEPERIDINE","0641-6052-01","NDC","","","","","facility","both","1","EA","","20.22","10.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 1 MG/ML SOLN 10 ML VIAL","0641-6056-01","NDC","","","","","facility","both","1","EA","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 1 MG/ML SOLN 2 ML VIAL","0641-6057-01","NDC","","","","","facility","both","1","EA","","6.86","3.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 1 MG/ML SOLN 2 ML VIAL","0641-6057-01","NDC","","","","","facility","both","1","EA","UD","6.86","3.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM 1 MG/ML SOLN 5 ML VIAL","0641-6059-01","NDC","","","","","facility","both","1","EA","","8.27","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 1 MG/ML SOLN 5 ML VIAL","0641-6059-01","NDC","","","","","facility","both","1","EA","UD","8.27","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM 5 MG/ML SOLN 1 ML VIAL","0641-6061-01","NDC","","","","","facility","both","1","EA","","12.2","6.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 5 MG/ML SOLN 1 ML VIAL","0641-6061-01","NDC","","","","","facility","both","1","EA","UD","12.2","6.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","0641-6078-01","NDC","","","","","facility","both","1","EA","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","0641-6078-01","NDC","","","","","facility","both","1","EA","UD","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","0641-6078-25","NDC","","","","","facility","both","1","EA","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","0641-6078-25","NDC","","","","","facility","both","1","EA","UD","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 2 MG/ML SOLN 20 ML VIAL","0641-6079-01","NDC","","","","","facility","both","1","EA","","3.75","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ONDANSETRON 2 MG/ML SOLN 20 ML VIAL","0641-6079-01","NDC","","","","","facility","both","1","EA","UD","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","0641-6080-01","NDC","","","","","facility","both","1","EA","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROMETHAZINE 25 MG/ML SOLN","0641-6084-01","NDC","","","","","facility","both","1","EA","","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROMETHAZINE 25 MG/ML SOLN","0641-6084-01","NDC","","","","","facility","both","1","EA","UD","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 100 MG/ML SOLN","0641-6103-01","NDC","","","","","facility","both","1","EA","","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHOCARBAMOL 100 MG/ML SOLN","0641-6103-01","NDC","","","","","facility","both","1","EA","UD","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN/SULBACTAM 1.5 GRAM SOLR 1 EACH VIAL","0641-6116-01","NDC","","","","","facility","both","1","EA","UD","17.13","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN/SULBACTAM 1.5 GRAM SOLR 1 EACH VIAL","0641-6116-01","NDC","","","","","facility","both","1","EA","","17.13","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","0641-6117-01","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","0641-6117-01","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE 10 MG/ML SOLN","0641-6127-01","NDC","","","","","facility","both","1","EA","","7.77","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 10 MG/ML SOLN","0641-6127-01","NDC","","","","","facility","both","1","EA","UD","11.93","5.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 10 MG/ML SOLN","0641-6127-25","NDC","","","","","facility","both","1","EA","","13.31","6.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MORPHINE 10 MG/ML SOLN","0641-6127-25","NDC","","","","","facility","both","1","EA","UD","16.08","8.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXONE 0.4 MG/ML SOLN","0641-6132-01","NDC","","","","","facility","both","1","EA","UD","28.75","14.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXONE 0.4 MG/ML SOLN","0641-6132-01","NDC","","","","","facility","both","1","EA","","28.75","14.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","0641-6135-01","NDC","","","","","facility","both","1","EA","","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","0641-6135-01","NDC","","","","","facility","both","1","EA","UD","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOSPHENYTOIN 100 MG PE/2 ML SOLN","0641-6136-01","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FOSPHENYTOIN 100 MG PE/2 ML SOLN","0641-6136-01","NDC","","","","","facility","both","1","EA","UD","19.5","9.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOSPHENYTOIN 100 MG PE/2 ML SOLN 2 ML VIAL","0641-6136-25","NDC","","","","","facility","both","1","EA","","59.5","29.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PHENYLEPHRINE 10 MG/ML SOLN","0641-6142-01","NDC","","","","","facility","both","1","EA","UD","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN","0641-6142-01","NDC","","","","","facility","both","1","EA","","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CAFFEINE CITRATED 30 MG/1.5 ML SOLN","0641-6164-01","NDC","","","","","facility","both","1","EA","","86.35","43.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL","0641-6166-01","NDC","","","","","facility","both","1","EA","","48.13","24.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OCTREOTIDE 50 MCG/ML SOLN","0641-6174-01","NDC","","","","","facility","both","1","EA","","17","8.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OCTREOTIDE 50 MCG/ML SOLN","0641-6174-01","NDC","","","","","facility","both","1","EA","UD","17","8.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 100 MCG/ML SOLN","0641-6175-01","NDC","","","","","facility","both","1","EA","","12.66","6.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OCTREOTIDE 100 MCG/ML SOLN","0641-6175-01","NDC","","","","","facility","both","1","EA","UD","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 100 MCG/ML SOLN","0641-6175-10","NDC","","","","","facility","both","1","EA","","23.75","11.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"OCTREOTIDE 500 MCG/ML SOLN","0641-6176-01","NDC","","","","","facility","both","1","EA","","95.63","47.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OCTREOTIDE ACETATE 200 MCG/ML SOLN 5 ML VIAL","0641-6177-01","NDC","","","","","facility","both","1","EA","","172.5","86.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","0641-6178-01","NDC","","","","","facility","both","1","EA","UD","99","49.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","0641-6178-01","NDC","","","","","facility","both","1","EA","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","0641-6188-01","NDC","","","","","facility","both","1","EA","UD","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","0641-6188-01","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN","0641-6189-01","NDC","","","","","facility","both","1","EA","UD","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN","0641-6189-01","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN","0641-6189-10","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PHENYLEPHRINE 10 MG/ML SOLN","0641-6189-10","NDC","","","","","facility","both","1","EA","UD","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","0641-6194-10","NDC","","","","","facility","both","1","EA","UD","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","0641-6194-10","NDC","","","","","facility","both","1","EA","","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","0641-6206-01","NDC","","","","","facility","both","1","EA","","17.2","8.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","0641-6206-01","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","0641-6228-01","NDC","","","","","facility","both","1","EA","","38.75","19.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","0641-6228-01","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","0641-6228-25","NDC","","","","","facility","both","1","EA","UD","118.75","59.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","0641-6228-25","NDC","","","","","facility","both","1","EA","","118.75","59.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HYDRALAZINE 20 MG/ML SOLN","0641-6231-01","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 20 MG/ML SOLN","0641-6231-01","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIAZEPAM 5 MG/ML SYRG","0641-6244-01","NDC","","","","","facility","both","1","EA","","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIAZEPAM 5 MG/ML SYRG","0641-6244-01","NDC","","","","","facility","both","1","EA","UD","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0641-6247-01","NDC","","","","","facility","both","1","EA","","16.7","8.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","0641-6247-01","NDC","","","","","facility","both","1","EA","UD","16.7","8.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"REGADENOSON 0.4 MG/5 ML SYRG","0641-6253-01","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"REGADENOSON 0.4 MG/5 ML SYRG","0641-6253-01","NDC","","","","","facility","both","1","EA","UD","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 5 MG/ML SOLN","0641-9217-01","NDC","","","","","facility","both","1","EA","","15.81","7.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BENZOCAINE 20 % SPRA","0699-3100-02","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 SPRAY"
"BENZOCAINE 20 % SPRA","0699-3100-02","NDC","","","","","facility","both","1","EA","UD","91.13","45.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 SPRAY | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE (PF) 10 MG/ML SOLN","0703-0018-01","NDC","","","","","facility","both","1","EA","","21.54","10.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE (PF) 10 MG/ML SOLN","0703-0018-01","NDC","","","","","facility","both","1","EA","UD","29.8","14.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","0703-0676-01","NDC","","","","","facility","both","1","EA","JG","346.28","173.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","0703-0676-01","NDC","","","","","facility","both","1","EA","UD","346.28","173.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","0703-0676-01","NDC","","","","","facility","both","1","EA","","415.04","207.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","0703-0676-01","NDC","","","","","facility","both","1","EA","JG,UD","483.8","241.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","0703-0676-01","NDC","","","","","facility","both","1","EA","TB","758.84","379.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","0703-0676-01","NDC","","","","","facility","both","1","EA","UD,TB","1446.43","723.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","0703-0686-01","NDC","","","","","facility","both","1","EA","JG","896.35","448.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","0703-0686-01","NDC","","","","","facility","both","1","EA","UD","4196.8","2098.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","0703-0686-01","NDC","","","","","facility","both","1","EA","JG,UD","4196.8","2098.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","0703-0686-01","NDC","","","","","facility","both","1","EA","","4196.8","2098.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","0703-0696-01","NDC","","","","","facility","both","1","EA","JG","1446.43","723.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","0703-0696-01","NDC","","","","","facility","both","1","EA","","7497.24","3748.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","0703-0696-01","NDC","","","","","facility","both","1","EA","UD","8322.35","4161.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","0703-0696-01","NDC","","","","","facility","both","1","EA","UD,TB","8322.35","4161.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALPROSTADIL 10MCG/1ML SOLN 1 ML VIAL","0703-1501-02","NDC","","","","","facility","both","1","EA","UD","5.06","2.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPROSTADIL 10MCG/1ML SOLN 1 ML VIAL","0703-1501-02","NDC","","","","","facility","both","1","EA","","10.11","5.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"PACLITAXEL 6 MG/ML CONC 5 ML VIAL","0703-3213-01","NDC","","","","","facility","both","1","EA","","97.65","48.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PACLITAXEL 6 MG/ML CONC 25 ML VIAL","0703-3217-01","NDC","","","","","facility","both","1","EA","UD","307.6","153.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOTREXATE 25 MG/ML SOLN 40 ML VIAL","0703-3678-01","NDC","","","","","facility","both","1","EA","","982.59","491.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GLYCINE DILUENT SOLN 50 ML VIAL","0703-9258-01","NDC","","","","","facility","both","1","EA","","149.38","74.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 10 ML VIAL","0703-9514-91","NDC","","","","","facility","both","1","EA","UD","154.5","77.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 10 ML VIAL","0703-9514-91","NDC","","","","","facility","both","1","EA","","154.5","77.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 30 ML VIAL","0703-9526-01","NDC","","","","","facility","both","1","EA","","136.45","68.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 30 ML VIAL","0703-9526-01","NDC","","","","","facility","both","1","EA","UD","152","76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OINT 28.4 G TUBE","0713-0280-31","NDC","","","","","facility","both","1","EA","","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","0713-0351-02","NDC","","","","","facility","both","1","EA","UD","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","0713-0351-02","NDC","","","","","facility","both","1","EA","","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCORTISONE 25 MG SUPP","0713-0503-06","NDC","","","","","facility","both","1","EA","UD","2.44","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 25 MG SUPP","0713-0503-06","NDC","","","","","facility","both","1","EA","","2.44","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE 25 MG SUPP","0713-0503-24","NDC","","","","","facility","both","1","EA","UD","2.44","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 25 MG SUPP","0713-0503-24","NDC","","","","","facility","both","1","EA","","2.44","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 12.5 MG SUPP","0713-0536-06","NDC","","","","","facility","both","1","EA","","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 12.5 MG SUPP","0713-0536-06","NDC","","","","","facility","both","1","EA","UD","18.67","9.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 0.75 % GEL 45 G TUBE","0713-0637-37","NDC","","","","","facility","both","1","EA","","344.04","172.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"METRONIDAZOLE 0.75 % GEL 45 G TUBE","0713-0637-37","NDC","","","","","facility","both","1","EA","UD","344.04","172.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BETAMETHASONE DIPROPIONATE 0.05 % CREA 15 G TUBE","0713-0659-15","NDC","","","","","facility","both","1","EA","","32.03","16.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % LOTN 60 ML BOTTLE","0713-0676-53","NDC","","","","","facility","both","1","EA","UD","64","32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % LOTN 60 ML BOTTLE","0713-0676-53","NDC","","","","","facility","both","1","EA","","64","32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GENTAMICIN 0.1 % CREA 15 G TUBE","0713-0683-15","NDC","","","","","facility","both","1","EA","","44.73","22.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CALCIUM CITRATE 200 MG (950 MG) TABS","0761-0195-20","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CITRATE 200 MG (950 MG) TABS","0761-0195-20","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM OXIDE 400 MG MAGNESIUM TABS","0761032024","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALPRAZOLAM 0.25 MG TABS","0781-1061-01","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALPRAZOLAM 0.25 MG TABS","0781-1061-01","NDC","","","","","facility","both","1","EA","UD","0.16","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPRAZOLAM 0.25 MG TABS","0781-1061-05","NDC","","","","","facility","both","1","EA","UD","0.16","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPRAZOLAM 0.25 MG TABS","0781-1061-05","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALPRAZOLAM 1 MG TABS","0781-1079-01","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALPRAZOLAM 1 MG TABS","0781-1079-01","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMITRIPTYLINE 10 MG TABS","0781-1486-01","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMITRIPTYLINE 10 MG TABS","0781-1486-01","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMTERENE-HCTZ 37.5-25 MG CAPS","0781-2074-01","NDC","","","","","facility","both","1","EA","UD","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMTERENE-HCTZ 37.5-25 MG CAPS","0781-2074-01","NDC","","","","","facility","both","1","EA","","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","0781-2081-02","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","0781-2081-02","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN 500 MG CAPS","0781-2145-01","NDC","","","","","facility","both","1","EA","UD","2.01","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 500 MG CAPS","0781-2145-01","NDC","","","","","facility","both","1","EA","","2.01","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PYRIDOSTIGMINE 5 MG/ML SOLN","0781-3040-72","NDC","","","","","facility","both","1","EA","UD","213.5","106.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 250 MCG/ML (0.25 MG/ML) SOLN","0781-3059-72","NDC","","","","","facility","both","1","EA","","36.88","18.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","0781-3098-94","NDC","","","","","facility","both","1","EA","UD","32.19","16.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","0781-3098-94","NDC","","","","","facility","both","1","EA","","32.19","16.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIPERACILLIN-TAZOBACTAM 2250 MG SOLR 1 EACH VIAL","0781-3110-90","NDC","","","","","facility","both","1","EA","","21.19","10.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIPERACILLIN-TAZOBACTAM 2250 MG SOLR 1 EACH VIAL","0781-3110-90","NDC","","","","","facility","both","1","EA","UD","21.19","10.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","0781-3113-90","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","0781-3113-90","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","0781-3114-91","NDC","","","","","facility","both","1","EA","UD","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","0781-3114-91","NDC","","","","","facility","both","1","EA","","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) SOLN","0781-3156-06","NDC","","","","","facility","both","1","EA","UD","49.38","24.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) SOLN","0781-3156-06","NDC","","","","","facility","both","1","EA","","49.38","24.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) SOLN","0781-3156-95","NDC","","","","","facility","both","1","EA","UD","49.38","24.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) SOLN","0781-3156-95","NDC","","","","","facility","both","1","EA","","49.38","24.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"OLANZAPINE 10 MG/2ML SOLR","0781-3159-72","NDC","","","","","facility","both","1","EA","UD","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG/2ML SOLR","0781-3159-72","NDC","","","","","facility","both","1","EA","","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTRIAXONE 2 GRAM SOLR 1 EACH VIAL","0781-3209-90","NDC","","","","","facility","both","1","EA","UD","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 2 GRAM SOLR 1 EACH VIAL","0781-3209-90","NDC","","","","","facility","both","1","EA","","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PANTOPRAZOLE 40 MG SOLR","0781-3232-94","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PANTOPRAZOLE 40 MG SOLR","0781-3232-94","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOPRAZOLE 40 MG SOLR 1 EACH VIAL","0781-3232-95","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 300 MG/50 ML PGBK","0781-3288-09","NDC","","","","","facility","both","1","EA","","27.8","13.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CLINDAMYCIN 300 MG/50 ML PGBK","0781-3288-91","NDC","","","","","facility","both","1","EA","","27.8","13.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLINDAMYCIN 300 MG/50 ML PGBK","0781-3288-91","NDC","","","","","facility","both","1","EA","UD","30.4","15.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 600 MG/50 ML PGBK","0781-3289-09","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CLINDAMYCIN 600 MG/50 ML PGBK","0781-3289-09","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 600 MG/50 ML PGBK","0781-3289-91","NDC","","","","","facility","both","1","EA","","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLINDAMYCIN 600 MG/50 ML PGBK","0781-3289-91","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 900 MG/50 ML PGBK","0781-3290-09","NDC","","","","","facility","both","1","EA","UD","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 900 MG/50 ML PGBK","0781-3290-09","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CLINDAMYCIN 900 MG/50 ML PGBK","0781-3290-91","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLINDAMYCIN 900 MG/50 ML PGBK","0781-3290-91","NDC","","","","","facility","both","1","EA","UD","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PALONOSETRON 0.25 MG/5 ML SOLN","0781-3312-75","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PALONOSETRON 0.25 MG/5 ML SOLN","0781-3312-75","NDC","","","","","facility","both","1","EA","","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMPICILLIN 500 MG SOLR","0781-3407-78","NDC","","","","","facility","both","1","EA","UD","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 500 MG SOLR","0781-3407-78","NDC","","","","","facility","both","1","EA","","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","0781-3408-80","NDC","","","","","facility","both","1","EA","UD","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","0781-3408-80","NDC","","","","","facility","both","1","EA","","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","0781-3408-95","NDC","","","","","facility","both","1","EA","UD","89.88","44.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","0781-3408-95","NDC","","","","","facility","both","1","EA","","89.88","44.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"VORICONAZOLE 200 MG SOLR 1 EACH VIAL","0781-3416-94","NDC","","","","","facility","both","1","EA","UD","145.69","72.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG SOLR 1 EACH VIAL","0781-3416-94","NDC","","","","","facility","both","1","EA","","288.88","144.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","0781-3433-46","NDC","","","","","facility","both","1","EA","UD","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","0781-3433-46","NDC","","","","","facility","both","1","EA","","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COSYNTROPIN 0.25 MG SOLR","0781-3440-71","NDC","","","","","facility","both","1","EA","","456.2","228.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COSYNTROPIN 0.25 MG SOLR","0781-3440-71","NDC","","","","","facility","both","1","EA","UD","456.2","228.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","0781-3443-94","NDC","","","","","facility","both","1","EA","UD","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","0781-3443-94","NDC","","","","","facility","both","1","EA","","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFAZOLIN","0781-3450-70","NDC","","","","","facility","both","1","EA","UD","36.43","18.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 5 MG/0.4 ML SYRG","0781-3454-94","NDC","","","","","facility","both","1","EA","UD","239.72","119.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","0781-3458-95","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FONDAPARINUX 7.5 MG/0.6 ML SYRG","0781-3465-94","NDC","","","","","facility","both","1","EA","UD","185.31","92.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 7.5 MG/0.6 ML SYRG","0781-3465-94","NDC","","","","","facility","both","1","EA","","185.31","92.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN","0781-3466-70","NDC","","","","","facility","both","1","EA","UD","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN","0781-3466-70","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TIGECYCLINE 50 MG SOLR 1 EACH VIAL","0781-3481-70","NDC","","","","","facility","both","1","EA","","359.24","179.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NOREPINEPHRINE 1 MG/ML SOLN","0781-3755-75","NDC","","","","","facility","both","1","EA","","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","0781-3755-75","NDC","","","","","facility","both","1","EA","UD","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","0781-3755-95","NDC","","","","","facility","both","1","EA","UD","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","0781-3755-95","NDC","","","","","facility","both","1","EA","","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"BROMOCRIPTINE 2.5 MG TABS","0781-5325-01","NDC","","","","","facility","both","1","EA","UD","10.01","5.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BROMOCRIPTINE 2.5 MG TABS","0781-5325-01","NDC","","","","","facility","both","1","EA","","10.01","5.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILUENT FOR TREPROSTINIL (GLY) SOLN 50 ML VIAL","0781-6021-94","NDC","","","","","facility","both","1","EA","UD","81.56","40.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILUENT FOR TREPROSTINIL (GLY) SOLN 50 ML VIAL","0781-6021-94","NDC","","","","","facility","both","1","EA","","160.63","80.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLARITHROMYCIN 250 MG/5 ML SUSR","0781-6023-52","NDC","","","","","facility","both","1","EA","","56.58","28.29","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PENICILLIN G POTASSIUM 300,000 SYRG","0781-6153-95","NDC","","","","","facility","both","1","EA","UD","41.79","20.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN G POTASSIUM 300,000 SYRG","0781-6153-95","NDC","","","","","facility","both","1","EA","","41.79","20.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","0781-6186-67","NDC","","","","","facility","both","1","EA","UD","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","0781-6186-67","NDC","","","","","facility","both","1","EA","","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RIVASTIGMINE 4.6 MG/24 HOUR PT24","0781-7304-58","NDC","","","","","facility","both","1","EA","UD","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVASTIGMINE 4.6 MG/24 HOUR PT24","0781-7304-58","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIFLUOPERAZINE 5 MG TABS","0781-8034-01","NDC","","","","","facility","both","1","EA","","4.41","2.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIFLUOPERAZINE 5 MG TABS","0781-8034-01","NDC","","","","","facility","both","1","EA","UD","4.41","2.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL","0781-9317-80","NDC","","","","","facility","both","1","EA","","60.86","30.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYBUTYNIN 5 MG TABS","0832-0038-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYBUTYNIN 5 MG TABS","0832-0038-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYBUTYNIN 5 MG TABS","0832-0038-89","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYBUTYNIN 5 MG TABS","0832-0038-89","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BETHANECHOL 25 MG TABS","0832-0512-01","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BETHANECHOL 25 MG TABS","0832051289","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BETHANECHOL 25 MG TABS","0832-0512-89","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TESTOSTERONE 1% GEL 5 G TUBE","0832-1120-65","NDC","","","","","facility","both","1","EA","UD","2909.5","1454.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TESTOSTERONE 1% GEL 5 G TUBE","0832-1120-65","NDC","","","","","facility","both","1","EA","","2909.5","1454.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"WARFARIN 1 MG TABS","0832-1211-00","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 0.5 MG TABS","0832-1211-01","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 1 MG TABS","0832-1211-89","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 1 MG TABS","0832-1211-89","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 2 MG TABS","0832-1212-89","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 3 MG TABS","0832-1214-89","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 3 MG TABS","0832-1214-89","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 7.5 MG TABS","0832-1218-00","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 7.5 MG TABS","0832-1218-00","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 7.5 MG TABS","0832-1218-89","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 7.5 MG TABS","0832-1218-89","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 10 MG TABS","0832-1219-00","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 10 MG TABS","0832-1219-00","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 10 MG TABS","0832-1219-89","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 10 MG TABS","0832-1219-89","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUVOXAMINE 50 MG TABS","0832-1671-11","NDC","","","","","facility","both","1","EA","","1.83","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUVOXAMINE 50 MG TABS","0832-1671-11","NDC","","","","","facility","both","1","EA","UD","2.46","1.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG/5 ML (4 MG/ML) SOLN","0832-6032-05","NDC","","","","","facility","both","1","EA","","17.68","8.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUOXETINE 20 MG/5 ML (4 MG/ML) SOLN","0832-6032-05","NDC","","","","","facility","both","1","EA","UD","17.68","8.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX DR 250 MG TBEC","0832-7123-89","NDC","","","","","facility","both","1","EA","UD","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX DR 250 MG TBEC","0832-7123-89","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 500 MG TBEC","0832-7124-89","NDC","","","","","facility","both","1","EA","","0.39","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 500 MG TBEC","0832-7124-89","NDC","","","","","facility","both","1","EA","UD","0.39","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPHENIRAMINE 4 MG TABS","0904-0012-61","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE HYCLATE 100 MG CAPS","0904-0428-04","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE HYCLATE 100 MG CAPS","0904-0428-04","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASCORBIC ACID (VITAMIN C) 500 MG TABS","0904052361","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASCORBIC ACID (VITAMIN C) 500 MG TABS","0904052361","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMIN WITH FOLIC ACID 400 MCG TABS","0904053961","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMIN WITH FOLIC ACID 400 MCG TABS","0904053961","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,000 UNIT/GRAM OINT 28 G TUBE","0904-0734-31","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,000 UNIT/GRAM OINT 28 G TUBE","0904-0734-31","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BISMUTH SUBSALICYLATE 262 MG CHEW","0904-1315-46","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISMUTH SUBSALICYLATE 262 MG CHEW","0904-1315-46","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABS","0904188361","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) TABS","0904188361","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENHYDRAMINE 50 MG CAPS","0904-2056-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENHYDRAMINE 50 MG CAPS","0904-2056-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VITAMIN A 10,000 UNIT CAPS","0904208560","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VITAMIN A 10,000 UNIT CAPS","0904208560","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIACIN 500 MG TABS","0904227260","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIACIN 500 MG TABS","0904227260","NDC","","","","","facility","both","1","EA","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALAMINE-ZINC OXIDE LOTN 177 ML BOTTLE","0904-2533-21","NDC","","","","","facility","both","1","EA","UD","5.96","2.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALAMINE-ZINC OXIDE LOTN 177 ML BOTTLE","0904-2533-21","NDC","","","","","facility","both","1","EA","","5.96","2.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 160-800 MG TABS","0904-2725-61","NDC","","","","","facility","both","1","EA","UD","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 160-800 MG TABS","0904-2725-61","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMAZEPINE 100 MG CHEW","0904-3854-61","NDC","","","","","facility","both","1","EA","UD","1.93","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE 100 MG CHEW","0904-3854-61","NDC","","","","","facility","both","1","EA","","1.93","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM CHLORIDE 0.65 % SPRA 44 ML SQUEEZ BTL","0904-3865-75","NDC","","","","","facility","both","1","EA","UD","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 0.65 % SPRA 44 ML SQUEEZ BTL","0904-3865-75","NDC","","","","","facility","both","1","EA","","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PSEUDOEPHEDRINE 30 MG TABS","0904-5053-59","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PSEUDOEPHEDRINE 30 MG TABS","0904-5053-59","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTASE 3,000 UNIT TABS","0904522452","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENHYDRAMINE 25 MG CAPS","0904-5306-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 25 MG CAPS","0904-5306-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRENATAL VIT-IRON-FOLIC ACID 27 MG IRON- 800 MCG TABS","0904531346","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRENATAL VIT-IRON-FOLIC ACID 27 MG IRON- 800 MCG TABS","0904531346","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRENATAL VIT-IRON-FOLIC ACID 27 MG IRON- 800 MCG TABS","0904531360","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRENATAL VIT-IRON-FOLIC ACID 27 MG IRON- 800 MCG TABS","0904531360","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE-ZINC 2-0.1 % CREA 28 G TUBE","0904-5354-31","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE-ZINC 2-0.1 % CREA 28 G TUBE","0904-5354-31","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PENTOXIFYLLINE CR 400 MG TBSR","0904-5448-61","NDC","","","","","facility","both","1","EA","","1.76","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PENTOXIFYLLINE CR 400 MG TBSR","0904-5448-61","NDC","","","","","facility","both","1","EA","UD","1.76","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM-VITAMIN D 500 MG-5 MCG (200 UNIT) TABS","0904546092","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM-VITAMIN D 500 MG-5 MCG (200 UNIT) TABS","0904546092","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRIL 5 MG TABS","0904-5502-61","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXAZOSIN 4 MG TABS","0904-5524-61","NDC","","","","","facility","both","1","EA","UD","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXAZOSIN 4 MG TABS","0904-5524-61","NDC","","","","","facility","both","1","EA","","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FISH OIL 500 MG CAPS","0904560413","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FISH OIL 500 MG CAPS","0904560413","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRIL 20 MG TABS","0904-5611-61","NDC","","","","","facility","both","1","EA","","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PAROXETINE 10 MG TABS","0904-5676-61","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 10 MG TABS","0904-5676-61","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WHITE PETROLATUM GEL 368 G JAR","0904-5731-82","NDC","","","","","facility","both","1","EA","UD","4.86","2.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM GEL 368 G JAR","0904-5731-82","NDC","","","","","facility","both","1","EA","","4.86","2.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"FLUOXETINE 10 MG CAPS","0904-5784-61","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUOXETINE 10 MG CAPS","0904-5784-61","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG CAPS","0904-5785-61","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG CAPS","0904-5785-61","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACYCLOVIR 200 MG CAPS","0904-5789-61","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACYCLOVIR 200 MG CAPS","0904-5789-61","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 400 MG TABS","0904-5853-40","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IBUPROFEN 400 MG TABS","0904-5853-40","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 400 MG TABS","0904-5853-61","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 400 MG TABS","0904-5853-61","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IBUPROFEN 600 MG TABS","0904-5854-60","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 600 MG TABS","0904-5854-60","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IBUPROFEN 600 MG TABS","0904-5854-61","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IBUPROFEN 600 MG TABS","0904-5854-61","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAVASTATIN 10 MG TABS","0904-5891-61","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAVASTATIN 10 MG TABS","0904-5891-61","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAVASTATIN 20 MG TABS","0904-5892-61","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAVASTATIN 20 MG TABS","0904-5892-61","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 125 MCG (0.125 MG) TABS","0904-5921-61","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIGOXIN 125 MCG (0.125 MG) TABS","0904-5921-61","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 250 MCG (0.25 MG) TABS","0904-5922-61","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 250 MCG (0.25 MG) TABS","0904-5922-61","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLINDAMYCIN 150 MG CAPS","0904-5959-61","NDC","","","","","facility","both","1","EA","UD","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 150 MG CAPS","0904-5959-61","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTIC ACID 12 % LOTN 226 G BOTTLE","0904598426","NDC","","","","","facility","both","1","EA","","11.28","5.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"LACTIC ACID 12 % LOTN 226 G BOTTLE","0904598426","NDC","","","","","facility","both","1","EA","UD","11.28","5.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 0.5 MG TABS","0904-6007-61","NDC","","","","","facility","both","1","EA","UD","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 0.5 MG TABS","0904-6007-61","NDC","","","","","facility","both","1","EA","","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 2 MG TABS","0904-6009-61","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 2 MG TABS","0904-6009-61","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLPIDEM 5 MG TABS","0904-6082-61","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZOLPIDEM 5 MG TABS","0904-6082-61","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CITALOPRAM 10 MG TABS","0904-6084-61","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CITALOPRAM 10 MG TABS","0904-6084-61","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CITALOPRAM 20 MG TABS","0904-6085-61","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CITALOPRAM 20 MG TABS","0904-6085-61","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMAZEPINE 200 MG TABS","0904-6172-61","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE 200 MG TABS","0904-6172-61","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN ER 100 MG CAPS","0904-6187-61","NDC","","","","","facility","both","1","EA","","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN ER 100 MG CAPS","0904-6187-61","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SORE THROAT LOZENGE 15-3.6 MG LOZG","0904-6255-49","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SORE THROAT LOZENGE 15-3.6 MG LOZG","0904-6255-49","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 2.5 MG TABS","0904-6283-61","NDC","","","","","facility","both","1","EA","","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 2.5 MG TABS","0904-6283-61","NDC","","","","","facility","both","1","EA","UD","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 10 MG TABS","0904-6290-61","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 10 MG TABS","0904-6290-61","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 20 MG TABS","0904-6291-61","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 20 MG TABS","0904-6291-61","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 40 MG TABS","0904-6292-61","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 40 MG TABS","0904-6292-61","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 80 MG TABS","0904-6293-04","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 80 MG TABS","0904-6293-04","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOPIDOGREL 75 MG TABS","0904-6294-61","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOPIDOGREL 75 MG TABS","0904-6294-61","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 3.125 MG TABS","0904-6300-61","NDC","","","","","facility","both","1","EA","UD","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARVEDILOL 3.125 MG TABS","0904-6300-61","NDC","","","","","facility","both","1","EA","","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","0904-6302-61","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARVEDILOL 12.5 MG TABS","0904-6302-61","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL XL 25 MG TB24","0904-6322-06","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 25 MG TB24","0904-6322-06","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL XL 25 MG TB24","0904-6322-61","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 25 MG TB24","0904-6322-61","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL XL 50 MG TB24","0904-6323-61","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 50 MG TB24","0904-6323-61","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0904-6329-46","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","0904-6329-46","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 250 MG TABS","0904-6351-61","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOFLOXACIN 250 MG TABS","0904-6351-61","NDC","","","","","facility","both","1","EA","UD","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 500 MG TABS","0904-6352-61","NDC","","","","","facility","both","1","EA","","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOFLOXACIN 500 MG TABS","0904-6352-61","NDC","","","","","facility","both","1","EA","UD","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 0.5 MG TABS","0904-6358-61","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 0.5 MG TABS","0904-6358-61","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 1 MG TABS","0904-6359-61","NDC","","","","","facility","both","1","EA","UD","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 1 MG TABS","0904-6359-61","NDC","","","","","facility","both","1","EA","","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 2 MG TABS","0904-6360-61","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 2 MG TABS","0904-6360-61","NDC","","","","","facility","both","1","EA","UD","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 3 MG TABS","0904-6361-61","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 3 MG TABS","0904-6361-61","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMLODIPINE 2.5 MG TABS","0904-6369-61","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMLODIPINE 2.5 MG TABS","0904-6369-61","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMLODIPINE 5 MG TABS","0904-6370-61","NDC","","","","","facility","both","1","EA","UD","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMLODIPINE 5 MG TABS","0904-6370-61","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMLODIPINE 10 MG TABS","0904-6371-61","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMLODIPINE 10 MG TABS","0904-6371-61","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPINIROLE 0.25 MG TABS","0904-6373-61","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPINIROLE 0.25 MG TABS","0904-6373-61","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROPINIROLE 1 MG TABS","0904-6374-61","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPINIROLE 1 MG TABS","0904-6374-61","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG TABS","0904-6376-61","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG TABS","0904-6376-61","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 5 MG TABS","0904-6377-61","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 5 MG TABS","0904-6377-61","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISACODYL EC 5 MG TBEC","0904-6407-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISACODYL EC 5 MG TBEC","0904-6407-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIZANIDINE 4 MG TABS","0904-6418-61","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIZANIDINE 4 MG TABS","0904-6418-61","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESCITALOPRAM 10 MG TABS","0904-6426-61","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESCITALOPRAM 10 MG TABS","0904-6426-61","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TEMAZEPAM 7.5 MG CAPS","0904-6436-04","NDC","","","","","facility","both","1","EA","","3.43","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMAZEPAM 7.5 MG CAPS","0904-6436-04","NDC","","","","","facility","both","1","EA","UD","2.43","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE MONONITRATE CR 30 MG TB24","0904-6449-61","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE MONONITRATE CR 30 MG TB24","0904-6449-61","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE MONONITRATE CR 60 MG TB24","0904-6450-61","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE MONONITRATE CR 60 MG TB24","0904-6450-61","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 25 MG TABS","0904-6461-61","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG TABS","0904-6461-61","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACLOFEN 10 MG TABS","0904-6475-61","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 10 MG TABS","0904-6475-61","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARTIFICIAL TEARS OINT 3.5 G TUBE","0904-6488-38","NDC","","","","","facility","both","1","EA","","11.46","5.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ARTIFICIAL TEARS OINT 3.5 G TUBE","0904-6488-38","NDC","","","","","facility","both","1","EA","UD","11.46","5.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 200 MG TABS","0904-6501-06","NDC","","","","","facility","both","1","EA","UD","1.71","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 200 MG TABS","0904-6501-06","NDC","","","","","facility","both","1","EA","","0.71","0.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 200 MG TABS","0904-6501-61","NDC","","","","","facility","both","1","EA","UD","1.71","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 200 MG TABS","0904-6501-61","NDC","","","","","facility","both","1","EA","","1.43","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CELECOXIB 100 MG CAPS","0904-6502-61","NDC","","","","","facility","both","1","EA","UD","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CELECOXIB 100 MG CAPS","0904-6502-61","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEMANTINE 5 MG TABS","0904-6505-61","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MECLIZINE 12.5 MG TABS","0904-6516-61","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNOSIDES 8.6 MG TABS","0904-6522-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG TABS","0904-6530-61","NDC","","","","","facility","both","1","EA","UD","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG TABS","0904-6530-61","NDC","","","","","facility","both","1","EA","","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 10 MG TABS","0904-6550-61","NDC","","","","","facility","both","1","EA","UD","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 10 MG TABS","0904-6550-61","NDC","","","","","facility","both","1","EA","","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ONDANSETRON 4 MG TABS","0904-6551-61","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG TABS","0904-6551-61","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ONDANSETRON 8 MG TABS","0904-6552-61","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ONDANSETRON 8 MG TABS","0904-6552-61","NDC","","","","","facility","both","1","EA","UD","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID 600 MG TABS","0904-6553-04","NDC","","","","","facility","both","1","EA","UD","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID 600 MG TABS","0904-6553-04","NDC","","","","","facility","both","1","EA","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE SR 30 MG TBSR","0904-6558-61","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE SR 30 MG TBSR","0904-6558-61","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENOBARBITAL 32.4 MG TABS","0904-6575-61","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENOBARBITAL 32.4 MG TABS","0904-6575-61","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMIVUDINE 150 MG TABS","0904-6583-04","NDC","","","","","facility","both","1","EA","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMIVUDINE 150 MG TABS","0904-6583-04","NDC","","","","","facility","both","1","EA","UD","5","2.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 50 MG TABS","0904-6596-04","NDC","","","","","facility","both","1","EA","","5.47","2.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VORICONAZOLE 50 MG TABS","0904-6596-04","NDC","","","","","facility","both","1","EA","UD","9.93","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 25 MG TABS","0904-6617-61","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 25 MG TABS","0904-6617-61","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 10 MG TABS","0904-6619-61","NDC","","","","","facility","both","1","EA","","0.37","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 10 MG TABS","0904-6619-61","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE DINITRATE 20 MG TABS","0904-6620-61","NDC","","","","","facility","both","1","EA","","0.18","0.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 20 MG TABS","0904-6620-61","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOSTIGMINE 60 MG TABS","0904-6622-61","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOSTIGMINE 60 MG TABS","0904-6622-61","NDC","","","","","facility","both","1","EA","","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 0.5 MG CAPS","0904-6623-61","NDC","","","","","facility","both","1","EA","UD","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 0.5 MG CAPS","0904-6623-61","NDC","","","","","facility","both","1","EA","","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 5 MG CAPS","0904-6624-61","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 5 MG CAPS","0904-6624-61","NDC","","","","","facility","both","1","EA","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","0904-6627-35","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","0904-6627-35","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPROPION 100 MG TABS","0904-6636-61","NDC","","","","","facility","both","1","EA","","0.16","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION 100 MG TABS","0904-6636-61","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIPIZIDE 5 MG TABS","0904-6637-61","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIPIZIDE 5 MG TABS","0904-6637-61","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 25 MG TABS","0904-6638-61","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 100 MG TABS","0904-6640-61","NDC","","","","","facility","both","1","EA","UD","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 100 MG TABS","0904-6640-61","NDC","","","","","facility","both","1","EA","","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 300 MG TABS","0904-6642-61","NDC","","","","","facility","both","1","EA","UD","0.38","0.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 300 MG TABS","0904-6642-61","NDC","","","","","facility","both","1","EA","","0.38","0.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE 250 MG TABS","0904-6663-61","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE 250 MG TABS","0904-6663-61","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 100 MG CAPS","0904-6665-61","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 100 MG CAPS","0904-6665-61","NDC","","","","","facility","both","1","EA","UD","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 300 MG CAPS","0904-6666-61","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 300 MG CAPS","0904-6666-61","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","0904-6667-61","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","0904-6667-61","NDC","","","","","facility","both","1","EA","UD","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILDENAFIL 20 MG TABS","0904-6671-06","NDC","","","","","facility","both","1","EA","","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SILDENAFIL 20 MG TABS","0904-6671-06","NDC","","","","","facility","both","1","EA","UD","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOFETILIDE 250 MCG CAPS","0904-6682-08","NDC","","","","","facility","both","1","EA","","0.35","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOFETILIDE 250 MCG CAPS","0904-6682-08","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOFETILIDE 500 MCG CAPS","0904-6683-08","NDC","","","","","facility","both","1","EA","","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAMIPEXOLE 0.25 MG TABS","0904-6704-61","NDC","","","","","facility","both","1","EA","","0.77","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAMIPEXOLE 0.25 MG TABS","0904-6704-61","NDC","","","","","facility","both","1","EA","UD","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 20 MG TABS","0904-6705-06","NDC","","","","","facility","both","1","EA","","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 20 MG TABS","0904-6705-06","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 20 MG TABS","0904-6705-61","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 20 MG TABS","0904-6705-61","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEGA-3 1 GRAM CAPS","0904-6706-06","NDC","","","","","facility","both","1","EA","","0.54","0.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEGA-3 1 GRAM CAPS","0904-6706-06","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SEVELAMER CARBONATE 800 MG TABS","0904-6707-06","NDC","","","","","facility","both","1","EA","","2.02","1.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","0904-6708-06","NDC","","","","","facility","both","1","EA","UD","2.33","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE 1 MG TABS","0904-6709-61","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE 1 MG TABS","0904-6709-61","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GUAIFENESIN ER 600 MG TA12","0904-6718-39","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GUAIFENESIN ER 600 MG TA12","0904-6718-39","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 500 MG TABS","0904-6720-80","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 500 MG TABS","0904-6720-80","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 500 MG TABS","0904-6730-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 500 MG TABS","0904-6730-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 81 MG TBEC","0904-6751-80","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 81 MG TBEC","0904-6751-80","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","0904-6761-30","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","0904-6761-30","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 325 MG TABS","0904-6773-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 325 MG TABS","0904-6773-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 5 MG TABS","0904-6778-61","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 5 MG TABS","0904-6778-61","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 20 MG TABS","0904-6780-61","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 20 MG TABS","0904-6780-61","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HALOPERIDOL 5 MG TABS","0904-6782-61","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 5 MG TABS","0904-6782-61","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN EC 81 MG TBEC","0904-6783-70","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 81 MG TBEC","0904-6783-70","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN 81 MG CHEW","0904-6794-80","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN 81 MG CHEW","0904-6794-80","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 5 MG TABS","0904-6797-61","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 5 MG TABS","0904-6797-61","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LISINOPRIL 10 MG TABS","0904-6798-61","NDC","","","","","facility","both","1","EA","","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 10 MG TABS","0904-6798-61","NDC","","","","","facility","both","1","EA","UD","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LISINOPRIL 20 MG TABS","0904-6799-61","NDC","","","","","facility","both","1","EA","UD","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LISINOPRIL 20 MG TABS","0904-6799-61","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE SR 50 MG TB24","0904-6801-61","NDC","","","","","facility","both","1","EA","","1.25","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE SR 200 MG TB24","0904-6803-61","NDC","","","","","facility","both","1","EA","UD","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE SR 200 MG TB24","0904-6803-61","NDC","","","","","facility","both","1","EA","","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE SR 300 MG TB24","0904-6804-61","NDC","","","","","facility","both","1","EA","UD","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MONTELUKAST 10 MG TABS","0904-6808-61","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MONTELUKAST 10 MG TABS","0904-6808-61","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 2.5 MG TABS","0904-6817-06","NDC","","","","","facility","both","1","EA","","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 2.5 MG TABS","0904-6817-06","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 2.5 MG TABS","0904-6817-61","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 2.5 MG TABS","0904-6817-61","NDC","","","","","facility","both","1","EA","","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 5 MG TABS","0904-6818-06","NDC","","","","","facility","both","1","EA","UD","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 5 MG TABS","0904-6818-06","NDC","","","","","facility","both","1","EA","","0.33","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 5 MG TABS","0904-6818-61","NDC","","","","","facility","both","1","EA","UD","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 5 MG TABS","0904-6818-61","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 10 MG TABS","0904-6819-07","NDC","","","","","facility","both","1","EA","","0.46","0.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 10 MG TABS","0904-6819-07","NDC","","","","","facility","both","1","EA","UD","0.46","0.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TENOFOVIR DISOPROXIL 300 MG TABS","0904-6821-04","NDC","","","","","facility","both","1","EA","","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TENOFOVIR DISOPROXIL 300 MG TABS","0904-6821-04","NDC","","","","","facility","both","1","EA","UD","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","0904-6825-61","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","0904-6825-61","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE 5 MG/5 ML SOLN","0904-6828-05","NDC","","","","","facility","both","1","EA","","13.16","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 5 MG/5 ML SOLN","0904-6828-05","NDC","","","","","facility","both","1","EA","UD","13.16","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FINASTERIDE 5 MG TABS","0904-6830-06","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FINASTERIDE 5 MG TABS","0904-6830-06","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FINASTERIDE 5 MG TABS","0904-6830-61","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 250 MG TBEC","0904-6860-61","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 250 MG TBEC","0904-6860-61","NDC","","","","","facility","both","1","EA","UD","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX DR 500 MG TBEC","0904-6861-61","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAZODONE 50 MG TABS","0904-6868-61","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAZODONE 50 MG TABS","0904-6868-61","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 250 MG TABS","0904-6890-04","NDC","","","","","facility","both","1","EA","","2.98","1.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 250 MG TABS","0904-6890-04","NDC","","","","","facility","both","1","EA","UD","4.96","2.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEPRAZOLE 20 MG CPDR","0904-6917-61","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEPRAZOLE 20 MG CPDR","0904-6917-61","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 10 MG TABS","0904-6923-61","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 10 MG TABS","0904-6923-61","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SERTRALINE 100 MG TABS","0904-6926-61","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SERTRALINE 100 MG TABS","0904-6926-61","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE 25 MG TABS","0904-6927-61","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SPIRONOLACTONE 25 MG TABS","0904-6927-61","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","0904-6931-86","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","0904-6931-86","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PALIPERIDONE 3 MG TR24","0904-6935-61","NDC","","","","","facility","both","1","EA","UD","6.5","3.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PALIPERIDONE 3 MG TR24","0904-6935-61","NDC","","","","","facility","both","1","EA","","7.5","3.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","0904-6938-06","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","0904-6938-06","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 25 MCG TABS","0904-6949-61","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 50 MCG TABS","0904-6950-61","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 50 MCG TABS","0904-6950-61","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG TABS","0904-6966-61","NDC","","","","","facility","both","1","EA","UD","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG TABS","0904-6966-61","NDC","","","","","facility","both","1","EA","","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PSEUDOEPHEDRINE 30 MG TABS","0904-6990-61","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PSEUDOEPHEDRINE 30 MG TABS","0904-6990-61","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 25 MG CAPS","0904-6991-04","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 25 MG CAPS","0904-6991-04","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 50 MG CAPS","0904-6992-61","NDC","","","","","facility","both","1","EA","UD","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 50 MG CAPS","0904-6992-61","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIODARONE 200 MG TABS","0904-6993-61","NDC","","","","","facility","both","1","EA","","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIODARONE 200 MG TABS","0904-6993-61","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCUSATE CALCIUM 240 MG CAPS","0904-6997-60","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCUSATE CALCIUM 240 MG CAPS","0904-6997-60","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 75 MG CAPS","0904-7000-61","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 75 MG CAPS","0904-7000-61","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 100 MG CAPS","0904-7001-61","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 100 MG CAPS","0904-7001-61","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMOTRIGINE 100 MG TABS","0904-7008-61","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE 100 MG TABS","0904-7008-61","NDC","","","","","facility","both","1","EA","UD","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE-NALOXONE 8-2 MG SUBL","0904-7010-06","NDC","","","","","facility","both","1","EA","","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE-NALOXONE 8-2 MG SUBL","0904-7010-06","NDC","","","","","facility","both","1","EA","UD","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 1 MG TABS","0904-7016-04","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAZOSIN 1 MG CAPS","0904-7020-61","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAZOSIN 1 MG CAPS","0904-7020-61","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACITRACIN 500 UNIT/GRAM OIPK","0904-7023-67","NDC","","","","","facility","both","1","EA","","144","72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VORICONAZOLE 200 MG TABS","0904-7024-04","NDC","","","","","facility","both","1","EA","","8.7","4.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALLOPURINOL 100 MG TABS","0904-7041-61","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 100 MG TABS","0904-7041-61","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DULOXETINE 20 MG CPDR","0904-7043-61","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DULOXETINE 20 MG CPDR","0904-7043-61","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DULOXETINE 30 MG CPDR","0904-7044-61","NDC","","","","","facility","both","1","EA","UD","0.18","0.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DULOXETINE 30 MG CPDR","0904-7044-61","NDC","","","","","facility","both","1","EA","","0.18","0.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOSARTAN 25 MG TABS","0904-7047-61","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOSARTAN 50 MG TABS","0904-7048-61","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 50 MG TABS","0904-7048-61","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN-DIPYRIDAMOLE 25-200 MG CM12","0904-7056-99","NDC","","","","","facility","both","1","EA","UD","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN-DIPYRIDAMOLE 25-200 MG CM12","0904-7056-99","NDC","","","","","facility","both","1","EA","","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 500 MG TABS","0904-7057-61","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","0904-7058-61","NDC","","","","","facility","both","1","EA","","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","0904-7058-61","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","0904-7064-41","NDC","","","","","facility","both","1","EA","","104.67","52.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NADOLOL 20 MG TABS","0904-7070-07","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NADOLOL 20 MG TABS","0904-7070-07","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NADOLOL 20 MG TABS","0904-7070-61","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NADOLOL 20 MG TABS","0904-7070-61","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NADOLOL 40 MG TABS","0904-7071-07","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE ER 150 MG CP24","0904-7076-61","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE ER 150 MG CP24","0904-7076-61","NDC","","","","","facility","both","1","EA","UD","0.34","0.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG TABS","0904-7078-61","NDC","","","","","facility","both","1","EA","UD","0.96","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG TABS","0904-7078-61","NDC","","","","","facility","both","1","EA","","1.93","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN 100 MG/4 ML SUSPENSION","0904-7079-24","NDC","","","","","facility","both","1","EA","UD","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYTOIN 100 MG/4 ML SUSPENSION","0904-7079-24","NDC","","","","","facility","both","1","EA","","7.67","3.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOXACIN HCL 500 MG TABS","0904-7083-61","NDC","","","","","facility","both","1","EA","UD","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN HCL 500 MG TABS","0904-7083-61","NDC","","","","","facility","both","1","EA","","1.47","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0904-7094-61","NDC","","","","","facility","both","1","EA","UD","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS","0904-7094-61","NDC","","","","","facility","both","1","EA","","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","0904-7095-61","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","0904-7095-61","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 1 MG CAPS","0904-7097-61","NDC","","","","","facility","both","1","EA","UD","0.88","0.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 1 MG CAPS","0904-7097-61","NDC","","","","","facility","both","1","EA","","0.88","0.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","0904-7103-04","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EZETIMIBE 10 MG TABS","0904-7103-04","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CAPTOPRIL 25 MG TABS","0904-7106-61","NDC","","","","","facility","both","1","EA","","3.54","1.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVASTIGMINE TARTRATE 1.5 MG CAPS","0904-7107-61","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVASTIGMINE TARTRATE 1.5 MG CAPS","0904-7107-61","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 100 MG TABS","0904-7109-61","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LABETALOL 100 MG TABS","0904-7109-61","NDC","","","","","facility","both","1","EA","UD","0.41","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","0904-7110-61","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","0904-7110-61","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","0904-7119-06","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","0904-7119-06","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COLCHICINE 0.6 MG TABS","0904-7120-04","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLCHICINE 0.6 MG TABS","0904-7120-04","NDC","","","","","facility","both","1","EA","","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 250 MG TABS","0904-7123-61","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 250 MG TABS","0904-7123-61","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","0904-7124-61","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","0904-7124-61","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","0904-7127-61","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 20 MG TABS","0904-7127-61","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORPROMAZINE 10 MG TABS","0904-7129-61","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORPROMAZINE 25 MG TABS","0904-7130-61","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 25 MG TABS","0904-7130-61","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORPROMAZINE 100 MG TABS","0904-7132-61","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUANFACINE 1 MG TABS","0904-7140-04","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GUANFACINE 1 MG TABS","0904-7140-04","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZONATATE 100 MG CAPS","0904-7153-61","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BENZONATATE 100 MG CAPS","0904-7153-61","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 250 MG TABS","0904-7156-61","NDC","","","","","facility","both","1","EA","","0.52","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METRONIDAZOLE 250 MG TABS","0904-7156-61","NDC","","","","","facility","both","1","EA","UD","0.52","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE 2.5 MG TABS","0904-7158-61","NDC","","","","","facility","both","1","EA","UD","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE 2.5 MG TABS","0904-7158-61","NDC","","","","","facility","both","1","EA","","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG TABS","0904-7172-07","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG TABS","0904-7172-07","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FUROSEMIDE 20 MG TABS","0904-7177-61","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FUROSEMIDE 20 MG TABS","0904-7177-61","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCUSATE SODIUM 100 MG CAPS","0904-7183-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCUSATE SODIUM 100 MG CAPS","0904-7183-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE 10 MG TABS","0904-7188-61","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NEBIVOLOL 5 MG TABS","0904-7189-04","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NEBIVOLOL 5 MG TABS","0904-7189-04","NDC","","","","","facility","both","1","EA","UD","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE 20 MG TABS","0904-7193-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE 20 MG TABS","0904-7193-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISMUTH SUBSALICYLATE 262 MG CHEW","0904-7205-46","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISMUTH SUBSALICYLATE 262 MG CHEW","0904-7205-46","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DANTROLENE 25 MG CAPS","0904-7211-04","NDC","","","","","facility","both","1","EA","","2.29","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DANTROLENE 25 MG CAPS","0904-7211-04","NDC","","","","","facility","both","1","EA","UD","2.29","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPROPION SR 150 MG SR12","0904-7214-61","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION SR 150 MG SR12","0904-7214-61","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 10 MEQ TBSR","0904-7216-61","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 10 MEQ TBSR","0904-7216-61","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 180 MG CP24","0904-7218-61","NDC","","","","","facility","both","1","EA","UD","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 180 MG CP24","0904-7218-61","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 24HR 240 MG CP24","0904-7219-61","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 240 MG CP24","0904-7219-61","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOLIC ACID 1 MG TABS","0904-7224-61","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOLIC ACID 1 MG TABS","0904-7224-61","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEBIVOLOL 2.5 MG TABS","0904-7225-04","NDC","","","","","facility","both","1","EA","","1.7","0.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIFEDIPINE 10 MG CAPS","0904-7229-61","NDC","","","","","facility","both","1","EA","","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIFEDIPINE 10 MG CAPS","0904-7229-61","NDC","","","","","facility","both","1","EA","UD","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEGESTROL 40 MG TABS","0904-7236-61","NDC","","","","","facility","both","1","EA","UD","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEGESTROL 40 MG TABS","0904-7236-61","NDC","","","","","facility","both","1","EA","","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENHYDRAMINE 25 MG CAPS","0904-7237-60","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 25 MG CAPS","0904-7237-60","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENHYDRAMINE 25 MG CAPS","0904-7237-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENHYDRAMINE 25 MG CAPS","0904-7237-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN HCL 500 MG TABS","0904-7243-61","NDC","","","","","facility","both","1","EA","","1.47","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CIPROFLOXACIN HCL 500 MG TABS","0904-7243-61","NDC","","","","","facility","both","1","EA","UD","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 50 MG TABS","0904-7244-68","NDC","","","","","facility","both","1","EA","UD","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 50 MG TABS","0904-7244-68","NDC","","","","","facility","both","1","EA","","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 100 MG TABS","0904-7245-68","NDC","","","","","facility","both","1","EA","","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 100 MG TABS","0904-7245-68","NDC","","","","","facility","both","1","EA","UD","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNOSIDES 8.6 MG TABS","0904-7252-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SENNOSIDES 8.6 MG TABS","0904-7252-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","0904-7257-61","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","0904-7257-61","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXCARBAZEPINE 150 MG TABS","0904-7262-61","NDC","","","","","facility","both","1","EA","","0.68","0.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXCARBAZEPINE 150 MG TABS","0904-7262-61","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXCARBAZEPINE 300 MG TABS","0904-7263-61","NDC","","","","","facility","both","1","EA","UD","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXCARBAZEPINE 300 MG TABS","0904-7263-61","NDC","","","","","facility","both","1","EA","","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","0904-7265-41","NDC","","","","","facility","both","1","EA","UD","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","0904-7265-41","NDC","","","","","facility","both","1","EA","","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE 4 MG TABS","0904-7266-61","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXAMETHASONE 4 MG TABS","0904-7266-61","NDC","","","","","facility","both","1","EA","UD","2.47","1.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","0904-7276-41","NDC","","","","","facility","both","1","EA","","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","0904-7276-41","NDC","","","","","facility","both","1","EA","UD","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCUSATE SODIUM 100 MG CAPS","0904-7280-80","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOCUSATE SODIUM 100 MG CAPS","0904-7280-80","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","0904-7293-61","NDC","","","","","facility","both","1","EA","UD","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","0904-7293-61","NDC","","","","","facility","both","1","EA","","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 25 MG TABS","0904-7304-61","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG TABS","0904-7304-61","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 3.125 MG TABS","0904-7305-61","NDC","","","","","facility","both","1","EA","","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 3.125 MG TABS","0904-7305-61","NDC","","","","","facility","both","1","EA","UD","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FISH OIL 500 MG CAPS","0904731813","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FISH OIL 500 MG CAPS","0904731813","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEPHALEXIN 250 MG CAPS","0904-7336-61","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEPHALEXIN 250 MG CAPS","0904-7336-61","NDC","","","","","facility","both","1","EA","","1.63","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUOXETINE 20 MG CAPS","0904-7346-61","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG CAPS","0904-7346-61","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","0904-7350-06","NDC","","","","","facility","both","1","EA","","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","0904-7350-06","NDC","","","","","facility","both","1","EA","UD","2.33","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 0.5 MG TABS","0904-7361-61","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 0.5 MG TABS","0904-7361-61","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 1 MG TABS","0904-7362-61","NDC","","","","","facility","both","1","EA","UD","0.4","0.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 1 MG TABS","0904-7362-61","NDC","","","","","facility","both","1","EA","","0.4","0.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 2 MG TABS","0904-7363-61","NDC","","","","","facility","both","1","EA","","0.44","0.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 2 MG TABS","0904-7363-61","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 3 MG TABS","0904-7364-61","NDC","","","","","facility","both","1","EA","","0.45","0.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 3 MG TABS","0904-7364-61","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","0904-7427-30","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","0904-7427-30","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LANOLIN ALCOH-MIN OIL-W.PETRO-CERESIN CREA 454 G JAR","0904775127","NDC","","","","","facility","both","1","EA","UD","454","227","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LANOLIN ALCOH-MIN OIL-W.PETRO-CERESIN CREA 454 G JAR","0904775127","NDC","","","","","facility","both","1","EA","","454","227","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"IBUPROFEN 200 MG TABS","0904-7914-61","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 200 MG TABS","0904-7914-61","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PERITONEAL DIALYSATE 1.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0409-01","NDC","","","","","facility","both","1","EA","UD","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 1.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0409-01","NDC","","","","","facility","both","1","EA","","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PERITONEAL DIALYSATE 1.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN 2,000 ML FLEX CONT","0941-0409-06","NDC","","","","","facility","both","1","EA","UD","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 1.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0411-05","NDC","","","","","facility","both","1","EA","UD","138","69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 1.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0411-05","NDC","","","","","facility","both","1","EA","","138","69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"PERITONEAL DIALYSATE 1.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0411-11","NDC","","","","","facility","both","1","EA","UD","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 1.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0411-11","NDC","","","","","facility","both","1","EA","","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PERITONEAL DIALYSATE 2.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN 6,000 ML FLEX CONT","0941-0413-01","NDC","","","","","facility","both","1","EA","","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PERITONEAL DIALYSATE 2.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0413-05","NDC","","","","","facility","both","1","EA","","142","71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"PERITONEAL DIALYSATE 4.25% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0415-01","NDC","","","","","facility","both","1","EA","","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PERITONEAL DIALYSATE 1.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0424-52","NDC","","","","","facility","both","1","EA","","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"PERITONEAL DIALYSATE 1.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0426-52","NDC","","","","","facility","both","1","EA","","98","49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"PERITONEAL DIALYSATE 2.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0427-52","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"PERITONEAL DIALYSATE 2.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0427-52","NDC","","","","","facility","both","1","EA","UD","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 2.5% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN 2,500 ML BAG","0941-0427-53","NDC","","","","","facility","both","1","EA","","182","91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"PERITONEAL DIALYSATE 4.25% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0429-52","NDC","","","","","facility","both","1","EA","UD","114","57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 4.25% STANDARD CALCIUM CA 3.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0429-52","NDC","","","","","facility","both","1","EA","","114","57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"PERITONEAL DIALYSATE 2.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN 2,000 ML BAG","0941-0430-52","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"PERITONEAL DIALYSATE 2.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0457-01","NDC","","","","","facility","both","1","EA","UD","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERITONEAL DIALYSATE 2.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0457-01","NDC","","","","","facility","both","1","EA","","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PERITONEAL DIALYSATE 2.5% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN 2,000 ML FLEX CONT","0941-0457-08","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"PERITONEAL DIALYSATE 4.25% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0459-01","NDC","","","","","facility","both","1","EA","","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PERITONEAL DIALYSATE 4.25% LOW CALCIUM CA 2.5 MEQ/L- MG 0.5 MEQ/L SOLN","0941-0459-01","NDC","","","","","facility","both","1","EA","UD","218","109","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CITRATE 4 % SOLN","0942-9504-10","NDC","","","","","facility","both","1","EA","","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"SODIUM CITRATE 4 % SOLN","0942-9504-10","NDC","","","","","facility","both","1","EA","UD","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPHA-1 PROTEINASE INHIB.(HUM) 500 MG SOLR","0944-2803-03","NDC","","","","","facility","both","1","EA","JG","10364.74","5182.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG SOLR","0944-2804-04","NDC","","","","","facility","both","1","EA","UD","30025.74","15012.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG SOLR","0944-2804-04","NDC","","","","","facility","both","1","EA","","30025.74","15012.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG SOLR","0944-2815-01","NDC","","","","","facility","both","1","EA","JG","10784.07","5392.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG SOLR","0944-2815-01","NDC","","","","","facility","both","1","EA","UD","30951.75","15475.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1 GRAM/50 ML (2 %) SOLN","0944-2884-01","NDC","","","","","facility","both","1","EA","","9981.17","4990.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PEGASPARGASE 750 UNIT/ML SOLN","0944-3810-01","NDC","","","","","facility","both","1","EA","JG","68003.42","34001.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ACETIC ACID 0.25 % SOLN 1,000 ML BOTTLE","0990-6143-09","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/100 ML PGBK","0990-7074-26","NDC","","","","","facility","both","1","EA","UD","14.8","7.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/100 ML PGBK","0990-7074-26","NDC","","","","","facility","both","1","EA","","14.8","7.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML PGBK","0990-7075-14","NDC","","","","","facility","both","1","EA","","16.2","8.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML PGBK","0990-7075-14","NDC","","","","","facility","both","1","EA","UD","16.2","8.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK","0990-7075-26","NDC","","","","","facility","both","1","EA","","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK","0990-7075-26","NDC","","","","","facility","both","1","EA","UD","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK","0990-7077-14","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK","0990-7077-14","NDC","","","","","facility","both","1","EA","UD","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROSE 70 % SOLP","0990-7120-07","NDC","","","","","facility","both","1","EA","","5.62","2.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML"
"DEXTROSE 70 % SOLP","0990-7120-07","NDC","","","","","facility","both","1","EA","UD","5.62","2.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MANNITOL 20 % SOLP","0990-7715-03","NDC","","","","","facility","both","1","EA","UD","78","39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MANNITOL 20 % SOLP","0990-7715-03","NDC","","","","","facility","both","1","EA","","78","39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"MANNITOL 20 % SOLP","0990-7715-12","NDC","","","","","facility","both","1","EA","","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXTROSE 70 % SOLP 500 ML FLEX CONT","0990-7918-19","NDC","","","","","facility","both","1","EA","UD","80.63","40.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROSE 70 % SOLP 500 ML FLEX CONT","0990-7918-19","NDC","","","","","facility","both","1","EA","","80.63","40.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"D20W 20 % SOLP","0990-7935-19","NDC","","","","","facility","both","1","EA","UD","48","24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D20W 20 % SOLP","0990-7935-19","NDC","","","","","facility","both","1","EA","","48","24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"ARTIFICIAL TEAR 0.5 % DROP 15 ML DROP BTL","0998-0408-15","NDC","","","","","facility","both","1","EA","","84.88","42.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABS","1000670028","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABS","1000670028","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM-VITAMIN D 500 MG-5 MCG (200 UNIT) TABS","1000670038","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM-VITAMIN D 500 MG-5 MCG (200 UNIT) TABS","1000670038","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","10019-055-61","NDC","","","","","facility","both","1","EA","UD","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","10019-055-61","NDC","","","","","facility","both","1","EA","","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,000 MG/100 ML SOLP 100 ML FLEX CONT","10019-075-87","NDC","","","","","facility","both","1","EA","","328.8","164.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,000 MG/100 ML SOLP 100 ML FLEX CONT","10019-075-87","NDC","","","","","facility","both","1","EA","UD","1646","823","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENDAMUSTINE 25 MG/ML SOLN 4 ML VIAL","10019-079-01","NDC","","","","","facility","both","1","EA","JG","11223.68","5611.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","10019-553-90","NDC","","","","","facility","both","1","EA","UD","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","10019-553-90","NDC","","","","","facility","both","1","EA","","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","10019-672-10","NDC","","","","","facility","both","1","EA","","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","10019-672-10","NDC","","","","","facility","both","1","EA","UD","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MESNA 100 MG/ML SOLN 10 ML VIAL","10019-953-01","NDC","","","","","facility","both","1","EA","","25.3","12.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MESNA 100 MG/ML SOLN 10 ML VIAL","10019-953-62","NDC","","","","","facility","both","1","EA","","25.3","12.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PORACTANT ALFA 240 MG/3 ML SUSPENSION","10122-510-01","NDC","","","","","facility","both","1","EA","","2683.93","1341.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PORACTANT ALFA 240 MG/3 ML SUSPENSION","10122-510-01","NDC","","","","","facility","both","1","EA","UD","2683.93","1341.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PORACTANT ALFA 240 MG/3 ML SUSPENSION","10122-510-03","NDC","","","","","facility","both","1","EA","","5223.17","2611.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PORACTANT ALFA 240 MG/3 ML SUSPENSION","10122-510-03","NDC","","","","","facility","both","1","EA","UD","5223.17","2611.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 10 MG TABS","10135-532-01","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACLOFEN 10 MG TABS","10135-532-01","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","10135-712-01","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","10135-712-01","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE 2.5 MG TABS","10135-726-01","NDC","","","","","facility","both","1","EA","UD","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFABUTIN 150 MG CAPS","10135-738-01","NDC","","","","","facility","both","1","EA","UD","14.93","7.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFABUTIN 150 MG CAPS","10135-738-01","NDC","","","","","facility","both","1","EA","","28.86","14.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 2.5 MG TABS","10135-775-01","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 2.5 MG TABS","10135-775-01","NDC","","","","","facility","both","1","EA","","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","10135-778-05","NDC","","","","","facility","both","1","EA","UD","0.31","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 20 MG TABS","10135-778-05","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","10135-778-10","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","10135-778-10","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 50 MG TABS","10135-779-01","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CETACAINE 2 %-2 %-14 % (200 MG/SEC) SPRA","10223-0201-3","NDC","","","","","facility","both","1","EA","","8.98","4.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BENZOCAINE-MENTHOL-ZINC CHLOR 20-0.26-0.15 % GEL 11.9 G TUBE","1031028313","NDC","","","","","facility","both","1","EA","UD","11.9","5.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE-MENTHOL-ZINC CHLOR 20-0.26-0.15 % GEL 11.9 G TUBE","1031028313","NDC","","","","","facility","both","1","EA","","11.9","5.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"AQUAPHOR OINT 420 G JAR","10356-201-00","NDC","","","","","facility","both","1","EA","UD","18.64","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AQUAPHOR OINT 420 G JAR","10356-201-00","NDC","","","","","facility","both","1","EA","","18.64","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 G"
"INJ RIMABOTULINUMTOXINB 100 UN","10454-711-10","NDC","","","","","facility","both","1","EA","PN","850","425","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML SOLA","10481-0112-8","NDC","","","","","facility","both","1","EA","","52.04","26.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML SOLA","10481-0112-8","NDC","","","","","facility","both","1","EA","UD","52.04","26.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 2.5 % CRPE 28.35 G TUBE","10631-407-01","NDC","","","","","facility","both","1","EA","UD","43.95","21.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 2.5 % CRPE 28.35 G TUBE","10631-407-01","NDC","","","","","facility","both","1","EA","","43.95","21.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PROMETHAZINE 25 MG TABS","10702-003-01","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 25 MG TABS","10702-003-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","10702-253-01","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","10702-253-01","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACITRACIN 500 UNIT/GRAM OINT 28.4 G TUBE","1093956433","NDC","","","","","facility","both","1","EA","","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 28.4 G TUBE","1093956833","NDC","","","","","facility","both","1","EA","","6.07","3.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MINERAL OIL OIL","1093-9744-30","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINERAL OIL OIL","1093-9744-30","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BENZOCAINE/RESORCIN 5-2 % CREA 28 G TUBE","1150900367","NDC","","","","","facility","both","1","EA","UD","10.31","5.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","11523-7268-3","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","11523-7268-3","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","1152372688","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","1152372688","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","11523-7268-8","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","11523-7268-8","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYL SALICYLATE-MENTHOL 15-10 % CREA 35 G TUBE","11527-057-40","NDC","","","","","facility","both","1","EA","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"GLUCOSE 4 GRAM CHEW","1191701440","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOOD SUPPLEMT, LACTOSE-REDUCED 0.05 GRAM- 1.5 KCAL/ML LIQD","1191712183","NDC","","","","","facility","both","1","EA","UD","350","175","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CONTRAST,DEFINITY","11994-011-01","NDC","","","","","facility","both","1","EA","","399","199.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SILVER NITRATE 75-25 % STCK 100 EACH TUBE","12165-100-01","NDC","","","","","facility","both","1","EA","UD","8.2","4.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER NITRATE 75-25 % STCK 100 EACH TUBE","12165-100-01","NDC","","","","","facility","both","1","EA","","8.2","4.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POVIDONE-IODINE 10 % OINT 30 G TUBE","12772-194-15","NDC","","","","","facility","both","1","EA","","6.57","3.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"POVIDONE-IODINE 10 % OINT 30 G TUBE","12772-194-15","NDC","","","","","facility","both","1","EA","UD","6.57","3.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER NITRATE 75-25 % STCK 100 EACH PACKET","12870-0001-1","NDC","","","","","facility","both","1","EA","UD","73","36.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER NITRATE 75-25 % STCK 100 EACH PACKET","12870-0001-1","NDC","","","","","facility","both","1","EA","","73","36.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","13107-021-01","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","13107-021-01","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 20 MG TABS","13107-155-90","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 20 MG TABS","13107-155-90","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIAZOXIDE (DIABETIC USE) 50 MG/ML SUSPENSION","13517-100-30","NDC","","","","","facility","both","1","EA","","8.88","4.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TD VACCINE NO PRSRV>/= 7IM","13533-131-00","NDC","","","","","facility","both","1","EA","","60","30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RABIES IMMUNE GLOB (PF) (1ML) 300 UNIT/ML SOLN","13533-318-01","NDC","","","","","facility","both","1","EA","","6604.04","3302.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RABIES IMMUNE GLOB (PF) (1ML) 300 UNIT/ML SOLN","13533-318-01","NDC","","","","","facility","both","1","EA","UD","13136.84","6568.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RABIES IMMUNE GLOB (PF) (5ML) 300 UNIT/ML SOLN","13533-318-05","NDC","","","","","facility","both","1","EA","","11340.22","5670.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RABIES IMMUNE GLOB (PF) (5ML) 300 UNIT/ML SOLN","13533-318-05","NDC","","","","","facility","both","1","EA","UD","16043.8","8021.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RABIES IMMUNE GLOB (PF) (1ML) 300 UNIT/ML SOLN","13533-318-10","NDC","","","","","facility","both","1","EA","","3337.64","1668.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RABIES IMMUNE GLOB (PF) (1ML) 300 UNIT/ML SOLN","13533-318-50","NDC","","","","","facility","both","1","EA","","5193.53","2596.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT SOLR","13533-602-50","NDC","","","","","facility","both","1","EA","","9000","4500","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT SOLR","13533-606-12","NDC","","","","","facility","both","1","EA","UD","36","18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML SYRG","13533-634-02","NDC","","","","","facility","both","1","EA","JG","3096.49","1548.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML SYRG","13533-634-02","NDC","","","","","facility","both","1","EA","","3187.26","1593.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML SYRG","13533-636-03","NDC","","","","","facility","both","1","EA","UD","495.8","247.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML SYRG","13533-636-03","NDC","","","","","facility","both","1","EA","","495.8","247.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) SOLN","13533-636-50","NDC","","","","","facility","both","1","EA","","3912.34","1956.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG (+/-)/20 ML SOLN","13533-705-01","NDC","","","","","facility","both","1","EA","","2567.24","1283.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALPHA-1 PROTEINASE INHIB.(HUM) 1,000 MG (+/-)/20 ML SOLN","13533-705-11","NDC","","","","","facility","both","1","EA","","14941.06","7470.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE ZYDIS 5 MG ODT.","13668-086-30","NDC","","","","","facility","both","1","EA","UD","3.31","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE ZYDIS 5 MG ODT.","13668-086-30","NDC","","","","","facility","both","1","EA","","3.31","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 25 MG TR24","13668-339-30","NDC","","","","","facility","both","1","EA","UD","3.11","1.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMOTRIGINE ER 25 MG TR24","13668-339-30","NDC","","","","","facility","both","1","EA","","5.21","2.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 100 MG TR24","13668-341-30","NDC","","","","","facility","both","1","EA","","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 100 MG TR24","13668-341-30","NDC","","","","","facility","both","1","EA","UD","5.51","2.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENOFIBRATE MICRONIZED 67 MG CAPS","13668-440-01","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENOFIBRATE MICRONIZED 67 MG CAPS","13668-440-01","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINOCYCLINE 50 MG CAPS","13668-482-01","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINOCYCLINE 50 MG CAPS","13668-482-01","NDC","","","","","facility","both","1","EA","UD","2.36","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TADALAFIL 20 MG TABS","13668-581-30","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 1 MG/ML SOLN","13668-589-06","NDC","","","","","facility","both","1","EA","","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RISPERIDONE 1 MG/ML SOLN","13668-589-06","NDC","","","","","facility","both","1","EA","UD","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX-VITAMIN C-FOLIC ACID 1 MG CAPS","1381152501","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX-VITAMIN C-FOLIC ACID 1 MG CAPS","1381152501","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PENTAMIDINE 300 MG SOLR","13925-522-01","NDC","","","","","facility","both","1","EA","UD","128","64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENTAMIDINE 300 MG SOLR","13925-522-01","NDC","","","","","facility","both","1","EA","","128","64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOPROTERENOL 0.2 MG/ML SOLN 1 ML VIAL","14789-011-07","NDC","","","","","facility","both","1","EA","","251.88","125.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ISOPROTERENOL 0.2 MG/ML SOLN 1 ML VIAL","14789-011-07","NDC","","","","","facility","both","1","EA","UD","251.88","125.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK","14789-107-08","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML PGBK","14789-107-08","NDC","","","","","facility","both","1","EA","UD","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK","14789-108-16","NDC","","","","","facility","both","1","EA","UD","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML PGBK","14789-108-16","NDC","","","","","facility","both","1","EA","","12.8","6.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PAPAVERINE 30 MG/ML SOLN 2 ML VIAL","14789-121-05","NDC","","","","","facility","both","1","EA","","145","72.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PAPAVERINE 30 MG/ML SOLN 2 ML VIAL","14789-121-07","NDC","","","","","facility","both","1","EA","","145","72.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENOBARBITAL 65 MG/ML SOLN","14789-127-07","NDC","","","","","facility","both","1","EA","UD","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 65 MG/ML SOLN","14789-127-07","NDC","","","","","facility","both","1","EA","","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPHEDRINE SULFATE 5 MG/ML SOLN","14789-250-07","NDC","","","","","facility","both","1","EA","UD","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPHEDRINE SULFATE 5 MG/ML SOLN","14789-250-07","NDC","","","","","facility","both","1","EA","","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCAINAMIDE 500 MG/ML SOLN 2 ML VIAL","14789-900-07","NDC","","","","","facility","both","1","EA","","912.03","456.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCAINAMIDE 100 MG/ML SOLN","14789-901-07","NDC","","","","","facility","both","1","EA","","60.04","30.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LANREOTIDE 120 MG/0.5 ML SYRG","15054-1120-4","NDC","","","","","facility","both","1","EA","","13222.96","6611.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CONDOM DEVI","16169-01013","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC DR 25 MG TBEC","16571-203-10","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEVIMELINE 30 MG CAPS","16571-657-10","NDC","","","","","facility","both","1","EA","","4.68","2.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOMIPRAMINE 25 MG CAPS","16571-683-03","NDC","","","","","facility","both","1","EA","","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOMIPRAMINE 25 MG CAPS","16571-683-03","NDC","","","","","facility","both","1","EA","UD","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAFENIDE 85 MG/G CREA 56.7 G TUBE","16571-723-60","NDC","","","","","facility","both","1","EA","","212.75","106.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MAFENIDE 85 MG/G CREA 56.7 G TUBE","16571-723-60","NDC","","","","","facility","both","1","EA","UD","212.75","106.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5-400-10,000 MG-UNIT-UNIT/G OINT 3.5 G TUBE","16571-754-53","NDC","","","","","facility","both","1","EA","UD","56.97","28.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 30 MG/0.3 ML SYRG","16714-006-01","NDC","","","","","facility","both","1","EA","UD","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 30 MG/0.3 ML SYRG","16714-006-01","NDC","","","","","facility","both","1","EA","","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 30 MG/0.3 ML SYRG","16714-006-10","NDC","","","","","facility","both","1","EA","","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ENOXAPARIN 30 MG/0.3 ML SYRG","16714-006-10","NDC","","","","","facility","both","1","EA","UD","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 40 MG/0.4 ML SYRG","16714-016-10","NDC","","","","","facility","both","1","EA","UD","20.06","10.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 40 MG/0.4 ML SYRG","16714-016-10","NDC","","","","","facility","both","1","EA","","20.06","10.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ENOXAPARIN 60 MG/0.6 ML SYRG","16714-026-01","NDC","","","","","facility","both","1","EA","","27.94","13.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 60 MG/0.6 ML SYRG","16714-026-01","NDC","","","","","facility","both","1","EA","UD","27.94","13.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","16714-027-01","NDC","","","","","facility","both","1","EA","","69","34.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 80 MG/0.8 ML SYRG","16714-036-01","NDC","","","","","facility","both","1","EA","","37.57","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 80 MG/0.8 ML SYRG","16714-036-01","NDC","","","","","facility","both","1","EA","UD","37.57","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 80 MG/0.8 ML SYRG","16714-036-10","NDC","","","","","facility","both","1","EA","","37.57","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ENOXAPARIN 80 MG/0.8 ML SYRG","16714-036-10","NDC","","","","","facility","both","1","EA","UD","37.57","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 100 MG/ML SYRG","16714-046-01","NDC","","","","","facility","both","1","EA","UD","46.31","23.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 100 MG/ML SYRG","16714-046-01","NDC","","","","","facility","both","1","EA","","46.31","23.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLOPIDOGREL 75 MG TABS","16714-052-10","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 120 MG/0.8 ML SYRG","16714-056-01","NDC","","","","","facility","both","1","EA","","55.07","27.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 120 MG/0.8 ML SYRG","16714-056-01","NDC","","","","","facility","both","1","EA","UD","55.07","27.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 150 MG/ML SYRG","16714-066-01","NDC","","","","","facility","both","1","EA","UD","68.38","34.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 150 MG/ML SYRG","16714-066-01","NDC","","","","","facility","both","1","EA","","68.38","34.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROXYZINE 10 MG TABS","16714-081-10","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYZINE 25 MG TABS","16714-082-10","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 25 MG TABS","16714-082-10","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IRINOTECAN 100 MG/5 ML SOLN 5 ML VIAL","16714-131-01","NDC","","","","","facility","both","1","EA","","100.6","50.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PENICILLIN V POTASSIUM 250 MG TABS","16714-234-01","NDC","","","","","facility","both","1","EA","UD","1.49","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN V POTASSIUM 250 MG TABS","16714-234-01","NDC","","","","","facility","both","1","EA","","1.49","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 400-57 MG/5 ML SUSR","16714-293-01","NDC","","","","","facility","both","1","EA","UD","38.8","19.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 400-57 MG/5 ML SUSR","16714-293-01","NDC","","","","","facility","both","1","EA","","38.8","19.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMOXICILLIN-CLAVULANATE 600-42.9 MG/5 ML SUSR","16714-294-01","NDC","","","","","facility","both","1","EA","UD","2.15","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN 250 MG CAPS","16714-298-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN 250 MG CAPS","16714-298-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN 250 MG CAPS","16714-298-02","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL","16714-309-01","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL","16714-309-01","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 100 MG/ML SOLN","16714-358-01","NDC","","","","","facility","both","1","EA","UD","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 100 MG/ML SOLN","16714-358-01","NDC","","","","","facility","both","1","EA","","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFPROZIL 250 MG TABS","16714-398-01","NDC","","","","","facility","both","1","EA","","3.1","1.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFPROZIL 250 MG TABS","16714-398-01","NDC","","","","","facility","both","1","EA","UD","3.1","1.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRIL 5 MG TABS","16714-443-01","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ENALAPRIL 5 MG TABS","16714-443-01","NDC","","","","","facility","both","1","EA","UD","0.16","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE","16714-496-01","NDC","","","","","facility","both","1","EA","UD","36.44","18.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % CREA 15 G TUBE","16714-496-01","NDC","","","","","facility","both","1","EA","","36.44","18.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"VANCOMYCIN 5 GRAM SOLR","16714-517-01","NDC","","","","","facility","both","1","EA","","12.77","6.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 5 GRAM SOLR","16714-517-01","NDC","","","","","facility","both","1","EA","UD","33.31","16.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ADENOSINE 3 MG/ML SOLN","16714-556-01","NDC","","","","","facility","both","1","EA","","62.08","31.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ADENOSINE 3 MG/ML SOLN","16714-556-01","NDC","","","","","facility","both","1","EA","UD","490","245","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 100 MG TABS","16714-576-02","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 100 MG TABS","16714-576-02","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SERTRALINE 25 MG TABS","16714-611-01","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","16714-628-01","NDC","","","","","facility","both","1","EA","UD","443.49","221.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALENDRONATE 70 MG TABS","16714-633-01","NDC","","","","","facility","both","1","EA","","2.4","1.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 100 MG CAPS","16714-661-02","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 400 MG CAPS","16714-663-02","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","16714-663-02","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 20 MG TABS","16714-683-02","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 20 MG TABS","16714-683-02","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPOFOL 10 MG/ML EMUL","16714-690-01","NDC","","","","","facility","both","1","EA","","73.13","36.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROPOFOL 10 MG/ML EMUL","16714-690-01","NDC","","","","","facility","both","1","EA","UD","73.13","36.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 150 MG TABS","16714-692-10","NDC","","","","","facility","both","1","EA","UD","2.57","1.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 150 MG TABS","16714-692-10","NDC","","","","","facility","both","1","EA","","2.57","1.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 10 MG/ML SUSR","16714-695-01","NDC","","","","","facility","both","1","EA","","17.21","8.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUCONAZOLE 10 MG/ML SUSR","16714-695-01","NDC","","","","","facility","both","1","EA","UD","33.41","16.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 40 MG/ML SUSR","16714-696-01","NDC","","","","","facility","both","1","EA","","8.03","4.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUCONAZOLE 40 MG/ML SUSR","16714-696-01","NDC","","","","","facility","both","1","EA","UD","8.03","4.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENTECAVIR 0.5 MG 0.5 MG TABS","16714-717-01","NDC","","","","","facility","both","1","EA","","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIPOTRIENE 0.005 % CREA 60 G TUBE","16714-763-01","NDC","","","","","facility","both","1","EA","UD","95.92","47.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOBETASOL 0.05 % OINT 15 G TUBE","16714-782-01","NDC","","","","","facility","both","1","EA","","10.14","5.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SUMATRIPTAN 25 MG TABS","16714-796-01","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUMATRIPTAN 25 MG TABS","16714-796-01","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SUMATRIPTAN 100 MG TABS","16714-798-01","NDC","","","","","facility","both","1","EA","UD","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUMATRIPTAN 100 MG TABS","16714-798-01","NDC","","","","","facility","both","1","EA","","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","16714-813-02","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","16714-813-02","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SEVELAMER CARBONATE 800 MG TABS","16714-814-01","NDC","","","","","facility","both","1","EA","","2.53","1.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","16714-950-01","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","16714-950-01","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOCONAZOLE 2 % CREA 15 G TUBE","16714-955-01","NDC","","","","","facility","both","1","EA","UD","12.08","6.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOCONAZOLE 2 % CREA 15 G TUBE","16714-955-01","NDC","","","","","facility","both","1","EA","","12.08","6.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 454 G JAR","16714-986-04","NDC","","","","","facility","both","1","EA","UD","62.97","31.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 454 G JAR","16714-986-04","NDC","","","","","facility","both","1","EA","","62.97","31.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TEMOZOLOMIDE 5 MG CAPS","16729-048-54","NDC","","","","","facility","both","1","EA","","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMOZOLOMIDE 20 MG CAPS","16729-049-53","NDC","","","","","facility","both","1","EA","","62.8","31.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMOZOLOMIDE 100 MG CAPS","16729-050-53","NDC","","","","","facility","both","1","EA","","127.93","63.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE 250 MG CAPS","16729-094-01","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE 250 MG CAPS","16729-094-01","NDC","","","","","facility","both","1","EA","UD","2.68","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE SR 150 MG TB24","16729-109-12","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOPOSIDE 20 MG/ML SOLN 25 ML VIAL","16729-114-08","NDC","","","","","facility","both","1","EA","","38.96","19.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL","16729-114-31","NDC","","","","","facility","both","1","EA","","22.4","11.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MITOMYCIN 5 MG SOLR 1 EACH VIAL","16729-115-05","NDC","","","","","facility","both","1","EA","JG","261.6","130.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"MITOMYCIN 5 MG SOLR 1 EACH VIAL","16729-115-05","NDC","","","","","facility","both","1","EA","TB","261.6","130.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"MITOMYCIN 40 MG SOLR","16729-116-38","NDC","","","","","facility","both","1","EA","JG","896","448","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"MITOMYCIN 40 MG SOLR","16729-116-38","NDC","","","","","facility","both","1","EA","","896","448","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.5 MG TABS","16729-136-00","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 0.5 MG TABS","16729-136-00","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXAZOSIN 4 MG TABS","16729-213-01","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXAZOSIN 4 MG TABS","16729-213-01","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCETAXEL 160 MG/8 ML (20 MG/ML) SOLN 8 ML VIAL","16729-267-65","NDC","","","","","facility","both","1","EA","","536.25","268.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","16729-275-03","NDC","","","","","facility","both","1","EA","","215.24","107.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","16729-275-03","NDC","","","","","facility","both","1","EA","UD","359.24","179.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOTREXATE 25 MG/ML SOLN 2 ML VIAL","16729-277-30","NDC","","","","","facility","both","1","EA","UD","7.71","3.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CISPLATIN 1 MG/ML SOLN 50 ML VIAL","16729-288-11","NDC","","","","","facility","both","1","EA","","18.12","9.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPLERENONE 25 MG TABS","16729-293-10","NDC","","","","","facility","both","1","EA","","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLMESARTAN 20 MG TABS","16729-321-15","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","16729-440-10","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","16729-440-10","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACITRACIN 500 UNIT/GRAM OINT 425 G JAR","1678411761","NDC","","","","","facility","both","1","EA","","425","212.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN 500 UNIT/GRAM OINT 425 G JAR","1678411761","NDC","","","","","facility","both","1","EA","UD","425","212.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE-MENTHOL 20-0.5 % AERO 56 G CANISTER","16864-680-02","NDC","","","","","facility","both","1","EA","UD","13.15","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CANISTER","16864-680-03","NDC","","","","","facility","both","1","EA","","19.45","9.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BENZOCAINE-MENTHOL 20-0.5 % AERO 85 G CANISTER","16864-680-03","NDC","","","","","facility","both","1","EA","UD","19.45","9.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHGR-RP IN111 LABELED WBC PER DOSE","17156-021-01","NDC","","","","","facility","both","1","EA","","3856","1928","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHGR-RP I-123 IOFLUPANE PER DOSE","17156-210-01","NDC","","","","","facility","both","1","EA","","4274","2137","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUORESCEIN 1 MG STRP","17238-900-99","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUORESCEIN 1 MG STRP","17238-900-99","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPIVACAINE (PF) 0.5% SOLN","17478-081-30","NDC","","","","","facility","both","1","EA","","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROPIVACAINE (PF) 0.5% SOLN","17478-081-30","NDC","","","","","facility","both","1","EA","UD","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10% 10 % DROP","17478-206-05","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10% 10 % DROP","17478-206-05","NDC","","","","","facility","both","1","EA","","86","43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FORTIFIED GENTAMICIN EYE DROPS 15 MG/ML DROP 5 ML DROP BTL","17478-283-10","NDC","","","","","facility","both","1","EA","UD","52.64","26.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.5 % DROP","17478-288-10","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.5 % DROP","17478-288-10","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CROMOLYN 4 % DROP 10 ML DROP BTL","17478-291-11","NDC","","","","","facility","both","1","EA","","79.75","39.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHADONE","17478-380-20","NDC","","","","","facility","both","1","EA","","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 2 % JELL 5 ML TUBE","17478-711-10","NDC","","","","","facility","both","1","EA","UD","25.5","12.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % JELL 5 ML TUBE","17478-711-10","NDC","","","","","facility","both","1","EA","","25.5","12.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOTIFEN 0.025 % (0.035 %) DROP","17478-717-10","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) LIQD","1785600102","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) LIQD","1785600102","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML"
"CHLORHEXIDINE 0.12 % MWSH","1785602722","NDC","","","","","facility","both","1","EA","UD","4.83","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORHEXIDINE 0.12 % MWSH","1785602722","NDC","","","","","facility","both","1","EA","","4.83","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","17856-0496-3","NDC","","","","","facility","both","1","EA","UD","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","17856-0496-3","NDC","","","","","facility","both","1","EA","","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"PROMETHAZINE 6.25 MG/5 ML SYRP 5 ML CUP","17856-0608-5","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML"
"PROMETHAZINE 6.25 MG/5 ML SYRP 5 ML CUP","17856-0608-5","NDC","","","","","facility","both","1","EA","UD","4","2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","17856-1045-1","NDC","","","","","facility","both","1","EA","","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","17856-1045-1","NDC","","","","","facility","both","1","EA","UD","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINERAL OIL OIL","17856-1110-1","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"MINERAL OIL OIL","17856-1110-1","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICYCLOMINE 10 MG/5 ML SOLN","17856-1161-1","NDC","","","","","facility","both","1","EA","","6.21","3.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 72 ML"
"BISMUTH SUBSALICYLATE 262 MG/15 ML SUSPENSION","17856-1313-3","NDC","","","","","facility","both","1","EA","UD","4.96","2.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISMUTH SUBSALICYLATE 262 MG/15 ML SUSPENSION","17856-1313-3","NDC","","","","","facility","both","1","EA","","4.96","2.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","17856-5725-3","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","17856-5725-3","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"HYALURONIDASE, HUMAN RECOMB. 150 UNIT/ML SOLN","18657-117-01","NDC","","","","","facility","both","1","EA","UD","339.08","169.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYALURONIDASE, HUMAN RECOMB. 150 UNIT/ML SOLN","18657-117-01","NDC","","","","","facility","both","1","EA","","339.08","169.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYALURONIDASE, HUMAN RECOMB. 150 UNIT/ML SOLN","18657-117-02","NDC","","","","","facility","both","1","EA","UD","76.6","38.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYALURONIDASE, HUMAN RECOMB. 150 UNIT/ML SOLN","18657-117-02","NDC","","","","","facility","both","1","EA","","124.81","62.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYALURONIDASE, HUMAN RECOMB. 150 UNIT/ML SOLN","18657-117-04","NDC","","","","","facility","both","1","EA","","339.08","169.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","19515-810-41","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","19515-810-41","NDC","","","","","facility","both","1","EA","PN","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","19515-810-41","NDC","","","","","facility","both","1","EA","UD","121.13","60.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","19515-810-52","NDC","","","","","facility","both","1","EA","PN","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","19515-810-52","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","19515-810-52","NDC","","","","","facility","both","1","EA","UD","121.13","60.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLUEN QUAD IM 3YR AND OLDER","19515-814-41","NDC","","","","","facility","both","1","EA","","98","49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INFLUENZA VACCINE ('24/'25) *LATEX FREE*","19515-818-41","NDC","","","","","facility","both","1","EA","UD","121.13","60.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLUENZA VACCINE ('24/'25) *LATEX FREE*","19515-818-41","NDC","","","","","facility","both","1","EA","","121.13","60.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ASCORBIC ACID (VITAMIN C) 250 MG TABS","2055500100","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASCORBIC ACID (VITAMIN C) 250 MG TABS","2055500100","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CETAPHIL CLEANSER CLSR 473 ML BOTTLE","20555-01100","NDC","","","","","facility","both","1","EA","UD","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CETAPHIL CLEANSER CLSR 473 ML BOTTLE","20555-01100","NDC","","","","","facility","both","1","EA","","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FERROUS GLUCONATE TABS","2055501900","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM-CHOLECALCIFEROL (D3) 250 (625)-125 MG-UNIT TABS","2055502500","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM-CHOLECALCIFEROL (D3) 250 (625)-125 MG-UNIT TABS","2055502500","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMIN WITH FOLIC ACID 400 MCG TABS","2055502700","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMIN WITH FOLIC ACID 400 MCG TABS","2055502700","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLECALCIFEROL 25 MCG (1,000 UNIT) TABS","2055503300","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLECALCIFEROL 25 MCG (1,000 UNIT) TABS","2055503300","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MELATONIN 3 MG TABS","2055503601","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MELATONIN 3 MG TABS","2055503601","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZINC SULFATE 50 MG ZINC (220 MG) CAPS","2055504000","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROGEN PEROXIDE 3 % SOLN 237 ML BOTTLE","2159934563","NDC","","","","","facility","both","1","EA","","3.49","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"CLOBETASOL 0.05 % OINT 15 G TUBE","21922-017-04","NDC","","","","","facility","both","1","EA","UD","10.14","5.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOBETASOL 0.05 % OINT 15 G TUBE","21922-017-04","NDC","","","","","facility","both","1","EA","","10.14","5.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PERMETHRIN 5 % CREA 60 G TUBE","21922-021-07","NDC","","","","","facility","both","1","EA","UD","104.53","52.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERMETHRIN 5 % CREA 60 G TUBE","21922-021-07","NDC","","","","","facility","both","1","EA","","106","53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDRALAZINE 10 MG TABS","23155-001-10","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 10 MG TABS","23155-001-10","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","23155-002-10","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 25 MG TABS","23155-002-10","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 80 MG TABS","23155-026-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 80 MG TABS","23155-026-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG CAPS","23155-029-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUOXETINE 20 MG CAPS","23155-029-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHIMAZOLE 10 MG TABS","23155-071-01","NDC","","","","","facility","both","1","EA","UD","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 10 MG CAPS","23155-194-01","NDC","","","","","facility","both","1","EA","UD","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 10 MG CAPS","23155-194-01","NDC","","","","","facility","both","1","EA","","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CIDOFOVIR 75 MG/ML SOLN 5 ML VIAL","23155-216-31","NDC","","","","","facility","both","1","EA","JG","78.34","39.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CIDOFOVIR 75 MG/ML SOLN 5 ML VIAL","23155-216-31","NDC","","","","","facility","both","1","EA","","78.34","39.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIDOFOVIR 75 MG/ML SOLN 5 ML VIAL","23155-216-31","NDC","","","","","facility","both","1","EA","UD","355.4","177.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIKACIN 500 MG/2 ML SOLN 2 ML VIAL","23155-290-31","NDC","","","","","facility","both","1","EA","UD","34.48","17.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIKACIN 500 MG/2 ML SOLN 2 ML VIAL","23155-290-31","NDC","","","","","facility","both","1","EA","","71.45","35.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL","23155-290-32","NDC","","","","","facility","both","1","EA","UD","45.63","22.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL","23155-290-32","NDC","","","","","facility","both","1","EA","","48.13","24.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMIKACIN 500 MG/2 ML SOLN 2 ML VIAL","23155-290-41","NDC","","","","","facility","both","1","EA","UD","34.48","17.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIKACIN 500 MG/2 ML SOLN 2 ML VIAL","23155-290-41","NDC","","","","","facility","both","1","EA","","71.45","35.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL","23155-290-42","NDC","","","","","facility","both","1","EA","UD","48.13","24.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","23155-294-31","NDC","","","","","facility","both","1","EA","UD","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","23155-294-31","NDC","","","","","facility","both","1","EA","","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROXYZINE 25 MG TABS","23155-501-01","NDC","","","","","facility","both","1","EA","","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYZINE 25 MG TABS","23155-501-01","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIMODIPINE 30 MG CAPS","23155-512-11","NDC","","","","","facility","both","1","EA","","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIMODIPINE 30 MG CAPS","23155-512-11","NDC","","","","","facility","both","1","EA","UD","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TROSPIUM 20 MG TABS","23155-530-06","NDC","","","","","facility","both","1","EA","","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TROSPIUM 20 MG TABS","23155-530-06","NDC","","","","","facility","both","1","EA","UD","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","23155-531-02","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","23155-531-02","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM IN NORMAL SALINE 1 MG/ML SOLN 10 ML VIAL","23155-601-42","NDC","","","","","facility","both","1","EA","","149.3","74.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MIDAZOLAM IN NORMAL SALINE 1 MG/ML SOLN 10 ML VIAL","23155-601-42","NDC","","","","","facility","both","1","EA","UD","149.3","74.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE 1 MG TABS","23155-606-01","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARMUSTINE 100 MG SOLR 1 EACH VIAL","23155-649-41","NDC","","","","","facility","both","1","EA","","1851.23","925.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","23155-686-31","NDC","","","","","facility","both","1","EA","UD","99","49.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","23155-686-31","NDC","","","","","facility","both","1","EA","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENALAPRIL 5 MG TABS","23155-705-01","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRIL 5 MG TABS","23155-705-01","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LABETALOL 200 MG TABS","23155-724-01","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","23155-724-01","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PERPHENAZINE 2 MG TABS","23155-799-01","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 25 MG TABS","23155-833-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE, MODIFIED 25 MG CAPS","23155-837-11","NDC","","","","","facility","both","1","EA","","5.62","2.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 125 MG CAPS","23155-858-78","NDC","","","","","facility","both","1","EA","","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 125 MG CAPS","23155-858-78","NDC","","","","","facility","both","1","EA","UD","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE","24200-0060-03","NDC","","","","","facility","both","1","EA","UD","56.67","28.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE","24200-0060-03","NDC","","","","","facility","both","1","EA","","56.67","28.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUCONATE","24200-0061-03","NDC","","","","","facility","both","1","EA","","61","30.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 150 MEQ IN D5W 1000 ML","24200-052-15","NDC","","","","","facility","both","1","EA","","54.86","27.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1UNIT/ML NACL 0.45% FLUSH/5ML SYRINGE","24200-0688-51","NDC","","","","","facility","both","1","EA","","5.79","2.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1UNIT/ML NACL 0.45% FLUSH/5ML SYRINGE","24200-0688-51","NDC","","","","","facility","both","1","EA","UD","5.79","2.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE BITARTRATE-NS 4 MG/250 ML (16 MCG/ML) SOLN","24200-1116-10","NDC","","","","","facility","both","1","EA","","74","37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL 10MCG/ML BUPIVACAINE 0.2% IN 10ML NS","24200-3449-50","NDC","","","","","facility","both","1","EA","","77.75","38.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCITONIN 200 UNIT/ML SOLN","24201-400-02","NDC","","","","","facility","both","1","EA","JG","13157.13","6578.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CALCITONIN 200 UNIT/ML SOLN","24201-400-02","NDC","","","","","facility","both","1","EA","UD","13157.13","6578.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 2 % DROP 15 ML DROP BTL","24208-276-15","NDC","","","","","facility","both","1","EA","","54.13","27.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM CHLORIDE 2 % DROP 15 ML DROP BTL","24208-276-15","NDC","","","","","facility","both","1","EA","UD","54.13","27.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) SPRY 5 ML AER W/ADAP","24208-342-05","NDC","","","","","facility","both","1","EA","","498.53","249.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VIT A,C & E-LUTEIN-MINERALS 300 MCG-200 MG-27 MG-2 MG TABS","2420838762","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LATANOPROST 0.005 % DROP 2.5 ML DROP BTL","24208-463-25","NDC","","","","","facility","both","1","EA","UD","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LATANOPROST 0.005 % DROP 2.5 ML DROP BTL","24208-463-25","NDC","","","","","facility","both","1","EA","","18.33","9.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DORZOLAMIDE 2 % DROP","24208-485-10","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DORZOLAMIDE 2 % DROP","24208-485-10","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML DROP 10 ML DROP BTL","24208-486-10","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VIT  A,C,E-ZINC-COPPER 4,296 MCG-226 MG-90 MG CAPS","2420853210","NDC","","","","","facility","both","1","EA","UD","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VIT  A,C,E-ZINC-COPPER 4,296 MCG-226 MG-90 MG CAPS","2420853210","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VIT  A,C,E-ZINC-COPPER 4,296 MCG-226 MG-90 MG CAPS","2420853230","NDC","","","","","facility","both","1","EA","UD","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VIT  A,C,E-ZINC-COPPER 4,296 MCG-226 MG-90 MG CAPS","2420853230","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 3.5 G TUBE","24208-555-55","NDC","","","","","facility","both","1","EA","","49.65","24.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 3.5 G TUBE","24208-555-55","NDC","","","","","facility","both","1","EA","UD","49.65","24.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-POLYMYXIN-HC OTIC 3.5-10,000-1 MG/ML-UNIT/ML-% SOLN 10 ML DROP BTL","24208-631-10","NDC","","","","","facility","both","1","EA","UD","73.03","36.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SULFACETAMIDE 10 % DROP 15 ML DROP BTL","24208-670-04","NDC","","","","","facility","both","1","EA","UD","78.12","39.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SULFACETAMIDE 10 % DROP 15 ML DROP BTL","24208-670-04","NDC","","","","","facility","both","1","EA","","90.93","45.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROPARACAINE 0.5 % DROP 15 ML DROP BTL","24208-730-06","NDC","","","","","facility","both","1","EA","UD","123.54","61.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPARACAINE 0.5 % DROP 15 ML DROP BTL","24208-730-06","NDC","","","","","facility","both","1","EA","","123.54","61.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPENTOLATE 1 % DROP","24208-735-01","NDC","","","","","facility","both","1","EA","UD","6.74","3.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPENTOLATE 1 % DROP","24208-735-01","NDC","","","","","facility","both","1","EA","","6.74","3.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5-400-10,000 MG-UNIT-UNIT/G OINT 3.5 G TUBE","24208-780-55","NDC","","","","","facility","both","1","EA","UD","56.97","28.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5-400-10,000 MG-UNIT-UNIT/G OINT 3.5 G TUBE","24208-780-55","NDC","","","","","facility","both","1","EA","","56.97","28.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NEOMYCIN-BACITRACIN-POLY-HC 3.5-400-10,000 MG-UNIT/G-1% OINT 3.5 G TUBE","24208-785-55","NDC","","","","","facility","both","1","EA","","31.7","15.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NEOMYCIN-GRAMICIDIN-POLYMYXIN 1.75 MG-10,000 UNIT-0.025MG/ML DROP 10 ML DROP BTL","24208-790-62","NDC","","","","","facility","both","1","EA","UD","97.01","48.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/G-10,000 UNIT/G-0.1 % OINT 3.5 G TUBE","24208-795-35","NDC","","","","","facility","both","1","EA","","45.21","22.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5MG/ML-10,000 UNIT/ML-0.1 % DRPS 5 ML DROP BTL","24208-830-60","NDC","","","","","facility","both","1","EA","","36.16","18.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","24208-910-19","NDC","","","","","facility","both","1","EA","UD","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","24208-910-19","NDC","","","","","facility","both","1","EA","","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 G"
"TROLAMINE SALICYLATE 10 % CREA","24385-165-53","NDC","","","","","facility","both","1","EA","UD","5.76","2.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHOS DIALY NO.3 W-OUT CALC,DEX K (4)-MG (1.5 MEQ/L)-PO4 (1) SOLN","24571-117-05","NDC","","","","","facility","both","1","EA","","182","91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PHOS DIALY NO.3 W-OUT CALC,DEX K (4)-MG (1.5 MEQ/L)-PO4 (1) SOLN","24571-117-05","NDC","","","","","facility","both","1","EA","UD","182","91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHOS DIALY NO.3 W-OUT CALC,DEX K (4)-MG (1.5 MEQ/L)-PO4 (1) SOLN","24571-117-06","NDC","","","","","facility","both","1","EA","","182","91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"PHOS DIALY NO.3 W-OUT CALC,DEX K (4)-MG (1.5 MEQ/L)-PO4 (1) SOLN","24571-117-06","NDC","","","","","facility","both","1","EA","UD","182","91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DONEPEZIL 23 MG TABS","24979-004-07","NDC","","","","","facility","both","1","EA","","3.5","1.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFOXITIN 1 GRAM SOLR","25021-109-10","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFOXITIN 1 GRAM SOLR","25021-109-10","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFOXITIN 2 GRAM SOLR 1 EACH VIAL","25021-110-20","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFOXITIN 2 GRAM SOLR 1 EACH VIAL","25021-110-20","NDC","","","","","facility","both","1","EA","","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CIPROFLOXACIN 400 MG/200 ML PGBK","25021-114-87","NDC","","","","","facility","both","1","EA","UD","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN 400 MG/200 ML PGBK","25021-114-87","NDC","","","","","facility","both","1","EA","","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"CLINDAMYCIN 150 MG/ML SOLN","25021-115-06","NDC","","","","","facility","both","1","EA","","25.15","12.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","25021-121-20","NDC","","","","","facility","both","1","EA","UD","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","25021-121-20","NDC","","","","","facility","both","1","EA","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","25021-122-50","NDC","","","","","facility","both","1","EA","UD","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","25021-122-50","NDC","","","","","facility","both","1","EA","","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFTAZIDIME 2 GRAM SOLR 1 EACH VIAL","25021-128-50","NDC","","","","","facility","both","1","EA","","40.03","20.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"LEVOFLOXACIN 500 MG/100 ML PGBK","25021-132-82","NDC","","","","","facility","both","1","EA","","10.4","5.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"LEVOFLOXACIN 500 MG/100 ML PGBK","25021-132-82","NDC","","","","","facility","both","1","EA","UD","10.4","5.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","25021-132-83","NDC","","","","","facility","both","1","EA","UD","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOFLOXACIN 750 MG/150 ML PGBK","25021-132-83","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"AMPICILLIN 1 GRAM SOLR 1 EACH VIAL","25021-136-10","NDC","","","","","facility","both","1","EA","UD","12.56","6.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","25021-143-30","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","25021-143-30","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 10 GRAM SOLR 1 EACH VIAL","25021-158-99","NDC","","","","","facility","both","1","EA","UD","39.23","19.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXACILLIN","25021-162-24","NDC","","","","","facility","both","1","EA","UD","2.91","1.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXACILLIN","25021-162-24","NDC","","","","","facility","both","1","EA","","3.17","1.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"FLUCONAZOLE 200 MG/100 ML PGBK","25021-184-82","NDC","","","","","facility","both","1","EA","","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FLUCONAZOLE 200 MG/100 ML PGBK","25021-184-82","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUCONAZOLE 400 MG/200 ML PGBK","25021-184-87","NDC","","","","","facility","both","1","EA","","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FLUCONAZOLE 400 MG/200 ML PGBK","25021-184-87","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GANCICLOVIR SODIUM 50 MG/ML SOLN 10 ML VIAL","25021-185-10","NDC","","","","","facility","both","1","EA","","21.2","10.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"GANCICLOVIR SODIUM 50 MG/ML SOLN 10 ML VIAL","25021-185-10","NDC","","","","","facility","both","1","EA","UD","30.8","15.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","25021-191-10","NDC","","","","","facility","both","1","EA","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","25021-191-10","NDC","","","","","facility","both","1","EA","UD","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN 400 MG/200 ML PGBK","25021-192-87","NDC","","","","","facility","both","1","EA","UD","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN 400 MG/200 ML PGBK","25021-192-87","NDC","","","","","facility","both","1","EA","","11.6","5.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"DOXORUBICIN 50 MG/25 ML SOLN 25 ML VIAL","25021-207-25","NDC","","","","","facility","both","1","EA","","118.82","59.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL","25021-207-51","NDC","","","","","facility","both","1","EA","","17.11","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL","25021-207-51","NDC","","","","","facility","both","1","EA","UD","17.11","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) SOLN 20 ML VIAL","25021-223-20","NDC","","","","","facility","both","1","EA","","88.55","44.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MITOMYCIN 5 MG SOLR 1 EACH VIAL","25021-250-20","NDC","","","","","facility","both","1","EA","JG","261.6","130.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"PACLITAXEL 6 MG/ML CONC 5 ML VIAL","25021-255-05","NDC","","","","","facility","both","1","EA","UD","14.41","7.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PACLITAXEL 6 MG/ML CONC 16.7 ML VIAL","25021-255-17","NDC","","","","","facility","both","1","EA","UD","130.44","65.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","25021-258-61","NDC","","","","","facility","both","1","EA","JG","4337.6","2168.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","25021-258-61","NDC","","","","","facility","both","1","EA","UD","5144","2572","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","25021-305-20","NDC","","","","","facility","both","1","EA","UD","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","25021-305-20","NDC","","","","","facility","both","1","EA","","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","25021-308-84","NDC","","","","","facility","both","1","EA","","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","25021-308-84","NDC","","","","","facility","both","1","EA","UD","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","25021-311-02","NDC","","","","","facility","both","1","EA","","8.13","4.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PHENYLEPHRINE 10 MG/ML SOLN 1 ML VIAL","25021-315-01","NDC","","","","","facility","both","1","EA","","16.63","8.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","25021-316-04","NDC","","","","","facility","both","1","EA","UD","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","25021-316-04","NDC","","","","","facility","both","1","EA","","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LABETALOL 5 MG/ML SOLN 40 ML VIAL","25021-317-40","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ADENOSINE 3 MG/ML SOLN","25021-318-02","NDC","","","","","facility","both","1","EA","UD","18.13","9.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ADENOSINE 3 MG/ML SOLN","25021-318-02","NDC","","","","","facility","both","1","EA","","18.13","9.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","25021-400-10","NDC","","","","","facility","both","1","EA","UD","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","25021-400-10","NDC","","","","","facility","both","1","EA","","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN PF 1,000 UNIT/ML SOLN","25021-401-02","NDC","","","","","facility","both","1","EA","UD","2.53","1.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN PF 1,000 UNIT/ML SOLN","25021-401-02","NDC","","","","","facility","both","1","EA","","9.14","4.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"TRANEXAMIC ACID 1,000 MG/100 ML (10 MG/ML) PGBK","25021-418-82","NDC","","","","","facility","both","1","EA","UD","84","42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 1,000 MG/100 ML (10 MG/ML) PGBK","25021-418-82","NDC","","","","","facility","both","1","EA","","84","42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","25021-467-05","NDC","","","","","facility","both","1","EA","UD","99","49.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","25021-467-05","NDC","","","","","facility","both","1","EA","","99","49.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"THIAMINE 100 MG/ML SOLN","25021-500-02","NDC","","","","","facility","both","1","EA","","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"THIAMINE 100 MG/ML SOLN","25021-500-02","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) SOLN","25021-601-03","NDC","","","","","facility","both","1","EA","","53.37","26.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) SOLN","25021-601-03","NDC","","","","","facility","both","1","EA","UD","50.87","25.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAFFEINE CITRATE","25021-602-03","NDC","","","","","facility","both","1","EA","","30.47","15.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CAFFEINE CITRATE","25021-602-03","NDC","","","","","facility","both","1","EA","UD","30.47","15.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","25021-608-20","NDC","","","","","facility","both","1","EA","UD","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","25021-608-20","NDC","","","","","facility","both","1","EA","","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","25021-612-81","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","25021-612-81","NDC","","","","","facility","both","1","EA","","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MIDAZOLAM PF 1 MG/ML SOLN","25021-655-02","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ROPIVACAINE 0.2% (PF) 2 MG/ML (0.2 %) SOLN 200 ML BAG","25021-671-87","NDC","","","","","facility","both","1","EA","UD","363.44","181.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % JELP","25021-673-77","NDC","","","","","facility","both","1","EA","","20.04","10.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PENTOBARBITAL 50 MG/ML SOLN","25021-676-50","NDC","","","","","facility","both","1","EA","","3060","1530","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETAMINE 10 MG/ML SOLN","25021-682-20","NDC","","","","","facility","both","1","EA","","120.8","60.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"KETOROLAC 15 MG/ML SOLN","25021-700-01","NDC","","","","","facility","both","1","EA","UD","4.94","2.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 15 MG/ML SOLN","25021-700-01","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PANTOPRAZOLE 40 MG SOLR 1 EACH VIAL","25021-751-10","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"PANTOPRAZOLE 40 MG SOLR 1 EACH VIAL","25021-751-10","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","25021-777-02","NDC","","","","","facility","both","1","EA","UD","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","25021-777-02","NDC","","","","","facility","both","1","EA","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","25021-790-02","NDC","","","","","facility","both","1","EA","UD","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","25021-790-02","NDC","","","","","facility","both","1","EA","","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LACOSAMIDE 200 MG/20 ML SOLN","25021-791-20","NDC","","","","","facility","both","1","EA","UD","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 200 MG/20 ML SOLN","25021-791-20","NDC","","","","","facility","both","1","EA","","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","25021-812-30","NDC","","","","","facility","both","1","EA","","107.31","53.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","25021-812-30","NDC","","","","","facility","both","1","EA","UD","282.24","141.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEUCOVORIN CALCIUM 100 MG SOLR 1 EACH VIAL","25021-814-30","NDC","","","","","facility","both","1","EA","","57.5","28.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 200 MG SOLR 1 EACH VIAL","25021-815-30","NDC","","","","","facility","both","1","EA","","96","48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 350 MG SOLR 1 EACH VIAL","25021-816-30","NDC","","","","","facility","both","1","EA","","218.73","109.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE DECANOATE 25 MG/ML SOLN","25021-838-05","NDC","","","","","facility","both","1","EA","","100","50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TIROFIBAN 250 MCG/ML CONC 15 ML VIAL","25208-001-04","NDC","","","","","facility","both","1","EA","UD","368.97","184.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIROFIBAN 250 MCG/ML CONC 15 ML VIAL","25208-001-04","NDC","","","","","facility","both","1","EA","","368.97","184.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RAVULIZUMAB-CWVZ 100 MG/ML SOLN 3 ML VIAL","25682-025-01","NDC","","","","","facility","both","1","EA","JG","24975.6","12487.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"RAVULIZUMAB-CWVZ 100 MG/ML SOLN 11 ML VIAL","25682-028-01","NDC","","","","","facility","both","1","EA","JG","275677.75","137838.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"AMINO ACIDS-PROTEIN HYDROLYS 15 GRAM- 100 KCAL/30 ML LIPK","2697430464","NDC","","","","","facility","both","1","EA","UD","5.2","2.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 96 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS-PROTEIN HYDROLYS 15 GRAM- 100 KCAL/30 ML LIPK","2697430464","NDC","","","","","facility","both","1","EA","","5.2","2.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 96 ML"
"AMINO ACIDS-PROTEIN HYDROLYS 15 GRAM- 100 KCAL/30 ML LIPK","2697441042","NDC","","","","","facility","both","1","EA","","4.2","2.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 96 ML"
"AMINO ACIDS-PROTEIN HYDROLYS 15 GRAM- 100 KCAL/30 ML LIPK","2697441042","NDC","","","","","facility","both","1","EA","UD","5.2","2.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 96 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS-PROTEIN HYDROLYS 15 GRAM- 100 KCAL/30 ML LIPK","2697441052","NDC","","","","","facility","both","1","EA","UD","5.2","2.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 96 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMINO ACIDS-PROTEIN HYDROLYS 15 GRAM- 100 KCAL/30 ML LIPK","2697441052","NDC","","","","","facility","both","1","EA","","5.2","2.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 96 ML"
"CHOLESTYRAMINE 4 GRAM PWPK","27241-134-21","NDC","","","","","facility","both","1","EA","UD","3.9","1.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHOLESTYRAMINE 4 GRAM PWPK","27241-134-21","NDC","","","","","facility","both","1","EA","","3.9","1.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CAPTOPRIL 25 MG TABS","27241-161-01","NDC","","","","","facility","both","1","EA","","6.09","3.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 1 MG/ML SOLN","27808-002-01","NDC","","","","","facility","both","1","EA","UD","1.25","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML SU12","2780-8086-05","NDC","","","","","facility","both","1","EA","UD","19.51","9.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML SU12","2780-8086-05","NDC","","","","","facility","both","1","EA","","19.51","9.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROSUVASTATIN 20 MG TABS","27808-157-01","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 20 MG TABS","27808-157-01","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 400 MCG/SPRAY SPRY","28595-120-49","NDC","","","","","facility","both","1","EA","","473.66","236.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"THEOPHYLLINE SR 400 MG TB24","29033-001-01","NDC","","","","","facility","both","1","EA","UD","3.33","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THEOPHYLLINE SR 400 MG TB24","29033-001-01","NDC","","","","","facility","both","1","EA","","3.33","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE SR 500 MG CPSR","29033-030-01","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISOPROLOL 5 MG TABS","29300-126-13","NDC","","","","","facility","both","1","EA","UD","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISOPROLOL 5 MG TABS","29300-126-13","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISOPROLOL/HCTZ 5-6.25 MG TABS","29300-188-13","NDC","","","","","facility","both","1","EA","","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISOPROLOL/HCTZ 10-6.25 MG TABS","29300-189-13","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LYSINE 500 MG TABS","30768-00830","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 TAB"
"DEFERASIROX 360 MG TABS","31722-013-30","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEFERASIROX 360 MG TABS","31722-013-30","NDC","","","","","facility","both","1","EA","","6","3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DROXIDOPA 100 MG CAPS","31722-014-90","NDC","","","","","facility","both","1","EA","","4.33","2.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DROXIDOPA 100 MG CAPS","31722-014-90","NDC","","","","","facility","both","1","EA","UD","4.33","2.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG SUPP","31722-041-31","NDC","","","","","facility","both","1","EA","","14.45","7.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 25 MG SUPP","31722-041-31","NDC","","","","","facility","both","1","EA","UD","14.45","7.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVABRADINE 5 MG TABS","31722-053-60","NDC","","","","","facility","both","1","EA","UD","8.25","4.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVABRADINE 5 MG TABS","31722-053-60","NDC","","","","","facility","both","1","EA","","8.25","4.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 200 MG TR24","31722-243-30","NDC","","","","","facility","both","1","EA","","4.81","2.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 200 MG TR24","31722-243-30","NDC","","","","","facility","both","1","EA","UD","5.81","2.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG/2ML SOLR","31722-308-01","NDC","","","","","facility","both","1","EA","","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 10 MG/2ML SOLR","31722-308-01","NDC","","","","","facility","both","1","EA","UD","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 10 MG TABS","31722-519-01","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 10 MG TABS","31722-519-01","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","31722-520-01","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","31722-520-01","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 25 MG CAPS","31722-542-01","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INDOMETHACIN 25 MG CAPS","31722-542-01","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOPINAVIR-RITONAVIR 200-50 MG TABS","31722-556-12","NDC","","","","","facility","both","1","EA","UD","31.59","15.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROFLUMILAST 500 MCG TABS","31722-623-30","NDC","","","","","facility","both","1","EA","","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROFLUMILAST 500 MCG TABS","31722-623-30","NDC","","","","","facility","both","1","EA","UD","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TADALAFIL 20 MG TABS","31722-647-30","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TADALAFIL 20 MG TABS","31722-647-30","NDC","","","","","facility","both","1","EA","UD","4","2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 50 MG TABS","31722-701-90","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOSARTAN 50 MG TABS","31722-701-90","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENTECAVIR 0.5 MG 0.5 MG TABS","31722-833-30","NDC","","","","","facility","both","1","EA","","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TOLVAPTAN 15 MG TABS","31722-868-03","NDC","","","","","facility","both","1","EA","UD","72.93","36.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBENDAZOLE 200 MG TABS","31722-935-02","NDC","","","","","facility","both","1","EA","","103.15","51.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIOGLITAZONE 15 MG TABS","33342-054-07","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 40 MG TABS","33342-062-07","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 80 MG TABS","33342-063-10","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 80 MG TABS","33342-063-10","NDC","","","","","facility","both","1","EA","UD","1.47","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVASTIGMINE TARTRATE 1.5 MG CAPS","33342-089-09","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 454 G JAR","33342-329-54","NDC","","","","","facility","both","1","EA","","62.97","31.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"KETOCONAZOLE 200 MG TABS","35573-433-30","NDC","","","","","facility","both","1","EA","UD","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 10 MG TABS","35573-450-02","NDC","","","","","facility","both","1","EA","UD","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 10 MG TABS","35573-450-02","NDC","","","","","facility","both","1","EA","","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUMAZENIL 0.1 MG/ML SOLN","36000-148-01","NDC","","","","","facility","both","1","EA","UD","43.13","21.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","36000-282-25","NDC","","","","","facility","both","1","EA","UD","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","36000-282-25","NDC","","","","","facility","both","1","EA","","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"FUROSEMIDE 10 MG/ML SOLN","36000-284-25","NDC","","","","","facility","both","1","EA","UD","12.06","6.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 10 MG/ML SOLN","36000-284-25","NDC","","","","","facility","both","1","EA","","12.06","6.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LABETALOL 5 MG/ML SOLN","36000-320-01","NDC","","","","","facility","both","1","EA","","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LABETALOL 5 MG/ML SOLN","36000-320-01","NDC","","","","","facility","both","1","EA","UD","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN 40 ML VIAL","36000-324-02","NDC","","","","","facility","both","1","EA","","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PSYLLIUM PACK","3848580857","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PSYLLIUM PACK","3848580857","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HOG ENEMA","3877906138","NDC","","","","","facility","both","1","EA","","26.2","13.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HOG ENEMA","3877906138","NDC","","","","","facility","both","1","EA","UD","52.4","26.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FERRIC SUBSULFATE 20 TO 22 GRAM/100 ML SOLN 500 ML BOTTLE","38779-1284-8","NDC","","","","","facility","both","1","EA","UD","90.25","45.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYPOCHLORITE 0.125 % SOLN 473 ML BOTTLE","3932806412","NDC","","","","","facility","both","1","EA","UD","34.11","17.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN 500 MG TABS","39822-0310-5","NDC","","","","","facility","both","1","EA","","7.11","3.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NEOMYCIN 500 MG TABS","39822-0310-5","NDC","","","","","facility","both","1","EA","UD","7.11","3.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPHOTERICIN B CONVENTIONAL 50 MG SOLR 1 EACH VIAL","39822-1055-5","NDC","","","","","facility","both","1","EA","UD","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOLIC ACID 5 MG/ML SOLN 10 ML VIAL","39822-1100-1","NDC","","","","","facility","both","1","EA","","169.38","84.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NEOMYCIN-POLYMYXIN 40 MG-200,000 UNIT/ML SOLN","39822-1201-1","NDC","","","","","facility","both","1","EA","UD","42.75","21.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-POLYMYXIN 40 MG-200,000 UNIT/ML SOLN","39822-1201-1","NDC","","","","","facility","both","1","EA","","42.75","21.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLONIDINE 1,000 MCG/10 ML (100 MCG/ML) SOLN","39822-2000-1","NDC","","","","","facility","both","1","EA","","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLONIDINE 1,000 MCG/10 ML (100 MCG/ML) SOLN","39822-2000-1","NDC","","","","","facility","both","1","EA","UD","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/GRAM POWD 15 G BOTTLE","39822-3015-1","NDC","","","","","facility","both","1","EA","UD","25.52","12.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/GRAM POWD 15 G BOTTLE","39822-3015-1","NDC","","","","","facility","both","1","EA","","25.52","12.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PENTAMIDINE 300 MG SOLR","39822-3030-1","NDC","","","","","facility","both","1","EA","UD","128","64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENTAMIDINE 300 MG SOLR","39822-3030-2","NDC","","","","","facility","both","1","EA","","128","64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROCURONIUM 10 MG/ML SOLN","39822-4200-6","NDC","","","","","facility","both","1","EA","","33.63","16.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PROMETHAZINE 25 MG/ML SOLN","39822-5525-2","NDC","","","","","facility","both","1","EA","","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROMETHAZINE 25 MG/ML SOLN","39822-5525-2","NDC","","","","","facility","both","1","EA","UD","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","4110080676","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYETHYLENE GLYCOL 17 GRAM PWPK","4110080676","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VIT A & D OINTMENT OINT 42.5 G TUBE","4110081163","NDC","","","","","facility","both","1","EA","UD","42.5","21.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM/DOSE POWD 119 G JAR","4110082076","NDC","","","","","facility","both","1","EA","","7.43","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"POLYETHYLENE GLYCOL 17 GRAM/DOSE POWD 119 G JAR","4110082076","NDC","","","","","facility","both","1","EA","UD","13.85","6.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 495 MG/5 GRAM GRAN","41163-602-43","NDC","","","","","facility","both","1","EA","","1.72","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MAGNESIUM SULFATE 495 MG/5 GRAM GRAN","41163-602-43","NDC","","","","","facility","both","1","EA","UD","1.72","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TROLAMINE SALICYLATE 10 % CREA 141 G TUBE","4116705724","NDC","","","","","facility","both","1","EA","UD","8.9","4.45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TROLAMINE SALICYLATE 10 % CREA 85 G TUBE","4116773003","NDC","","","","","facility","both","1","EA","UD","5.76","2.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BLISTEX 0.6-0.5-1.1-0.5 % OINT 10 G TUBE","41388-210-41","NDC","","","","","facility","both","1","EA","UD","5.8","2.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOHEXITAL 500 MG SOLR","42023-105-01","NDC","","","","","facility","both","1","EA","","86.14","43.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOHEXITAL 500 MG SOLR","42023-105-01","NDC","","","","","facility","both","1","EA","UD","195.37","97.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 10 MG/ML SOLN","42023-113-10","NDC","","","","","facility","both","1","EA","UD","120.8","60.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 10 MG/ML SOLN","42023-113-10","NDC","","","","","facility","both","1","EA","","120.8","60.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"OXYTOCIN 10 UNIT/ML SOLN","42023-116-02","NDC","","","","","facility","both","1","EA","UD","19.32","9.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYTOCIN 10 UNIT/ML SOLN","42023-116-02","NDC","","","","","facility","both","1","EA","","19.32","9.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"OXYTOCIN 10 UNIT/ML SOLN","42023-116-25","NDC","","","","","facility","both","1","EA","","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"OXYTOCIN 10 UNIT/ML SOLN","42023-116-25","NDC","","","","","facility","both","1","EA","UD","11.88","5.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE DECANOATE 25 MG/ML SOLN","42023-129-01","NDC","","","","","facility","both","1","EA","","100","50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUPHENAZINE DECANOATE 25 MG/ML SOLN","42023-129-01","NDC","","","","","facility","both","1","EA","UD","51.25","25.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 1 MG/ML (1 ML) SOLN","42023-159-01","NDC","","","","","facility","both","1","EA","","8.34","4.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPINEPHRINE 1 MG/ML (1 ML) SOLN","42023-159-01","NDC","","","","","facility","both","1","EA","UD","8.34","4.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","42023-164-01","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","42023-164-01","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 1 MG/ML SOLN","42023-168-01","NDC","","","","","facility","both","1","EA","UD","152.93","76.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 1 MG/ML SOLN","42023-168-01","NDC","","","","","facility","both","1","EA","","152.93","76.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GANCICLOVIR 500 MG SOLR 1 EACH VIAL","42023-173-01","NDC","","","","","facility","both","1","EA","","133.8","66.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","42023-187-01","NDC","","","","","facility","both","1","EA","UD","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","42023-187-01","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNITS/50 ML PGBK","42023-190-01","NDC","","","","","facility","both","1","EA","UD","1546.12","773.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNITS/50 ML PGBK","42023-190-01","NDC","","","","","facility","both","1","EA","","1546.12","773.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","42023-207-01","NDC","","","","","facility","both","1","EA","JG","2134.03","1067.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","42023-208-01","NDC","","","","","facility","both","1","EA","","2821.61","1410.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","42023-208-01","NDC","","","","","facility","both","1","EA","UD","4196.8","2098.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","42023-208-01","NDC","","","","","facility","both","1","EA","JG","1446.43","723.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","42023-209-01","NDC","","","","","facility","both","1","EA","JG","6947.17","3473.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","42023-209-01","NDC","","","","","facility","both","1","EA","","8322.35","4161.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","42023-209-01","NDC","","","","","facility","both","1","EA","UD","8322.35","4161.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN 10 ML VIAL","42023-215-01","NDC","","","","","facility","both","1","EA","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN 10 ML VIAL","42023-215-01","NDC","","","","","facility","both","1","EA","UD","65","32.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","42023-229-01","NDC","","","","","facility","both","1","EA","","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","42023-229-01","NDC","","","","","facility","both","1","EA","UD","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","42023-229-10","NDC","","","","","facility","both","1","EA","","150","75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","42023-229-10","NDC","","","","","facility","both","1","EA","UD","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","42023-230-01","NDC","","","","","facility","both","1","EA","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","42023-230-01","NDC","","","","","facility","both","1","EA","UD","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOSTIGMINE-GLYCOPYRROLATE 3 MG-0.6 MG/3ML (1 MG-0.2MG/ML) SYRG","42023-269-01","NDC","","","","","facility","both","1","EA","UD","113.17","56.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOSTIGMINE-GLYCOPYRROLATE 3 MG-0.6 MG/3ML (1 MG-0.2MG/ML) SYRG","42023-269-01","NDC","","","","","facility","both","1","EA","","46.77","23.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","4203710478","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","4203710478","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYOSCYAMINE 0.125 MG SUBL","42192-339-01","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYOSCYAMINE 0.125 MG SUBL","42192-339-01","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CICLOPIROX 8 % SOLN 6.6 ML BOTTLE","42192-715-06","NDC","","","","","facility","both","1","EA","UD","60.39","30.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOBETASOL 0.05 % CREA 15 G TUBE","42291-076-15","NDC","","","","","facility","both","1","EA","","8.51","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"AZITHROMYCIN 600 MG TABS","42291-084-30","NDC","","","","","facility","both","1","EA","","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 600 MG TABS","42291-084-30","NDC","","","","","facility","both","1","EA","UD","17.16","8.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZELASTINE 137 MCG (0.1 %) SPRY 30 ML SQUEEZ BTL","42291-094-30","NDC","","","","","facility","both","1","EA","","40.38","20.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ERGOCALCIFEROL 50,000 UNIT CAPS","42291-266-01","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERGOCALCIFEROL 50,000 UNIT CAPS","42291-266-01","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOFETILIDE 250 MCG CAPS","42291-412-60","NDC","","","","","facility","both","1","EA","","0.35","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOFETILIDE 250 MCG CAPS","42291-412-60","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOFETILIDE 500 MCG CAPS","42291-413-60","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOFETILIDE 500 MCG CAPS","42291-413-60","NDC","","","","","facility","both","1","EA","UD","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","42291-459-30","NDC","","","","","facility","both","1","EA","UD","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","42291-459-30","NDC","","","","","facility","both","1","EA","","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LUBIPROSTONE 24 MCG CAPS","42291-476-60","NDC","","","","","facility","both","1","EA","","2.89","1.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN ER 100 MG CAPS","42291-772-10","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TENOFOVIR DISOPROXIL 300 MG TABS","42291-800-30","NDC","","","","","facility","both","1","EA","UD","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALSARTAN 80 MG TABS","42291-857-90","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 80 MG TABS","42291-857-90","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENLAFAXINE ER 37.5 MG CP24","42291-897-90","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE ER 37.5 MG CP24","42291-897-90","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PALIPERIDONE 3 MG TR24","42292-026-01","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 88 MCG TABS","42292-038-01","NDC","","","","","facility","both","1","EA","","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 88 MCG TABS","42292-038-01","NDC","","","","","facility","both","1","EA","UD","0.44","0.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 112 MCG TABS","42292-039-01","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 112 MCG TABS","42292-039-01","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLCHICINE 0.6 MG TABS","42292-054-01","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLCHICINE 0.6 MG TABS","42292-054-01","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENOBARBITAL 65 MG/ML SOLN","42494-415-01","NDC","","","","","facility","both","1","EA","UD","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 65 MG/ML SOLN","42494-415-01","NDC","","","","","facility","both","1","EA","","90","45","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL","42494-416-01","NDC","","","","","facility","both","1","EA","UD","457.33","228.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 130 MG/ML SOLN 1 ML VIAL","42494-416-01","NDC","","","","","facility","both","1","EA","","790.83","395.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCORTISONE","42543-141-01","NDC","","","","","facility","both","1","EA","","27.1","13.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CITRATE ER 5 MEQ (540 MG) TBSR","42543-406-01","NDC","","","","","facility","both","1","EA","","1.94","0.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CITRATE ER 5 MEQ (540 MG) TBSR","42543-406-01","NDC","","","","","facility","both","1","EA","UD","2.87","1.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 0.5 % DROP 5 ML DROP BTL","42571-137-25","NDC","","","","","facility","both","1","EA","","76","38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DORZOLAMIDE 2 % DROP 10 ML DROP BTL","42571-141-26","NDC","","","","","facility","both","1","EA","UD","18.15","9.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DORZOLAMIDE 2 % DROP 10 ML DROP BTL","42571-141-26","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMOXICILLIN-CLAVULANATE 250-125 MG TABS","42571-160-30","NDC","","","","","facility","both","1","EA","UD","7.5","3.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 250-125 MG TABS","42571-160-30","NDC","","","","","facility","both","1","EA","","7.5","3.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","42571-161-01","NDC","","","","","facility","both","1","EA","","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","42571-161-01","NDC","","","","","facility","both","1","EA","UD","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","42571-161-42","NDC","","","","","facility","both","1","EA","","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAUNORUBICIN 5 MG/ML 5 MG/ML SOLN 4 ML VIAL","42658-021-01","NDC","","","","","facility","both","1","EA","","1092.77","546.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DAUNORUBICIN 5 MG/ML 5 MG/ML SOLN 4 ML VIAL","42658-021-02","NDC","","","","","facility","both","1","EA","","2181.53","1090.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIOTHYRONINE 5 MCG TABS","42794-018-12","NDC","","","","","facility","both","1","EA","UD","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIOTHYRONINE 5 MCG TABS","42794-018-12","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOPERAMIDE 2 MG CAPS","42799-605-01","NDC","","","","","facility","both","1","EA","","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IVERMECTIN 3 MG TABS","42799-806-01","NDC","","","","","facility","both","1","EA","UD","50.69","25.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTRADIOL 0.5 MG TABS","42806-087-01","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESTRADIOL 0.5 MG TABS","42806-087-01","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTRADIOL 1 MG TABS","42806-088-01","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTRADIOL 1 MG TABS","42806-088-01","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","42806-270-98","NDC","","","","","facility","both","1","EA","UD","3.65","1.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHOLESTYRAMINE 4 GRAM PWPK","42806-270-98","NDC","","","","","facility","both","1","EA","","3.65","1.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","42806-341-01","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION SR 150 MG SR12","42806-425-01","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION SR 150 MG SR12","42806-425-01","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICARDIPINE 20 MG CAPS","42806-501-09","NDC","","","","","facility","both","1","EA","UD","6.23","3.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUINIDINE SULFATE 200 MG TABS","42806-513-30","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUINIDINE SULFATE 200 MG TABS","42806-513-30","NDC","","","","","facility","both","1","EA","UD","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DUTASTERIDE 0.5 MG CAPS","42806-549-09","NDC","","","","","facility","both","1","EA","UD","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DUTASTERIDE 0.5 MG CAPS","42806-549-09","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEGA-3 1 GRAM CAPS","42806-552-12","NDC","","","","","facility","both","1","EA","","0.54","0.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEGA-3 1 GRAM CAPS","42806-552-12","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZONATATE 100 MG CAPS","42806-714-01","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BENZONATATE 100 MG CAPS","42806-714-01","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZONATATE 100 MG CAPS","42806-714-05","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BENZONATATE 100 MG CAPS","42806-714-05","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG TABS","42858-001-10","NDC","","","","","facility","both","1","EA","UD","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG TABS","42858-001-10","NDC","","","","","facility","both","1","EA","","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS","42858-103-01","NDC","","","","","facility","both","1","EA","","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 7.5-325 MG TABS","42858-103-01","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENOFIBRATE MICRONIZED 200 MG CAPS","42858-200-01","NDC","","","","","facility","both","1","EA","","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENOFIBRATE MICRONIZED 200 MG CAPS","42858-200-01","NDC","","","","","facility","both","1","EA","UD","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG TABS","42858-301-01","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 2 MG TABS","42858-301-01","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG TABS","42858-301-25","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 2 MG TABS","42858-301-25","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 4 MG TABS","42858-302-25","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 4 MG TABS","42858-302-25","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE CR 12.5 MG TB24","42858-703-03","NDC","","","","","facility","both","1","EA","","3.49","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN","43066-008-01","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN","43066-008-01","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","43066-090-01","NDC","","","","","facility","both","1","EA","","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","43066-090-01","NDC","","","","","facility","both","1","EA","UD","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIODARONE 360 MG/200 ML (1.8 MG/ML) SOLN","43066-360-20","NDC","","","","","facility","both","1","EA","UD","186.8","93.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 600 MG/50 ML PGBK","43066-993-24","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 900 MG/50 ML PGBK","43066-995-24","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","43066-997-01","NDC","","","","","facility","both","1","EA","UD","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","43066-997-01","NDC","","","","","facility","both","1","EA","","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RIBOFLAVIN 25 MG TABS","4329255538","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIBOFLAVIN 25 MG TABS","4329255538","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CRANBERRY EXTRACT 425 MG CAPS","4329255812","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CRANBERRY EXTRACT 425 MG CAPS","4329255812","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLUCOSAMINE 500 MG CAPS","4329255857","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLUCOSAMINE 500 MG CAPS","4329255857","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIBOFLAVIN 100 MG TABS","4329256000","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPINIROLE 1 MG TABS","43547-270-10","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPINIROLE 1 MG TABS","43547-270-10","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESCITALOPRAM 5 MG TABS","43547-280-10","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 20 MG TABS","43547-354-10","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 20 MG TABS","43547-354-10","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALSARTAN 40 MG TABS","43547-367-03","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ENALAPRIL 20 MG TABS","43547-548-10","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ENALAPRIL 20 MG TABS","43547-548-10","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE 0.2 MG/ML SOLN","43547-640-01","NDC","","","","","facility","both","1","EA","","10.31","5.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCITONIN 200 UNIT/ML SOLN","43598-051-11","NDC","","","","","facility","both","1","EA","JG","10379.27","5189.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CALCITONIN 200 UNIT/ML SOLN","43598-051-11","NDC","","","","","facility","both","1","EA","","11325.5","5662.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCITONIN 200 UNIT/ML SOLN","43598-051-11","NDC","","","","","facility","both","1","EA","UD","11325.5","5662.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITONIN 200 UNIT/ML SOLN","43598-051-11","NDC","","","","","facility","both","1","EA","TB","10379.27","5189.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"LACOSAMIDE 200 MG/20 ML SOLN","43598-087-11","NDC","","","","","facility","both","1","EA","","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LACOSAMIDE 200 MG/20 ML SOLN","43598-087-11","NDC","","","","","facility","both","1","EA","UD","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 40 MG SOLR","43598-127-45","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC 40 MG SOLR","43598-127-45","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SODIUM SUCC 500 MG SOLR 1 EACH VIAL","43598-128-11","NDC","","","","","facility","both","1","EA","","71.25","35.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SODIUM SUCC 500 MG SOLR 1 EACH VIAL","43598-128-11","NDC","","","","","facility","both","1","EA","UD","71.25","35.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR 1 EACH VIAL","43598-129-01","NDC","","","","","facility","both","1","EA","","40.38","20.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR 1 EACH VIAL","43598-129-01","NDC","","","","","facility","both","1","EA","UD","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR 1 EACH VIAL","43598-129-25","NDC","","","","","facility","both","1","EA","","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR 1 EACH VIAL","43598-129-25","NDC","","","","","facility","both","1","EA","UD","83.25","41.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 1,000 MG SOLR 1 EACH VIAL","43598-130-74","NDC","","","","","facility","both","1","EA","UD","205.63","102.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 1,000 MG SOLR 1 EACH VIAL","43598-130-74","NDC","","","","","facility","both","1","EA","","205.63","102.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SILVER SULFADIAZINE 1 % CREA 400 G JAR","43598-210-40","NDC","","","","","facility","both","1","EA","","122.8","61.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SILVER SULFADIAZINE 1 % CREA 400 G JAR","43598-210-40","NDC","","","","","facility","both","1","EA","UD","122.8","61.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER SULFADIAZINE 1 % CREA 50 G TUBE","43598-210-50","NDC","","","","","facility","both","1","EA","UD","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER SULFADIAZINE 1 % CREA 50 G TUBE","43598-210-50","NDC","","","","","facility","both","1","EA","","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SILVER SULFADIAZINE 1 % CREA 50 G JAR","43598-210-55","NDC","","","","","facility","both","1","EA","UD","43.88","21.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER SULFADIAZINE 1 % CREA 50 G JAR","43598-210-55","NDC","","","","","facility","both","1","EA","","43.88","21.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","43598-326-75","NDC","","","","","facility","both","1","EA","UD","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","43598-326-75","NDC","","","","","facility","both","1","EA","","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","43598-392-48","NDC","","","","","facility","both","1","EA","JG,UD","3632","1816","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","43598-392-48","NDC","","","","","facility","both","1","EA","","3704","1852","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","43598-392-48","NDC","","","","","facility","both","1","EA","JG","4294.4","2147.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN","43598-405-11","NDC","","","","","facility","both","1","EA","UD","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN","43598-405-11","NDC","","","","","facility","both","1","EA","","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN","43598-405-16","NDC","","","","","facility","both","1","EA","UD","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN","43598-405-16","NDC","","","","","facility","both","1","EA","","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"DAPTOMYCIN 500 MG SOLR","43598-413-11","NDC","","","","","facility","both","1","EA","","34.86","17.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","43598-413-11","NDC","","","","","facility","both","1","EA","UD","48.98","24.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 0.4 MG SUBL","43598-436-35","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.4 MG SUBL","43598-436-35","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 7 MG/24 HR PT24","43598-446-71","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 7 MG/24 HR PT24","43598-446-71","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 14 MG/24 HR PT24","43598-447-71","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 14 MG/24 HR PT24","43598-447-71","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 21 MG/24 HR PT24","43598-448-71","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 21 MG/24 HR PT24","43598-448-71","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBENDAZOLE 200 MG TABS","43598-452-02","NDC","","","","","facility","both","1","EA","","103.15","51.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SEVELAMER CARBONATE 2400 MG PWPK","43598-479-01","NDC","","","","","facility","both","1","EA","","6.67","3.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SEVELAMER CARBONATE 2400 MG PWPK","43598-479-01","NDC","","","","","facility","both","1","EA","UD","6.67","3.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOSTIGMINE METHYLSULFATE 5 MG/5 ML (1 MG/ML) SYRG","43598-529-36","NDC","","","","","facility","both","1","EA","","79.69","39.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"NEOSTIGMINE METHYLSULFATE 5 MG/5 ML (1 MG/ML) SYRG","43598-529-36","NDC","","","","","facility","both","1","EA","UD","79.69","39.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHG - INJ,REGADENOSON,0.1MG,LEXISCAN","43598-616-11","NDC","","","","","facility","both","1","EA","","2256","1128","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPROST 250 MCG/ML SOLN","43598-698-11","NDC","","","","","facility","both","1","EA","UD","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPROST 250 MCG/ML SOLN","43598-698-11","NDC","","","","","facility","both","1","EA","","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPROPION SR 100 MG SR12","43598-751-01","NDC","","","","","facility","both","1","EA","","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION SR 100 MG SR12","43598-751-01","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIPRASIDONE 20 MG/ML (FINAL CONC.) SOLR 1 EACH VIAL","43598-848-11","NDC","","","","","facility","both","1","EA","","126.94","63.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZIPRASIDONE 20 MG/ML (FINAL CONC.) SOLR 1 EACH VIAL","43598-848-11","NDC","","","","","facility","both","1","EA","UD","64.72","32.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","43598-914-06","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","43598-914-06","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","43598-914-11","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","43598-914-11","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","43598-914-25","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","43598-914-25","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOSAPREPITANT 150 MG SOLR 1 EACH VIAL","43598-948-11","NDC","","","","","facility","both","1","EA","","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","43598-975-11","NDC","","","","","facility","both","1","EA","UD","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","43598-975-11","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) SOLN","43598-976-11","NDC","","","","","facility","both","1","EA","","57.6","28.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","43598-977-10","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","43598-977-10","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THROMBIN (RECOMNINANT) 5,000 UNIT SOLR 1 EACH KIT","43825-606-41","NDC","","","","","facility","both","1","EA","UD","185","92.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THROMBIN (RECOMNINANT) 5,000 UNIT SOLR 1 EACH KIT","43825-606-41","NDC","","","","","facility","both","1","EA","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NUTRITION SUPPLEMENT-IMPAIRED DIGESTION 0.05-1 GRAM-KCAL/ML LIQD","4390036250","NDC","","","","","facility","both","1","EA","","26.2","13.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"PALIPERIDONE 1.5 MG TR24","43975-349-03","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","JG","581.88","290.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","UD","581.88","290.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","","581.88","290.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","JG,TB","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","UD,TB","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","TB","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-10","NDC","","","","","facility","both","1","EA","JG,UD","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","TB","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","UD","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","JG,UD","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","JG","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","JG,UD,TB","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 25 % SOLP","44206-251-91","NDC","","","","","facility","both","1","EA","UD,TB","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"RHIG","44206-300-01","NDC","","","","","facility","both","1","EA","","460","230","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","TB","290.63","145.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","UD","290.63","145.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","JG,UD","290.63","145.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","JG","290.63","145.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","","290.63","145.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","JG,UD,TB","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","JG,TB","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-25","NDC","","","","","facility","both","1","EA","UD,TB","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-50","NDC","","","","","facility","both","1","EA","TB","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-50","NDC","","","","","facility","both","1","EA","UD","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-50","NDC","","","","","facility","both","1","EA","JG,UD","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-50","NDC","","","","","facility","both","1","EA","JG","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-50","NDC","","","","","facility","both","1","EA","UD,TB","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-50","NDC","","","","","facility","both","1","EA","","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","TB","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","JG,UD","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","JG","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","UD","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","JG,UD,TB","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","UD,TB","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-90","NDC","","","","","facility","both","1","EA","","293.13","146.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-91","NDC","","","","","facility","both","1","EA","UD,TB","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-91","NDC","","","","","facility","both","1","EA","","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-91","NDC","","","","","facility","both","1","EA","UD","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-91","NDC","","","","","facility","both","1","EA","TB","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-91","NDC","","","","","facility","both","1","EA","JG,UD","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 5% 5 % SOLP","44206-310-91","NDC","","","","","facility","both","1","EA","JG","583.75","291.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","JG","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","JG,JA","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JA: Administered intravenously"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","UD","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","TB","2444.04","1222.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","JG,TB","2444.04","1222.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","UD,TB","2444.04","1222.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-436-05","NDC","","","","","facility","both","1","EA","JG,UD","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-436-90","NDC","","","","","facility","both","1","EA","JG,UD","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-436-90","NDC","","","","","facility","both","1","EA","JG","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-436-90","NDC","","","","","facility","both","1","EA","","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-436-90","NDC","","","","","facility","both","1","EA","UD","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-436-90","NDC","","","","","facility","both","1","EA","TB","2444.04","1222.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","JG,UD","4612.14","2306.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","JG","4612.14","2306.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","","4612.14","2306.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","JG,JA","4614.14","2307.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JA: Administered intravenously"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","UD,TB","4888.08","2444.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","TB","4888.08","2444.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","JG,TB","4890.08","2445.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-437-10","NDC","","","","","facility","both","1","EA","UD","2306.07","1153.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-437-91","NDC","","","","","facility","both","1","EA","JG","4612.14","2306.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-437-91","NDC","","","","","facility","both","1","EA","UD","4612.14","2306.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-437-91","NDC","","","","","facility","both","1","EA","JG,UD","4614.14","2307.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-437-91","NDC","","","","","facility","both","1","EA","","4614.14","2307.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-437-91","NDC","","","","","facility","both","1","EA","TB","4890.08","2445.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","JG","4612.14","2306.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","JG,UD","9224.28","4612.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","","4888.08","2444.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","UD","9224.28","4612.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","JG,JA","9226.28","4613.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JA: Administered intravenously"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","TB","9776.16","4888.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-438-20","NDC","","","","","facility","both","1","EA","UD,TB","9776.16","4888.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-438-92","NDC","","","","","facility","both","1","EA","JG","9224.28","4612.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-438-92","NDC","","","","","facility","both","1","EA","","9224.28","4612.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-438-92","NDC","","","","","facility","both","1","EA","UD","9224.28","4612.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-438-92","NDC","","","","","facility","both","1","EA","JG,UD","9226.28","4613.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-438-92","NDC","","","","","facility","both","1","EA","TB","9778.16","4889.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-438-92","NDC","","","","","facility","both","1","EA","UD,TB","58658.96","29329.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-439-40","NDC","","","","","facility","both","1","EA","UD","18448.56","9224.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-439-40","NDC","","","","","facility","both","1","EA","","18448.56","9224.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-439-40","NDC","","","","","facility","both","1","EA","JG,UD","18450.56","9225.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-439-40","NDC","","","","","facility","both","1","EA","TB","19552.32","9776.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-439-40","NDC","","","","","facility","both","1","EA","UD,TB","19554.32","9777.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-439-40","NDC","","","","","facility","both","1","EA","JG","18448.56","9224.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-439-93","NDC","","","","","facility","both","1","EA","JG","18448.56","9224.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IVIG 10 % SOLN","44206-439-93","NDC","","","","","facility","both","1","EA","UD","18450.56","9225.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVIG 10 % SOLN","44206-439-93","NDC","","","","","facility","both","1","EA","","18450.56","9225.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IVIG 10 % SOLN","44206-439-93","NDC","","","","","facility","both","1","EA","TB","19554.32","9777.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"IVIG 10 % SOLN","44206-439-93","NDC","","","","","facility","both","1","EA","JG,UD","19554.32","9777.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 500 MG SOLR","44567-101-10","NDC","","","","","facility","both","1","EA","","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN 1 GRAM SOLR 1 EACH VIAL","44567-102-10","NDC","","","","","facility","both","1","EA","","12.56","6.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","44567-211-10","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAFCILLIN 1 GRAM SOLR 1 EACH VIAL","44567-221-10","NDC","","","","","facility","both","1","EA","UD","715","357.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAFCILLIN 1 GRAM SOLR 1 EACH VIAL","44567-221-10","NDC","","","","","facility","both","1","EA","","715","357.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","44567-222-10","NDC","","","","","facility","both","1","EA","","53.81","26.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFTAZIDIME 1 GRAM SOLR","44567-235-25","NDC","","","","","facility","both","1","EA","","17.79","8.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"CEFTAZIDIME 1 GRAM SOLR","44567-235-25","NDC","","","","","facility","both","1","EA","UD","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","44567-241-10","NDC","","","","","facility","both","1","EA","UD","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","44567-241-10","NDC","","","","","facility","both","1","EA","","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFOXITIN 2 GRAM SOLR 1 EACH VIAL","44567-246-25","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFOXITIN 2 GRAM SOLR 1 EACH VIAL","44567-246-25","NDC","","","","","facility","both","1","EA","","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","44567-410-24","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","44567-410-24","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","44567-420-00","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","44567-420-00","NDC","","","","","facility","both","1","EA","","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","44567-420-24","NDC","","","","","facility","both","1","EA","","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","44567-420-24","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","44567-450-01","NDC","","","","","facility","both","1","EA","","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","44567-450-01","NDC","","","","","facility","both","1","EA","UD","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 2,000 MG/100 ML SOLP 100 ML BAG","44567-451-01","NDC","","","","","facility","both","1","EA","","986.4","493.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXMEDETOMIDINE 100 MCG/ML SOLN 10 ML VIAL","44567-601-04","NDC","","","","","facility","both","1","EA","","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"DEXMEDETOMIDINE 100 MCG/ML SOLN 10 ML VIAL","44567-601-04","NDC","","","","","facility","both","1","EA","UD","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","44567-610-01","NDC","","","","","facility","both","1","EA","","86","43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","44567-610-01","NDC","","","","","facility","both","1","EA","UD","86","43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","44567-611-01","NDC","","","","","facility","both","1","EA","","167","83.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML SOLN","44567-620-01","NDC","","","","","facility","both","1","EA","UD","81","40.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML SOLN","44567-620-01","NDC","","","","","facility","both","1","EA","","81","40.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUC IN NACL, ISO-OSM 2 GRAM/100 ML SOLN","44567-621-01","NDC","","","","","facility","both","1","EA","UD","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUC IN NACL, ISO-OSM 2 GRAM/100 ML SOLN","44567-621-01","NDC","","","","","facility","both","1","EA","","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFTRIAXONE 1 GRAM SOLR","44567-701-25","NDC","","","","","facility","both","1","EA","","8.88","4.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"CEFTRIAXONE 1 GRAM SOLR","44567-701-25","NDC","","","","","facility","both","1","EA","UD","8.88","4.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 2 GRAM SOLR","44567-702-25","NDC","","","","","facility","both","1","EA","UD","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 2 GRAM SOLR","44567-702-25","NDC","","","","","facility","both","1","EA","","14.5","7.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"CEFAZOLIN 500 MG SOLR 1 EACH VIAL","44567-706-25","NDC","","","","","facility","both","1","EA","","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"CEFAZOLIN 1 GRAM SOLR 1 EACH VIAL","44567-707-25","NDC","","","","","facility","both","1","EA","UD","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 1 GRAM SOLR 1 EACH VIAL","44567-707-25","NDC","","","","","facility","both","1","EA","","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","44567-802-10","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","44567-811-10","NDC","","","","","facility","both","1","EA","UD","480","240","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","44567-811-10","NDC","","","","","facility","both","1","EA","","480","240","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,000 MG/100 ML (20 MG/ML) SOLP 100 ML BAG","44567-812-10","NDC","","","","","facility","both","1","EA","","520","260","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,000 MG/100 ML (20 MG/ML) SOLP 100 ML BAG","44567-812-10","NDC","","","","","facility","both","1","EA","UD","2592","1296","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 3 GRAM SOLR 1 EACH VIAL","44567-845-01","NDC","","","","","facility","both","1","EA","","39.38","19.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFAZOLIN 3 GRAM SOLR 1 EACH VIAL","44567-845-01","NDC","","","","","facility","both","1","EA","UD","39.38","19.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHGR-RP TC 99 SULFUR COLLOID PER DOSE","45567-0030-1","NDC","","","","","facility","both","1","EA","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GENTAMICIN 0.1 % OINT 15 G TUBE","45802-046-35","NDC","","","","","facility","both","1","EA","","139.23","69.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NYSTATIN 100,000 UNIT/GRAM OINT 15 G TUBE","45802-048-35","NDC","","","","","facility","both","1","EA","UD","19.11","9.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/GRAM OINT 15 G TUBE","45802-048-35","NDC","","","","","facility","both","1","EA","","19.11","9.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 15 G TUBE","45802-055-35","NDC","","","","","facility","both","1","EA","","8.72","4.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 15 G TUBE","45802-055-35","NDC","","","","","facility","both","1","EA","UD","8.72","4.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % OINT 80 G TUBE","45802-055-36","NDC","","","","","facility","both","1","EA","","48.04","24.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"GENTAMICIN 0.1 % CREA 15 G TUBE","45802-056-35","NDC","","","","","facility","both","1","EA","","44.73","22.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"GENTAMICIN 0.1 % CREA 15 G TUBE","45802-056-35","NDC","","","","","facility","both","1","EA","UD","44.73","22.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN/BALMEX MIXTURE 8OZ 15 G TUBE","45802-059-35","NDC","","","","","facility","both","1","EA","","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NYSTATIN/BALMEX MIXTURE 8OZ 15 G TUBE","45802-059-35","NDC","","","","","facility","both","1","EA","UD","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OINT 28 G TUBE","45802-060-03","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OINT 28 G TUBE","45802-060-03","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN 500 UNIT/GRAM OINT 454 G JAR","45802-060-05","NDC","","","","","facility","both","1","EA","","454","227","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN 500 UNIT/GRAM OINT 454 G JAR","45802-060-05","NDC","","","","","facility","both","1","EA","UD","454","227","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 80 G TUBE","45802-064-36","NDC","","","","","facility","both","1","EA","","21.72","10.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ESTRADIOL 0.01 % (0.1 MG/GRAM) CREA 42.5 G TUBE","45802-097-35","NDC","","","","","facility","both","1","EA","UD","42.5","21.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTRADIOL 0.01 % (0.1 MG/GRAM) CREA 42.5 G TUBE","45802-097-35","NDC","","","","","facility","both","1","EA","","42.5","21.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MUPIROCIN 2 % OINT 22 G TUBE","45802-112-22","NDC","","","","","facility","both","1","EA","UD","30.72","15.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MUPIROCIN 2 % OINT 22 G TUBE","45802-112-22","NDC","","","","","facility","both","1","EA","","30.72","15.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"METRONIDAZOLE 0.75 % (37.5MG/5 GRAM) GEL 70 G TUBE","45802-139-70","NDC","","","","","facility","both","1","EA","","71.07","35.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"METRONIDAZOLE 0.75 % (37.5MG/5 GRAM) GEL 70 G TUBE","45802-139-70","NDC","","","","","facility","both","1","EA","UD","71.07","35.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CICLOPIROX 8 % SOLN 6.6 ML BOTTLE","45802-141-67","NDC","","","","","facility","both","1","EA","UD","60.39","30.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,000 UNIT/GRAM OINT 14 G TUBE","45802-143-01","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,000 UNIT/GRAM OINT 14 G TUBE","45802-143-01","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROGLYCERIN 400 MCG/SPRAY SPRY","45802-210-01","NDC","","","","","facility","both","1","EA","","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NITROGLYCERIN 400 MCG/SPRAY SPRY","45802-210-01","NDC","","","","","facility","both","1","EA","UD","473.66","236.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERMETHRIN 5 % CREA 60 G TUBE","45802-269-37","NDC","","","","","facility","both","1","EA","","106","53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 1 % OINT 28 G TUBE","45802-276-03","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","45802-410-59","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXTROMETHORPHAN POLY COMPLEX SR 30 MG/5 ML 30 MG/5 ML SU12","45802-433-21","NDC","","","","","facility","both","1","EA","","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLOTRIMAZOLE 1 % CREA 15 G TUBE","45802-434-01","NDC","","","","","facility","both","1","EA","UD","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 1 % CREA 15 G TUBE","45802-434-01","NDC","","","","","facility","both","1","EA","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 1 % CREA 28 G TUBE","45802-438-03","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 1 % CREA 28 G TUBE","45802-438-03","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"KETOCONAZOLE 2 % SHAM 120 ML BOTTLE","45802-465-64","NDC","","","","","facility","both","1","EA","","69.88","34.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LACTIC ACID 12 % LOTN 227 G BOTTLE","4580252555","NDC","","","","","facility","both","1","EA","UD","11.33","5.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 1 % SOLN 30 ML BOTTLE","45802-562-01","NDC","","","","","facility","both","1","EA","UD","34.6","17.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 1 % SOLN 30 ML BOTTLE","45802-562-01","NDC","","","","","facility","both","1","EA","","34.6","17.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","45802-580-01","NDC","","","","","facility","both","1","EA","","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 650 MG SUPP","45802-730-00","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 650 MG SUPP","45802-730-00","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 650 MG SUPP","45802-730-32","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 650 MG SUPP","45802-730-32","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 120 MG SUPP","45802-732-00","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 12.5 MG SUPP","45802-758-00","NDC","","","","","facility","both","1","EA","","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 12.5 MG SUPP","45802-758-00","NDC","","","","","facility","both","1","EA","UD","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 12.5 MG SUPP","45802-758-30","NDC","","","","","facility","both","1","EA","UD","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 12.5 MG SUPP","45802-758-30","NDC","","","","","facility","both","1","EA","","11.78","5.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 25 MG SUPP","45802-759-00","NDC","","","","","facility","both","1","EA","UD","14.33","7.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG SUPP","45802-759-00","NDC","","","","","facility","both","1","EA","","14.33","7.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 25 MG SUPP","45802-759-30","NDC","","","","","facility","both","1","EA","","14.33","7.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% CREA 15 G TUBE","45802-880-14","NDC","","","","","facility","both","1","EA","","52.71","26.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% CREA 15 G TUBE","45802-880-14","NDC","","","","","facility","both","1","EA","UD","58.49","29.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 10 GRAM/15 ML SOLN 473 ML BOTTLE","45963-438-64","NDC","","","","","facility","both","1","EA","UD","14.65","7.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 10 GRAM/15 ML SOLN 473 ML BOTTLE","45963-438-64","NDC","","","","","facility","both","1","EA","","14.65","7.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUDARABINE 50 MG SOLR 1 EACH VIAL","45963-609-55","NDC","","","","","facility","both","1","EA","","464.78","232.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL","45963-733-60","NDC","","","","","facility","both","1","EA","UD","17.11","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXORUBICIN 2 MG/ML SOLN 100 ML VIAL","45963-733-60","NDC","","","","","facility","both","1","EA","","17.11","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROGEN PEROXIDE 3 % SOLN 473 ML BOTTLE","46122-334-43","NDC","","","","","facility","both","1","EA","","2.66","1.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROGEN PEROXIDE 3 % SOLN 473 ML BOTTLE","46122-334-43","NDC","","","","","facility","both","1","EA","UD","2.66","1.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML SUSPENSION","46287-006-60","NDC","","","","","facility","both","1","EA","","73.9","36.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML SUSPENSION","46287-006-60","NDC","","","","","facility","both","1","EA","UD","73.9","36.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % PTMD","46581-830-06","NDC","","","","","facility","both","1","EA","UD","2.76","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % PTMD","46581-830-06","NDC","","","","","facility","both","1","EA","","2.76","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","47335-330-40","NDC","","","","","facility","both","1","EA","","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VECURONIUM 10 MG SOLR","47335-931-40","NDC","","","","","facility","both","1","EA","UD","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VECURONIUM 10 MG SOLR","47335-931-40","NDC","","","","","facility","both","1","EA","","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VECURONIUM 10 MG SOLR","47335-931-44","NDC","","","","","facility","both","1","EA","","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"VECURONIUM 10 MG SOLR","47335-931-44","NDC","","","","","facility","both","1","EA","UD","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALFUZOSIN 10 MG TB24","47335-956-88","NDC","","","","","facility","both","1","EA","","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","47335-992-01","NDC","","","","","facility","both","1","EA","","10.8","5.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","47335-992-01","NDC","","","","","facility","both","1","EA","UD","10.8","5.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 500 MG/100 ML PGBK","47335-993-01","NDC","","","","","facility","both","1","EA","UD","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 500 MG/100 ML PGBK","47335-993-01","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"HYOSCYAMINE SR 0.375 MG TB12","47781-014-01","NDC","","","","","facility","both","1","EA","","1.9","0.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","47781-176-01","NDC","","","","","facility","both","1","EA","","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","47781-176-01","NDC","","","","","facility","both","1","EA","UD","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOSTIGMINE CR 180 MG TBSR","47781-335-30","NDC","","","","","facility","both","1","EA","UD","18.61","9.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOSTIGMINE CR 180 MG TBSR","47781-335-30","NDC","","","","","facility","both","1","EA","","18.61","9.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE-NALOXONE 2-0.5 MG FILM","47781-355-11","NDC","","","","","facility","both","1","EA","","7.68","3.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE-NALOXONE 2-0.5 MG FILM","47781-355-11","NDC","","","","","facility","both","1","EA","UD","7.68","3.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE-NALOXONE 8-2 MG FILM","47781-357-11","NDC","","","","","facility","both","1","EA","UD","5.23","2.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE-NALOXONE 8-2 MG FILM","47781-357-11","NDC","","","","","facility","both","1","EA","","9.45","4.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 12 MCG/HR PT72","47781-423-11","NDC","","","","","facility","both","1","EA","","38.48","19.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 25 MCG/HR PT72","47781-424-11","NDC","","","","","facility","both","1","EA","","10.54","5.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 25 MCG/HR PT72","47781-424-11","NDC","","","","","facility","both","1","EA","UD","10.54","5.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 50 MCG/HR PT72","47781-426-11","NDC","","","","","facility","both","1","EA","UD","17.66","8.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 50 MCG/HR PT72","47781-426-11","NDC","","","","","facility","both","1","EA","","17.66","8.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 75 MCG/HR PT72","47781-427-11","NDC","","","","","facility","both","1","EA","UD","23.79","11.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 75 MCG/HR PT72","47781-427-11","NDC","","","","","facility","both","1","EA","","23.79","11.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 100 MCG/HR PT72","47781-428-11","NDC","","","","","facility","both","1","EA","","53.22","26.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OSELTAMIVIR 30 MG CAPS","47781-468-13","NDC","","","","","facility","both","1","EA","","3.52","1.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINERAL OIL OIL","48433-202-30","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINERAL OIL OIL","48433-202-30","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"IODINE, STRONG 5 % SOLN 14 ML BOTTLE","48433-230-15","NDC","","","","","facility","both","1","EA","UD","113.9","56.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IODINE, STRONG 5 % SOLN 14 ML BOTTLE","48433-230-15","NDC","","","","","facility","both","1","EA","","113.9","56.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CETAPHIL CLEANSER CLSR 473 ML BOTTLE","4902219018","NDC","","","","","facility","both","1","EA","UD","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CETAPHIL CLEANSER CLSR 473 ML BOTTLE","4902219018","NDC","","","","","facility","both","1","EA","","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIPH, PERTUS, TET VACCINE SYRG","49281-400-10","NDC","","","","","facility","both","1","EA","UD","290.02","145.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPH, PERTUS, TET VACCINE SYRG","49281-400-10","NDC","","","","","facility","both","1","EA","","290.02","145.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"TDAP VACCINE >7 IM","49281-400-58","NDC","","","","","facility","both","1","EA","PN","143","71.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TDAP VACCINE >7 IM","49281-400-58","NDC","","","","","facility","both","1","EA","","290.02","145.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TDAP VACCINE >7 IM","49281-400-58","NDC","","","","","facility","both","1","EA","UD","290.02","145.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TDAP VACCINE >7 IM","49281-400-89","NDC","","","","","facility","both","1","EA","","143","71.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HAEMOPH B POLY CONJ-TET TOX/PF 10 MCG/0.5 ML SOLR","49281-547-58","NDC","","","","","facility","both","1","EA","UD","75.64","37.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HAEMOPH B POLY CONJ-TET TOX/PF 10 MCG/0.5 ML SOLR","49281-547-58","NDC","","","","","facility","both","1","EA","","75.64","37.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML SOLN","49281-590-05","NDC","","","","","facility","both","1","EA","UD","869.14","434.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML SOLN","49281-590-58","NDC","","","","","facility","both","1","EA","","869.14","434.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML SOLN","49281-590-58","NDC","","","","","facility","both","1","EA","UD","869.14","434.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SKIN TEST TB INTRADERMAL","49281-752-21","NDC","","","","","facility","both","1","EA","PN","41","20.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"SKIN TEST TB INTRADERMAL","49281-752-21","NDC","","","","","facility","both","1","EA","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TUBERCULIN 5 TUB. UNIT /0.1 ML SOLN","49281-752-22","NDC","","","","","facility","both","1","EA","","106.95","53.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SKIN TEST TB INTRADERMAL","49281-752-78","NDC","","","","","facility","both","1","EA","","41","20.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALAMINE-ZINC OXIDE LOTN 177 ML BOTTLE","49348-011-34","NDC","","","","","facility","both","1","EA","","5.96","2.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NICOTINE POLACRILEX 2 MG GUM","49348-691-36","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE POLACRILEX 2 MG GUM","49348-691-36","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FAMOTIDINE 20 MG TABS","49348-817-09","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FAMOTIDINE 20 MG TABS","49348-817-09","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 17 GRAM/DOSE POWD 119 G BOTTLE","49348-893-50","NDC","","","","","facility","both","1","EA","","13.85","6.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PHENOL AEROSOL SPRAY 1.4 % SPRA 177 ML BOTTLE","49348-991-36","NDC","","","","","facility","both","1","EA","UD","177","88.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOL AEROSOL SPRAY 1.4 % SPRA 177 ML BOTTLE","49348-991-36","NDC","","","","","facility","both","1","EA","","177","88.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BELIMUMAB 120 MG SOLR 1 EACH VIAL","49401-101-01","NDC","","","","","facility","both","1","EA","UD,TB","2240.28","1120.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BELIMUMAB 120 MG SOLR 1 EACH VIAL","49401-101-01","NDC","","","","","facility","both","1","EA","","3655.06","1827.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BELIMUMAB 120 MG SOLR 1 EACH VIAL","49401-101-01","NDC","","","","","facility","both","1","EA","UD","7994.83","3997.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BELIMUMAB 400 MG SOLR 1 EACH VIAL","49401-102-01","NDC","","","","","facility","both","1","EA","UD","15628.6","7814.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BELIMUMAB 400 MG SOLR 1 EACH VIAL","49401-102-01","NDC","","","","","facility","both","1","EA","JG,UD,JA","7800.36","3900.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier JA: Administered intravenously"
"BELIMUMAB 400 MG SOLR 1 EACH VIAL","49401-102-01","NDC","","","","","facility","both","1","EA","","15406.95","7703.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BELIMUMAB 400 MG SOLR 1 EACH VIAL","49401-102-01","NDC","","","","","facility","both","1","EA","JG,UD","7800.36","3900.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 0.3 MG/0.3 ML ATIN","49502-102-01","NDC","","","","","facility","both","1","EA","UD","764.1","382.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 0.3 MG/0.3 ML ATIN","49502-102-01","NDC","","","","","facility","both","1","EA","","764.1","382.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML SOLN","49591-532-50","NDC","","","","","facility","both","1","EA","JG","9261.25","4630.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML SOLN","49591-532-51","NDC","","","","","facility","both","1","EA","JG","18517.5","9258.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML SOLN","49591-532-51","NDC","","","","","facility","both","1","EA","TB","54904.06","27452.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ZIDOVUDINE","49702-213-01","NDC","","","","","facility","both","1","EA","","37.09","18.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZIDOVUDINE","49702-213-01","NDC","","","","","facility","both","1","EA","UD","37.09","18.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIDOVUDINE 10 MG/ML SOLN","49702-213-26","NDC","","","","","facility","both","1","EA","","185","92.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"ZIDOVUDINE 10 MG/ML SOLN","49702-213-26","NDC","","","","","facility","both","1","EA","UD","185","92.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOLUTEGRAVIR 50 MG TABS","49702-228-13","NDC","","","","","facility","both","1","EA","","109.03","54.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOLUTEGRAVIR 50 MG TABS","49702-228-13","NDC","","","","","facility","both","1","EA","UD","109.03","54.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INJ, CABOTE RILPIVIR 2MG 3MG","49702-240-15","NDC","","","","","facility","both","1","EA","","7.5","3.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CABOTEGRAVIR 600 MG/3 ML (200 MG/ML) SPSR","49702-264-23","NDC","","","","","facility","both","1","EA","UD","13483.45","6741.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VARENICLINE 0.5 MG TABS","49884-155-76","NDC","","","","","facility","both","1","EA","","3.95","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VARENICLINE 0.5 MG TABS","49884-155-76","NDC","","","","","facility","both","1","EA","UD","3.95","1.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE-FLUOXETINE 6-25 MG CAPS","49884-250-11","NDC","","","","","facility","both","1","EA","","25.17","12.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINOXIDIL 2.5 MG TABS","49884-256-01","NDC","","","","","facility","both","1","EA","","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINOXIDIL 2.5 MG TABS","49884-256-01","NDC","","","","","facility","both","1","EA","UD","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 0.125 MG ODT.","49884-306-52","NDC","","","","","facility","both","1","EA","","3.77","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.25 MG ODT.","49884-307-52","NDC","","","","","facility","both","1","EA","UD","3.77","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 0.25 MG ODT.","49884-307-52","NDC","","","","","facility","both","1","EA","","3.77","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE (DISINTEGRATING) 0.5 MG ODT.","49884-311-52","NDC","","","","","facility","both","1","EA","UD","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE (DISINTEGRATING) 0.5 MG ODT.","49884-311-52","NDC","","","","","facility","both","1","EA","","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE (DISINTEGRATING) 1 MG ODT.","49884-315-52","NDC","","","","","facility","both","1","EA","UD","6.53","3.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE (DISINTEGRATING) 1 MG ODT.","49884-315-52","NDC","","","","","facility","both","1","EA","","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE (DISINTEGRATING) 2 MG ODT.","49884-401-52","NDC","","","","","facility","both","1","EA","UD","10.02","5.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE (DISINTEGRATING) 2 MG ODT.","49884-401-52","NDC","","","","","facility","both","1","EA","","10.02","5.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALISKIREN 150 MG TABS","49884-424-11","NDC","","","","","facility","both","1","EA","","16.87","8.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","49884-465-64","NDC","","","","","facility","both","1","EA","","3.9","1.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","49884-466-63","NDC","","","","","facility","both","1","EA","","3.65","1.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","49884-466-63","NDC","","","","","facility","both","1","EA","UD","3.65","1.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOLVAPTAN 15 MG TABS","49884-768-52","NDC","","","","","facility","both","1","EA","UD","72.93","36.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOLVAPTAN 15 MG TABS","49884-768-52","NDC","","","","","facility","both","1","EA","","72.93","36.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPSONE 100 MG TABS","49938-101-30","NDC","","","","","facility","both","1","EA","","4.24","2.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAZODONE 50 MG TABS","50111-560-01","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAZODONE 50 MG TABS","50111-560-01","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAZODONE 50 MG TABS","50111-560-02","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAZODONE 50 MG TABS","50111-560-02","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUOXETINE 20 MG CAPS","50111-648-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG CAPS","50111-648-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM CHLORIDE 3 % NEBU","5019014263","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 3 % NEBU","5019014263","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"QUETIAPINE SR 150 MG TB24","50228-381-60","NDC","","","","","facility","both","1","EA","","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE SR 150 MG TB24","50228-381-60","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RANOLAZINE 500 MG TB12","50228-423-60","NDC","","","","","facility","both","1","EA","UD","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RANOLAZINE 500 MG TB12","50228-423-60","NDC","","","","","facility","both","1","EA","","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 10-100 MG TABS","50228-457-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA 10-100 MG TABS","50228-457-01","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NABUMETONE 500 MG TABS","50228-465-01","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 30 MG TABS","50228-481-01","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 30 MG TABS","50228-481-01","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 60 MG TABS","50228-482-01","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 60 MG TABS","50228-482-01","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMALIZUMAB 150 MG/ML SOLR","50242-040-62","NDC","","","","","facility","both","1","EA","UD,TB","14449.59","7224.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"OMALIZUMAB 150 MG/ML SOLR","50242-040-62","NDC","","","","","facility","both","1","EA","","13685.29","6842.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMALIZUMAB 150 MG/ML SOLR","50242-040-62","NDC","","","","","facility","both","1","EA","JG,UD","13685.29","6842.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMALIZUMAB 150 MG/ML SOLR","50242-040-62","NDC","","","","","facility","both","1","EA","JG","8589.67","4294.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"OMALIZUMAB 150 MG/ML SOLR","50242-040-62","NDC","","","","","facility","both","1","EA","TB","9048.25","4524.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ALTEPLASE 50 MG SOLR 1 EACH VIAL","50242-044-06","NDC","","","","","facility","both","1","EA","UD","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALTEPLASE 50 MG SOLR 1 EACH VIAL","50242-044-06","NDC","","","","","facility","both","1","EA","","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALTEPLASE 50 MG SOLR 1 EACH VIAL","50242-044-13","NDC","","","","","facility","both","1","EA","UD","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALTEPLASE 50 MG SOLR 1 EACH VIAL","50242-044-13","NDC","","","","","facility","both","1","EA","","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALTEPLASE 100 MG SOLR 1 EACH VIAL","50242-085-25","NDC","","","","","facility","both","1","EA","JG","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALTEPLASE 100 MG SOLR 1 EACH VIAL","50242-085-25","NDC","","","","","facility","both","1","EA","","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALTEPLASE 100 MG SOLR 1 EACH VIAL","50242-085-27","NDC","","","","","facility","both","1","EA","JG","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALTEPLASE 100 MG SOLR 1 EACH VIAL","50242-085-27","NDC","","","","","facility","both","1","EA","UD","4378.37","2189.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DORNASE ALPHA 1 MG/ML SOLN","50242-100-39","NDC","","","","","facility","both","1","EA","UD","167.88","83.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DORNASE ALPHA 1 MG/ML SOLN","50242-100-39","NDC","","","","","facility","both","1","EA","","290.19","145.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DORNASE ALPHA 1 MG/ML SOLN 2.5 ML AMPUL","50242-100-40","NDC","","","","","facility","both","1","EA","","297.76","148.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"POLATUZUMAB VEDOTIN-PIIQ 140 MG SOLR 1 EACH VIAL","50242-105-01","NDC","","","","","facility","both","1","EA","","61342.06","30671.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TENECTEPLASE 50 MG SOLR 1 EACH VIAL","50242-120-47","NDC","","","","","facility","both","1","EA","UD,TB","9493.97","4746.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"TENECTEPLASE 50 MG SOLR 1 EACH VIAL","50242-120-47","NDC","","","","","facility","both","1","EA","UD","10104.52","5052.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TENECTEPLASE 50 MG SOLR 1 EACH VIAL","50242-120-47","NDC","","","","","facility","both","1","EA","","11305.31","5652.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRASTUZUMAB 150 MG SOLR 1 EACH VIAL","50242-132-01","NDC","","","","","facility","both","1","EA","JG","10518.16","5259.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TOCILIZUMAB 80 MG/4 ML (20 MG/ML) SOLN 4 ML VIAL","50242-135-01","NDC","","","","","facility","both","1","EA","JG,UD","1274.78","637.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOCILIZUMAB 80 MG/4 ML (20 MG/ML) SOLN 4 ML VIAL","50242-135-01","NDC","","","","","facility","both","1","EA","JG","1912.18","956.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TOCILIZUMAB 200 MG/10 ML (20 MG/ML) SOLN 10 ML VIAL","50242-136-01","NDC","","","","","facility","both","1","EA","UD","5099.18","2549.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMITRIPTYLINE 10 MG TABS","50268-037-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMITRIPTYLINE 10 MG TABS","50268-037-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAZOLAMIDE SR 500 MG CPSR","50268-042-11","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE SR 500 MG CPSR","50268-042-11","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACEBUTOLOL 200 MG CAPS","50268-050-11","NDC","","","","","facility","both","1","EA","","2.76","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE 250 MG TABS","50268-054-11","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAZOLAMIDE 250 MG TABS","50268-054-11","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOMOXETINE 60 MG CAPS","50268-059-11","NDC","","","","","facility","both","1","EA","UD","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOMOXETINE 60 MG CAPS","50268-059-11","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMANTADINE HCL 100 MG CAPS","50268-069-11","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMANTADINE HCL 100 MG CAPS","50268-069-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMANTADINE HCL 100 MG CAPS","50268-069-15","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMANTADINE HCL 100 MG CAPS","50268-069-15","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 250 MG TABS","50268-074-11","NDC","","","","","facility","both","1","EA","","0.66","0.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","50268-074-11","NDC","","","","","facility","both","1","EA","UD","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANASTROZOLE 1 MG TABS","50268-075-11","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANASTROZOLE 1 MG TABS","50268-075-11","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","50268-086-11","NDC","","","","","facility","both","1","EA","UD","51.84","25.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","50268-086-11","NDC","","","","","facility","both","1","EA","","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ARIPIPRAZOLE 2 MG TABS","50268-087-11","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 2 MG TABS","50268-087-11","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 5 MG TABS","50268-088-11","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 5 MG TABS","50268-088-11","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 10 MG TABS","50268-089-11","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 10 MG TABS","50268-089-11","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 15 MG TABS","50268-090-11","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 15 MG TABS","50268-090-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 10 MG TABS","50268-093-11","NDC","","","","","facility","both","1","EA","","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 10 MG TABS","50268-093-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 5 MG TABS","50268-105-11","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACLOFEN 5 MG TABS","50268-105-11","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 10 MG TABS","50268-106-11","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACLOFEN 10 MG TABS","50268-106-11","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISOPROLOL 5 MG TABS","50268-127-11","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISOPROLOL 5 MG TABS","50268-127-11","NDC","","","","","facility","both","1","EA","UD","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 0.5 MG TABS","50268-130-11","NDC","","","","","facility","both","1","EA","","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUMETANIDE 0.5 MG TABS","50268-130-11","NDC","","","","","facility","both","1","EA","UD","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 1 MG TABS","50268-131-11","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 1 MG TABS","50268-131-11","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUMETANIDE 1 MG TABS","50268-131-15","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 1 MG TABS","50268-131-15","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION 75 MG TABS","50268-142-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPROPION 75 MG TABS","50268-142-11","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE/NALOXONE 2-0.5 MG SUBL","50268-144-11","NDC","","","","","facility","both","1","EA","UD","2.46","1.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE/NALOXONE 2-0.5 MG SUBL","50268-144-11","NDC","","","","","facility","both","1","EA","","2.46","1.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE-NALOXONE 8-2 MG SUBL","50268-145-11","NDC","","","","","facility","both","1","EA","UD","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE-NALOXONE 8-2 MG SUBL","50268-145-11","NDC","","","","","facility","both","1","EA","","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEPHALEXIN 250 MG CAPS","50268-151-11","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEPHALEXIN 250 MG CAPS","50268-151-11","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CINACALCET 30 MG TABS","50268-153-11","NDC","","","","","facility","both","1","EA","","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CINACALCET 30 MG TABS","50268-153-11","NDC","","","","","facility","both","1","EA","UD","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 10 MG TABS","50268-162-11","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 10 MG TABS","50268-162-11","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORPROMAZINE 25 MG TABS","50268-163-11","NDC","","","","","facility","both","1","EA","UD","0.6","0.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 25 MG TABS","50268-163-11","NDC","","","","","facility","both","1","EA","","0.6","0.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CELECOXIB 100 MG CAPS","50268-168-11","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CELECOXIB 100 MG CAPS","50268-168-11","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE ER 12 HOUR 200 MG CM12","50268-171-11","NDC","","","","","facility","both","1","EA","","5.87","2.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.5 MG TABS","50268-173-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CILOSTAZOL 50 MG TABS","50268-176-11","NDC","","","","","facility","both","1","EA","","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CILOSTAZOL 50 MG TABS","50268-176-11","NDC","","","","","facility","both","1","EA","UD","1.91","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLARITHROMYCIN 500 MG TABS","50268-179-11","NDC","","","","","facility","both","1","EA","","3.29","1.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLARITHROMYCIN 500 MG TABS","50268-179-11","NDC","","","","","facility","both","1","EA","UD","3.29","1.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOPIDOGREL 300 MG TABS","50268-184-11","NDC","","","","","facility","both","1","EA","UD","19.86","9.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOPIDOGREL 300 MG TABS","50268-184-11","NDC","","","","","facility","both","1","EA","","19.86","9.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYPROHEPTADINE 4 MG TABS","50268-189-11","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYPROHEPTADINE 4 MG TABS","50268-189-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOBENZAPRINE 10 MG TABS","50268-191-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 10 MG TABS","50268-191-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE HCL 0.1 MG TABS","50268-192-11","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE HCL 0.1 MG TABS","50268-192-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CAPSAICIN 0.025 % CREA 60 G TUBE","50268-195-60","NDC","","","","","facility","both","1","EA","","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CAPSAICIN 0.025 % CREA 60 G TUBE","50268-195-60","NDC","","","","","facility","both","1","EA","UD","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX ER 250 MG TB24","50268-259-11","NDC","","","","","facility","both","1","EA","","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX ER 250 MG TB24","50268-259-11","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE HYCLATE 100 MG CAPS","50268-278-11","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE HYCLATE 100 MG CAPS","50268-278-11","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE 100 MG CAPS","50268-281-15","NDC","","","","","facility","both","1","EA","","1.82","0.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE 100 MG CAPS","50268-281-15","NDC","","","","","facility","both","1","EA","UD","1.82","0.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERGOCALCIFEROL 50,000 UNIT CAPS","50268-297-11","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERGOCALCIFEROL 50,000 UNIT CAPS","50268-297-11","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","50268-298-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EZETIMIBE 10 MG TABS","50268-298-11","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FINASTERIDE 5 MG TABS","50268-314-11","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FINASTERIDE 5 MG TABS","50268-314-11","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLECAINIDE 100 MG TABS","50268-321-11","NDC","","","","","facility","both","1","EA","UD","1.42","0.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLECAINIDE 100 MG TABS","50268-321-11","NDC","","","","","facility","both","1","EA","","1.42","0.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUDROCORTISONE 0.1 MG TABS","50268-330-11","NDC","","","","","facility","both","1","EA","UD","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUDROCORTISONE 0.1 MG TABS","50268-330-11","NDC","","","","","facility","both","1","EA","","2.39","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 100 MG TABS","50268-337-11","NDC","","","","","facility","both","1","EA","","2.03","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 100 MG TABS","50268-337-11","NDC","","","","","facility","both","1","EA","UD","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOLIC ACID 400 MCG TABS","5026834611","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOLIC ACID 400 MCG TABS","5026834611","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIMEPIRIDE 1 MG TABS","50268-358-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIMEPIRIDE 1 MG TABS","50268-358-11","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIMEPIRIDE 1 MG TABS","50268-358-15","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIMEPIRIDE 4 MG TABS","50268-360-11","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIMEPIRIDE 4 MG TABS","50268-360-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE 1 MG TABS","50268-366-11","NDC","","","","","facility","both","1","EA","","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE 1 MG TABS","50268-366-11","NDC","","","","","facility","both","1","EA","UD","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE 10 MG TABS","50268-369-11","NDC","","","","","facility","both","1","EA","","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE 10 MG TABS","50268-369-11","NDC","","","","","facility","both","1","EA","UD","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLUCOSAMINE 500 MG CAPS","5026837511","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLUCOSAMINE 500 MG CAPS","5026837511","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLUCOSAMINE-CHONDROIT-VIT C-MN 500-400 MG CAPS","5026837611","NDC","","","","","facility","both","1","EA","UD","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLUCOSAMINE-CHONDROIT-VIT C-MN 500-400 MG CAPS","5026837611","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","50268-402-11","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 10-325 MG TABS","50268-402-11","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCHLOROTHIAZIDE 12.5 MG CAPS","50268-404-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCHLOROTHIAZIDE 12.5 MG CAPS","50268-404-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE 10 MG TABS","50268-406-11","NDC","","","","","facility","both","1","EA","UD","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 10 MG TABS","50268-406-11","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYCHLOROQUINE 200 MG TABS","50268-412-11","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYCHLOROQUINE 200 MG TABS","50268-412-11","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 25 MG CAPS","50268-430-11","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 25 MG CAPS","50268-430-11","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 10 MG TABS","50268-448-11","NDC","","","","","facility","both","1","EA","UD","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE DINITRATE 20 MG TABS","50268-449-11","NDC","","","","","facility","both","1","EA","","1.43","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 20 MG TABS","50268-449-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","50268-470-11","NDC","","","","","facility","both","1","EA","UD","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","50268-470-11","NDC","","","","","facility","both","1","EA","","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LETROZOLE 2.5 MG TABS","50268-476-11","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LETROZOLE 2.5 MG TABS","50268-476-11","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEFLUNOMIDE 10 MG TABS","50268-477-11","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEFLUNOMIDE 10 MG TABS","50268-477-11","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEFLUNOMIDE 20 MG TABS","50268-478-11","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORATADINE 10 MG TABS","50268-489-11","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORATADINE 10 MG TABS","50268-489-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOSARTAN 50 MG TABS","50268-505-11","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 50 MG TABS","50268-505-11","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 500 MG TABS","50268-520-11","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 500 MG TABS","50268-520-11","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","50268-521-11","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 750 MG TABS","50268-521-11","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MECLIZINE 12.5 MG TABS","50268-522-11","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MECLIZINE 12.5 MG TABS","50268-522-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MELOXICAM 7.5 MG TABS","50268-525-11","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MELOXICAM 7.5 MG TABS","50268-525-11","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOTREXATE 2.5 MG TABS","50268-527-11","NDC","","","","","facility","both","1","EA","","5.01","2.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOTREXATE 2.5 MG TABS","50268-527-11","NDC","","","","","facility","both","1","EA","UD","7.02","3.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METAXALONE 800 MG TABS","50268-530-11","NDC","","","","","facility","both","1","EA","","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METAXALONE 800 MG TABS","50268-530-11","NDC","","","","","facility","both","1","EA","UD","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METAXALONE 800 MG TABS","50268-530-15","NDC","","","","","facility","both","1","EA","","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METRONIDAZOLE 250 MG TABS","50268-534-11","NDC","","","","","facility","both","1","EA","","0.52","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METRONIDAZOLE 250 MG TABS","50268-534-11","NDC","","","","","facility","both","1","EA","UD","0.52","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 25 MG TB24","50268-540-11","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL XL 25 MG TB24","50268-540-11","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 50 MG TB24","50268-541-11","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL XL 50 MG TB24","50268-541-11","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHENAMINE HIPPURATE 1 GRAM TABS","50268-549-11","NDC","","","","","facility","both","1","EA","","1.84","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN ER 500 MG TB24","50268-550-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN ER 500 MG TB24","50268-550-11","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN ER 750 MG TB24","50268-551-11","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN ER 750 MG TB24","50268-551-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 10 MG TABS","50268-563-11","NDC","","","","","facility","both","1","EA","UD","0.46","0.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 10 MG TABS","50268-563-11","NDC","","","","","facility","both","1","EA","","0.46","0.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MONTELUKAST 5 MG CHEW","50268-574-11","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MONTELUKAST 5 MG CHEW","50268-574-11","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MOXIFLOXACIN 400 MG TABS","50268-576-11","NDC","","","","","facility","both","1","EA","UD","7.45","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 400 MG TABS","50268-576-11","NDC","","","","","facility","both","1","EA","","7.45","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIACIN ER 500 MG TB24","50268-584-11","NDC","","","","","facility","both","1","EA","","2.59","1.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PANTOPRAZOLE 20 MG TBEC","50268-585-11","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAPROXEN 275 MG TABS","50268-592-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NAPROXEN 275 MG TABS","50268-592-11","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAPROXEN 250 MG TABS","50268-594-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NAPROXEN 250 MG TABS","50268-594-11","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 30 MG TR24","50268-597-11","NDC","","","","","facility","both","1","EA","UD","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 30 MG TR24","50268-597-11","NDC","","","","","facility","both","1","EA","","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIFEDIPINE 24HR 90 MG TR24","50268-599-11","NDC","","","","","facility","both","1","EA","UD","1.65","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 90 MG TR24","50268-599-11","NDC","","","","","facility","both","1","EA","","1.65","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NORTRIPTYLINE 10 MG CAPS","50268-603-11","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NORTRIPTYLINE 10 MG CAPS","50268-603-11","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NORTRIPTYLINE 25 MG CAPS","50268-604-11","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NORTRIPTYLINE 25 MG CAPS","50268-604-11","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROFURANTOIN MONOHYDRATE MACRO 100 MG CAPS","50268-625-11","NDC","","","","","facility","both","1","EA","UD","2.07","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROFURANTOIN MONOHYDRATE MACRO 100 MG CAPS","50268-625-11","NDC","","","","","facility","both","1","EA","","2.07","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 100 MG TABS","50268-632-11","NDC","","","","","facility","both","1","EA","UD","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 100 MG TABS","50268-632-11","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 400 MG TABS","50268-635-11","NDC","","","","","facility","both","1","EA","UD","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 400 MG TABS","50268-635-11","NDC","","","","","facility","both","1","EA","","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) SUSPENSION","50268-649-05","NDC","","","","","facility","both","1","EA","","17.74","8.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) SUSPENSION","50268-649-05","NDC","","","","","facility","both","1","EA","UD","20.5","10.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEPRAZOLE 20 MG CPDR","50268-656-11","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEPRAZOLE 20 MG CPDR","50268-656-11","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 10 MG TABS","50268-662-11","NDC","","","","","facility","both","1","EA","","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 10 MG TABS","50268-662-11","NDC","","","","","facility","both","1","EA","UD","0.18","0.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAVASTATIN 10 MG TABS","50268-665-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAVASTATIN 20 MG TABS","50268-666-11","NDC","","","","","facility","both","1","EA","UD","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAVASTATIN 20 MG TABS","50268-666-11","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYVINYL ALCOHOL 1.4 % DROP 15 ML DROP BTL","50268-678-15","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYVINYL ALCOHOL 1.4 % DROP 15 ML DROP BTL","50268-678-15","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POSACONAZOLE 100 MG TBEC","50268-683-11","NDC","","","","","facility","both","1","EA","","9.87","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POSACONAZOLE 100 MG TBEC","50268-683-11","NDC","","","","","facility","both","1","EA","UD","24","12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROCHLORPERAZINE 5 MG TABS","50268-684-11","NDC","","","","","facility","both","1","EA","","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROCHLORPERAZINE 5 MG TABS","50268-684-11","NDC","","","","","facility","both","1","EA","UD","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRIMIDONE 50 MG TABS","50268-686-11","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRIMIDONE 50 MG TABS","50268-686-11","NDC","","","","","facility","both","1","EA","UD","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RAMELTEON 8 MG TABS","50268-708-11","NDC","","","","","facility","both","1","EA","","4.12","2.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RAMELTEON 8 MG TABS","50268-708-11","NDC","","","","","facility","both","1","EA","UD","4.12","2.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 10 MG TABS","50268-709-11","NDC","","","","","facility","both","1","EA","","0.52","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 10 MG TABS","50268-709-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 20 MG TABS","50268-710-11","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 20 MG TABS","50268-710-11","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 40 MG TABS","50268-711-11","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 40 MG TABS","50268-711-11","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SILDENAFIL 20 MG TABS","50268-717-11","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILDENAFIL 20 MG TABS","50268-717-11","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIROLIMUS 1 MG TABS","50268-718-11","NDC","","","","","facility","both","1","EA","UD","17.19","8.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIROLIMUS 1 MG TABS","50268-718-11","NDC","","","","","facility","both","1","EA","","17.19","8.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SEVELAMER CARBONATE 800 MG TABS","50268-720-11","NDC","","","","","facility","both","1","EA","UD","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SEVELAMER CARBONATE 800 MG TABS","50268-720-11","NDC","","","","","facility","both","1","EA","","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RANOLAZINE 500 MG TB12","50268-722-11","NDC","","","","","facility","both","1","EA","","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RANOLAZINE 500 MG TB12","50268-722-11","NDC","","","","","facility","both","1","EA","UD","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SOTALOL 80 MG TABS","50268-724-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SOTALOL 80 MG TABS","50268-724-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SOTALOL 120 MG TABS","50268-725-11","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TADALAFIL 5 MG TABS","50268-738-11","NDC","","","","","facility","both","1","EA","","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TADALAFIL 5 MG TABS","50268-738-11","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TAMSULOSIN 0.4 MG CAPS","50268-740-11","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TAMSULOSIN 0.4 MG CAPS","50268-740-11","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROPINIROLE 1 MG TABS","50268-743-11","NDC","","","","","facility","both","1","EA","","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TORSEMIDE 5 MG TABS","50268-754-11","NDC","","","","","facility","both","1","EA","","1.42","0.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TORSEMIDE 5 MG TABS","50268-754-11","NDC","","","","","facility","both","1","EA","UD","1.84","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TENOFOVIR DISOPROXIL 300 MG TABS","50268-758-11","NDC","","","","","facility","both","1","EA","","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TENOFOVIR DISOPROXIL 300 MG TABS","50268-758-11","NDC","","","","","facility","both","1","EA","UD","3.72","1.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIZANIDINE 2 MG TABS","50268-759-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIZANIDINE 2 MG TABS","50268-759-11","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIZANIDINE 4 MG TABS","50268-760-11","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TERAZOSIN 1 MG CAPS","50268-764-11","NDC","","","","","facility","both","1","EA","UD","1.58","0.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERAZOSIN 1 MG CAPS","50268-764-11","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TERAZOSIN 5 MG CAPS","50268-766-11","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TERAZOSIN 5 MG CAPS","50268-766-11","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 650 MG TABS","50268-772-11","NDC","","","","","facility","both","1","EA","UD","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 650 MG TABS","50268-772-11","NDC","","","","","facility","both","1","EA","","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMAZEPAM 15 MG CAPS","50268-779-11","NDC","","","","","facility","both","1","EA","UD","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TEMAZEPAM 15 MG CAPS","50268-779-11","NDC","","","","","facility","both","1","EA","","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALGANCICLOVIR 450 MG TABS","50268-787-11","NDC","","","","","facility","both","1","EA","UD","12.01","6.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALGANCICLOVIR 450 MG TABS","50268-787-11","NDC","","","","","facility","both","1","EA","","12.01","6.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALGANCICLOVIR 450 MG TABS","50268-787-12","NDC","","","","","facility","both","1","EA","","23.02","11.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 300 MG CAPS","50268-797-11","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 300 MG CAPS","50268-797-11","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG TABS","50268-803-11","NDC","","","","","facility","both","1","EA","","7.7","3.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VORICONAZOLE 200 MG TABS","50268-803-11","NDC","","","","","facility","both","1","EA","UD","7.7","3.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIPRASIDONE 20 MG CAPS","50268-811-11","NDC","","","","","facility","both","1","EA","","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZIPRASIDONE 20 MG CAPS","50268-811-11","NDC","","","","","facility","both","1","EA","UD","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZONISAMIDE 100 MG CAPS","50268-816-11","NDC","","","","","facility","both","1","EA","","0.88","0.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZONISAMIDE 100 MG CAPS","50268-816-11","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE MONONITRATE 100 MG TABS","5026885111","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THIAMINE MONONITRATE 100 MG TABS","5026885111","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 100 MCG TABS","5026885211","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 100 MCG TABS","5026885211","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 250 MCG TABS","5026885311","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 250 MCG TABS","5026885311","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 250 MCG TABS","5026885315","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 500 MCG TABS","5026885411","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 500 MCG TABS","5026885411","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 1,000 MCG TABS","5026885511","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 1,000 MCG TABS","5026885511","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PYRIDOXINE (VITAMIN B6) 50 MG TABS","5026885811","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PYRIDOXINE (VITAMIN B6) 50 MG TABS","5026885811","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASCORBIC ACID (VITAMIN C) 250 MG TABS","5026886011","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASCORBIC ACID (VITAMIN C) 250 MG TABS","5026886011","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLECALCIFEROL 10 MCG (400 UNIT) TABS","5026886311","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLECALCIFEROL 10 MCG (400 UNIT) TABS","5026886311","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHOLECALCIFEROL 125 MCG (5,000 UNIT) TABS","5026886611","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHOLECALCIFEROL 125 MCG (5,000 UNIT) TABS","5026886611","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WITCH HAZEL-GLYCERIN 12.5-50 % PADM 40 EACH BOX","50289-3250-1","NDC","","","","","facility","both","1","EA","","8.98","4.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NYSTATIN 100,000 UNIT/ML SUSPENSION 473 ML BOTTLE","50383-587-16","NDC","","","","","facility","both","1","EA","","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LORAZEPAM 2 MG/ML CONC 30 ML BOTTLE","50383-705-30","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG/ML CONC 30 ML BOTTLE","50383-705-30","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOCUSATE SODIUM 50 MG/5 ML LIQD","50383-771-89","NDC","","","","","facility","both","1","EA","UD","2.62","1.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCUSATE SODIUM 50 MG/5 ML LIQD","50383-771-89","NDC","","","","","facility","both","1","EA","","2.62","1.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAG&AL&SIM/DIPHENHYD/LIDOCAINE 200-25-400-40 MG/30 ML MWSH","50383-775-15","NDC","","","","","facility","both","1","EA","UD","2.69","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAG&AL&SIM/DIPHENHYD/LIDOCAINE 200-25-400-40 MG/30 ML MWSH","50383-775-15","NDC","","","","","facility","both","1","EA","","2.69","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAG&AL&SIM/DIPHENHYD/LIDOCAINE 200-25-400-40 MG/30 ML MWSH","50383-775-17","NDC","","","","","facility","both","1","EA","","2.69","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML"
"MAG&AL&SIM/DIPHENHYD/LIDOCAINE 200-25-400-40 MG/30 ML MWSH","50383-775-17","NDC","","","","","facility","both","1","EA","UD","2.69","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 40 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","50383-823-16","NDC","","","","","facility","both","1","EA","UD","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 40-200 MG/5 ML SUSPENSION","50383-823-16","NDC","","","","","facility","both","1","EA","","10.48","5.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RIOCIGUAT 0.5 MG TABS","50419-250-01","NDC","","","","","facility","both","1","EA","","328.02","164.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIOCIGUAT 0.5 MG TABS","50419-250-01","NDC","","","","","facility","both","1","EA","UD","328.02","164.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) SOLN","50419-320-01","NDC","","","","","facility","both","1","EA","","285","142.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) SOLN","50419-320-01","NDC","","","","","facility","both","1","EA","UD","342","171","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) SOLN","50419-320-05","NDC","","","","","facility","both","1","EA","","399","199.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"LEVONORGESTREL 21 MCG/24HR (UP TO 8 YRS) 52 MG IUD","50419-423-01","NDC","","","","","facility","both","1","EA","","1791.19","895.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CANAGLIFLOZIN 100 MG TABS","50458-140-30","NDC","","","","","facility","both","1","EA","","102.76","51.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CANAGLIFLOZIN 100 MG TABS","50458-140-30","NDC","","","","","facility","both","1","EA","UD","102.76","51.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVAROXABAN 2.5 MG TABS","50458-577-01","NDC","","","","","facility","both","1","EA","UD","22.47","11.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVAROXABAN 2.5 MG TABS","50458-577-01","NDC","","","","","facility","both","1","EA","","22.47","11.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 15 MG TABS","50458-578-01","NDC","","","","","facility","both","1","EA","UD","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVAROXABAN 15 MG TABS","50458-578-01","NDC","","","","","facility","both","1","EA","","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 15 MG TABS","50458-578-10","NDC","","","","","facility","both","1","EA","","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 20 MG TABS","50458-579-01","NDC","","","","","facility","both","1","EA","UD","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVAROXABAN 20 MG TABS","50458-579-01","NDC","","","","","facility","both","1","EA","","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 20 MG TABS","50458-579-10","NDC","","","","","facility","both","1","EA","","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 20 MG TABS","50458-579-10","NDC","","","","","facility","both","1","EA","UD","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVAROXABAN 10 MG TABS","50458-580-01","NDC","","","","","facility","both","1","EA","","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 10 MG TABS","50458-580-01","NDC","","","","","facility","both","1","EA","UD","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIVAROXABAN 10 MG TABS","50458-580-10","NDC","","","","","facility","both","1","EA","","36.93","18.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIVAROXABAN 10 MG TABS","50458-580-10","NDC","","","","","facility","both","1","EA","UD","38.38","19.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BRIVARACETAM 25 MG TABS","50474-470-09","NDC","","","","","facility","both","1","EA","UD","44.67","22.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BRIVARACETAM 50 MG TABS","50474-570-09","NDC","","","","","facility","both","1","EA","","44.67","22.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BRIVARACETAM 50 MG TABS","50474-570-09","NDC","","","","","facility","both","1","EA","UD","44.67","22.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BRIVARACETAM 10 MG/ML SOLN","50474-970-63","NDC","","","","","facility","both","1","EA","UD","370.84","185.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLLAGENASE 250 UNIT/GRAM OINT 30 G TUBE","50484-010-30","NDC","","","","","facility","both","1","EA","UD","725.85","362.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLLAGENASE 250 UNIT/GRAM OINT 30 G TUBE","50484-010-30","NDC","","","","","facility","both","1","EA","","725.85","362.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BENZOCAINE 10 % GEL 9.4 G TUBE","50486-550-32","NDC","","","","","facility","both","1","EA","UD","15.61","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE 10 % GEL 9.4 G TUBE","50486-550-32","NDC","","","","","facility","both","1","EA","","15.61","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ACETAMINOPHEN 500 MG TABS","50580-457-11","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 500 MG TABS","50580-457-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 325 MG TABS","50580-458-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 325 MG TABS","50580-458-11","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RABIES VACCINE 2.5 UNIT SUSR","50632-010-01","NDC","","","","","facility","both","1","EA","","1890.63","945.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RABIES VACCINE 2.5 UNIT SUSR","50632-010-01","NDC","","","","","facility","both","1","EA","UD","1890.63","945.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RABIES VACCINE 2.5 UNIT SUSR","50632-013-01","NDC","","","","","facility","both","1","EA","","1890.63","945.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL","50633-120-11","NDC","","","","","facility","both","1","EA","","112868.43","56434.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIGOXIN IMMUNE FAB 40 MG SOLR 1 EACH VIAL","50633-120-11","NDC","","","","","facility","both","1","EA","JG","144435.03","72217.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CABERGOLINE 0.5 MG TABS","50742-118-08","NDC","","","","","facility","both","1","EA","","7.09","3.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE MONONITRATE CR 60 MG TB24","50742-176-01","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE MONONITRATE CR 60 MG TB24","50742-176-01","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 150 MG CAPS","50742-239-01","NDC","","","","","facility","both","1","EA","","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 150 MG CAPS","50742-239-01","NDC","","","","","facility","both","1","EA","UD","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 200 MG CAPS","50742-240-01","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 200 MG CAPS","50742-240-01","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 24HR 180 MG CP24","50742-249-90","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 24HR 180 MG CP24","50742-249-90","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC POTASSIUM 50 MG TABS","50742-279-01","NDC","","","","","facility","both","1","EA","UD","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC POTASSIUM 50 MG TABS","50742-279-01","NDC","","","","","facility","both","1","EA","","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBOPLATIN 10 MG/ML SOLN 45 ML VIAL","50742-447-45","NDC","","","","","facility","both","1","EA","UD","10.12","5.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPLATIN 10 MG/ML SOLN 45 ML VIAL","50742-447-45","NDC","","","","","facility","both","1","EA","","50.58","25.29","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","50742-505-01","NDC","","","","","facility","both","1","EA","UD","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SCOPOLAMINE 1 MG OVER 3 DAYS PT3D","50742-505-01","NDC","","","","","facility","both","1","EA","","23.2","11.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 2.5 ML VIAL","50742-519-02","NDC","","","","","facility","both","1","EA","JG,UD","62.83","31.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 2.5 ML VIAL","50742-519-02","NDC","","","","","facility","both","1","EA","JG","95.38","47.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 2.5 ML VIAL","50742-519-02","NDC","","","","","facility","both","1","EA","","245.59","122.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 2.5 ML VIAL","50742-519-02","NDC","","","","","facility","both","1","EA","UD","278.15","139.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","50742-520-05","NDC","","","","","facility","both","1","EA","UD","344.5","172.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","50742-520-05","NDC","","","","","facility","both","1","EA","","344.5","172.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL","50742-521-10","NDC","","","","","facility","both","1","EA","JG,UD","1146.27","573.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL","50742-521-10","NDC","","","","","facility","both","1","EA","UD","740.77","370.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL","50742-521-10","NDC","","","","","facility","both","1","EA","JG","677.94","338.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL","50742-521-10","NDC","","","","","facility","both","1","EA","","369.53","184.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METOLAZONE 2.5 MG TABS","51079-023-01","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOLAZONE 2.5 MG TABS","51079-023-01","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOLAZONE 2.5 MG TABS","51079-023-20","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOLAZONE 2.5 MG TABS","51079-023-20","NDC","","","","","facility","both","1","EA","UD","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 5 MG CAPS","51079-028-01","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 5 MG CAPS","51079-028-01","NDC","","","","","facility","both","1","EA","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORTHALIDONE 25 MG TABS","51079-058-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORTHALIDONE 25 MG TABS","51079-058-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FUROSEMIDE 40 MG TABS","51079-073-01","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 40 MG TABS","51079-073-01","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 10 MG TABS","51079-074-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 10 MG TABS","51079-074-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 10 MG TABS","51079-074-20","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 10 MG TABS","51079-074-20","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 25 MG TABS","51079-075-01","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 25 MG TABS","51079-075-01","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISONIAZID 300 MG TABS","51079-083-01","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISONIAZID 300 MG TABS","51079-083-01","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIRTAZAPINE 15 MG TABS","51079-086-01","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIRTAZAPINE 15 MG TABS","51079-086-01","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE 25 MG TABS","51079-103-01","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SPIRONOLACTONE 25 MG TABS","51079-103-01","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE 25 MG TABS","51079-103-20","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE 25 MG TABS","51079-103-20","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORDIAZEPOXIDE 25 MG CAPS","51079-141-01","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORDIAZEPOXIDE 25 MG CAPS","51079-141-01","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LITHIUM 450 MG TBSR","51079-142-01","NDC","","","","","facility","both","1","EA","UD","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 100 MG TABS","51079-205-01","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALLOPURINOL 100 MG TABS","51079-205-01","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 300 MG TABS","51079-206-01","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALLOPURINOL 300 MG TABS","51079-206-01","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 300 MG TABS","51079-206-20","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 300 MG TABS","51079-206-20","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICLOFENAC DR 75 MG TBEC","51079-224-01","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL 25 MG TABS","51079-255-01","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL 25 MG TABS","51079-255-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 2 MG TABS","51079-284-01","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 2 MG TABS","51079-284-01","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIAZEPAM 5 MG TABS","51079-285-01","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 5 MG TABS","51079-285-01","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORDIAZEPOXIDE 5 MG CAPS","51079-374-01","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORDIAZEPOXIDE 5 MG CAPS","51079-374-01","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE 500 MG TABS","51079-379-01","NDC","","","","","facility","both","1","EA","UD","0.96","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG TABS","51079-379-01","NDC","","","","","facility","both","1","EA","","0.96","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 2 MG TABS","51079-387-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 2 MG TABS","51079-387-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXEPIN 10 MG CAPS","51079-436-01","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXEPIN 10 MG CAPS","51079-436-01","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXEPIN 25 MG CAPS","51079-437-01","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXEPIN 25 MG CAPS","51079-437-01","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 50 MCG TABS","51079-440-01","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 50 MCG TABS","51079-440-01","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 75 MCG TABS","51079-441-01","NDC","","","","","facility","both","1","EA","","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 75 MCG TABS","51079-441-01","NDC","","","","","facility","both","1","EA","UD","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 100 MCG TABS","51079-442-01","NDC","","","","","facility","both","1","EA","","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 100 MCG TABS","51079-442-01","NDC","","","","","facility","both","1","EA","UD","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 25 MCG TABS","51079-444-01","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 25 MCG TABS","51079-444-01","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 5 MG TABS","51079-453-01","NDC","","","","","facility","both","1","EA","UD","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 5 MG TABS","51079-453-01","NDC","","","","","facility","both","1","EA","","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORPROMAZINE 100 MG TABS","51079-516-01","NDC","","","","","facility","both","1","EA","UD","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 10 MG TABS","51079-518-01","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIFLUOPERAZINE 1 MG TABS","51079-572-01","NDC","","","","","facility","both","1","EA","","4.67","2.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIFLUOPERAZINE 1 MG TABS","51079-572-01","NDC","","","","","facility","both","1","EA","UD","4.67","2.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAZOSIN 1 MG CAPS","51079-630-01","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAZOSIN 1 MG CAPS","51079-630-01","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAZOSIN 5 MG CAPS","51079-632-01","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAZOSIN 5 MG CAPS","51079-632-01","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOBENZAPRINE 10 MG TABS","51079-644-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 10 MG TABS","51079-644-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXEPIN 100 MG CAPS","51079-651-01","NDC","","","","","facility","both","1","EA","UD","0.57","0.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXEPIN 100 MG CAPS","51079-651-01","NDC","","","","","facility","both","1","EA","","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOTREXATE 2.5 MG TABS","51079-670-01","NDC","","","","","facility","both","1","EA","","2.01","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOTREXATE 2.5 MG TABS","51079-670-01","NDC","","","","","facility","both","1","EA","UD","7.02","3.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATENOLOL 50 MG TABS","51079-684-01","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATENOLOL 50 MG TABS","51079-684-01","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 250 MG CAPS","51079-721-01","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE 250 MG CAPS","51079-721-01","NDC","","","","","facility","both","1","EA","UD","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 250 MG CAPS","51079-721-20","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HALOPERIDOL 0.5 MG TABS","51079-733-01","NDC","","","","","facility","both","1","EA","UD","1.7","0.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 0.5 MG TABS","51079-733-01","NDC","","","","","facility","both","1","EA","","0.7","0.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HALOPERIDOL 1 MG TABS","51079-734-01","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 1 MG TABS","51079-734-01","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HALOPERIDOL 1 MG TABS","51079-734-20","NDC","","","","","facility","both","1","EA","UD","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 5 MG TABS","51079-736-01","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 5 MG TABS","51079-736-01","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 60 MG TABS","51079-746-20","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUCRALFATE 1 GRAM TABS","51079-753-01","NDC","","","","","facility","both","1","EA","UD","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUCRALFATE 1 GRAM TABS","51079-753-01","NDC","","","","","facility","both","1","EA","","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATENOLOL 25 MG TABS","51079-759-01","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATENOLOL 25 MG TABS","51079-759-01","NDC","","","","","facility","both","1","EA","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL 50 MG TABS","51079-801-01","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL 50 MG TABS","51079-801-01","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIPIZIDE 5 MG TABS","51079-810-20","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NADOLOL 20 MG TABS","51079-812-01","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 1 MG CAPS","51079-818-01","NDC","","","","","facility","both","1","EA","UD","0.88","0.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 1 MG CAPS","51079-818-01","NDC","","","","","facility","both","1","EA","","0.88","0.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 500 MG TABS","51079-821-01","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","51079-821-01","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CAPTOPRIL TABS","51079-863-01","NDC","","","","","facility","both","1","EA","","1.93","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOCLOPRAMIDE 5 MG TABS","51079-886-01","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 5 MG TABS","51079-886-01","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOCLOPRAMIDE 5 MG TABS","51079-886-20","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOCLOPRAMIDE 5 MG TABS","51079-886-20","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 10 MG TABS","51079-888-01","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 10 MG TABS","51079-888-01","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 24HR 120 MG C24P","51079-917-01","NDC","","","","","facility","both","1","EA","UD","5.37","2.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 24HR 120 MG C24P","51079-917-01","NDC","","","","","facility","both","1","EA","","5.37","2.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOZAPINE 25 MG TABS","51079-921-01","NDC","","","","","facility","both","1","EA","UD","0.61","0.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOZAPINE 25 MG TABS","51079-921-20","NDC","","","","","facility","both","1","EA","UD","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOZAPINE 100 MG TABS","51079-922-01","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOZAPINE 100 MG TABS","51079-922-20","NDC","","","","","facility","both","1","EA","UD","3.82","1.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 12HR 60 MG CP12","51079-924-01","NDC","","","","","facility","both","1","EA","UD","8.5","4.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 12HR 60 MG CP12","51079-924-01","NDC","","","","","facility","both","1","EA","","8.5","4.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 12HR 90 MG CP12","51079-925-01","NDC","","","","","facility","both","1","EA","UD","9.55","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 12HR 90 MG CP12","51079-925-01","NDC","","","","","facility","both","1","EA","","18.1","9.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LABETALOL 100 MG TABS","51079-928-01","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 100 MG TABS","51079-928-01","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","51079-931-01","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","51079-931-01","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA CR 25-100 MG TBSR","51079-978-01","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUSPIRONE 5 MG TABS","51079-985-01","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUSPIRONE 5 MG TABS","51079-985-01","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUSPIRONE 10 MG TABS","51079-986-01","NDC","","","","","facility","both","1","EA","UD","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUSPIRONE 10 MG TABS","51079-986-01","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUSPIRONE 10 MG TABS","51079-986-20","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUSPIRONE 10 MG TABS","51079-986-20","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAMADOL 50 MG TABS","51079-991-20","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAMADOL 50 MG TABS","51079-991-20","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUVOXAMINE 50 MG TABS","51079-992-01","NDC","","","","","facility","both","1","EA","UD","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHOLECALCIFEROL 10 MCG/DROP (400 UNIT/DROP) DROP 2.5 ML DROP BTL","5122800006","NDC","","","","","facility","both","1","EA","UD","2.61","1.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHOLECALCIFEROL 10 MCG/DROP (400 UNIT/DROP) DROP 2.5 ML DROP BTL","5122800006","NDC","","","","","facility","both","1","EA","","2.61","1.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENAZOPYRIDINE 100 MG TABS","51293-810-01","NDC","","","","","facility","both","1","EA","","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENAZOPYRIDINE 100 MG TABS","51293-810-01","NDC","","","","","facility","both","1","EA","UD","2.62","1.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TAMOXIFEN 10 MG TABS","51407-439-60","NDC","","","","","facility","both","1","EA","","3.58","1.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETIC ACID (BULK) 3 % LIQD 500 ML BOTTLE","5155200516","NDC","","","","","facility","both","1","EA","UD","60.5","30.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PSEUDOEPHEDRINE SR 120 MG TBSR","51660-204-69","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PSEUDOEPHEDRINE SR 120 MG TBSR","51660-204-69","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOBETASOL 0.05 % OINT 15 G TUBE","51672-1259-1","NDC","","","","","facility","both","1","EA","","10.14","5.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOBETASOL 0.05 % OINT 15 G TUBE","51672-1259-1","NDC","","","","","facility","both","1","EA","UD","10.14","5.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 1 % SOLN 30 ML BOTTLE","51672-1260-3","NDC","","","","","facility","both","1","EA","","45.19","22.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CLOTRIMAZOLE 1 % SOLN 30 ML BOTTLE","51672-1260-3","NDC","","","","","facility","both","1","EA","UD","45.19","22.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % PSTE 5 G TUBE","51672-1267-5","NDC","","","","","facility","both","1","EA","UD","166.68","83.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERCONAZOLE 0.4 % CREA 45 G TUBE/KIT","51672-1304-6","NDC","","","","","facility","both","1","EA","","126.37","63.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CICLOPIROX 0.77 % CREA 30 G TUBE","51672-1318-2","NDC","","","","","facility","both","1","EA","UD","47.41","23.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CICLOPIROX 0.77 % CREA 30 G TUBE","51672-1318-2","NDC","","","","","facility","both","1","EA","","47.41","23.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MICONAZOLE 2 % CREA 30 G TUBE","51672-2001-2","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOTRIMAZOLE 1 % CREA 45 G TUBE/KIT","51672-2003-6","NDC","","","","","facility","both","1","EA","UD","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 1 % CREA 45 G TUBE/KIT","51672-2003-6","NDC","","","","","facility","both","1","EA","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 0.5 % CREA 28.4 G TUBE","51672-2010-2","NDC","","","","","facility","both","1","EA","UD","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 0.5 % CREA 28.4 G TUBE","51672-2010-2","NDC","","","","","facility","both","1","EA","","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MICONAZOLE 2 % CREA 45 G TUBE/KIT","51672-2035-6","NDC","","","","","facility","both","1","EA","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"MICONAZOLE 2 % CREA 45 G TUBE/KIT","51672-2035-6","NDC","","","","","facility","both","1","EA","UD","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERBINAFINE HCL 1 % CREA 15 G TUBE","51672-2080-1","NDC","","","","","facility","both","1","EA","","23.52","11.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TERBINAFINE HCL 1 % CREA 15 G TUBE","51672-2080-1","NDC","","","","","facility","both","1","EA","UD","23.52","11.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 325 MG SUPP","51672-2116-0","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 325 MG SUPP","51672-2116-0","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE 5 % OINT 35.44 G TUBE","51672-3020-9","NDC","","","","","facility","both","1","EA","","15.27","7.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOMIPRAMINE 25 MG CAPS","51672-4011-6","NDC","","","","","facility","both","1","EA","","1.99","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 1 MG TABS","51672-4027-1","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 1 MG TABS","51672-4027-1","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENALAPRIL 2.5 MG TABS","51672-4037-1","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ENALAPRIL 2.5 MG TABS","51672-4037-1","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE XR 12 HOUR 100 MG TB12","51672-4123-1","NDC","","","","","facility","both","1","EA","UD","2.1","1.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE XR 12 HOUR 100 MG TB12","51672-4123-1","NDC","","","","","facility","both","1","EA","","2.1","1.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN 50 MG CHEW","51672-4146-1","NDC","","","","","facility","both","1","EA","UD","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 1,000 MG/100 ML (10 MG/ML) PGBK","51754-0108-1","NDC","","","","","facility","both","1","EA","","51.2","25.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRANEXAMIC ACID 1,000 MG/100 ML (10 MG/ML) PGBK","51754-0108-1","NDC","","","","","facility","both","1","EA","UD","84","42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 10 ML VIAL","51754-1000-4","NDC","","","","","facility","both","1","EA","","13.31","6.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 10 ML VIAL","51754-1000-4","NDC","","","","","facility","both","1","EA","UD","13.31","6.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROPRUSSIDE IN 0.9 % NACL 50 MG/100 ML (0.5 MG/ML) SOLN","51754-1006-1","NDC","","","","","facility","both","1","EA","","277.5","138.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYSTEINE (L-CYSTEINE) 50 MG/ML SOLN 10 ML VIAL","51754-1007-1","NDC","","","","","facility","both","1","EA","UD","101.94","50.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYSTEINE (L-CYSTEINE) 50 MG/ML SOLN 10 ML VIAL","51754-1007-1","NDC","","","","","facility","both","1","EA","","129.4","64.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM ACETATE 2 MEQ/ML SOLN 20 ML VIAL","51754-2001-4","NDC","","","","","facility","both","1","EA","","23.5","11.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","51754-5001-1","NDC","","","","","facility","both","1","EA","","39.38","19.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","51754-5001-1","NDC","","","","","facility","both","1","EA","UD","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE ER 100 MG/0.28 ML SERS","51759-520-10","NDC","","","","","facility","both","1","EA","","10555.83","5277.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RISPERIDONE ER 100 MG/0.28 ML SERS","51759-520-10","NDC","","","","","facility","both","1","EA","UD","10940.37","5470.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 125 MG/0.35 ML SERS","51759-630-10","NDC","","","","","facility","both","1","EA","TB","13438.71","6719.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"RISPERIDONE 125 MG/0.35 ML SERS","51759-630-10","NDC","","","","","facility","both","1","EA","","13438.71","6719.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM BICARBONATE 25 MEQ TBEF","51801-001-01","NDC","","","","","facility","both","1","EA","","2.02","1.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIMETHOPRIM 100 MG TABS","51862-486-01","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINERAL OIL OIL 1 ML BOTTLE","5192712910","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHYLERGONOVINE 0.2 MG/ML (1 ML) SOLN","51991-144-99","NDC","","","","","facility","both","1","EA","UD","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLERGONOVINE 0.2 MG/ML (1 ML) SOLN","51991-144-99","NDC","","","","","facility","both","1","EA","","45","22.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DESVENLAFAXINE SUCCINATE 50 MG TB24","51991-311-33","NDC","","","","","facility","both","1","EA","UD","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESVENLAFAXINE SUCCINATE 50 MG TB24","51991-311-33","NDC","","","","","facility","both","1","EA","","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DESVENLAFAXINE SUCCINATE 100 MG TB24","51991-312-33","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DESVENLAFAXINE SUCCINATE 100 MG TB24","51991-312-33","NDC","","","","","facility","both","1","EA","UD","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESVENLAFAXINE SUCCINATE 100 MG TB24","51991-312-90","NDC","","","","","facility","both","1","EA","","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DESVENLAFAXINE SUCCINATE 100 MG TB24","51991-312-90","NDC","","","","","facility","both","1","EA","UD","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABS","51991-379-99","NDC","","","","","facility","both","1","EA","","38.5","19.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOLIC ACID-VIT B6-VIT B12 2.5-25-2 MG TABS","5199138490","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOLIC ACID-VIT B6-VIT B12 2.5-25-2 MG TABS","5199138490","NDC","","","","","facility","both","1","EA","","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYPROHEPTADINE 4 MG TABS","51991-838-01","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOMEFOLATE CA 3 MG-B6 35 MG-B12 2MG 3 MG-35 MG-2 MG -90.314 MG CAPS","5199191333","NDC","","","","","facility","both","1","EA","UD","5.18","2.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FIDAXOMICIN 200 MG TABS","52015-080-01","NDC","","","","","facility","both","1","EA","UD","272.94","136.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FIDAXOMICIN 200 MG TABS","52015-080-01","NDC","","","","","facility","both","1","EA","","272.94","136.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYETHYLENE GLYCOL 236-22.74-6.74 -5.86 GRAM SOLR 4,000 ML BOTTLE","52268-100-01","NDC","","","","","facility","both","1","EA","UD","43","21.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYETHYLENE GLYCOL 236-22.74-6.74 -5.86 GRAM SOLR 4,000 ML BOTTLE","52268-100-01","NDC","","","","","facility","both","1","EA","","43","21.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ERYTHROMYCIN 333 MG TBEC","52536-183-03","NDC","","","","","facility","both","1","EA","","2.54","1.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERYTHROMYCIN 333 MG TBEC","52536-183-03","NDC","","","","","facility","both","1","EA","UD","2.54","1.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RAMELTEON 8 MG TABS","52817-235-30","NDC","","","","","facility","both","1","EA","","4.12","2.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 5 MG TABS","52817-330-10","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 5 MG TABS","52817-330-10","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOBENZAPRINE 10 MG TABS","52817-332-10","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 10 MG TABS","52817-332-10","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","52817-391-10","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 454 G JAR","52817-811-54","NDC","","","","","facility","both","1","EA","UD","62.97","31.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE 0.1 % CREA 454 G JAR","52817-811-54","NDC","","","","","facility","both","1","EA","","62.97","31.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 30 G TUBE","52959-054-07","NDC","","","","","facility","both","1","EA","UD","6.36","3.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM OINT 30 G TUBE","52959-054-07","NDC","","","","","facility","both","1","EA","","6.36","3.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML SU12","53014-548-05","NDC","","","","","facility","both","1","EA","UD","19.51","9.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-CHLORPHENIRAMINE 10-8 MG/5 ML SU12","53014-548-05","NDC","","","","","facility","both","1","EA","","19.51","9.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BACITRACIN 500 UNIT/GRAM OIPK","53329-089-87","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUINIDINE GLUCONATE SR 324 MG TBSR","53489-141-01","NDC","","","","","facility","both","1","EA","","16.16","8.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BETHANECHOL 5 MG TABS","53746-571-01","NDC","","","","","facility","both","1","EA","","1.42","0.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BETHANECHOL 5 MG TABS","53746-571-01","NDC","","","","","facility","both","1","EA","UD","1.85","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUANFACINE 1 MG TABS","53746-711-01","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUANFACINE 1 MG TABS","53746-711-01","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","53746-831-53","NDC","","","","","facility","both","1","EA","UD","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","53746-831-53","NDC","","","","","facility","both","1","EA","","443.49","221.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MESALAMINE SR 250 MG CPSR","54092-189-81","NDC","","","","","facility","both","1","EA","","10.11","5.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) SOLN","54288-103-10","NDC","","","","","facility","both","1","EA","UD","71.25","35.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) SOLN","54288-103-10","NDC","","","","","facility","both","1","EA","","71.25","35.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ETHYL ALCOHOL 99 % SOLN","54288-105-02","NDC","","","","","facility","both","1","EA","","2936.84","1468.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETHYL ALCOHOL 99 % SOLN","54288-105-02","NDC","","","","","facility","both","1","EA","UD","14399.24","7199.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 1 MG/ML SOLN","54288-120-01","NDC","","","","","facility","both","1","EA","","96.25","48.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPINEPHRINE 1 MG/ML SOLN","54288-120-01","NDC","","","","","facility","both","1","EA","UD","190","95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","54288-141-01","NDC","","","","","facility","both","1","EA","JG","61.38","30.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","54288-141-01","NDC","","","","","facility","both","1","EA","JG,UD","96.25","48.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","54288-141-04","NDC","","","","","facility","both","1","EA","JG","61.38","30.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","54288-141-04","NDC","","","","","facility","both","1","EA","JG,UD","96.25","48.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","54288-141-04","NDC","","","","","facility","both","1","EA","","179.13","89.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH"
"METHYLENE BLUE 1 % (10 MG/ML) SOLN 10 ML VIAL","54288-147-01","NDC","","","","","facility","both","1","EA","","979.06","489.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHYLENE BLUE 1 % (10 MG/ML) SOLN 10 ML VIAL","54288-147-01","NDC","","","","","facility","both","1","EA","JG","1568.58","784.29","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"METHYLENE BLUE 1 % (10 MG/ML) SOLN 10 ML VIAL","54288-147-01","NDC","","","","","facility","both","1","EA","UD","1078.62","539.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","54569-4557-0","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOXYMETHYLCELLULOSE 0.5 % DPET","54569-4557-0","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 250 MCG TABS","54629-0580-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 250 MCG TABS","54629-0580-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MULTIVITAMINS - PEDIATRIC 80 MG-400 UNIT- 200 MCG/5 ML SOLN 50 ML VIAL","54643-5647-0","NDC","","","","","facility","both","1","EA","UD","41.71","20.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMINS - PEDIATRIC 80 MG-400 UNIT- 200 MCG/5 ML SOLN 50 ML VIAL","54643-5647-0","NDC","","","","","facility","both","1","EA","","47.59","23.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MULTIVITAMIN 3,300 UNIT-150 MCG/10 ML (2 X 5 ML VIALS) SOLN 10 ML VIAL","54643-5649-1","NDC","","","","","facility","both","1","EA","UD","86.13","43.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVITAMIN 3,300 UNIT-150 MCG/10 ML (2 X 5 ML VIALS) SOLN 10 ML VIAL","54643-5649-1","NDC","","","","","facility","both","1","EA","","86.13","43.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"MULTIVITAMIN 3,300 UNIT-150 MCG/10 ML (2 X 5 ML VIALS) SOLN 100 ML VIAL","54643-9015-2","NDC","","","","","facility","both","1","EA","","73.38","36.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MULTIVITAMIN 3,300 UNIT-150 MCG/10 ML (2 X 5 ML VIALS) SOLN 100 ML VIAL","54643-9015-2","NDC","","","","","facility","both","1","EA","UD","73.38","36.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMIVUDINE 10 MG/ML SOLN","54838-566-70","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LAMIVUDINE 10 MG/ML SOLN","54838-566-70","NDC","","","","","facility","both","1","EA","UD","10.99","5.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX-VITAMIN C-FOLIC ACID 900 MCG/5 ML LIQD","54859-516-05","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"B COMPLEX-VITAMIN C-FOLIC ACID 900 MCG/5 ML LIQD","54859-516-05","NDC","","","","","facility","both","1","EA","UD","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFABUTIN 150 MG CAPS","55045-2203-1","NDC","","","","","facility","both","1","EA","UD","28.86","14.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE ZYDIS 5 MG ODT.","55111-262-79","NDC","","","","","facility","both","1","EA","UD","3.31","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE ZYDIS 5 MG ODT.","55111-262-79","NDC","","","","","facility","both","1","EA","","3.31","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE ZYDIS 10 MG ODT.","55111-263-79","NDC","","","","","facility","both","1","EA","","3.39","1.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE ZYDIS 10 MG ODT.","55111-263-79","NDC","","","","","facility","both","1","EA","UD","3.39","1.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DONEPEZIL 23 MG TABS","55111-302-30","NDC","","","","","facility","both","1","EA","","3.5","1.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NATEGLINIDE 60 MG TABS","55111-328-90","NDC","","","","","facility","both","1","EA","","2.37","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DECITABINE 50 MG SOLR 1 EACH VIAL","55111-556-10","NDC","","","","","facility","both","1","EA","","377.6","188.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DECITABINE 50 MG SOLR 1 EACH VIAL","55111-556-10","NDC","","","","","facility","both","1","EA","UD","384.8","192.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","55111-652-07","NDC","","","","","facility","both","1","EA","UD","129.84","64.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","55111-652-07","NDC","","","","","facility","both","1","EA","","129.84","64.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","55111-678-11","NDC","","","","","facility","both","1","EA","","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","55111-678-11","NDC","","","","","facility","both","1","EA","UD","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLEDRONIC ACID 4 MG/5 ML SOLN 5 ML VIAL","55111-685-07","NDC","","","","","facility","both","1","EA","UD","107.97","53.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLEDRONIC ACID 4 MG/5 ML SOLN 5 ML VIAL","55111-685-07","NDC","","","","","facility","both","1","EA","","140","70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZOLEDRONIC ACID-MANNITOL&WATER 5 MG/100 ML PGBK","55111-688-52","NDC","","","","","facility","both","1","EA","","627.5","313.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PALONOSETRON 0.25 MG/5 ML SOLN","55111-694-07","NDC","","","","","facility","both","1","EA","","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PALONOSETRON 0.25 MG/5 ML SOLN","55111-694-07","NDC","","","","","facility","both","1","EA","UD","40","20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 500 MG SOLR","55150-112-10","NDC","","","","","facility","both","1","EA","","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN 1 GRAM SOLR 1 EACH VIAL","55150-113-10","NDC","","","","","facility","both","1","EA","UD","12.56","6.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 1 GRAM SOLR 1 EACH VIAL","55150-113-10","NDC","","","","","facility","both","1","EA","","12.56","6.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","55150-114-20","NDC","","","","","facility","both","1","EA","UD","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","55150-114-20","NDC","","","","","facility","both","1","EA","","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN/SULBACTAM 1.5 GRAM SOLR 1 EACH VIAL","55150-116-20","NDC","","","","","facility","both","1","EA","UD","17.13","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN/SULBACTAM 1.5 GRAM SOLR 1 EACH VIAL","55150-116-20","NDC","","","","","facility","both","1","EA","","17.13","8.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","55150-117-20","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","55150-117-20","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 2250 MG SOLR 1 EACH VIAL","55150-119-30","NDC","","","","","facility","both","1","EA","","21.19","10.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"PIPERACILLIN-TAZOBACTAM 2250 MG SOLR 1 EACH VIAL","55150-119-30","NDC","","","","","facility","both","1","EA","UD","21.19","10.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","55150-120-30","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","55150-120-30","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","55150-121-50","NDC","","","","","facility","both","1","EA","UD","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","55150-121-50","NDC","","","","","facility","both","1","EA","","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","55150-123-15","NDC","","","","","facility","both","1","EA","","53.81","26.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","55150-123-15","NDC","","","","","facility","both","1","EA","UD","53.81","26.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXACILLIN 10 GRAM SOLR 1 EACH VIAL","55150-129-99","NDC","","","","","facility","both","1","EA","UD","74.74","37.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 50 MG/ML SOLN","55150-154-10","NDC","","","","","facility","both","1","EA","","4.33","2.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ACYCLOVIR 50 MG/ML SOLN","55150-154-10","NDC","","","","","facility","both","1","EA","UD","5.42","2.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 50 MG/ML SOLN","55150-155-20","NDC","","","","","facility","both","1","EA","UD","5.47","2.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 50 MG/ML SOLN","55150-155-20","NDC","","","","","facility","both","1","EA","","53.75","26.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","55150-161-02","NDC","","","","","facility","both","1","EA","UD","9.06","4.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","55150-161-02","NDC","","","","","facility","both","1","EA","","9.06","4.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","55150-162-05","NDC","","","","","facility","both","1","EA","UD","7.75","3.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","55150-162-05","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","55150-163-30","NDC","","","","","facility","both","1","EA","","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","55150-163-30","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML SOLN","55150-166-13","NDC","","","","","facility","both","1","EA","","1158.75","579.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML SOLN","55150-166-13","NDC","","","","","facility","both","1","EA","UD","1158.75","579.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE HCL INJECTION 0.25%, PER ML","55150-167-10","NDC","","","","","facility","both","1","EA","PN","0.84","0.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BUPIVACAINE HCL INJECTION 0.25%, PER ML","55150-167-10","NDC","","","","","facility","both","1","EA","","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE HCL INJECTION 0.25%, PER ML","55150-167-10","NDC","","","","","facility","both","1","EA","UD","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","55150-168-30","NDC","","","","","facility","both","1","EA","UD","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","55150-168-30","NDC","","","","","facility","both","1","EA","","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","55150-168-30","NDC","","","","","facility","both","1","EA","PN","0.28","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BUPIVACAINE PF (MARCAINE-PF) 0.5% 0.5% SOLN 10 ML VIAL","55150-169-10","NDC","","","","","facility","both","1","EA","UD","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.5% 0.5% SOLN 10 ML VIAL","55150-169-10","NDC","","","","","facility","both","1","EA","","2.52","1.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE PF (MARCAINE-PF) 0.5% 0.5% SOLN","55150-170-30","NDC","","","","","facility","both","1","EA","UD","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.5% 0.5% SOLN","55150-170-30","NDC","","","","","facility","both","1","EA","","13.13","6.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"SUMATRIPTAN 6 MG/0.5 ML SOLN","55150-173-01","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"SUMATRIPTAN 6 MG/0.5 ML SOLN","55150-173-01","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUMATRIPTAN 6 MG/0.5 ML SOLN","55150-173-05","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","55150-174-10","NDC","","","","","facility","both","1","EA","UD","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","55150-174-10","NDC","","","","","facility","both","1","EA","","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"NICARDIPINE 25 MG/10 ML SOLN","55150-183-01","NDC","","","","","facility","both","1","EA","UD","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICARDIPINE 25 MG/10 ML SOLN","55150-183-01","NDC","","","","","facility","both","1","EA","","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","55150-183-02","NDC","","","","","facility","both","1","EA","UD","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","55150-183-02","NDC","","","","","facility","both","1","EA","","111.88","55.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","55150-183-10","NDC","","","","","facility","both","1","EA","","218.75","109.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"NICARDIPINE 25 MG/10 ML SOLN 10 ML VIAL","55150-183-10","NDC","","","","","facility","both","1","EA","UD","221.25","110.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN","55150-188-10","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN","55150-188-10","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IBANDRONATE 3 MG/3 ML SYRG","55150-191-83","NDC","","","","","facility","both","1","EA","JG","1223.24","611.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ADENOSINE 3 MG/ML SOLN","55150-192-01","NDC","","","","","facility","both","1","EA","","83.75","41.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ADENOSINE 3 MG/ML SOLN","55150-192-01","NDC","","","","","facility","both","1","EA","UD","124.38","62.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 100 MG/10 ML (10 MG/ML) SOLN","55150-194-10","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 100 MG/10 ML (10 MG/ML) SOLN","55150-194-10","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ROPIVACAINE (PF) 0.5% SOLN","55150-198-30","NDC","","","","","facility","both","1","EA","","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ROPIVACAINE (PF) 0.5% SOLN","55150-198-30","NDC","","","","","facility","both","1","EA","UD","20.88","10.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOPRAZOLE 40 MG SOLR","55150-202-00","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOPRAZOLE 40 MG SOLR","55150-202-00","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEROPENEM 500 MG SOLR","55150-207-20","NDC","","","","","facility","both","1","EA","","16.25","8.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"MEROPENEM 500 MG SOLR","55150-207-20","NDC","","","","","facility","both","1","EA","UD","16.25","8.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEROPENEM 1 GRAM SOLR","55150-208-30","NDC","","","","","facility","both","1","EA","UD","32.19","16.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEROPENEM 1 GRAM SOLR","55150-208-30","NDC","","","","","facility","both","1","EA","","15.28","7.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"ETOMIDATE 2 MG/ML SOLN","55150-222-20","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOMIDATE 2 MG/ML SOLN","55150-222-20","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"METHOCARBAMOL 100 MG/ML SOLN","55150-223-10","NDC","","","","","facility","both","1","EA","UD","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 100 MG/ML SOLN","55150-223-10","NDC","","","","","facility","both","1","EA","","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ROCURONIUM 10 MG/ML SOLN","55150-225-05","NDC","","","","","facility","both","1","EA","","12.19","6.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ROCURONIUM 10 MG/ML SOLN","55150-225-05","NDC","","","","","facility","both","1","EA","UD","12.19","6.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","55150-230-00","NDC","","","","","facility","both","1","EA","UD","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","55150-230-00","NDC","","","","","facility","both","1","EA","","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FONDAPARINUX 7.5 MG/0.6 ML SYRG","55150-232-00","NDC","","","","","facility","both","1","EA","","185.31","92.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VECURONIUM 10 MG SOLR","55150-235-01","NDC","","","","","facility","both","1","EA","UD","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VECURONIUM 10 MG SOLR","55150-235-01","NDC","","","","","facility","both","1","EA","","27.25","13.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","55150-242-51","NDC","","","","","facility","both","1","EA","","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","55150-242-51","NDC","","","","","facility","both","1","EA","UD","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE HCL INJECTION 0.25%, PER ML","55150-249-50","NDC","","","","","facility","both","1","EA","PN","0.28","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LIDOCAINE (XYLOCAINE) 1% SOLN","55150-251-10","NDC","","","","","facility","both","1","EA","","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","55150-252-20","NDC","","","","","facility","both","1","EA","UD","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","55150-252-20","NDC","","","","","facility","both","1","EA","","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 2% SOLN","55150-254-10","NDC","","","","","facility","both","1","EA","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 2% SOLN","55150-254-10","NDC","","","","","facility","both","1","EA","UD","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 2% SOLN","55150-255-20","NDC","","","","","facility","both","1","EA","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ERTAPENEM 1 GRAM SOLR","55150-282-20","NDC","","","","","facility","both","1","EA","","190","95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"ERTAPENEM 1 GRAM SOLR","55150-282-20","NDC","","","","","facility","both","1","EA","UD","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","55150-297-01","NDC","","","","","facility","both","1","EA","UD","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","55150-297-01","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","55150-301-01","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE PF 10 MG/ML SOLN 1 ML VIAL","55150-304-01","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE PF 10 MG/ML SOLN 1 ML VIAL","55150-304-01","NDC","","","","","facility","both","1","EA","","13.44","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE PF 10 MG/ML SOLN 1 ML VIAL","55150-304-25","NDC","","","","","facility","both","1","EA","","13.44","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"OLANZAPINE 10 MG/2ML SOLR","55150-308-01","NDC","","","","","facility","both","1","EA","","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 10 MG/2ML SOLR","55150-308-01","NDC","","","","","facility","both","1","EA","UD","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOPROTERENOL 0.2 MG/ML SOLN 5 ML AMPUL","55150-317-01","NDC","","","","","facility","both","1","EA","","440","220","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MEDROXYPROGESTERONE 150 MG/ML SUSPENSION","55150-329-01","NDC","","","","","facility","both","1","EA","UD","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEDROXYPROGESTERONE 150 MG/ML SUSPENSION","55150-329-01","NDC","","","","","facility","both","1","EA","","158.75","79.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BORTEZOMIB 3.5 MG SOLR","55150-337-01","NDC","","","","","facility","both","1","EA","UD","124.06","62.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BORTEZOMIB 3.5 MG SOLR","55150-337-01","NDC","","","","","facility","both","1","EA","JG","153.04","76.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"NALOXONE 1 MG/ML SYRG","55150-345-01","NDC","","","","","facility","both","1","EA","UD","100.94","50.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXONE 1 MG/ML SYRG","55150-345-01","NDC","","","","","facility","both","1","EA","","100.94","50.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","55150-352-01","NDC","","","","","facility","both","1","EA","UD","34.5","17.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","55150-352-01","NDC","","","","","facility","both","1","EA","","34.5","17.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 300 MG/15 ML SOLN 15 ML VIAL","55150-354-01","NDC","","","","","facility","both","1","EA","","229.98","114.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMPHOTERICIN B LIPOSOMAL 50 MG SUSR 1 EACH VIAL","55150-365-01","NDC","","","","","facility","both","1","EA","","6796.64","3398.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPHOTERICIN B LIPOSOMAL 50 MG SUSR 1 EACH VIAL","55150-365-01","NDC","","","","","facility","both","1","EA","JG","8019.44","4009.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"AMPHOTERICIN B LIPOSOMAL 50 MG SUSR 1 EACH VIAL","55150-365-01","NDC","","","","","facility","both","1","EA","TB","9242.24","4621.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"VASOPRESSIN 20 UNIT/ML SOLN","55150-370-00","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","55150-370-01","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","55150-370-01","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","55150-370-25","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","55150-370-25","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL","55150-386-01","NDC","","","","","facility","both","1","EA","","206.31","103.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETAMINE 10 MG/ML SOLN","55150-438-01","NDC","","","","","facility","both","1","EA","","236.6","118.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETAMINE 10 MG/ML SOLN","55150-438-10","NDC","","","","","facility","both","1","EA","","584","292","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL","55150-471-01","NDC","","","","","facility","both","1","EA","UD","128.13","64.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL","55150-471-01","NDC","","","","","facility","both","1","EA","","128.13","64.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACLOFEN 10 MG TABS","55154-7635-0","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 10 MG TABS","55154-7635-0","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARTIFICIAL SALIVA SPRP 120 ML SQUEEZ BTL","5529960104","NDC","","","","","facility","both","1","EA","UD","32.08","16.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARTIFICIAL SALIVA SPRP 120 ML SQUEEZ BTL","5529960104","NDC","","","","","facility","both","1","EA","","32.08","16.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACYCLOVIR 75MG/15ML SYRG","55390-612-10","NDC","","","","","facility","both","1","EA","UD","4.56","2.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 75MG/15ML SYRG","55390-612-10","NDC","","","","","facility","both","1","EA","","4.56","2.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"TRASTUZUMAB-ANNS 420 MG SOLR 1 EACH VIAL","55513-132-01","NDC","","","","","facility","both","1","EA","UD","7311.76","3655.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRASTUZUMAB-ANNS 150 MG SOLR 1 EACH VIAL","55513-141-01","NDC","","","","","facility","both","1","EA","UD","7311.74","3655.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA (ESRD) 4,000 UNIT/ML SOLN","55513-148-01","NDC","","","","","facility","both","1","EA","","389.58","194.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BLINATUMOMAB 35 MCG KIT 1 EACH VIAL","55513-160-01","NDC","","","","","facility","both","1","EA","","11796.31","5898.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PEGFILGRASTIM 6 MG/0.6 ML SYRG","55513-190-01","NDC","","","","","facility","both","1","EA","JG","25976.39","12988.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"PEGFILGRASTIM 6 MG/0.6 ML SYRG","55513-190-01","NDC","","","","","facility","both","1","EA","","25976.39","12988.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROMIPLOSTIM 250 MCG SOLR","55513-221-01","NDC","","","","","facility","both","1","EA","","3085.55","1542.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROMIPLOSTIM 500 MCG SOLR","55513-222-01","NDC","","","","","facility","both","1","EA","JG","28850.32","14425.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"RITUXIMAB-ARRX 10 MG/ML SOLN 10 ML VIAL","55513-224-01","NDC","","","","","facility","both","1","EA","UD","3511.88","1755.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RITUXIMAB-ARRX 10 MG/ML SOLN 50 ML VIAL","55513-326-01","NDC","","","","","facility","both","1","EA","UD","17203.2","8601.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVABRADINE 5 MG TABS","55513-800-60","NDC","","","","","facility","both","1","EA","UD","8.25","4.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IVABRADINE 5 MG TABS","55513-800-60","NDC","","","","","facility","both","1","EA","","23.14","11.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IVABRADINE 7.5 MG TABS","55513-810-60","NDC","","","","","facility","both","1","EA","","8.25","4.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IVABRADINE 7.5 MG TABS","55513-810-60","NDC","","","","","facility","both","1","EA","UD","8.25","4.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-880-01","NDC","","","","","facility","both","1","EA","JG","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SYRG","55513-880-02","NDC","","","","","facility","both","1","EA","","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SYRG","55513-880-02","NDC","","","","","facility","both","1","EA","UD","11199.75","5599.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-998-02","NDC","","","","","facility","both","1","EA","","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-998-02","NDC","","","","","facility","both","1","EA","JG,TB","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-998-02","NDC","","","","","facility","both","1","EA","JG,UD,TB","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-998-02","NDC","","","","","facility","both","1","EA","TB","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-998-02","NDC","","","","","facility","both","1","EA","JG,UD","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROMOSOZUMAB-AQQG 105 MG/1.17 ML SYRG","55513-998-02","NDC","","","","","facility","both","1","EA","JG","10710.81","5355.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"DINOPROSTONE 10 MG INSR","55566-2800-0","NDC","","","","","facility","both","1","EA","UD","541.83","270.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DINOPROSTONE 10 MG INSR","55566-2800-0","NDC","","","","","facility","both","1","EA","","541.83","270.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DINOPROSTONE 10 MG INSR","55566-2800-1","NDC","","","","","facility","both","1","EA","UD","541.83","270.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DINOPROSTONE 10 MG INSR","55566-2800-1","NDC","","","","","facility","both","1","EA","","541.83","270.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLUCOSE 4 GRAM CHEW","56151-1610-51","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLUCOSE 4 GRAM CHEW","56151-1610-51","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLUCOSE 4 GRAM CHEW","56151-1611-51","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 0.5 % CREA 28.35 G TUBE","56641-022-17","NDC","","","","","facility","both","1","EA","","28.35","14.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ZINC OXIDE 13 % CREA 120 G TUBE","57074-001-88","NDC","","","","","facility","both","1","EA","UD","11.92","5.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN V POTASSIUM 250 MG TABS","57237-040-01","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PENICILLIN V POTASSIUM 250 MG TABS","57237-040-01","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ONDANSETRON 4 MG TABS","57237-075-30","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG ODT.","57237-077-10","NDC","","","","","facility","both","1","EA","UD","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG ODT.","57237-077-10","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFDINIR 300 MG CAPS","57237-099-60","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALFUZOSIN 10 MG TB24","57237-114-90","NDC","","","","","facility","both","1","EA","","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","57237-324-03","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALUM-MAG HYDROXIDE-SIMETH DS 400-400-40 MG/5 ML SUSPENSION","57237-324-03","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 2 MG/ML SOLN","5751-3040-21","NDC","","","","","facility","both","1","EA","UD","11.43","5.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG/ML SOLN","5751-3040-21","NDC","","","","","facility","both","1","EA","","11.43","5.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","57664-683-31","NDC","","","","","facility","both","1","EA","","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","57664-683-31","NDC","","","","","facility","both","1","EA","UD","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXEGOL 12.5 MG TABS","57841-1300-1","NDC","","","","","facility","both","1","EA","","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALOXEGOL 25 MG TABS","57841-1301-3","NDC","","","","","facility","both","1","EA","","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALOXEGOL 25 MG TABS","57841-1301-3","NDC","","","","","facility","both","1","EA","UD","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-030-01","NDC","","","","","facility","both","1","EA","JG","4631.24","2315.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-030-01","NDC","","","","","facility","both","1","EA","UD","6911.24","3455.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-030-01","NDC","","","","","facility","both","1","EA","","20591.24","10295.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-160-01","NDC","","","","","facility","both","1","EA","JG","6911.24","3455.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-160-01","NDC","","","","","facility","both","1","EA","UD","6911.24","3455.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-160-01","NDC","","","","","facility","both","1","EA","","6911.24","3455.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INFLIXIMAB 100 MG SOLR 1 EACH VIAL","57894-160-01","NDC","","","","","facility","both","1","EA","JG,UD","25151.24","12575.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"GOLIMUMAB 12.5 MG/ML SOLN 4 ML VIAL","57894-350-01","NDC","","","","","facility","both","1","EA","TB","18303.87","9151.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"GOLIMUMAB 12.5 MG/ML SOLN 4 ML VIAL","57894-350-01","NDC","","","","","facility","both","1","EA","JG","18783.68","9391.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"GOLIMUMAB 12.5 MG/ML SOLN 4 ML VIAL","57894-350-01","NDC","","","","","facility","both","1","EA","JG,UD","21902.42","10951.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACITRACIN 500 UNIT/GRAM OIPK 1 EACH PACKET","57896-111-09","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACITRACIN 500 UNIT/GRAM OIPK 1 EACH PACKET","57896-111-09","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYL SALICYLATE-MENTHOL 15-10 % CREA 28 G TUBE","57896-116-01","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"METHYL SALICYLATE-MENTHOL 15-10 % CREA 28 G TUBE","57896-116-01","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","57896-147-01","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","57896-147-01","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SENNA-DOCUSATE 8.6-50 MG TABS","57896-303-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMETHICONE 80 MG CHEW","57896-791-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMETHICONE 80 MG CHEW","57896-791-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COENZYME Q10 100 MG CAPS","5789687503","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COENZYME Q10 100 MG CAPS","5789687503","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN 325 MG TABS","57896-901-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN 325 MG TABS","57896-901-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 325 MG TBEC","57896-921-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 325 MG TBEC","57896-921-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DALBAVANCIN 500 MG SOLN 1 EACH VIAL","57970-100-01","NDC","","","","","facility","both","1","EA","JG","7884.84","3942.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"DALBAVANCIN 500 MG SOLN 1 EACH VIAL","57970-100-01","NDC","","","","","facility","both","1","EA","TB","21762.05","10881.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"DALBAVANCIN 500 MG SOLN 1 EACH VIAL","57970-100-01","NDC","","","","","facility","both","1","EA","UD","7682.74","3841.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DALBAVANCIN 500 MG SOLN 1 EACH VIAL","57970-100-01","NDC","","","","","facility","both","1","EA","JG,UD","7682.74","3841.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"DALBAVANCIN 500 MG SOLN 1 EACH VIAL","57970-100-01","NDC","","","","","facility","both","1","EA","","7682.74","3841.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HEP B-DP(ACELL)T-POLIO VAC-PF 10 MCG-25LF-25 MCG-10LF/0.5 ML SYRG","58160-811-43","NDC","","","","","facility","both","1","EA","","497.88","248.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS A AND B VACCINE (PF) 720 ELISA UNIT- 20 MCG/ML SYRG","58160-815-43","NDC","","","","","facility","both","1","EA","","646.76","323.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS A AND B VACCINE (PF) 720 ELISA UNIT- 20 MCG/ML SYRG","58160-815-43","NDC","","","","","facility","both","1","EA","UD","646.76","323.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VARICELLA-ZOSTER 50 MCG/0.5 ML SUSR","58160-819-12","NDC","","","","","facility","both","1","EA","","951.59","475.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HEPATITIS B VACCINE (PF) 10 MCG/0.5ML","58160-820-43","NDC","","","","","facility","both","1","EA","","198.96","99.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS B VACCINE (PF) 10 MCG/0.5ML","58160-820-43","NDC","","","","","facility","both","1","EA","UD","198.96","99.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS B VIRUS VACCINE (PF) 20 MCG/ML SUSPENSION","58160-821-01","NDC","","","","","facility","both","1","EA","","705.76","352.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS B VIRUS VACCINE (PF) 20 MCG/ML SUSPENSION","58160-821-01","NDC","","","","","facility","both","1","EA","UD","731.14","365.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS B VIRUS VACCINE (PF) 20 MCG/ML SUSPENSION","58160-821-11","NDC","","","","","facility","both","1","EA","UD","388.5","194.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS B VIRUS VACCINE (PF) 20 MCG/ML SUSPENSION","58160-821-11","NDC","","","","","facility","both","1","EA","","388.5","194.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HEPATITIS B VIRUS VACCINE (PF) 20 MCG/ML SYRG","58160-821-43","NDC","","","","","facility","both","1","EA","UD","388.5","194.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS B VIRUS VACCINE (PF) 20 MCG/ML SYRG","58160-821-43","NDC","","","","","facility","both","1","EA","","388.5","194.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HZV VACC RECOMBINANT IM","58160-823-11","NDC","","","","","facility","both","1","EA","","689","344.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML SYRG","58160-826-43","NDC","","","","","facility","both","1","EA","UD","450.24","225.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML SYRG","58160-826-43","NDC","","","","","facility","both","1","EA","","465.4","232.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML SYRG","58160-826-52","NDC","","","","","facility","both","1","EA","UD","450.24","225.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPATITIS A VIRUS VACCINE (PF) 1,440 ELISA UNIT/ML SYRG","58160-826-52","NDC","","","","","facility","both","1","EA","","450.24","225.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HZV VACC RECOMBINANT IM","58160-828-03","NDC","","","","","facility","both","1","EA","PN","689","344.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HZV VACC RECOMBINANT IM","58160-828-03","NDC","","","","","facility","both","1","EA","","689","344.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RABIES VACCINE 2.5 UNIT SUSR","58160-964-12","NDC","","","","","facility","both","1","EA","","1890.63","945.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COAGULATION FACTOR IX (RECOMB) 2,000 UNIT SOLR","58394-136-03","NDC","","","","","facility","both","1","EA","UD","10500","5250","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTITHYMOCYTE GLOBULIN (RABBIT) 25 MG SOLR 1 EACH VIAL","58468-0080-1","NDC","","","","","facility","both","1","EA","UD","12888.89","6444.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTITHYMOCYTE GLOBULIN (RABBIT) 25 MG SOLR 1 EACH VIAL","58468-0080-1","NDC","","","","","facility","both","1","EA","","12888.89","6444.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ANTITHYMOCYTE GLOBULIN (RABBIT) 25 MG SOLR 1 EACH VIAL","58468-0080-1","NDC","","","","","facility","both","1","EA","UD,TB","13420.3","6710.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTITHYMOCYTE GLOBULIN (RABBIT) 25 MG SOLR 1 EACH VIAL","58468-0080-1","NDC","","","","","facility","both","1","EA","JG","16869.77","8434.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ANTITHYMOCYTE GLOBULIN (RABBIT) 25 MG SOLR 1 EACH VIAL","58468-0080-1","NDC","","","","","facility","both","1","EA","JG,UD","20850.66","10425.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTITHYMOCYTE GLOBULIN (RABBIT) 25 MG SOLR 1 EACH VIAL","58468-0080-1","NDC","","","","","facility","both","1","EA","TB","50842.52","25421.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","58468-0123-0","NDC","","","","","facility","both","1","EA","UD","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","58468-0123-0","NDC","","","","","facility","both","1","EA","","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","58468-0123-1","NDC","","","","","facility","both","1","EA","UD","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2%-EPINEPHRINE 1:100,000 2 %-1:100,000 SOLN","58472-032-50","NDC","","","","","facility","both","1","EA","UD","3.55","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2%-EPINEPHRINE 1:100,000 2 %-1:100,000 SOLN","58472-032-50","NDC","","","","","facility","both","1","EA","","3.55","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"LORATADINE 10 MG TABS","58602-702-83","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN HCL 250 MG TABS","58657-675-01","NDC","","","","","facility","both","1","EA","","0.35","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CIPROFLOXACIN HCL 250 MG TABS","58657-675-01","NDC","","","","","facility","both","1","EA","UD","1.69","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THERAPEUTIC MULTIVITAMIN-MINERALS TABS","58865-014-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICYCLOMINE 10 MG/ML SOLN","58914-080-52","NDC","","","","","facility","both","1","EA","","78.25","39.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"DICYCLOMINE 10 MG/ML SOLN","58914-080-52","NDC","","","","","facility","both","1","EA","UD","78.25","39.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BALSAM PERU-CASTOR OIL OINT 56.7 G TUBE","58980-780-21","NDC","","","","","facility","both","1","EA","UD","65.7","32.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BALSAM PERU-CASTOR OIL OINT 56.7 G TUBE","58980-780-21","NDC","","","","","facility","both","1","EA","","65.7","32.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"EMOLLIENT COMBINATION NO.10 EMUL 90 G TUBE","5898096031","NDC","","","","","facility","both","1","EA","UD","126.06","63.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE CR 10 MG TR12","59011-410-20","NDC","","","","","facility","both","1","EA","","7.26","3.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE CR 10 MG TR12","59011-410-20","NDC","","","","","facility","both","1","EA","UD","8.26","4.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE ER/CR 20 MG TR12","59011-420-10","NDC","","","","","facility","both","1","EA","","14.53","7.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE ER/CR 20 MG TR12","59011-420-20","NDC","","","","","facility","both","1","EA","UD","13.53","6.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE ER/CR 20 MG TR12","59011-420-20","NDC","","","","","facility","both","1","EA","","13.53","6.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE ER/CR 40 MG TR12","59011-440-20","NDC","","","","","facility","both","1","EA","UD","17.87","8.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE ER/CR 40 MG TR12","59011-440-20","NDC","","","","","facility","both","1","EA","","17.87","8.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 400 MG SSRR","59148-019-71","NDC","","","","","facility","both","1","EA","JG,UD","11551.23","5775.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 400 MG SSRR","59148-019-71","NDC","","","","","facility","both","1","EA","","11551.23","5775.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 300 MG SERS","59148-045-80","NDC","","","","","facility","both","1","EA","","8899.97","4449.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 400 MG SERS","59148-072-80","NDC","","","","","facility","both","1","EA","JG,UD","11551.23","5775.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 400 MG SERS","59148-072-80","NDC","","","","","facility","both","1","EA","","11551.23","5775.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RESLIZUMAB 10 MG/ML SOLN 10 ML VIAL","59310-610-31","NDC","","","","","facility","both","1","EA","UD,TB","14836.83","7418.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"RESLIZUMAB 10 MG/ML SOLN 10 ML VIAL","59310-610-31","NDC","","","","","facility","both","1","EA","TB","11607.2","5803.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"RESLIZUMAB 10 MG/ML SOLN 10 ML VIAL","59310-610-31","NDC","","","","","facility","both","1","EA","JG,UD","14329.4","7164.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"RESLIZUMAB 10 MG/ML SOLN 10 ML VIAL","59310-610-31","NDC","","","","","facility","both","1","EA","JG","11048.36","5524.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"GUAIFENESIN 100 MG/5 ML LIQD","59390-004-10","NDC","","","","","facility","both","1","EA","","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","59390-004-10","NDC","","","","","facility","both","1","EA","UD","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUAIFENESIN 100 MG/5 ML LIQD","59390-004-13","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"FLUORESCEIN-PROPARACAINE 0.25-0.5 % DROP 5 ML DROP BTL","59390-205-05","NDC","","","","","facility","both","1","EA","","33.03","16.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFIDEROCOL 1 GRAM SOLR 1 EACH VIAL","59630-266-01","NDC","","","","","facility","both","1","EA","","1056.25","528.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFIDEROCOL 1 GRAM SOLR 1 EACH VIAL","59630-266-01","NDC","","","","","facility","both","1","EA","UD","2179.98","1089.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFIDEROCOL 1 GRAM SOLR 1 EACH VIAL","59630-266-10","NDC","","","","","facility","both","1","EA","","1075.4","537.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"CEFIDEROCOL 1 GRAM SOLR 1 EACH VIAL","59630-266-10","NDC","","","","","facility","both","1","EA","UD","2179.98","1089.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML SUSR","59651-026-75","NDC","","","","","facility","both","1","EA","","10.96","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML SUSR","59651-026-75","NDC","","","","","facility","both","1","EA","UD","20.92","10.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEBIVOLOL 5 MG TABS","59651-138-30","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZELASTINE 137 MCG (0.1 %) SPRY 30 ML SQUEEZ BTL","59651-214-30","NDC","","","","","facility","both","1","EA","UD","40.38","20.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZELASTINE 137 MCG (0.1 %) SPRY 30 ML SQUEEZ BTL","59651-214-30","NDC","","","","","facility","both","1","EA","","40.38","20.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IMATINIB 400 MG TABS","59651-241-30","NDC","","","","","facility","both","1","EA","UD","18.32","9.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IMATINIB 400 MG TABS","59651-241-30","NDC","","","","","facility","both","1","EA","","18.32","9.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TAMOXIFEN 10 MG TABS","59651-299-60","NDC","","","","","facility","both","1","EA","","3.58","1.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEVIMELINE 30 MG CAPS","59651-422-01","NDC","","","","","facility","both","1","EA","","4.68","2.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 10-100 MG TABS","59651-456-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 10-100 MG TABS","59651-456-01","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISOLONE 5 MG TABS","59651-491-01","NDC","","","","","facility","both","1","EA","","146.41","73.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EXEMESTANE 25 MG TABS","59651-516-30","NDC","","","","","facility","both","1","EA","UD","4.3","2.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EXEMESTANE 25 MG TABS","59651-516-30","NDC","","","","","facility","both","1","EA","","4.3","2.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICLOXACILLIN 250 MG CAPS","59651-565-01","NDC","","","","","facility","both","1","EA","UD","1.9","0.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOXACILLIN 250 MG CAPS","59651-565-01","NDC","","","","","facility","both","1","EA","","1.9","0.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIPIZIDE XL 2.5 MG TR24","59651-780-30","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RILPIVIRINE HCL 25 MG TABS","59676-278-01","NDC","","","","","facility","both","1","EA","","80.01","40.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RILPIVIRINE HCL 25 MG TABS","59676-278-01","NDC","","","","","facility","both","1","EA","UD","80.01","40.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA (ESRD) 10,000 UNIT/ML SOLN","59676-310-00","NDC","","","","","facility","both","1","EA","UD","707.91","353.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA (ESRD) 10,000 UNIT/ML SOLN","59676-310-00","NDC","","","","","facility","both","1","EA","","389.58","194.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPOETIN ALFA (NON-ESRD) 10,000 UNIT/ML SOLN","59676-310-01","NDC","","","","","facility","both","1","EA","JG","867.08","433.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"EPOETIN ALFA (ESRD) 10,000 UNIT/ML SOLN","59676-310-02","NDC","","","","","facility","both","1","EA","UD","867.08","433.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA (ESRD) 10,000 UNIT/ML SOLN","59676-310-02","NDC","","","","","facility","both","1","EA","","867.08","433.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"EPOETIN ALFA (ESRD) 20,000 UNIT/ML SOLN","59676-320-00","NDC","","","","","facility","both","1","EA","","1185.42","592.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPOETIN ALFA (ESRD) 20,000 UNIT/ML SOLN","59676-320-00","NDC","","","","","facility","both","1","EA","JG","1662.92","831.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"EPOETIN ALFA (ESRD) 20,000 UNIT/ML SOLN","59676-320-00","NDC","","","","","facility","both","1","EA","UD","1662.92","831.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA (ESRD) 20,000 UNIT/ML SOLN","59676-320-00","NDC","","","","","facility","both","1","EA","TB","1662.92","831.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"EPOETIN ALFA (ESRD) 20,000 UNIT/ML SOLN","59676-320-00","NDC","","","","","facility","both","1","EA","JG,UD","4846.28","2423.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPOETIN ALFA (ESRD) 20,000 UNIT/ML SOLN","59676-320-04","NDC","","","","","facility","both","1","EA","","1185.42","592.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"DARUNAVIR 800 MG TABS","59676-566-30","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DARUNAVIR 800 MG TABS","59676-566-30","NDC","","","","","facility","both","1","EA","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ETRAVIRINE 100 MG TABS","59676-570-01","NDC","","","","","facility","both","1","EA","UD","32.78","16.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE (DISINTEGRATING) 0.5 MG ODT.","59746-010-32","NDC","","","","","facility","both","1","EA","","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE (DISINTEGRATING) 0.5 MG ODT.","59746-010-32","NDC","","","","","facility","both","1","EA","UD","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE (DISINTEGRATING) 2 MG ODT.","59746-030-22","NDC","","","","","facility","both","1","EA","UD","10.02","5.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE (DISINTEGRATING) 2 MG ODT.","59746-030-22","NDC","","","","","facility","both","1","EA","","10.02","5.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROCHLORPERAZINE 5 MG TABS","59746-113-06","NDC","","","","","facility","both","1","EA","","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROCHLORPERAZINE 5 MG TABS","59746-113-06","NDC","","","","","facility","both","1","EA","UD","1.59","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 1 MG TABS","59746-171-06","NDC","","","","","facility","both","1","EA","","1.42","0.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","59746-175-09","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","59746-175-09","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERAZOSIN 1 MG CAPS","59746-383-06","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE 10 MG TABS","59762-0074-1","NDC","","","","","facility","both","1","EA","UD","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 10 MG TABS","59762-0074-1","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SULFASALAZINE EC 500 MG TBEC","59762-0104-5","NDC","","","","","facility","both","1","EA","UD","3.33","1.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SULFASALAZINE EC 500 MG TBEC","59762-0104-5","NDC","","","","","facility","both","1","EA","","2.63","1.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LATANOPROST 0.005 % DROP 2.5 ML DROP BTL","59762-0333-2","NDC","","","","","facility","both","1","EA","","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NIFEDIPINE 10 MG CAPS","59762-1004-1","NDC","","","","","facility","both","1","EA","UD","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 10 MG CAPS","59762-1004-1","NDC","","","","","facility","both","1","EA","","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CABERGOLINE 0.5 MG TABS","59762-1005-1","NDC","","","","","facility","both","1","EA","UD","7.09","3.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CABERGOLINE 0.5 MG TABS","59762-1005-1","NDC","","","","","facility","both","1","EA","","7.09","3.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS","59762-1061-1","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS","59762-1061-1","NDC","","","","","facility","both","1","EA","","1.58","0.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPLERENONE 25 MG TABS","59762-1710-1","NDC","","","","","facility","both","1","EA","","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","59762-2198-7","NDC","","","","","facility","both","1","EA","UD","0.66","0.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 250 MG TABS","59762-2198-7","NDC","","","","","facility","both","1","EA","","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 1 GRAM PACK","59762-3051-5","NDC","","","","","facility","both","1","EA","UD","46.84","23.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 1 GRAM PACK","59762-3051-5","NDC","","","","","facility","both","1","EA","","46.84","23.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 200 MG/5 ML SUSR","59762-3120-1","NDC","","","","","facility","both","1","EA","UD","23.42","11.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 200 MG/5 ML SUSR","59762-3120-1","NDC","","","","","facility","both","1","EA","","23.42","11.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NITROGLYCERIN 0.4 MG SUBL","59762-3304-3","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH"
"NITROGLYCERIN 0.4 MG SUBL","59762-3304-3","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPRAZOLAM 0.25 MG TABS","59762-3719-1","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPRAZOLAM 0.25 MG TABS","59762-3719-1","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SULFASALAZINE 500 MG TABS","59762-5000-5","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SULFASALAZINE 500 MG TABS","59762-5000-5","NDC","","","","","facility","both","1","EA","UD","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MISOPROSTOL 100 MCG TABS","59762-5007-1","NDC","","","","","facility","both","1","EA","UD","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MISOPROSTOL 100 MCG TABS","59762-5007-1","NDC","","","","","facility","both","1","EA","","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MISOPROSTOL 200 MCG TABS","59762-5008-1","NDC","","","","","facility","both","1","EA","UD","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MISOPROSTOL 200 MCG TABS","59762-5008-1","NDC","","","","","facility","both","1","EA","","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLINDAMYCIN 2 % CREA 40 G TUBE/KIT","59762-5009-1","NDC","","","","","facility","both","1","EA","UD","254.4","127.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 2 % CREA 40 G TUBE/KIT","59762-5009-1","NDC","","","","","facility","both","1","EA","","305.08","152.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"FLUCONAZOLE 40 MG/ML SUSR","59762-5030-1","NDC","","","","","facility","both","1","EA","","15.05","7.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TETRACYCLINE 250 MG CAPS","60219-1522-1","NDC","","","","","facility","both","1","EA","UD","2.14","1.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TETRACYCLINE 250 MG CAPS","60219-1522-1","NDC","","","","","facility","both","1","EA","","2.63","1.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THIOTHIXENE 1 MG CAPS","60219-1673-1","NDC","","","","","facility","both","1","EA","","6.42","3.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ETRAVIRINE 100 MG TABS","60219-1721-7","NDC","","","","","facility","both","1","EA","","32.78","16.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ETRAVIRINE 100 MG TABS","60219-1721-7","NDC","","","","","facility","both","1","EA","UD","32.78","16.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 1 % DROP 5 ML DROP BTL","60219-1749-3","NDC","","","","","facility","both","1","EA","UD","110","55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 1 % DROP 5 ML DROP BTL","60219-1749-3","NDC","","","","","facility","both","1","EA","","110","55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHOS-NAK 280-160-250 MG PWPK","6025800601","NDC","","","","","facility","both","1","EA","UD","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHOS-NAK 280-160-250 MG PWPK","6025800601","NDC","","","","","facility","both","1","EA","","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHOS-NAK 280-160-250 MG PWPK","6025800615","NDC","","","","","facility","both","1","EA","UD","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHOS-NAK 280-160-250 MG PWPK","6025800615","NDC","","","","","facility","both","1","EA","","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) SOLN","60267-705-50","NDC","","","","","facility","both","1","EA","UD","671.25","335.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) SOLN","60267-705-50","NDC","","","","","facility","both","1","EA","","671.25","335.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION SPSN 16 G AER W/ADAP","60429-195-15","NDC","","","","","facility","both","1","EA","","12.54","6.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML SUSR","60432-065-47","NDC","","","","","facility","both","1","EA","UD","20.92","10.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML SUSR","60432-065-75","NDC","","","","","facility","both","1","EA","","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMOXICILLIN-CLAVULANATE 250-62.5 MG/5 ML SUSR","60432-065-75","NDC","","","","","facility","both","1","EA","UD","13.96","6.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 10 MG/5 ML SOLN","60432-150-16","NDC","","","","","facility","both","1","EA","UD","4.59","2.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 10 MG/5 ML SOLN","60432-150-16","NDC","","","","","facility","both","1","EA","","9.01","4.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUVOXAMINE 50 MG TABS","60505-0165-1","NDC","","","","","facility","both","1","EA","UD","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUVOXAMINE 50 MG TABS","60505-0165-1","NDC","","","","","facility","both","1","EA","","3.5","1.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DESMOPRESSIN 0.1 MG TABS","60505-0257-1","NDC","","","","","facility","both","1","EA","UD","2.34","1.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESMOPRESSIN 0.1 MG TABS","60505-0257-1","NDC","","","","","facility","both","1","EA","","2.34","1.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PAROXETINE 10 MG/5 ML SUSPENSION","60505-0402-5","NDC","","","","","facility","both","1","EA","UD","43.84","21.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 10 MG/5 ML SUSPENSION","60505-0402-5","NDC","","","","","facility","both","1","EA","","65.26","32.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MOXIFLOXACIN 0.5 % DROP","60505-0582-4","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 0.5 % DROP","60505-0582-4","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCITONIN (SALMON) 200 UNIT/ACTUATION SPRY 3.7 ML SQUEEZ BTL","60505-0823-6","NDC","","","","","facility","both","1","EA","UD","193.17","96.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITONIN (SALMON) 200 UNIT/ACTUATION SPRY 3.7 ML SQUEEZ BTL","60505-0823-6","NDC","","","","","facility","both","1","EA","","193.17","96.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION SPSN 16 G AER W/ADAP","60505-0829-1","NDC","","","","","facility","both","1","EA","UD","12.54","6.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUTICASONE PROPIONATE 50 MCG/ACTUATION SPSN 16 G AER W/ADAP","60505-0829-1","NDC","","","","","facility","both","1","EA","","12.54","6.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"KETOROLAC 0.5 % DROP","60505-1003-1","NDC","","","","","facility","both","1","EA","","6.7","3.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OLANZAPINE 2.5 MG TABS","60505-3110-0","NDC","","","","","facility","both","1","EA","","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 2.5 MG TABS","60505-3110-0","NDC","","","","","facility","both","1","EA","UD","0.37","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 5 MG TABS","60505-3111-0","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 5 MG TABS","60505-3111-0","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 10 MG TABS","60505-3113-0","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE 10 MG TABS","60505-3113-0","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMIVUDINE 100 MG TABS","60505-3250-6","NDC","","","","","facility","both","1","EA","UD","26.75","13.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMIVUDINE 100 MG TABS","60505-3250-6","NDC","","","","","facility","both","1","EA","","26.75","13.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IBANDRONATE 3 MG/3 ML SYRG","60505-6097-0","NDC","","","","","facility","both","1","EA","JG","1223.24","611.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CHG - INJ,REGADENOSON,0.1MG,LEXISCAN","60505-6116-0","NDC","","","","","facility","both","1","EA","","2256","1128","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 100 MG/5 ML SOLN 5 ML VIAL","60505-6128-1","NDC","","","","","facility","both","1","EA","","52.3","26.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 100 MG/5 ML SOLN 5 ML VIAL","60505-6128-1","NDC","","","","","facility","both","1","EA","UD","52.3","26.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","60505-6130-0","NDC","","","","","facility","both","1","EA","","2.88","1.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","60505-6130-0","NDC","","","","","facility","both","1","EA","UD","2.88","1.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL","60505-6132-7","NDC","","","","","facility","both","1","EA","","25.59","12.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFAZOLIN 1 GRAM SOLR 1 EACH VIAL","60505-6142-0","NDC","","","","","facility","both","1","EA","","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","60505-6146-0","NDC","","","","","facility","both","1","EA","UD","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","60505-6146-0","NDC","","","","","facility","both","1","EA","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","60505-6147-0","NDC","","","","","facility","both","1","EA","UD","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","60505-6147-0","NDC","","","","","facility","both","1","EA","","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTRIAXONE 500 MG SOLR 1 EACH VIAL","60505-6152-1","NDC","","","","","facility","both","1","EA","UD","8.53","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTRIAXONE 500 MG SOLR 1 EACH VIAL","60505-6152-1","NDC","","","","","facility","both","1","EA","","8.53","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","60505-6157-0","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIPERACILLIN-TAZOBACTAM 3375 MG SOLR 1 EACH VIAL","60505-6157-0","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","60505-6159-0","NDC","","","","","facility","both","1","EA","","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","60505-6159-0","NDC","","","","","facility","both","1","EA","UD","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","60505-6196-0","NDC","","","","","facility","both","1","EA","","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","60505-6196-0","NDC","","","","","facility","both","1","EA","UD","190","95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOSPORINE 0.05 % DPET","60505-6202-1","NDC","","","","","facility","both","1","EA","","12.27","6.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOSPORINE 0.05 % DPET","60505-6202-1","NDC","","","","","facility","both","1","EA","UD","12.27","6.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 1 % DROP","60505-6226-1","NDC","","","","","facility","both","1","EA","UD","7.04","3.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 1 % DROP","60505-6226-1","NDC","","","","","facility","both","1","EA","","7.04","3.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CEFAZOLIN 2 GRAM SOLR","60505-6231-0","NDC","","","","","facility","both","1","EA","UD","39.06","19.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFAZOLIN 2 GRAM SOLR","60505-6231-0","NDC","","","","","facility","both","1","EA","","39.06","19.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEFEROXAMINE 500 MG SOLR","60505-6236-0","NDC","","","","","facility","both","1","EA","UD","164.38","82.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEFEROXAMINE 500 MG SOLR 1 EACH VIAL","60505-6236-6","NDC","","","","","facility","both","1","EA","","164.38","82.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH"
"DEFEROXAMINE 500 MG SOLR 1 EACH VIAL","60505-6236-6","NDC","","","","","facility","both","1","EA","UD","488.13","244.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 7 MG/24 HR PT24","60505-7061-0","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 7 MG/24 HR PT24","60505-7061-0","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 14 MG/24 HR PT24","60505-7062-0","NDC","","","","","facility","both","1","EA","UD","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NICOTINE 14 MG/24 HR PT24","60505-7062-0","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NICOTINE 21 MG/24 HR PT24","60505-7063-0","NDC","","","","","facility","both","1","EA","","3.14","1.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENTANYL 25 MCG/HR PT72","60505-7081-0","NDC","","","","","facility","both","1","EA","","10.54","5.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 300 MG CAPS","60687-100-11","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 300 MG CAPS","60687-100-11","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 10 MG TABS","60687-104-11","NDC","","","","","facility","both","1","EA","UD","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 10 MG TABS","60687-104-11","NDC","","","","","facility","both","1","EA","","2.7","1.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEDROXYPROGESTERONE 10 MG TABS","60687-105-11","NDC","","","","","facility","both","1","EA","","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ANASTROZOLE 1 MG TABS","60687-112-11","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ANASTROZOLE 1 MG TABS","60687-112-21","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE HCL 0.1 MG TABS","60687-113-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONIDINE HCL 0.1 MG TABS","60687-113-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACAMPROSATE 333 MG TBEC","60687-121-95","NDC","","","","","facility","both","1","EA","","5.93","2.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACAMPROSATE 333 MG TBEC","60687-121-95","NDC","","","","","facility","both","1","EA","UD","5.93","2.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 5 MG TABS","60687-122-11","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 5 MG TABS","60687-122-11","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEGA-3 1 GRAM CAPS","60687-127-11","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OMEGA-3 1 GRAM CAPS","60687-127-11","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 10 MG TABS","60687-134-11","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 10 MG TABS","60687-134-11","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN 850 MG TABS","60687-143-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN 850 MG TABS","60687-143-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 20 MG TABS","60687-145-01","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 20 MG TABS","60687-145-01","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","60687-145-11","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 20 MG TABS","60687-145-11","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEPHALEXIN 250 MG CAPS","60687-152-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEPHALEXIN 250 MG CAPS","60687-152-11","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN 500 MG TABS","60687-155-01","NDC","","","","","facility","both","1","EA","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN 500 MG TABS","60687-155-01","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN 500 MG TABS","60687-155-11","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN 500 MG TABS","60687-155-11","NDC","","","","","facility","both","1","EA","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENYTOIN 50 MG CHEW","60687-156-95","NDC","","","","","facility","both","1","EA","UD","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 5 MG TABS","60687-168-11","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 5 MG TABS","60687-168-11","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEMANTINE 5 MG TABS","60687-173-11","NDC","","","","","facility","both","1","EA","","0.41","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEMANTINE 5 MG TABS","60687-173-11","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAVASTATIN 20 MG TABS","60687-178-11","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAVASTATIN 20 MG TABS","60687-178-11","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 10 MG TABS","60687-179-11","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 15 MG TABS","60687-191-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 15 MG TABS","60687-191-11","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 120 MG CP24","60687-195-11","NDC","","","","","facility","both","1","EA","UD","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 120 MG CP24","60687-195-11","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 24HR 180 MG CP24","60687-206-11","NDC","","","","","facility","both","1","EA","UD","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 180 MG CP24","60687-206-11","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 40 MG TABS","60687-210-11","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 125 MG TBEC","60687-211-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX DR 125 MG TBEC","60687-211-11","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL LA 60 MG CS24","60687-215-11","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL LA 60 MG CS24","60687-215-11","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 24HR 240 MG CP24","60687-217-11","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 240 MG CP24","60687-217-11","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GEMFIBROZIL 600 MG TABS","60687-224-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GEMFIBROZIL 600 MG TABS","60687-224-11","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL LA 80 MG CS24","60687-226-11","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL LA 80 MG CS24","60687-226-11","NDC","","","","","facility","both","1","EA","UD","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 300 MG CP24","60687-228-11","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOPERAMIDE 2 MG CAPS","60687-229-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOPERAMIDE 2 MG CAPS","60687-229-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZONISAMIDE 100 MG CAPS","60687-230-11","NDC","","","","","facility","both","1","EA","","0.88","0.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SERTRALINE 25 MG TABS","60687-231-11","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SERTRALINE 25 MG TABS","60687-231-11","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 5 MG TABS","60687-234-11","NDC","","","","","facility","both","1","EA","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 5 MG TABS","60687-234-11","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SERTRALINE 50 MG TABS","60687-242-11","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SERTRALINE 50 MG TABS","60687-242-11","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 10 MG TABS","60687-245-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 10 MG TABS","60687-245-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SERTRALINE 100 MG TABS","60687-253-11","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SERTRALINE 100 MG TABS","60687-253-11","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 20 MG TABS","60687-256-01","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 20 MG TABS","60687-256-01","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 20 MG TABS","60687-256-11","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RALOXIFENE 60 MG TABS","60687-266-11","NDC","","","","","facility","both","1","EA","","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BROMOCRIPTINE 2.5 MG TABS","60687-286-11","NDC","","","","","facility","both","1","EA","","10.01","5.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DONEPEZIL 5 MG TABS","60687-292-11","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DONEPEZIL 5 MG TABS","60687-292-11","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NORTRIPTYLINE 25 MG CAPS","60687-293-11","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ITRACONAZOLE 100 MG CAPS","60687-299-95","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ITRACONAZOLE 100 MG CAPS","60687-299-95","NDC","","","","","facility","both","1","EA","UD","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID 600 MG TABS","60687-309-11","NDC","","","","","facility","both","1","EA","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NADOLOL 40 MG TABS","60687-313-95","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NADOLOL 40 MG TABS","60687-313-95","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 10 MG TABS","60687-325-11","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 10 MG TABS","60687-325-11","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 25 MG TABS","60687-327-11","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 25 MG TABS","60687-327-11","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 20 MG TABS","60687-333-11","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 20 MG TABS","60687-333-11","NDC","","","","","facility","both","1","EA","UD","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPROPION 75 MG TABS","60687-340-11","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION 75 MG TABS","60687-340-11","NDC","","","","","facility","both","1","EA","UD","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITRIOL 0.25 MCG CAPS","60687-345-11","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCITRIOL 0.25 MCG CAPS","60687-345-11","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZTROPINE 1 MG TABS","60687-368-11","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICYCLOMINE 10 MG CAPS","60687-369-11","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICYCLOMINE 10 MG CAPS","60687-369-11","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","60687-373-11","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","60687-373-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EZETIMIBE 10 MG TABS","60687-373-21","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EZETIMIBE 10 MG TABS","60687-373-21","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DRONABINOL 2.5 MG CAPS","60687-375-11","NDC","","","","","facility","both","1","EA","UD","5.15","2.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DRONABINOL 2.5 MG CAPS","60687-375-11","NDC","","","","","facility","both","1","EA","","5.15","2.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DRONABINOL 2.5 MG CAPS","60687-375-21","NDC","","","","","facility","both","1","EA","","5.91","2.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DRONABINOL 2.5 MG CAPS","60687-375-21","NDC","","","","","facility","both","1","EA","UD","9.3","4.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPRAZOLAM 0.25 MG TABS","60687-377-11","NDC","","","","","facility","both","1","EA","UD","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALPRAZOLAM 0.25 MG TABS","60687-377-11","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICYCLOMINE 20 MG TABS","60687-380-11","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICYCLOMINE 20 MG TABS","60687-380-11","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHYTONADIONE (VITAMIN K1) 5 MG TABS","60687-381-11","NDC","","","","","facility","both","1","EA","UD","3.09","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 5 MG TABS","60687-381-11","NDC","","","","","facility","both","1","EA","","3.09","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 400 MG TABS","60687-382-11","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 1 MG TABS","60687-384-95","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUMETANIDE 1 MG TABS","60687-384-95","NDC","","","","","facility","both","1","EA","UD","2.02","1.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLESEVELAM 625 MG TABS","60687-385-95","NDC","","","","","facility","both","1","EA","","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COLESEVELAM 625 MG TABS","60687-385-95","NDC","","","","","facility","both","1","EA","UD","2.14","1.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLCHICINE 0.6 MG TABS","60687-389-11","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLCHICINE 0.6 MG TABS","60687-389-11","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL XL 25 MG TB24","60687-390-11","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIOGLITAZONE 15 MG TABS","60687-391-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIOGLITAZONE 15 MG TABS","60687-391-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MESALAMINE SR 1.2 GRAM TBEC","60687-397-95","NDC","","","","","facility","both","1","EA","","4.65","2.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 5 MG TABS","60687-398-11","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 5 MG TABS","60687-398-11","NDC","","","","","facility","both","1","EA","UD","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 50 MG TB24","60687-402-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL XL 50 MG TB24","60687-402-11","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 10 MG TABS","60687-409-95","NDC","","","","","facility","both","1","EA","","0.54","0.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIDODRINE 10 MG TABS","60687-409-95","NDC","","","","","facility","both","1","EA","UD","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 10 MG TABS","60687-419-11","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RITONAVIR 100 MG TABS","60687-420-25","NDC","","","","","facility","both","1","EA","UD","16.34","8.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RITONAVIR 100 MG TABS","60687-420-95","NDC","","","","","facility","both","1","EA","UD","16.34","8.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RITONAVIR 100 MG TABS","60687-420-95","NDC","","","","","facility","both","1","EA","","16.34","8.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOBAZAM 10 MG TABS","60687-423-11","NDC","","","","","facility","both","1","EA","UD","0.92","0.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOBAZAM 10 MG TABS","60687-423-11","NDC","","","","","facility","both","1","EA","","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FINASTERIDE 5 MG TABS","60687-428-11","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMITRIPTYLINE 25 MG TABS","60687-433-01","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMITRIPTYLINE 25 MG TABS","60687-433-11","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMITRIPTYLINE 25 MG TABS","60687-433-11","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CELECOXIB 100 MG CAPS","60687-436-11","NDC","","","","","facility","both","1","EA","UD","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CELECOXIB 100 MG CAPS","60687-436-11","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE 500 MG TABS","60687-438-11","NDC","","","","","facility","both","1","EA","","0.96","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE 500 MG TABS","60687-438-11","NDC","","","","","facility","both","1","EA","UD","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 100 MG TABS","60687-439-11","NDC","","","","","facility","both","1","EA","","0.41","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LABETALOL 100 MG TABS","60687-439-11","NDC","","","","","facility","both","1","EA","UD","0.41","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAZODONE 50 MG TABS","60687-443-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAZODONE 50 MG TABS","60687-443-11","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IBUPROFEN 400 MG TABS","60687-446-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IBUPROFEN 400 MG TABS","60687-446-11","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LABETALOL 200 MG TABS","60687-450-11","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","60687-450-11","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPLERENONE 25 MG TABS","60687-451-11","NDC","","","","","facility","both","1","EA","","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPLERENONE 25 MG TABS","60687-451-11","NDC","","","","","facility","both","1","EA","UD","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORPROMAZINE 100 MG TABS","60687-452-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PALIPERIDONE 3 MG TR24","60687-459-11","NDC","","","","","facility","both","1","EA","","6.5","3.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PALIPERIDONE 3 MG TR24","60687-459-11","NDC","","","","","facility","both","1","EA","UD","6.5","3.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROFURANTOIN 50 MG CAPS","60687-472-11","NDC","","","","","facility","both","1","EA","","1.64","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROFURANTOIN 50 MG CAPS","60687-472-11","NDC","","","","","facility","both","1","EA","UD","2.28","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 25 MG CAPS","60687-473-11","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 25 MG CAPS","60687-473-11","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIPIZIDE XL 2.5 MG TR24","60687-480-11","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIPIZIDE XL 2.5 MG TR24","60687-480-11","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE HCL 2 MG SUBL","60687-481-11","NDC","","","","","facility","both","1","EA","UD","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE HCL 2 MG SUBL","60687-481-11","NDC","","","","","facility","both","1","EA","","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 50 MG CAPS","60687-484-11","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 50 MG CAPS","60687-484-11","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SPIRONOLACTONE 100 MG TABS","60687-487-11","NDC","","","","","facility","both","1","EA","","0.49","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE HCL 8 MG SUBL","60687-492-11","NDC","","","","","facility","both","1","EA","UD","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPRENORPHINE HCL 8 MG SUBL","60687-492-11","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE HCL 8 MG SUBL","60687-492-21","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPRENORPHINE HCL 8 MG SUBL","60687-492-21","NDC","","","","","facility","both","1","EA","UD","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 75 MG CAPS","60687-495-11","NDC","","","","","facility","both","1","EA","","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 75 MG CAPS","60687-495-11","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREGABALIN 100 MG CAPS","60687-506-11","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREGABALIN 100 MG CAPS","60687-506-11","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE HYCLATE 100 MG CAPS","60687-513-11","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE HYCLATE 100 MG CAPS","60687-513-11","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POSACONAZOLE 100 MG TBEC","60687-523-11","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POSACONAZOLE 100 MG TBEC","60687-523-21","NDC","","","","","facility","both","1","EA","UD","37.6","18.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POSACONAZOLE 100 MG TBEC","60687-523-21","NDC","","","","","facility","both","1","EA","","44","22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CINACALCET 30 MG TABS","60687-525-11","NDC","","","","","facility","both","1","EA","UD","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","60687-525-11","NDC","","","","","facility","both","1","EA","","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","60687-534-40","NDC","","","","","facility","both","1","EA","","51.84","25.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","60687-534-40","NDC","","","","","facility","both","1","EA","UD","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FEBUXOSTAT 40 MG TABS","60687-538-11","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.5 MG TABS","60687-544-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONAZEPAM 0.5 MG TABS","60687-544-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 0.5 MG TABS","60687-544-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RANOLAZINE 500 MG TB12","60687-549-11","NDC","","","","","facility","both","1","EA","UD","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RANOLAZINE 500 MG TB12","60687-549-11","NDC","","","","","facility","both","1","EA","","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIGOXIN 250 MCG (0.25 MG) TABS","60687-551-11","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIGOXIN 250 MCG (0.25 MG) TABS","60687-551-11","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISONIAZID 300 MG TABS","60687-553-11","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MESALAMINE 400 MG CDTI","60687-556-33","NDC","","","","","facility","both","1","EA","","10.81","5.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 10 MG TABS","60687-558-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOBENZAPRINE 10 MG TABS","60687-558-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 500 MG TABS","60687-559-11","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","60687-568-11","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","60687-568-11","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAMIPEXOLE 0.25 MG TABS","60687-570-11","NDC","","","","","facility","both","1","EA","","1.26","0.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 2 MG TABS","60687-579-11","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 2 MG TABS","60687-579-11","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCORTISONE 10 MG TABS","60687-582-11","NDC","","","","","facility","both","1","EA","UD","0.86","0.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 10 MG TABS","60687-582-11","NDC","","","","","facility","both","1","EA","","1.72","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMAZEPINE XR 12 HOUR 200 MG TB12","60687-583-11","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMAZEPINE XR 12 HOUR 200 MG TB12","60687-583-11","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFAMPIN 300 MG CAPS","60687-586-11","NDC","","","","","facility","both","1","EA","UD","7.54","3.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFAMPIN 300 MG CAPS","60687-586-11","NDC","","","","","facility","both","1","EA","","4.27","2.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 4 MG TABS","60687-590-11","NDC","","","","","facility","both","1","EA","","0.31","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROMORPHONE 4 MG TABS","60687-590-11","NDC","","","","","facility","both","1","EA","UD","0.31","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 300 MG CAPS","60687-591-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 300 MG CAPS","60687-591-11","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAMIPEXOLE 1 MG TABS","60687-592-11","NDC","","","","","facility","both","1","EA","","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCHLOROTHIAZIDE 25 MG TABS","60687-593-01","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCHLOROTHIAZIDE 25 MG TABS","60687-593-01","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCHLOROTHIAZIDE 25 MG TABS","60687-593-11","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCHLOROTHIAZIDE 25 MG TABS","60687-593-11","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUDESONIDE 3 MG CECX","60687-596-33","NDC","","","","","facility","both","1","EA","UD","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUDESONIDE 3 MG CECX","60687-596-33","NDC","","","","","facility","both","1","EA","","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 20 MG TABS","60687-598-11","NDC","","","","","facility","both","1","EA","","0.22","0.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 20 MG TABS","60687-598-11","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 400 MG CAPS","60687-602-11","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","60687-602-11","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC DR 50 MG TBEC","60687-606-11","NDC","","","","","facility","both","1","EA","UD","1.25","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DICLOFENAC DR 50 MG TBEC","60687-606-11","NDC","","","","","facility","both","1","EA","","1.25","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DESVENLAFAXINE SUCCINATE 50 MG TB24","60687-607-11","NDC","","","","","facility","both","1","EA","UD","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESVENLAFAXINE SUCCINATE 50 MG TB24","60687-607-11","NDC","","","","","facility","both","1","EA","","2.41","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 40 MG TABS","60687-612-11","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 40 MG TABS","60687-612-11","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 160-800 MG TABS","60687-614-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 160-800 MG TABS","60687-614-11","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SENNA-DOCUSATE 8.6-50 MG TABS","60687-622-11","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA-DOCUSATE 8.6-50 MG TABS","60687-622-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALSARTAN 80 MG TABS","60687-623-11","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALSARTAN 80 MG TABS","60687-623-11","NDC","","","","","facility","both","1","EA","","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 0.5 MG TABS","60687-627-11","NDC","","","","","facility","both","1","EA","","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 0.5 MG TABS","60687-627-11","NDC","","","","","facility","both","1","EA","UD","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NABUMETONE 500 MG TABS","60687-630-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOCLOPRAMIDE 10 MG TABS","60687-631-11","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOCLOPRAMIDE 10 MG TABS","60687-631-11","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROFURANTOIN MONOHYDRATE MACRO 100 MG CAPS","60687-633-11","NDC","","","","","facility","both","1","EA","UD","2.07","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROFURANTOIN MONOHYDRATE MACRO 100 MG CAPS","60687-633-11","NDC","","","","","facility","both","1","EA","","2.07","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN ER 500 MG TB24","60687-640-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEBIVOLOL 5 MG TABS","60687-641-11","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORAZEPAM 2 MG TABS","60687-649-11","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORAZEPAM 2 MG TABS","60687-649-11","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 2.5 MG TABS","60687-656-11","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 2.5 MG TABS","60687-656-11","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","60687-657-11","NDC","","","","","facility","both","1","EA","UD","0.62","0.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","60687-657-11","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICLOFENAC DR 75 MG TBEC","60687-658-11","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICLOFENAC DR 75 MG TBEC","60687-658-11","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 12.5 MG TABS","60687-660-11","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 12.5 MG TABS","60687-660-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","60687-661-11","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA 25-100 MG TABS","60687-661-11","NDC","","","","","facility","both","1","EA","","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHIMAZOLE 5 MG TABS","60687-669-11","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHIMAZOLE 5 MG TABS","60687-669-11","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ELIX","60687-671-40","NDC","","","","","facility","both","1","EA","UD","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ELIX","60687-671-40","NDC","","","","","facility","both","1","EA","","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","60687-672-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","60687-672-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","60687-672-65","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-325-40 MG TABS","60687-672-65","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 50 MG TABS","60687-676-11","NDC","","","","","facility","both","1","EA","UD","0.77","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 50 MG TABS","60687-676-11","NDC","","","","","facility","both","1","EA","","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALLOPURINOL 100 MG TABS","60687-677-11","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 100 MG TABS","60687-677-11","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BISOPROLOL 5 MG TABS","60687-679-11","NDC","","","","","facility","both","1","EA","","1.56","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHIMAZOLE 10 MG TABS","60687-680-11","NDC","","","","","facility","both","1","EA","","0.66","0.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHIMAZOLE 10 MG TABS","60687-680-11","NDC","","","","","facility","both","1","EA","UD","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 100 MG TABS","60687-687-11","NDC","","","","","facility","both","1","EA","","0.47","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 100 MG TABS","60687-687-11","NDC","","","","","facility","both","1","EA","UD","1.47","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUCRALFATE 1 GRAM TABS","60687-695-11","NDC","","","","","facility","both","1","EA","","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFDINIR 300 MG CAPS","60687-699-11","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFDINIR 300 MG CAPS","60687-699-11","NDC","","","","","facility","both","1","EA","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENOFIBRATE MICRONIZED 200 MG CAPS","60687-713-11","NDC","","","","","facility","both","1","EA","UD","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENOFIBRATE MICRONIZED 200 MG CAPS","60687-713-11","NDC","","","","","facility","both","1","EA","","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 30 MG TABS","60687-717-11","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 30 MG TABS","60687-717-11","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMIVUDINE 150 MG TABS","60687-720-11","NDC","","","","","facility","both","1","EA","UD","5","2.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXCARBAZEPINE 300 MG TABS","60687-722-11","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DULOXETINE 20 MG CPDR","60687-723-21","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DULOXETINE 20 MG CPDR","60687-723-21","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PANTOPRAZOLE 20 MG TBEC","60687-725-11","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOPRAZOLE 20 MG TBEC","60687-725-11","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 60 MG TABS","60687-728-11","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 60 MG TABS","60687-728-11","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DULOXETINE 30 MG CPDR","60687-734-01","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DULOXETINE 30 MG CPDR","60687-734-01","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MISOPROSTOL 100 MCG TABS","60687-735-11","NDC","","","","","facility","both","1","EA","UD","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MISOPROSTOL 100 MCG TABS","60687-735-11","NDC","","","","","facility","both","1","EA","","0.61","0.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","60687-742-11","NDC","","","","","facility","both","1","EA","","0.66","0.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 250 MG TABS","60687-742-11","NDC","","","","","facility","both","1","EA","UD","0.66","0.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MISOPROSTOL 200 MCG TABS","60687-746-11","NDC","","","","","facility","both","1","EA","","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MISOPROSTOL 200 MCG TABS","60687-746-11","NDC","","","","","facility","both","1","EA","UD","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","60687-756-11","NDC","","","","","facility","both","1","EA","UD","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","60687-756-11","NDC","","","","","facility","both","1","EA","","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIPIZIDE XL 2.5 MG TR24","60687-768-11","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIPIZIDE XL 2.5 MG TR24","60687-768-11","NDC","","","","","facility","both","1","EA","UD","2.01","1.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 150 MG CAPS","60687-778-11","NDC","","","","","facility","both","1","EA","","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 150 MG CAPS","60687-778-11","NDC","","","","","facility","both","1","EA","UD","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROFLUMILAST 500 MCG TABS","60687-786-11","NDC","","","","","facility","both","1","EA","UD","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROFLUMILAST 500 MCG TABS","60687-786-11","NDC","","","","","facility","both","1","EA","","1.88","0.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","60687-792-11","NDC","","","","","facility","both","1","EA","","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","60687-792-11","NDC","","","","","facility","both","1","EA","UD","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAMADOL 50 MG TABS","60687-795-11","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAMADOL 50 MG TABS","60687-795-11","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 875-125 MG TABS","60687-803-11","NDC","","","","","facility","both","1","EA","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 875-125 MG TABS","60687-803-11","NDC","","","","","facility","both","1","EA","UD","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 5 MG TABS","60687-804-11","NDC","","","","","facility","both","1","EA","UD","0.27","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BACLOFEN 5 MG TABS","60687-804-11","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLORDIAZEPOXIDE 25 MG CAPS","60687-807-11","NDC","","","","","facility","both","1","EA","UD","0.24","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORDIAZEPOXIDE 25 MG CAPS","60687-807-11","NDC","","","","","facility","both","1","EA","","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 10 MEQ TBSR","60687-810-11","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 10 MEQ TBSR","60687-810-11","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLERGONOVINE 0.2 MG TABS","60687-813-11","NDC","","","","","facility","both","1","EA","UD","30.44","15.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBIDOPA-LEVODOPA 25-250 MG TABS","60687-836-01","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISOLONE ACETATE 1 % DRPS","60758-119-05","NDC","","","","","facility","both","1","EA","","7.1","3.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PREDNISOLONE ACETATE 1 % DRPS","60758-119-05","NDC","","","","","facility","both","1","EA","UD","7.1","3.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.5 % DROP","60758-801-05","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TIMOLOL 0.25 % DROP 5 ML DROP BTL","60758-802-05","NDC","","","","","facility","both","1","EA","","11.43","5.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUOROMETHOLONE 0.1 % DRPS 5 ML DROP BTL","60758-880-05","NDC","","","","","facility","both","1","EA","","199.6","99.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUOROMETHOLONE 0.1 % DRPS 5 ML DROP BTL","60758-880-05","NDC","","","","","facility","both","1","EA","UD","199.6","99.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THROMBIN (BOVINE) 5,000 UNIT NSSY 1 EACH KIT","60793-205-05","NDC","","","","","facility","both","1","EA","","182.3","91.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THROMBIN (BOVINE) 5,000 UNIT SOLR 1 EACH VIAL","60793-215-05","NDC","","","","","facility","both","1","EA","","164.2","82.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THROMBIN (BOVINE) 5,000 UNIT SOLR 1 EACH VIAL","60793-215-05","NDC","","","","","facility","both","1","EA","UD","164.2","82.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THROMBIN 20,000 UNIT SOLR 1 EACH VIAL","60793-217-20","NDC","","","","","facility","both","1","EA","UD","482.69","241.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THROMBIN 20,000 UNIT SOLR 1 EACH VIAL","60793-217-20","NDC","","","","","facility","both","1","EA","","482.69","241.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THROMBIN (BOVINE) 5,000 UNIT SOLR 1 EACH VIAL","60793-315-01","NDC","","","","","facility","both","1","EA","","164.2","82.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DORZOLAMIDE 2 % DROP 10 ML DROP BTL","61314-019-10","NDC","","","","","facility","both","1","EA","","18.15","9.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIFLURIDINE 1 % DROP 7.5 ML DROP BTL","61314-044-75","NDC","","","","","facility","both","1","EA","","329.1","164.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIFLURIDINE 1 % DROP 7.5 ML DROP BTL","61314-044-75","NDC","","","","","facility","both","1","EA","UD","329.1","164.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 0.5 % DROP","61314-126-05","NDC","","","","","facility","both","1","EA","","6.7","3.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 0.5 % DROP","61314-126-05","NDC","","","","","facility","both","1","EA","UD","6.7","3.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BRIMONIDINE 0.2 % DROP","61314-143-05","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BRIMONIDINE 0.2 % DROP","61314-143-05","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BRIMONIDINE 0.2 % DROP 10 ML DROP BTL","61314-143-10","NDC","","","","","facility","both","1","EA","","21.97","10.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BRIMONIDINE 0.15 % DROP 5 ML DROP BTL","61314-144-05","NDC","","","","","facility","both","1","EA","","389.33","194.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PILOCARPINE 1 % DROP","61314-203-15","NDC","","","","","facility","both","1","EA","UD","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PILOCARPINE 1 % DROP","61314-203-15","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PILOCARPINE 2 % DROP","61314-204-15","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PILOCARPINE 2 % DROP","61314-204-15","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TIMOLOL 0.25 % DROP 5 ML DROP BTL","61314-226-05","NDC","","","","","facility","both","1","EA","UD","11.43","5.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.25 % DROP 5 ML DROP BTL","61314-226-05","NDC","","","","","facility","both","1","EA","","11.43","5.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TIMOLOL 0.5 % DROP 5 ML DROP BTL","61314-227-05","NDC","","","","","facility","both","1","EA","UD","20.15","10.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.5 % DROP 5 ML DROP BTL","61314-227-05","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TIMOLOL 0.5 % DROP 10 ML DROP BTL","61314-227-10","NDC","","","","","facility","both","1","EA","","29.04","14.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TROPICAMIDE 1 % DROP","61314-355-01","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TROPICAMIDE 1 % DROP","61314-355-01","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPENTOLATE 1 % DROP","61314-396-01","NDC","","","","","facility","both","1","EA","","6.74","3.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPENTOLATE 1 % DROP","61314-396-01","NDC","","","","","facility","both","1","EA","UD","6.74","3.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LATANOPROST 0.005 % DROP 2.5 ML DROP BTL","61314-547-01","NDC","","","","","facility","both","1","EA","UD","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LATANOPROST 0.005 % DROP 2.5 ML DROP BTL","61314-547-01","NDC","","","","","facility","both","1","EA","","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POLYMYXIN B - TRIMETHOPRIM 10,000 UNIT- 1 MG/ML DROP 10 ML DROP BTL","61314-628-10","NDC","","","","","facility","both","1","EA","UD","33.97","16.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POLYMYXIN B - TRIMETHOPRIM 10,000 UNIT- 1 MG/ML DROP 10 ML DROP BTL","61314-628-10","NDC","","","","","facility","both","1","EA","","33.97","16.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5MG/ML-10,000 UNIT/ML-0.1 % DRPS 5 ML DROP BTL","61314-630-06","NDC","","","","","facility","both","1","EA","UD","32.64","16.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-POLYMYXIN-DEXAMETHASONE 3.5MG/ML-10,000 UNIT/ML-0.1 % DRPS 5 ML DROP BTL","61314-630-06","NDC","","","","","facility","both","1","EA","","32.64","16.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/G-10,000 UNIT/G-0.1 % OINT 3.5 G TUBE","61314-631-36","NDC","","","","","facility","both","1","EA","","45.21","22.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/G-10,000 UNIT/G-0.1 % OINT 3.5 G TUBE","61314-631-36","NDC","","","","","facility","both","1","EA","UD","45.21","22.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 0.3 % DROP 5 ML DROP BTL","61314-633-05","NDC","","","","","facility","both","1","EA","UD","16.26","8.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN 0.3 % DROP","61314-643-05","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TOBRAMYCIN 0.3 % DROP","61314-643-05","NDC","","","","","facility","both","1","EA","UD","18.5","9.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOMYCIN-POLYMYXIN-HC OTIC 3.5-10,000-1 MG/ML-UNIT/ML-% DRPS 10 ML DROP BTL","61314-645-11","NDC","","","","","facility","both","1","EA","UD","71.39","35.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % DRPS 5 ML DROP BTL","61314-647-05","NDC","","","","","facility","both","1","EA","UD","92.63","46.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % DRPS 5 ML DROP BTL","61314-647-05","NDC","","","","","facility","both","1","EA","","92.63","46.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOXACIN HCL 0.3 % DROP","61314-656-05","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOXACIN HCL 0.3 % DROP 2.5 ML DROP BTL","61314-656-25","NDC","","","","","facility","both","1","EA","","27.18","13.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOXACIN HCL 0.3 % DROP 2.5 ML DROP BTL","61314-656-25","NDC","","","","","facility","both","1","EA","UD","27.18","13.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE 20 % SPRA","61322-1000-02","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE 20 % SPRA","61322-1000-02","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SILVER SULFADIAZINE 1 % CREA 400 G JAR","61570-131-40","NDC","","","","","facility","both","1","EA","UD","122.8","61.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SILVER SULFADIAZINE 1 % CREA 400 G JAR","61570-131-40","NDC","","","","","facility","both","1","EA","","122.8","61.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SILVER SULFADIAZINE 1 % CREA 50 G TUBE","61570-131-55","NDC","","","","","facility","both","1","EA","","43.88","21.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SILVER SULFADIAZINE 1 % CREA 50 G TUBE","61570-131-55","NDC","","","","","facility","both","1","EA","UD","43.88","21.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYTARABINE (PF) 20 MG/ML SOLN 50 ML VIAL","61703-303-46","NDC","","","","","facility","both","1","EA","","38.59","19.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) SOLN 5 ML VIAL","61703-305-38","NDC","","","","","facility","both","1","EA","","19.3","9.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) SOLN 5 ML VIAL","61703-305-38","NDC","","","","","facility","both","1","EA","UD","25.85","12.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) SOLN 5 ML VIAL","61703-305-58","NDC","","","","","facility","both","1","EA","","47.7","23.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VINCRISTINE 1 MG/ML SOLN 1 ML VIAL","61703-309-06","NDC","","","","","facility","both","1","EA","","42.94","21.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VINCRISTINE 1 MG/ML SOLN 1 ML VIAL","61703-309-06","NDC","","","","","facility","both","1","EA","UD","59.38","29.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VINCRISTINE 2 MG/2 ML SOLN 2 ML VIAL","61703-309-16","NDC","","","","","facility","both","1","EA","","29.72","14.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VINCRISTINE 2 MG/2 ML SOLN 2 ML VIAL","61703-309-16","NDC","","","","","facility","both","1","EA","UD","32.34","16.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAMIDRONATE 90 MG/10 ML (9 MG/ML) SOLN 10 ML VIAL","61703-326-18","NDC","","","","","facility","both","1","EA","UD","229.94","114.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAMIDRONATE 90 MG/10 ML (9 MG/ML) SOLN 10 ML VIAL","61703-326-18","NDC","","","","","facility","both","1","EA","","229.94","114.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BLEOMYCIN 15 UNIT SOLR 1 EACH VIAL","61703-332-18","NDC","","","","","facility","both","1","EA","","98.11","49.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBOPLATIN 10 MG/ML SOLN 15 ML VIAL","61703-339-22","NDC","","","","","facility","both","1","EA","","13.65","6.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPLATIN 10 MG/ML SOLN 15 ML VIAL","61703-339-22","NDC","","","","","facility","both","1","EA","UD","68.24","34.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPLATIN 10 MG/ML SOLN 45 ML VIAL","61703-339-50","NDC","","","","","facility","both","1","EA","","155.73","77.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL","61703-339-56","NDC","","","","","facility","both","1","EA","","159.1","79.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPLATIN 10 MG/ML SOLN 60 ML VIAL","61703-339-56","NDC","","","","","facility","both","1","EA","UD","206.31","103.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PACLITAXEL 6 MG/ML CONC 50 ML VIAL","61703-342-50","NDC","","","","","facility","both","1","EA","","44.79","22.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PACLITAXEL 6 MG/ML CONC 50 ML VIAL","61703-342-50","NDC","","","","","facility","both","1","EA","UD","98.39","49.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IRINOTECAN 100 MG/5 ML SOLN 5 ML VIAL","61703-349-09","NDC","","","","","facility","both","1","EA","","126.36","63.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHOTREXATE 25 MG/ML SOLN","61703-350-37","NDC","","","","","facility","both","1","EA","","21.49","10.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHOTREXATE 25 MG/ML SOLN 40 ML VIAL","61703-408-41","NDC","","","","","facility","both","1","EA","UD","52.93","26.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOTREXATE 25 MG/ML SOLN 40 ML VIAL","61703-408-41","NDC","","","","","facility","both","1","EA","","69.75","34.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EUCERIN CREA 107 G JAR","6192417804","NDC","","","","","facility","both","1","EA","","107","53.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 G"
"EUCERIN CREA 454 G JAR","6192417816","NDC","","","","","facility","both","1","EA","UD","454","227","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EUCERIN CREA 454 G JAR","6192417816","NDC","","","","","facility","both","1","EA","","454","227","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 G"
"MICONAZOLE 2 % CREA 106 G TUBE","61924-234-04","NDC","","","","","facility","both","1","EA","UD","106","53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EMTRICITABINE 200 MG CAPS","61958-0601-1","NDC","","","","","facility","both","1","EA","","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EMTRICITABINE 200 MG CAPS","61958-0601-1","NDC","","","","","facility","both","1","EA","UD","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EMTRICITABINE-TENOFOVIR (STARTER PACK) 30 EACH BOTTLE","61958-0701-1","NDC","","","","","facility","both","1","EA","UD","325.2","162.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EMTRICITABINE-TENOFOVIR (STARTER PACK) 30 EACH BOTTLE","61958-0701-1","NDC","","","","","facility","both","1","EA","","325.2","162.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMBRISENTAN 5 MG TABS","61958-0801-1","NDC","","","","","facility","both","1","EA","","53.73","26.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMBRISENTAN 5 MG TABS","61958-0801-1","NDC","","","","","facility","both","1","EA","UD","99.47","49.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COBICISTAT 150 MG TABS","61958-1401-1","NDC","","","","","facility","both","1","EA","","50.22","25.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COBICISTAT 150 MG TABS","61958-1401-1","NDC","","","","","facility","both","1","EA","UD","52.53","26.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ELVITEG-COB-EMTRI-TENOF ALAFEN 150-150-200-10 MG TABS","61958-1901-1","NDC","","","","","facility","both","1","EA","UD","155.83","77.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ELVITEG-COB-EMTRI-TENOF ALAFEN 150-150-200-10 MG TABS","61958-1901-1","NDC","","","","","facility","both","1","EA","","155.83","77.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TENOFOVIR ALAFENAMIDE 25 MG TABS","61958-2301-1","NDC","","","","","facility","both","1","EA","UD","81.29","40.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TENOFOVIR ALAFENAMIDE 25 MG TABS","61958-2301-1","NDC","","","","","facility","both","1","EA","","81.29","40.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BICTEGRAV-EMTRICIT-TENOFOV 50-200-25 MG TABS","61958-2501-1","NDC","","","","","facility","both","1","EA","UD","164.51","82.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BICTEGRAV-EMTRICIT-TENOFOV 50-200-25 MG TABS","61958-2501-1","NDC","","","","","facility","both","1","EA","","164.51","82.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"REMDESIVIR 100 MG SOLR 1 EACH VIAL","61958-2901-2","NDC","","","","","facility","both","1","EA","TB","2567.24","1283.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"REMDESIVIR 100 MG SOLR 1 EACH VIAL","61958-2901-2","NDC","","","","","facility","both","1","EA","UD,TB","2567.24","1283.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"REMDESIVIR 100 MG SOLR 1 EACH VIAL","61958-2901-2","NDC","","","","","facility","both","1","EA","","2567.24","1283.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"REMDESIVIR 100 MG SOLR 1 EACH VIAL","61958-2901-2","NDC","","","","","facility","both","1","EA","UD","2567.24","1283.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISOLONE 5 MG TABS","62135-437-30","NDC","","","","","facility","both","1","EA","","19.77","9.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISOLONE 5 MG TABS","62135-437-30","NDC","","","","","facility","both","1","EA","UD","26","13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 10 MG/5 ML SOLN","62135-502-47","NDC","","","","","facility","both","1","EA","","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROXYZINE 10 MG/5 ML SOLN","62135-502-47","NDC","","","","","facility","both","1","EA","UD","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 10 MG TABS","62135-579-12","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 10 MG TABS","62135-579-12","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","62135-712-15","NDC","","","","","facility","both","1","EA","UD","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","62135-712-15","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROXYZINE 10 MG/5 ML SOLN","62135-750-47","NDC","","","","","facility","both","1","EA","UD","0.59","0.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 10 MG/5 ML SOLN","62135-750-47","NDC","","","","","facility","both","1","EA","","3.48","1.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"STERILE TALC 4 GRAM SUSR","62327-444-44","NDC","","","","","facility","both","1","EA","","208","104","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH"
"STERILE TALC 4 GRAM SUSR","62327-444-44","NDC","","","","","facility","both","1","EA","UD","378","189","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEFLUNOMIDE 20 MG TABS","62332-062-30","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEFLUNOMIDE 20 MG TABS","62332-062-30","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENOFIBRATE MICRONIZED 200 MG CAPS","62332-086-31","NDC","","","","","facility","both","1","EA","","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENOFIBRATE MICRONIZED 200 MG CAPS","62332-086-31","NDC","","","","","facility","both","1","EA","UD","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 0.125 MG ODT.","62332-364-06","NDC","","","","","facility","both","1","EA","UD","3.77","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLONAZEPAM 0.125 MG ODT.","62332-364-06","NDC","","","","","facility","both","1","EA","","3.77","1.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MOXIFLOXACIN 0.5 % DROP","62332-505-03","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPHOSPHAMIDE 50 MG CAPS","62332-619-31","NDC","","","","","facility","both","1","EA","","222.6","111.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOCETAXEL 80 MG/8 ML (10 MG/ML) SOLN 8 ML VIAL","62332-678-08","NDC","","","","","facility","both","1","EA","","198.06","99.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","62332-690-02","NDC","","","","","facility","both","1","EA","","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","62332-690-02","NDC","","","","","facility","both","1","EA","UD","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","62332-690-30","NDC","","","","","facility","both","1","EA","UD","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXERCALCIFEROL 4 MCG/2 ML SOLN","62332-690-30","NDC","","","","","facility","both","1","EA","","13.75","6.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 50 ML"
"UREA 15 GRAM PWPK","62530-00109","NDC","","","","","facility","both","1","EA","UD","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"UREA 15 GRAM PWPK","62530-00109","NDC","","","","","facility","both","1","EA","","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INDAPAMIDE 1.25 MG TABS","62559-510-01","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDAPAMIDE 1.25 MG TABS","62559-510-01","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML SUSR","62559-630-01","NDC","","","","","facility","both","1","EA","","30.52","15.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TERBUTALINE 2.5 MG TABS","62559-721-01","NDC","","","","","facility","both","1","EA","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 150 MG CAPS","62559-820-01","NDC","","","","","facility","both","1","EA","UD","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 150 MG CAPS","62559-820-01","NDC","","","","","facility","both","1","EA","","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 250 MG CAPS","62559-822-01","NDC","","","","","facility","both","1","EA","","3.07","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL 25 MG TABS","62584-265-11","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METOPROLOL 25 MG TABS","62584-265-11","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 50 MG TABS","62584-266-11","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 50 MG TABS","62584-266-11","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","62584-733-11","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 25 MG TABS","62584-733-11","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 2 MG TABS","62584-984-01","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 2 MG TABS","62584-984-11","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 2 MG TABS","62584-984-11","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 5 MG TABS","62584-994-11","NDC","","","","","facility","both","1","EA","UD","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 5 MG TABS","62584-994-11","NDC","","","","","facility","both","1","EA","","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPOPROSTENOL 1.5 MG SOLR","62756-060-40","NDC","","","","","facility","both","1","EA","","280.63","140.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPOPROSTENOL 1.5 MG SOLR","62756-060-40","NDC","","","","","facility","both","1","EA","UD","280.63","140.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIAGABINE 4 MG TABS","62756-224-83","NDC","","","","","facility","both","1","EA","UD","5.82","2.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIAGABINE 4 MG TABS","62756-224-83","NDC","","","","","facility","both","1","EA","","5.82","2.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","62756-427-90","NDC","","","","","facility","both","1","EA","UD","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","62756-427-90","NDC","","","","","facility","both","1","EA","","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIOTHYRONINE 5 MCG TABS","62756-589-88","NDC","","","","","facility","both","1","EA","UD","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIOTHYRONINE 5 MCG TABS","62756-589-88","NDC","","","","","facility","both","1","EA","","1.67","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 125 MG TBEC","62756-796-88","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 125 MG TBEC","62756-796-88","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 200 MG CAPS","62756-956-01","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEXILETINE 200 MG CAPS","62756-956-01","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEXILETINE 250 MG CAPS","62756-957-01","NDC","","","","","facility","both","1","EA","","3.07","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LECANEMAB-IRMB 100 MG/ML SOLN 2 ML VIAL","62856-212-01","NDC","","","","","facility","both","1","EA","TB","1161.93","580.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"LECANEMAB-IRMB 100 MG/ML SOLN 2 ML VIAL","62856-212-01","NDC","","","","","facility","both","1","EA","TB,Q0","1161.93","580.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study"
"LECANEMAB-IRMB 100 MG/ML SOLN 2 ML VIAL","62856-212-01","NDC","","","","","facility","both","1","EA","","1993.63","996.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LECANEMAB-IRMB 100 MG/ML SOLN 5 ML VIAL","62856-215-01","NDC","","","","","facility","both","1","EA","TB,Q0","2213.77","1106.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study"
"LECANEMAB-IRMB 100 MG/ML SOLN 5 ML VIAL","62856-215-01","NDC","","","","","facility","both","1","EA","","2605.16","1302.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LECANEMAB-IRMB 100 MG/ML SOLN 5 ML VIAL","62856-215-01","NDC","","","","","facility","both","1","EA","TB","2825.31","1412.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"PERAMPANEL 2 MG TABS","62856-272-30","NDC","","","","","facility","both","1","EA","","133.01","66.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RANOLAZINE 500 MG TB12","63304-017-60","NDC","","","","","facility","both","1","EA","","1.54","0.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GENTAMICIN 40 MG/ML SOLN","63323-010-02","NDC","","","","","facility","both","1","EA","UD","8.09","4.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 40 MG/ML SOLN","63323-010-02","NDC","","","","","facility","both","1","EA","","8.09","4.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"GENTAMICIN 40 MG/ML SOLN 20 ML VIAL","63323-010-03","NDC","","","","","facility","both","1","EA","UD","9.61","4.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 40 MG/ML SOLN 20 ML VIAL","63323-010-03","NDC","","","","","facility","both","1","EA","","12.45","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GENTAMICIN 25MG/5ML","63323-010-96","NDC","","","","","facility","both","1","EA","UD","5.29","2.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 25MG/5ML","63323-010-96","NDC","","","","","facility","both","1","EA","","5.29","2.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"THIAMINE 100 MG/ML SOLN","63323-013-01","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG/ML SOLN","63323-013-01","NDC","","","","","facility","both","1","EA","","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MANNITOL 25 % SOLN","63323-024-01","NDC","","","","","facility","both","1","EA","","31.25","15.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN 10 ML VIAL","63323-047-01","NDC","","","","","facility","both","1","EA","","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 2 ML VIAL","63323-064-01","NDC","","","","","facility","both","1","EA","UD","9.5","4.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 2 ML VIAL","63323-064-01","NDC","","","","","facility","both","1","EA","","9.5","4.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 1 GRAM INJ","63323-064-03","NDC","","","","","facility","both","1","EA","UD","9.5","4.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1 GRAM INJ","63323-064-03","NDC","","","","","facility","both","1","EA","","9.5","4.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN","63323-064-04","NDC","","","","","facility","both","1","EA","UD","13.31","6.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN","63323-064-04","NDC","","","","","facility","both","1","EA","","13.31","6.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 2 ML VIAL","63323-064-21","NDC","","","","","facility","both","1","EA","","9.5","4.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 2 ML VIAL","63323-064-21","NDC","","","","","facility","both","1","EA","UD","9.5","4.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 5 ML VIAL","63323-086-05","NDC","","","","","facility","both","1","EA","UD","95.06","47.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 5 ML VIAL","63323-086-05","NDC","","","","","facility","both","1","EA","","95.06","47.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","63323-089-50","NDC","","","","","facility","both","1","EA","","78.75","39.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CISPLATIN 1 MG/ML SOLN 50 ML VIAL","63323-103-51","NDC","","","","","facility","both","1","EA","","15.54","7.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CISPLATIN 1 MG/ML SOLN 100 ML VIAL","63323-103-65","NDC","","","","","facility","both","1","EA","","24.82","12.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL","63323-104-01","NDC","","","","","facility","both","1","EA","","22.4","11.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL","63323-104-01","NDC","","","","","facility","both","1","EA","UD","25.85","12.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL","63323-104-06","NDC","","","","","facility","both","1","EA","","17.8","8.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOPOSIDE 20 MG/ML SOLN 5 ML VIAL","63323-104-06","NDC","","","","","facility","both","1","EA","UD","25.85","12.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOPOSIDE 20 MG/ML SOLN 25 ML VIAL","63323-104-25","NDC","","","","","facility","both","1","EA","","22.72","11.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETOPOSIDE 20 MG/ML SOLN 25 ML VIAL","63323-104-25","NDC","","","","","facility","both","1","EA","UD","37.21","18.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","63323-106-02","NDC","","","","","facility","both","1","EA","","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 2G/50ML (4%) IN WATER PGBK","63323-106-02","NDC","","","","","facility","both","1","EA","UD","19.6","9.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) SOLP","63323-106-15","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) SOLP","63323-106-15","NDC","","","","","facility","both","1","EA","UD","7.5","3.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","63323-108-00","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","63323-108-00","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOROURACIL 500 MG/10 ML SOLN 10 ML VIAL","63323-117-00","NDC","","","","","facility","both","1","EA","UD","29.3","14.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOROURACIL 500 MG/10 ML SOLN 10 ML VIAL","63323-117-00","NDC","","","","","facility","both","1","EA","","29.3","14.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUOROURACIL 1 GRAM/20 ML SOLN 20 ML VIAL","63323-117-01","NDC","","","","","facility","both","1","EA","","24.97","12.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUOROURACIL 1 GRAM/20 ML SOLN 20 ML VIAL","63323-117-20","NDC","","","","","facility","both","1","EA","","29.58","14.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FLUOROURACIL 2.5 GRAM/50 ML SOLN 50 ML VIAL","63323-117-51","NDC","","","","","facility","both","1","EA","","58.74","29.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) SOLN 20 ML VIAL","63323-120-20","NDC","","","","","facility","both","1","EA","UD","88.55","44.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) SOLN 20 ML VIAL","63323-120-20","NDC","","","","","facility","both","1","EA","","88.55","44.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DACARBAZINE 100 MG SOLR 1 EACH VIAL","63323-127-00","NDC","","","","","facility","both","1","EA","","56.99","28.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DACARBAZINE 200 MG SOLR 1 EACH VIAL","63323-128-20","NDC","","","","","facility","both","1","EA","","169.6","84.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"DOXYCYCLINE 100 MG SOLR 1 EACH VIAL","63323-130-02","NDC","","","","","facility","both","1","EA","UD","94.21","47.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE 100 MG SOLR 1 EACH VIAL","63323-130-02","NDC","","","","","facility","both","1","EA","","94.21","47.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE 100 MG SOLR 1 EACH VIAL","63323-130-11","NDC","","","","","facility","both","1","EA","","94.21","47.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"DOXYCYCLINE 100 MG SOLR 1 EACH VIAL","63323-130-11","NDC","","","","","facility","both","1","EA","UD","94.21","47.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MITOXANTRONE 2 MG/ML CONC 12.5 ML VIAL","63323-132-12","NDC","","","","","facility","both","1","EA","","513.08","256.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 15 MG/ML SOLN","63323-161-00","NDC","","","","","facility","both","1","EA","","4.94","2.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 15 MG/ML SOLN","63323-161-00","NDC","","","","","facility","both","1","EA","UD","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 30 MG/ML SOLN","63323-162-00","NDC","","","","","facility","both","1","EA","UD","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 30 MG/ML SOLN","63323-162-00","NDC","","","","","facility","both","1","EA","","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TORADOL PER 15MG","63323-162-01","NDC","","","","","facility","both","1","EA","PN","144","72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TORADOL PER 15MG","63323-162-01","NDC","","","","","facility","both","1","EA","","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"TORADOL PER 15MG","63323-162-01","NDC","","","","","facility","both","1","EA","UD","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 20 MG/2 ML SOLN 2 ML VIAL","63323-173-01","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GENTAMICIN 20 MG/2 ML SOLN 2 ML VIAL","63323-173-01","NDC","","","","","facility","both","1","EA","","5.43","2.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GENTAMICIN 20 MG/2 ML SOLN","63323-173-02","NDC","","","","","facility","both","1","EA","","7.34","3.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"GENTAMICIN 20 MG/2 ML SOLN","63323-173-02","NDC","","","","","facility","both","1","EA","UD","6.77","3.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOXINE (VITAMIN B6) 100 MG/ML SOLN","63323-180-00","NDC","","","","","facility","both","1","EA","UD","121.63","60.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOXINE (VITAMIN B6) 100 MG/ML SOLN","63323-180-00","NDC","","","","","facility","both","1","EA","","138.31","69.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FOLIC ACID 5 MG/ML SOLN 10 ML VIAL","63323-184-10","NDC","","","","","facility","both","1","EA","","169.38","84.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FOLIC ACID 5 MG/ML SOLN 10 ML VIAL","63323-184-10","NDC","","","","","facility","both","1","EA","UD","169.38","84.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUDARABINE 50 MG/2 ML SOLN 2 ML VIAL","63323-192-02","NDC","","","","","facility","both","1","EA","","534.27","267.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-201-02","NDC","","","","","facility","both","1","EA","UD","5.55","2.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-201-02","NDC","","","","","facility","both","1","EA","","8.6","4.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-201-03","NDC","","","","","facility","both","1","EA","","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-201-03","NDC","","","","","facility","both","1","EA","UD","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-201-10","NDC","","","","","facility","both","1","EA","UD","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-201-10","NDC","","","","","facility","both","1","EA","","12.25","6.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 2% SOLN","63323-202-02","NDC","","","","","facility","both","1","EA","","18.75","9.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (XYLOCAINE) 2% SOLN","63323-202-02","NDC","","","","","facility","both","1","EA","UD","18.75","9.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE HCL (PF) 20 MG/ML (2 %) SOLN 5 ML VIAL","63323-208-01","NDC","","","","","facility","both","1","EA","UD","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE HCL (PF) 20 MG/ML (2 %) SOLN 5 ML VIAL","63323-208-01","NDC","","","","","facility","both","1","EA","","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (PF) 20 MG/ML (2 %) SOLN","63323-208-05","NDC","","","","","facility","both","1","EA","","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE (PF) 20 MG/ML (2 %) SOLN","63323-208-05","NDC","","","","","facility","both","1","EA","UD","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 500 MG SOLR","63323-221-33","NDC","","","","","facility","both","1","EA","","17.94","8.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 500 MG SOLR","63323-221-33","NDC","","","","","facility","both","1","EA","UD","17.94","8.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 3MG/0.3ML","63323-221-41","NDC","","","","","facility","both","1","EA","","14.96","7.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 3MG/0.3ML","63323-221-41","NDC","","","","","facility","both","1","EA","UD","14.96","7.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROTAMINE 10 MG/ML SOLN","63323-229-01","NDC","","","","","facility","both","1","EA","","56.81","28.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROTAMINE 10 MG/ML SOLN","63323-229-01","NDC","","","","","facility","both","1","EA","UD","56.81","28.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROTAMINE 10 MG/ML SOLN","63323-229-05","NDC","","","","","facility","both","1","EA","","56.81","28.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"PROTAMINE 10 MG/ML SOLN","63323-229-05","NDC","","","","","facility","both","1","EA","UD","56.81","28.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROTAMINE 10 MG/ML SOLN","63323-229-21","NDC","","","","","facility","both","1","EA","UD","56.81","28.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROTAMINE 10 MG/ML SOLN","63323-229-21","NDC","","","","","facility","both","1","EA","","56.81","28.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROTAMINE 10 MG/ML SOLN","63323-229-30","NDC","","","","","facility","both","1","EA","","187.99","94.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROTAMINE 10 MG/ML SOLN","63323-229-30","NDC","","","","","facility","both","1","EA","UD","200.35","100.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINERAL OIL, LIGHT STERILE OIL","6332325410","NDC","","","","","facility","both","1","EA","","53.59","26.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MINERAL OIL, LIGHT STERILE OIL","6332325410","NDC","","","","","facility","both","1","EA","UD","53.59","26.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 40 MG SOLR","63323-255-03","NDC","","","","","facility","both","1","EA","","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"METHYLPREDNISOLONE SOD SUCC 40 MG SOLR","63323-255-03","NDC","","","","","facility","both","1","EA","UD","28","14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR","63323-258-03","NDC","","","","","facility","both","1","EA","UD","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR","63323-258-03","NDC","","","","","facility","both","1","EA","","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"HEPARIN 5,000 UNIT/ML SOLN","63323-262-03","NDC","","","","","facility","both","1","EA","UD","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 5,000 UNIT/ML SOLN","63323-262-03","NDC","","","","","facility","both","1","EA","","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN","63323-262-09","NDC","","","","","facility","both","1","EA","UD","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 5,000 UNIT/ML SOLN","63323-262-09","NDC","","","","","facility","both","1","EA","","10.06","5.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROPOFOL 10 MG/ML EMUL","63323-269-50","NDC","","","","","facility","both","1","EA","","39.69","19.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"PROPOFOL 10 MG/ML EMUL","63323-269-57","NDC","","","","","facility","both","1","EA","","39.69","19.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"PROPOFOL 10 MG/ML EMUL","63323-269-65","NDC","","","","","facility","both","1","EA","UD","73.13","36.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","63323-269-65","NDC","","","","","facility","both","1","EA","","73.13","36.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PROPOFOL 10 MG/ML EMUL","63323-269-67","NDC","","","","","facility","both","1","EA","","73.13","36.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SUMATRIPTAN 6 MG/0.5 ML SOLN","63323-273-01","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SUMATRIPTAN 6 MG/0.5 ML SOLN","63323-273-01","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN PF 1,000 UNIT/ML SOLN","63323-276-01","NDC","","","","","facility","both","1","EA","","2.53","1.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN PF 1,000 UNIT/ML SOLN","63323-276-01","NDC","","","","","facility","both","1","EA","UD","2.53","1.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN PF 1,000 UNIT/ML SOLN 2 ML VIAL","63323-276-02","NDC","","","","","facility","both","1","EA","","15.78","7.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN PF 1,000 UNIT/ML SOLN 2 ML VIAL","63323-276-02","NDC","","","","","facility","both","1","EA","UD","55.63","27.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VINBLASTINE 1 MG/ML SOLN 10 ML VIAL","63323-278-10","NDC","","","","","facility","both","1","EA","","300.76","150.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUPHENAZINE 2.5 MG/ML SOLN","63323-281-10","NDC","","","","","facility","both","1","EA","","1202.94","601.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FLUPHENAZINE 2.5 MG/ML SOLN","63323-281-10","NDC","","","","","facility","both","1","EA","UD","1202.94","601.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROPIVACAINE 0.2% (PF) 2 MG/ML (0.2 %) SOLN","63323-285-65","NDC","","","","","facility","both","1","EA","UD","157.5","78.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROPIVACAINE 0.2% (PF) 2 MG/ML (0.2 %) SOLN","63323-285-65","NDC","","","","","facility","both","1","EA","","157.5","78.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"ROPIVACAINE (PF) 0.5% SOLN","63323-286-23","NDC","","","","","facility","both","1","EA","","31.5","15.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"TOBRAMYCIN 1.2 GRAM SOLR","63323-303-55","NDC","","","","","facility","both","1","EA","","416.84","208.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 EACH"
"TOBRAMYCIN 1.2 GRAM SOLR","63323-303-55","NDC","","","","","facility","both","1","EA","UD","416.84","208.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN 40 MG/ML SOLN","63323-306-02","NDC","","","","","facility","both","1","EA","UD","14.13","7.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN 40 MG/ML SOLN 30 ML VIAL","63323-306-30","NDC","","","","","facility","both","1","EA","","136.56","68.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IMIPENEM-CILASTATIN 500 MG SOLR 1 EACH VIAL","63323-322-01","NDC","","","","","facility","both","1","EA","","80.63","40.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IMIPENEM-CILASTATIN 500 MG SOLR 1 EACH VIAL","63323-322-25","NDC","","","","","facility","both","1","EA","","80.63","40.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 EACH"
"ACYCLOVIR 50 MG/ML SOLN","63323-325-03","NDC","","","","","facility","both","1","EA","","5.42","2.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACYCLOVIR 50 MG/ML SOLN","63323-325-03","NDC","","","","","facility","both","1","EA","UD","5.42","2.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 50 MG/ML SOLN 20 ML VIAL","63323-325-09","NDC","","","","","facility","both","1","EA","","56.25","28.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACYCLOVIR 50 MG/ML SOLN 20 ML VIAL","63323-325-09","NDC","","","","","facility","both","1","EA","UD","56.25","28.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 50 MG/ML SOLN 10 ML VIAL","63323-325-10","NDC","","","","","facility","both","1","EA","UD","56.25","28.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 50 MG/ML SOLN 10 ML VIAL","63323-325-10","NDC","","","","","facility","both","1","EA","","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","63323-326-21","NDC","","","","","facility","both","1","EA","UD","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFEPIME 1 GRAM SOLR 1 EACH VIAL","63323-326-21","NDC","","","","","facility","both","1","EA","","18.63","9.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","63323-328-21","NDC","","","","","facility","both","1","EA","","53.81","26.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFEPIME 2 GRAM SOLR 1 EACH VIAL","63323-340-21","NDC","","","","","facility","both","1","EA","","32.5","16.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN","63323-360-01","NDC","","","","","facility","both","1","EA","UD","65.13","32.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN","63323-360-03","NDC","","","","","facility","both","1","EA","","12.47","6.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN","63323-360-03","NDC","","","","","facility","both","1","EA","UD","339.38","169.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN","63323-360-05","NDC","","","","","facility","both","1","EA","","6.18","3.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN","63323-360-05","NDC","","","","","facility","both","1","EA","UD","124.91","62.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 10 ML VIAL","63323-360-19","NDC","","","","","facility","both","1","EA","","9.96","4.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 10 ML VIAL","63323-360-19","NDC","","","","","facility","both","1","EA","UD","9.44","4.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 50 ML VIAL","63323-360-59","NDC","","","","","facility","both","1","EA","","676.25","338.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML VIAL","63323-360-61","NDC","","","","","facility","both","1","EA","UD","616.25","308.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML VIAL","63323-360-61","NDC","","","","","facility","both","1","EA","","616.25","308.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"OCTREOTIDE 100 MCG/ML SOLN","63323-376-00","NDC","","","","","facility","both","1","EA","","22.81","11.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OCTREOTIDE 100 MCG/ML SOLN","63323-376-00","NDC","","","","","facility","both","1","EA","UD","23.75","11.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 100 MCG/ML SOLN","63323-376-01","NDC","","","","","facility","both","1","EA","","22.81","11.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"OCTREOTIDE 100 MCG/ML SOLN","63323-376-01","NDC","","","","","facility","both","1","EA","UD","23.75","11.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OCTREOTIDE 1,000 MCG/ML SOLN 5 ML VIAL","63323-379-05","NDC","","","","","facility","both","1","EA","","195.5","97.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COLISTIMETHATE 150 MG SOLR","63323-393-06","NDC","","","","","facility","both","1","EA","","67.19","33.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","63323-398-12","NDC","","","","","facility","both","1","EA","UD","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","63323-398-12","NDC","","","","","facility","both","1","EA","","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"AZTREONAM 2 GRAM SOLR 1 EACH VIAL","63323-402-20","NDC","","","","","facility","both","1","EA","","333.42","166.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"FOSPHENYTOIN 100 MG PE/2 ML SOLN 2 ML VIAL","63323-403-02","NDC","","","","","facility","both","1","EA","","70.5","35.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MIDAZOLAM 1 MG/ML SOLN 2 ML VIAL","63323-411-15","NDC","","","","","facility","both","1","EA","UD","6.86","3.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM 1 MG/ML SOLN 2 ML VIAL","63323-411-15","NDC","","","","","facility","both","1","EA","","6.86","3.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 1 MG/ML SOLN 5 ML VIAL","63323-411-18","NDC","","","","","facility","both","1","EA","","8.27","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MIDAZOLAM 1 MG/ML SOLN 5 ML VIAL","63323-411-18","NDC","","","","","facility","both","1","EA","UD","8.27","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDAZOLAM 5 MG/ML SOLN 1 ML VIAL","63323-412-18","NDC","","","","","facility","both","1","EA","UD","12.2","6.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CISATRACURIUM 2 MG/ML SOLN","63323-417-10","NDC","","","","","facility","both","1","EA","","59.5","29.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CISATRACURIUM 2 MG/ML SOLN","63323-417-10","NDC","","","","","facility","both","1","EA","UD","59.5","29.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CISATRACURIUM 10 MG/ML CONC. (ICU USE ONLY) SOLN 20 ML VIAL","63323-418-01","NDC","","","","","facility","both","1","EA","UD","590","295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CISATRACURIUM 10 MG/ML CONC. (ICU USE ONLY) SOLN 20 ML VIAL","63323-418-01","NDC","","","","","facility","both","1","EA","","590","295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CISATRACURIUM 10 MG/ML CONC. (ICU USE ONLY) SOLN 20 ML VIAL","63323-418-20","NDC","","","","","facility","both","1","EA","UD","590","295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUMAZENIL 0.1 MG/ML SOLN","63323-424-05","NDC","","","","","facility","both","1","EA","UD","43.13","21.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUMAZENIL 0.1 MG/ML SOLN","63323-424-05","NDC","","","","","facility","both","1","EA","","43.13","21.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MORPHINE 10 MG/ML SOLN","63323-451-00","NDC","","","","","facility","both","1","EA","UD","11.93","5.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 10 MG/ML SOLN","63323-451-00","NDC","","","","","facility","both","1","EA","","11.93","5.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 5 MG/ML SOLN","63323-455-00","NDC","","","","","facility","both","1","EA","UD","22.22","11.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.25%-EPINEPHRINE 1:200,000 0.25 %-1:200,000 SOLN","63323-461-57","NDC","","","","","facility","both","1","EA","UD","39.69","19.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.25%-EPINEPHRINE 1:200,000 0.25 %-1:200,000 SOLN","63323-461-57","NDC","","","","","facility","both","1","EA","","39.69","19.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE 0.5%-EPINEPHRINE 1:200,000 (PF) 0.5 %-1:200,000 SOLN","63323-462-17","NDC","","","","","facility","both","1","EA","","19.06","9.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE 0.5%-EPINEPHRINE 1:200,000 (PF) 0.5 %-1:200,000 SOLN","63323-462-17","NDC","","","","","facility","both","1","EA","UD","19.06","9.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.5%-EPINEPHRINE 1:200,000 (PF) 0.5 %-1:200,000 SOLN","63323-462-31","NDC","","","","","facility","both","1","EA","","19.75","9.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"BUPIVACAINE 0.5%-EPINEPHRINE 1:200,000 (PF) 0.5 %-1:200,000 SOLN","63323-462-31","NDC","","","","","facility","both","1","EA","UD","19.75","9.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.5%-EPINEPHRINE 1:200,000 0.5 %-1:200,000 SOLN","63323-463-57","NDC","","","","","facility","both","1","EA","UD","42.81","21.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE 0.5%-EPINEPHRINE 1:200,000 0.5 %-1:200,000 SOLN","63323-463-57","NDC","","","","","facility","both","1","EA","","42.81","21.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"BUPIVACAINE HCL INJECTION 0.5%, PER ML","63323-466-03","NDC","","","","","facility","both","1","EA","PN","5.88","2.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"BUPIVACAINE HCL INJECTION 0.5%, PER ML","63323-466-03","NDC","","","","","facility","both","1","EA","","15.06","7.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUPIVACAINE HCL INJECTION 0.5%, PER ML","63323-466-17","NDC","","","","","facility","both","1","EA","PN","0.84","0.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"HALOPERIDOL DECANOATE 50 MG/ML SOLN","63323-469-01","NDC","","","","","facility","both","1","EA","UD","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL DECANOATE 50 MG/ML SOLN","63323-469-01","NDC","","","","","facility","both","1","EA","","127.5","63.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HALOPERIDOL DECANOATE 100 MG/ML SOLN","63323-471-01","NDC","","","","","facility","both","1","EA","UD","171.25","85.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL DECANOATE 100 MG/ML SOLN","63323-471-01","NDC","","","","","facility","both","1","EA","","171.25","85.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHLOROPROCAINE 20 MG/ML (2 %) SOLN","63323-476-37","NDC","","","","","facility","both","1","EA","UD","60.25","30.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLOROPROCAINE (PF) 20 MG/ML (2 %) SOLN","63323-477-01","NDC","","","","","facility","both","1","EA","","4.17","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 SOLN","63323-481-01","NDC","","","","","facility","both","1","EA","UD","26.56","13.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","63323-482-03","NDC","","","","","facility","both","1","EA","","14.38","7.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","63323-482-03","NDC","","","","","facility","both","1","EA","UD","14.38","7.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","63323-482-05","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","63323-482-05","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","63323-482-17","NDC","","","","","facility","both","1","EA","UD","24.19","12.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 1%-EPINEPHRINE 1:100,000 1 %-1:100,000 SOLN","63323-482-17","NDC","","","","","facility","both","1","EA","","24.19","12.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 2%-EPINEPHRINE 1:100,000 2 %-1:100,000 SOLN","63323-483-03","NDC","","","","","facility","both","1","EA","","23.38","11.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-485-01","NDC","","","","","facility","both","1","EA","UD","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-485-01","NDC","","","","","facility","both","1","EA","","12.38","6.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-485-03","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE (XYLOCAINE) 1% SOLN","63323-485-03","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 2% SOLN","63323-486-02","NDC","","","","","facility","both","1","EA","UD","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (XYLOCAINE) 2% SOLN","63323-486-02","NDC","","","","","facility","both","1","EA","","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 SOLN 10 ML VIAL","63323-487-01","NDC","","","","","facility","both","1","EA","","55.56","27.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 SOLN 10 ML VIAL","63323-487-01","NDC","","","","","facility","both","1","EA","UD","63","31.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 SOLN","63323-487-07","NDC","","","","","facility","both","1","EA","","66.06","33.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","63323-492-04","NDC","","","","","facility","both","1","EA","UD","9.06","4.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","63323-492-04","NDC","","","","","facility","both","1","EA","","9.06","4.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","63323-492-07","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","63323-492-07","NDC","","","","","facility","both","1","EA","","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","63323-492-08","NDC","","","","","facility","both","1","EA","","29.56","14.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","63323-492-97","NDC","","","","","facility","both","1","EA","","29.56","14.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","63323-494-01","NDC","","","","","facility","both","1","EA","","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","63323-494-01","NDC","","","","","facility","both","1","EA","UD","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","63323-494-05","NDC","","","","","facility","both","1","EA","UD","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","63323-494-05","NDC","","","","","facility","both","1","EA","","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIDOCAINE (PF) 20 MG/ML (2 %) SOLN","63323-495-04","NDC","","","","","facility","both","1","EA","UD","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE (PF) 20 MG/ML (2 %) SOLN","63323-495-04","NDC","","","","","facility","both","1","EA","","9.56","4.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE PF 10 MG/ML SOLN","63323-506-01","NDC","","","","","facility","both","1","EA","UD","7.97","3.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE PF 10 MG/ML SOLN","63323-506-01","NDC","","","","","facility","both","1","EA","","9.06","4.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"MEROPENEM 500 MG SOLR 1 EACH VIAL","63323-507-01","NDC","","","","","facility","both","1","EA","","16.25","8.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","63323-508-01","NDC","","","","","facility","both","1","EA","","29.69","14.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","63323-508-01","NDC","","","","","facility","both","1","EA","UD","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","63323-508-21","NDC","","","","","facility","both","1","EA","UD","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","63323-508-30","NDC","","","","","facility","both","1","EA","","32.19","16.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"MEROPENEM 1 GRAM SOLR 1 EACH VIAL","63323-508-30","NDC","","","","","facility","both","1","EA","UD","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN (PORCINE)-0.45% NACL 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","63323-517-01","NDC","","","","","facility","both","1","EA","UD","10.09","5.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN (PORCINE)-0.45% NACL 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","63323-517-01","NDC","","","","","facility","both","1","EA","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","63323-523-01","NDC","","","","","facility","both","1","EA","UD","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 25,000 UNIT/250 ML(100 UNIT/ML) SOLP","63323-523-01","NDC","","","","","facility","both","1","EA","","35","17.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1,000 UNIT/ML SOLN","63323-540-03","NDC","","","","","facility","both","1","EA","","6.39","3.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1,000 UNIT/ML SOLN","63323-540-03","NDC","","","","","facility","both","1","EA","UD","14.18","7.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","63323-540-05","NDC","","","","","facility","both","1","EA","UD","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","63323-540-05","NDC","","","","","facility","both","1","EA","","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","63323-540-07","NDC","","","","","facility","both","1","EA","","16.81","8.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 100 UNIT/ML SOLN","63323-545-01","NDC","","","","","facility","both","1","EA","","52.81","26.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN 100 UNIT/ML SOLN","63323-545-01","NDC","","","","","facility","both","1","EA","UD","52.81","26.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 100 UNIT/ML SOLN","63323-545-05","NDC","","","","","facility","both","1","EA","","14.94","7.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"HEPARIN 100 UNIT/ML SOLN","63323-545-05","NDC","","","","","facility","both","1","EA","UD","14.94","7.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 30 MG/0.3 ML SYRG","63323-559-21","NDC","","","","","facility","both","1","EA","","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 30 MG/0.3 ML SYRG","63323-559-21","NDC","","","","","facility","both","1","EA","UD","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEFEROXAMINE 500 MG SOLR 1 EACH VIAL","63323-597-10","NDC","","","","","facility","both","1","EA","","120.73","60.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEFEROXAMINE 2 GRAM SOLR 1 EACH VIAL","63323-599-30","NDC","","","","","facility","both","1","EA","UD","99.38","49.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 1 MG/ML SOLN","63323-604-00","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 1 MG/ML SOLN","63323-604-01","NDC","","","","","facility","both","1","EA","","196.25","98.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HYDRALAZINE 20 MG/ML SOLN","63323-614-00","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDRALAZINE 20 MG/ML SOLN","63323-614-00","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 20 MG/ML SOLN","63323-614-21","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMIODARONE 50 MG/ML SOLN","63323-616-01","NDC","","","","","facility","both","1","EA","","13.43","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMIODARONE 50 MG/ML SOLN","63323-616-03","NDC","","","","","facility","both","1","EA","","13.43","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"AMIODARONE 50 MG/ML SOLN","63323-616-03","NDC","","","","","facility","both","1","EA","UD","13.43","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM SULFATE 500 MG/ML (50 %) SOLN 20 ML VIAL","63323-642-01","NDC","","","","","facility","both","1","EA","","3.58","1.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVOTHYROXINE 200 MCG SOLR 1 EACH VIAL","63323-647-10","NDC","","","","","facility","both","1","EA","","984.92","492.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 500 MCG SOLR","63323-648-10","NDC","","","","","facility","both","1","EA","","2354.36","1177.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVOTHYROXINE 100 MCG SOLR 1 EACH VIAL","63323-649-07","NDC","","","","","facility","both","1","EA","","511.93","255.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","63323-658-20","NDC","","","","","facility","both","1","EA","","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHLOROTHIAZIDE 500 MG SOLR 1 EACH VIAL","63323-658-20","NDC","","","","","facility","both","1","EA","UD","200.5","100.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 5 MG/5 ML SOLN","63323-660-01","NDC","","","","","facility","both","1","EA","","7.56","3.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METOPROLOL 5 MG/5 ML SOLN","63323-660-01","NDC","","","","","facility","both","1","EA","UD","7.56","3.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 50 MG/ML SOLN","63323-664-00","NDC","","","","","facility","both","1","EA","UD","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIPHENHYDRAMINE 50 MG/ML SOLN","63323-664-00","NDC","","","","","facility","both","1","EA","","7.63","3.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TERBUTALINE 1 MG/ML SOLN","63323-665-00","NDC","","","","","facility","both","1","EA","UD","10.63","5.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERBUTALINE 1 MG/ML SOLN","63323-665-00","NDC","","","","","facility","both","1","EA","","10.63","5.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TERBUTALINE 1 MG/ML SOLN","63323-665-01","NDC","","","","","facility","both","1","EA","UD","10.63","5.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERBUTALINE 1 MG/ML SOLN","63323-665-01","NDC","","","","","facility","both","1","EA","","10.63","5.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","63323-690-30","NDC","","","","","facility","both","1","EA","UD","20.71","10.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 3 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","63323-690-30","NDC","","","","","facility","both","1","EA","","20.71","10.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 3 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","63323-694-04","NDC","","","","","facility","both","1","EA","UD","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN","63323-694-04","NDC","","","","","facility","both","1","EA","","19","9.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"ACETYLCYSTEINE 100 MG/ML (10 %) SOLN","63323-695-04","NDC","","","","","facility","both","1","EA","UD","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 100 MG/ML (10 %) SOLN","63323-695-04","NDC","","","","","facility","both","1","EA","","29.38","14.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LEUCOVORIN CALCIUM 200 MG SOLR 1 EACH VIAL","63323-710-50","NDC","","","","","facility","both","1","EA","","82.8","41.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 500 MG SOLR 1 EACH VIAL","63323-711-00","NDC","","","","","facility","both","1","EA","","228.45","114.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","63323-713-03","NDC","","","","","facility","both","1","EA","","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"REMIFENTANIL 1 MG SOLR 1 EACH VIAL","63323-723-01","NDC","","","","","facility","both","1","EA","","265.8","132.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"REMIFENTANIL 1 MG SOLR 1 EACH VIAL","63323-723-01","NDC","","","","","facility","both","1","EA","UD","265.8","132.9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","63323-728-01","NDC","","","","","facility","both","1","EA","","165","82.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","63323-728-01","NDC","","","","","facility","both","1","EA","UD","452.5","226.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","63323-729-01","NDC","","","","","facility","both","1","EA","","300","150","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","63323-729-01","NDC","","","","","facility","both","1","EA","UD","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE (PF) 10 MG/ML SOLN","63323-739-11","NDC","","","","","facility","both","1","EA","UD","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE (PF) 10 MG/ML SOLN","63323-739-11","NDC","","","","","facility","both","1","EA","","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","63323-760-20","NDC","","","","","facility","both","1","EA","","3704","1852","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MELPHALAN HCL 50 MG SOLR 1 EACH VIAL","63323-760-20","NDC","","","","","facility","both","1","EA","UD","5144","2572","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PACLITAXEL 6 MG/ML CONC 50 ML VIAL","63323-763-50","NDC","","","","","facility","both","1","EA","UD","98.39","49.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","63323-806-11","NDC","","","","","facility","both","1","EA","","16.7","8.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN","63323-806-11","NDC","","","","","facility","both","1","EA","UD","16.7","8.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE PF (SUBLIMAZE) 50 MCG/ML SOLN 2 ML VIAL","63323-806-12","NDC","","","","","facility","both","1","EA","UD","9.92","4.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXACILLIN 10 GRAM SOLR 1 EACH BOTTLE","63323-811-00","NDC","","","","","facility","both","1","EA","","73.89","36.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL","63323-815-04","NDC","","","","","facility","both","1","EA","","48.13","24.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"AMIKACIN 1,000 MG/4 ML SOLN 4 ML VIAL","63323-815-22","NDC","","","","","facility","both","1","EA","","48.13","24.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE (PF) 10 MG/ML SOLN","63323-851-50","NDC","","","","","facility","both","1","EA","","21.54","10.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE (PF) 10 MG/ML SOLN","63323-851-50","NDC","","","","","facility","both","1","EA","UD","28.35","14.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 1 MG/ML SOLN","63323-852-03","NDC","","","","","facility","both","1","EA","UD","15.59","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 1 MG/ML SOLN","63323-852-03","NDC","","","","","facility","both","1","EA","","15.59","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 2 MG/ML SOLN","63323-853-03","NDC","","","","","facility","both","1","EA","","23.1","11.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PENTAMIDINE 300 MG SOLR","63323-877-15","NDC","","","","","facility","both","1","EA","","128","64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL","63323-881-01","NDC","","","","","facility","both","1","EA","","116.69","58.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM PHOSPHATE 3 MMOL/ML SOLN 15 ML VIAL","63323-881-01","NDC","","","","","facility","both","1","EA","UD","116.69","58.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXORUBICIN 50 MG/25 ML SOLN 25 ML VIAL","63323-883-30","NDC","","","","","facility","both","1","EA","","118.82","59.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEVOTHYROXINE 100 MCG/ML SOLN","63323-895-10","NDC","","","","","facility","both","1","EA","UD","116.2","58.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVOTHYROXINE 100 MCG/ML SOLN","63323-895-10","NDC","","","","","facility","both","1","EA","JG","340.99","170.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"LEVOTHYROXINE 100 MCG/ML SOLN","63323-895-10","NDC","","","","","facility","both","1","EA","","880.48","440.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","63323-930-00","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","63323-930-00","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","63323-930-01","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","63323-930-01","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","63323-940-04","NDC","","","","","facility","both","1","EA","","43.75","21.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","63323-940-04","NDC","","","","","facility","both","1","EA","UD","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","63323-940-21","NDC","","","","","facility","both","1","EA","UD","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","63323-940-21","NDC","","","","","facility","both","1","EA","","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","63323-963-30","NDC","","","","","facility","both","1","EA","","283.78","141.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL","63323-965-02","NDC","","","","","facility","both","1","EA","","16.88","8.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL","63323-965-02","NDC","","","","","facility","both","1","EA","UD","16.88","8.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 30 ML VIAL","63323-967-01","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM CHLORIDE 2 MEQ/ML SOLN 30 ML VIAL","63323-967-01","NDC","","","","","facility","both","1","EA","UD","5.09","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESLICARBAZEPINE 200 MG TABS","63402-202-30","NDC","","","","","facility","both","1","EA","","263.74","131.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LURASIDONE 40 MG TABS","63402-304-30","NDC","","","","","facility","both","1","EA","UD","4.26","2.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENDAMUSTINE 25 MG/ML SOLN 4 ML VIAL","63459-348-04","NDC","","","","","facility","both","1","EA","JG","11223.68","5611.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BENDAMUSTINE 25 MG/ML SOLN 4 ML VIAL","63459-348-04","NDC","","","","","facility","both","1","EA","UD","19058","9529","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENDAMUSTINE 25 MG/ML SOLN 4 ML VIAL","63459-348-04","NDC","","","","","facility","both","1","EA","","19058","9529","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCORTISONE 2.5 % CRPE 30 G TUBE","63629-1952-1","NDC","","","","","facility","both","1","EA","","46.45","23.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 2.5 % CRPE 30 G TUBE","63629-1952-1","NDC","","","","","facility","both","1","EA","UD","46.45","23.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOLIC ACID 1 MG TABS","63629-9257-1","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOLIC ACID 1 MG TABS","63629-9257-1","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BENZOCAINE 20 % OINT 28 G TUBE","6373603751","NDC","","","","","facility","both","1","EA","","14.62","7.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PERMETHRIN 1 % LIQD 59 ML BOTTLE","6373612002","NDC","","","","","facility","both","1","EA","UD","19.38","9.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARTIFICIAL TEARS OINT 3.5 G TUBE","6373614308","NDC","","","","","facility","both","1","EA","UD","11.46","5.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARTIFICIAL TEARS OINT 3.5 G TUBE","6373614308","NDC","","","","","facility","both","1","EA","","11.46","5.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TEMAZEPAM 7.5 MG CAPS","63739-003-33","NDC","","","","","facility","both","1","EA","","3.43","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TEMAZEPAM 7.5 MG CAPS","63739-003-33","NDC","","","","","facility","both","1","EA","UD","3.43","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG TABS","63739-008-33","NDC","","","","","facility","both","1","EA","UD","7.7","3.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VORICONAZOLE 200 MG TABS","63739-008-33","NDC","","","","","facility","both","1","EA","","7.7","3.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DILTIAZEM 24HR 240 MG CP24","63739-016-10","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIODARONE 200 MG TABS","63739-051-10","NDC","","","","","facility","both","1","EA","","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMIODARONE 200 MG TABS","63739-051-10","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORHEXIDINE 0.12 % MWSH","63739-052-74","NDC","","","","","facility","both","1","EA","","4.83","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHLORHEXIDINE 0.12 % MWSH","63739-052-74","NDC","","","","","facility","both","1","EA","UD","4.83","2.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 10 MG TABS","63739-074-10","NDC","","","","","facility","both","1","EA","","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE 10 MG TABS","63739-074-10","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROIC ACID 250 MG CAPS","63739-086-10","NDC","","","","","facility","both","1","EA","UD","1.79","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROIC ACID 250 MG CAPS","63739-086-10","NDC","","","","","facility","both","1","EA","","1.79","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACETAMINOPHEN 325 MG TABS","63739-087-02","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 325 MG TABS","63739-087-02","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIRTAZAPINE 15 MG TABS","63739-098-10","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIRTAZAPINE 15 MG TABS","63739-098-10","NDC","","","","","facility","both","1","EA","UD","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 5 MG TABS","63739-145-10","NDC","","","","","facility","both","1","EA","UD","1.33","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIDODRINE 5 MG TABS","63739-145-10","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FERROUS SULFATE 300 MG (60 MG IRON)/5 ML LIQD","6373915770","NDC","","","","","facility","both","1","EA","UD","7.54","3.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG/5 ML (5 ML) SOLN","63739-158-70","NDC","","","","","facility","both","1","EA","","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","63739-160-10","NDC","","","","","facility","both","1","EA","UD","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","63739-160-10","NDC","","","","","facility","both","1","EA","","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","63739-160-70","NDC","","","","","facility","both","1","EA","","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","63739-160-70","NDC","","","","","facility","both","1","EA","UD","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE","63739-164-74","NDC","","","","","facility","both","1","EA","UD","2.99","1.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE","63739-164-74","NDC","","","","","facility","both","1","EA","","3.16","1.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","63739-196-01","NDC","","","","","facility","both","1","EA","UD","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","63739-196-01","NDC","","","","","facility","both","1","EA","","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","63739-203-01","NDC","","","","","facility","both","1","EA","UD","51.84","25.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","63739-203-01","NDC","","","","","facility","both","1","EA","","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ASPIRIN EC 81 MG TBEC","63739-212-02","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN EC 81 MG TBEC","63739-212-02","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","63739-327-10","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","63739-327-10","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE DINITRATE 20 MG TABS","63739-367-10","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 20 MG TABS","63739-367-10","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALLOPURINOL 100 MG TABS","63739-410-10","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALLOPURINOL 100 MG TABS","63739-410-10","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA-DOCUSATE 8.6-50 MG TABS","63739-432-02","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNA-DOCUSATE 8.6-50 MG TABS","63739-432-02","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN 81 MG CHEW","63739-434-02","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYZINE 10 MG TABS","63739-483-10","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYZINE 10 MG TABS","63739-483-10","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYZINE 25 MG TABS","63739-486-10","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYZINE 25 MG TABS","63739-486-10","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML SYRP","63739-506-01","NDC","","","","","facility","both","1","EA","","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SPIRONOLACTONE 25 MG TABS","63739-544-10","NDC","","","","","facility","both","1","EA","UD","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SPIRONOLACTONE 25 MG TABS","63739-544-10","NDC","","","","","facility","both","1","EA","","0.15","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TAMSULOSIN 0.4 MG CAPS","63739-567-10","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TAMSULOSIN 0.4 MG CAPS","63739-567-10","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ISOSORBIDE DINITRATE 10 MG TABS","63739-569-10","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ISOSORBIDE DINITRATE 10 MG TABS","63739-569-10","NDC","","","","","facility","both","1","EA","","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 5 MG TABS","63739-570-10","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 5 MG TABS","63739-570-10","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 20 MG TABS","63739-572-10","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 20 MG TABS","63739-572-10","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 40 MG TABS","63739-573-10","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 40 MG TABS","63739-573-10","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FAMOTIDINE 20 MG TABS","63739-645-10","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FAMOTIDINE 20 MG TABS","63739-645-10","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 25 MG TABS","63739-673-10","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 25 MG TABS","63739-673-10","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOSARTAN 50 MG TABS","63739-686-10","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 50 MG TABS","63739-686-10","NDC","","","","","facility","both","1","EA","","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIMODIPINE 30 MG CAPS","63739-797-33","NDC","","","","","facility","both","1","EA","","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIMODIPINE 30 MG CAPS","63739-797-33","NDC","","","","","facility","both","1","EA","UD","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 10 MG TABS","63739-888-10","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 100 MG CAPS","63739-902-10","NDC","","","","","facility","both","1","EA","UD","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 100 MG CAPS","63739-902-10","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 300 MG CAPS","63739-903-10","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GABAPENTIN 300 MG CAPS","63739-903-10","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","63739-904-10","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","63739-904-10","NDC","","","","","facility","both","1","EA","UD","0.16","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 5,000 UNIT/ML SOLN","63739-953-11","NDC","","","","","facility","both","1","EA","","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN","63739-953-11","NDC","","","","","facility","both","1","EA","UD","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","63739-973-10","NDC","","","","","facility","both","1","EA","UD","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE ER 20 MEQ TBTQ","63739-973-10","NDC","","","","","facility","both","1","EA","","0.53","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOCUSATE SODIUM 50 MG/5 ML LIQD","63739-976-01","NDC","","","","","facility","both","1","EA","","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOCUSATE SODIUM 50 MG/5 ML LIQD","63739-976-01","NDC","","","","","facility","both","1","EA","UD","2.62","1.31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 500 MG TABS","63739-991-10","NDC","","","","","facility","both","1","EA","","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 500 MG TABS","63739-991-10","NDC","","","","","facility","both","1","EA","UD","0.09","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12","6382405620","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG TB12","63824-056-34","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 500 UNIT (400-620 UNIT) SOLR","63833-386-02","NDC","","","","","facility","both","1","EA","TB","4200","2100","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 500 UNIT (400-620 UNIT) SOLR","63833-386-02","NDC","","","","","facility","both","1","EA","JG,UD","4200","2100","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 500 UNIT (400-620 UNIT) SOLR","63833-386-02","NDC","","","","","facility","both","1","EA","JG","4200","2100","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 500 UNIT (400-620 UNIT) SOLR","63833-386-02","NDC","","","","","facility","both","1","EA","UD","4232","2116","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-387-02","NDC","","","","","facility","both","1","EA","UD","8344","4172","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-387-02","NDC","","","","","facility","both","1","EA","JG","7800","3900","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-387-02","NDC","","","","","facility","both","1","EA","TB","8184","4092","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-387-02","NDC","","","","","facility","both","1","EA","","8184","4092","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-387-02","NDC","","","","","facility","both","1","EA","JG,UD","8264","4132","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-397-01","NDC","","","","","facility","both","1","EA","JG,UD","8264","4132","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-397-01","NDC","","","","","facility","both","1","EA","UD,TB","8424","4212","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-397-01","NDC","","","","","facility","both","1","EA","UD","8552","4276","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-397-01","NDC","","","","","facility","both","1","EA","","8184","4092","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-397-01","NDC","","","","","facility","both","1","EA","JG","8184","4092","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"HUMAN PROTHROMBIN COMPLEX (KCENTRA/PCC4) 1,000 UNIT (800-1240 UNIT) SOLR","63833-397-01","NDC","","","","","facility","both","1","EA","TB","8000","4000","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTIHEMOPHILIC FACTOR-VWF 250-600 UNIT SOLR","63833-615-02","NDC","","","","","facility","both","1","EA","","19692","9846","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTIHEMOPHILIC FACTOR-VWF 500-1,200 UNIT SOLR","63833-616-02","NDC","","","","","facility","both","1","EA","","9297","4648.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"C1 ESTERASE INHIBITOR 500 UNIT (10 ML) KIT","63833-825-02","NDC","","","","","facility","both","1","EA","UD","16812.21","8406.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"C1 ESTERASE INHIBITOR 500 UNIT (10 ML) SOLR","63833-835-01","NDC","","","","","facility","both","1","EA","","43308.3","21654.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HEPARIN, PORCINE (PF) 10 UNIT/ML SYRG","6425322233","NDC","","","","","facility","both","1","EA","","5.74","2.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"HEPARIN 1UNIT/ML W/NACL 0.9% FLUSH 5ML SYRINGE","6425322235","NDC","","","","","facility","both","1","EA","UD","137.75","68.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN PF 100 UNIT/ML SYRG","6425333330","NDC","","","","","facility","both","1","EA","","5.63","2.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"HEPARIN PF 100 UNIT/ML SYRG","6425333335","NDC","","","","","facility","both","1","EA","UD","5.94","2.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN PF 100 UNIT/ML SYRG","6425333335","NDC","","","","","facility","both","1","EA","","5.94","2.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"ATROPINE 0.1 MG/ML SYRG","64253-400-30","NDC","","","","","facility","both","1","EA","","65","32.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATROPINE 0.1 MG/ML SYRG","64253-400-30","NDC","","","","","facility","both","1","EA","UD","55.56","27.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SYRG","64253-900-30","NDC","","","","","facility","both","1","EA","","58.75","29.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHACHOLINE CHLORIDE 0 TO 48 MG/3 ML NEBU","64281-110-05","NDC","","","","","facility","both","1","EA","","224","112","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHACHOLINE CHLORIDE 0 TO 48 MG/3 ML NEBU","64281-110-05","NDC","","","","","facility","both","1","EA","UD","224","112","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TESTOSTERONE 1% GLPK 5 G PACKET","64380-152-01","NDC","","","","","facility","both","1","EA","","830.5","415.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"OLANZAPINE ZYDIS 5 MG ODT.","64380-172-01","NDC","","","","","facility","both","1","EA","","2.31","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLANZAPINE ZYDIS 5 MG ODT.","64380-172-01","NDC","","","","","facility","both","1","EA","UD","2.31","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPAFENONE 325 MG CP12","64380-185-01","NDC","","","","","facility","both","1","EA","","3.25","1.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMIVUDINE 150 MG TABS","64380-710-03","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMIVUDINE 150 MG TABS","64380-710-03","NDC","","","","","facility","both","1","EA","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 5 MG CAPS","64380-722-06","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 5 MG CAPS","64380-722-06","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG TABS","64380-725-06","NDC","","","","","facility","both","1","EA","","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","64380-734-08","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 25 MG TABS","64380-734-08","NDC","","","","","facility","both","1","EA","UD","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERGOCALCIFEROL 50,000 UNIT CAPS","64380-737-06","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERGOCALCIFEROL 50,000 UNIT CAPS","64380-737-06","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACARBOSE 25 MG TABS","64380-758-06","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PREDNISONE 1 MG TABS","64380-782-06","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PREDNISONE 1 MG TABS","64380-782-06","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OSELTAMIVIR 30 MG CAPS","64380-797-01","NDC","","","","","facility","both","1","EA","","3.52","1.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OSELTAMIVIR 75 MG CAPS","64380-799-01","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OSELTAMIVIR 75 MG CAPS","64380-799-01","NDC","","","","","facility","both","1","EA","UD","4.89","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","64380-883-04","NDC","","","","","facility","both","1","EA","UD","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CINACALCET 30 MG TABS","64380-883-04","NDC","","","","","facility","both","1","EA","","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 250 MG TABS","64380-918-06","NDC","","","","","facility","both","1","EA","","2.98","1.49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"URSODIOL 250 MG TABS","64380-918-06","NDC","","","","","facility","both","1","EA","UD","4.96","2.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NATALIZUMAB 300 MG/15 ML SOLN 15 ML VIAL","64406-008-01","NDC","","","","","facility","both","1","EA","JG","39476.12","19738.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"NATALIZUMAB 300 MG/15 ML SOLN 15 ML VIAL","64406-008-01","NDC","","","","","facility","both","1","EA","UD","39476.12","19738.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NATALIZUMAB 300 MG/15 ML SOLN 15 ML VIAL","64406-008-01","NDC","","","","","facility","both","1","EA","JG,UD","39476.12","19738.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"NATALIZUMAB 300 MG/15 ML SOLN 15 ML VIAL","64406-008-01","NDC","","","","","facility","both","1","EA","","39476.12","19738.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","64679-012-02","NDC","","","","","facility","both","1","EA","","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","64679-012-02","NDC","","","","","facility","both","1","EA","UD","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","64679-465-50","NDC","","","","","facility","both","1","EA","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","64679-465-51","NDC","","","","","facility","both","1","EA","","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE 4 % (40 MG/ML) SOLN 50 ML BOTTLE","64679-465-51","NDC","","","","","facility","both","1","EA","UD","71","35.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LUBIPROSTONE 8 MCG CAPS","64764-080-60","NDC","","","","","facility","both","1","EA","","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LUBIPROSTONE 8 MCG CAPS","64764-080-60","NDC","","","","","facility","both","1","EA","UD","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL","64764-300-20","NDC","","","","","facility","both","1","EA","UD","32832.71","16416.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL","64764-300-20","NDC","","","","","facility","both","1","EA","JG,JA","32832.71","16416.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JA: Administered intravenously"
"VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL","64764-300-20","NDC","","","","","facility","both","1","EA","JG,UD","32832.71","16416.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL","64764-300-20","NDC","","","","","facility","both","1","EA","JG","32832.71","16416.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"VEDOLIZUMAB 300 MG SOLR 1 EACH VIAL","64764-300-20","NDC","","","","","facility","both","1","EA","","32832.71","16416.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VORTIOXETINE 10 MG TABS","64764-730-30","NDC","","","","","facility","both","1","EA","","57.74","28.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","64850-502-01","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABS","64850-502-01","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24","64850-511-01","NDC","","","","","facility","both","1","EA","","1.7","0.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPHETAMINE-DEXTROAMPHETAMINE XR 10 MG CP24","64850-511-01","NDC","","","","","facility","both","1","EA","UD","2.39","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-HOMATROPINE 5-1.5 MG/5 ML (5 ML) SYRP","64950-342-05","NDC","","","","","facility","both","1","EA","","23.89","11.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYCODONE 5 MG/5 ML SOLN","64950-354-05","NDC","","","","","facility","both","1","EA","UD","13.16","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG/5 ML SOLN","64950-354-05","NDC","","","","","facility","both","1","EA","","13.16","6.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COCAINE 4 % SOLN","64950-362-04","NDC","","","","","facility","both","1","EA","","276.5","138.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COCAINE 4 % SOLN","64950-362-04","NDC","","","","","facility","both","1","EA","UD","276.5","138.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATE 250 MG TABS","6498010401","NDC","","","","","facility","both","1","EA","UD","2.02","1.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATE 250 MG TABS","6498010401","NDC","","","","","facility","both","1","EA","","2.02","1.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTOBACILLUS ACIDOPH 100 MILLION CELL GRPK","6498014698","NDC","","","","","facility","both","1","EA","","3.57","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTOBACILLUS ACIDOPH 100 MILLION CELL GRPK","6498014698","NDC","","","","","facility","both","1","EA","UD","3.57","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOSTIGMINE CR 180 MG TBSR","64980-220-03","NDC","","","","","facility","both","1","EA","UD","18.61","9.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIPIZIDE XL 10 MG TR24","64980-281-01","NDC","","","","","facility","both","1","EA","","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIAMCINOLONE ACETONIDE 0.1 % PSTE 5 G TUBE","64980-320-05","NDC","","","","","facility","both","1","EA","UD","166.68","83.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 2.5 % CRPE 30 G TUBE","64980-324-30","NDC","","","","","facility","both","1","EA","","46.45","23.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"HYDROCORTISONE 2.5 % CRPE 30 G TUBE","64980-324-30","NDC","","","","","facility","both","1","EA","UD","46.45","23.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOMOXETINE 40 MG CAPS","64980-376-03","NDC","","","","","facility","both","1","EA","","5.05","2.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATOMOXETINE 40 MG CAPS","64980-376-03","NDC","","","","","facility","both","1","EA","UD","5.05","2.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 75 MG/5 ML SOLR","64980-511-10","NDC","","","","","facility","both","1","EA","UD","15.7","7.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.5 % DROP","64980-514-05","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIMOLOL 0.5 % DROP","64980-514-05","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NAPROXEN 250 MG TABS","65162-188-10","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAPROXEN 250 MG TABS","65162-188-10","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PALIPERIDONE 1.5 MG TR24","65162-280-03","NDC","","","","","facility","both","1","EA","UD","13","6.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PALIPERIDONE 3 MG TR24","65162-281-03","NDC","","","","","facility","both","1","EA","UD","7.5","3.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZELASTINE 137 MCG (0.1 %) SPRA 30 ML SQUEEZ BTL","65162-676-84","NDC","","","","","facility","both","1","EA","UD","40.38","20.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZELASTINE 137 MCG (0.1 %) SPRA 30 ML SQUEEZ BTL","65162-676-84","NDC","","","","","facility","both","1","EA","","40.38","20.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENAZOPYRIDINE 100 MG TABS","65162-681-10","NDC","","","","","facility","both","1","EA","","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENAZOPYRIDINE 100 MG TABS","65162-681-10","NDC","","","","","facility","both","1","EA","UD","1.81","0.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESCITALOPRAM OXALATE 5 MG/5 ML SOLN","65162-705-88","NDC","","","","","facility","both","1","EA","UD","7.27","3.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 5 % OINT 30 G TUBE","65162-835-96","NDC","","","","","facility","both","1","EA","","47.94","23.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"LURASIDONE 40 MG TABS","65162-880-03","NDC","","","","","facility","both","1","EA","UD","2.63","1.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 5 % OINT 35.44 G TUBE","65162-918-38","NDC","","","","","facility","both","1","EA","UD","15.27","7.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 5 % OINT 35.44 G TUBE","65162-918-38","NDC","","","","","facility","both","1","EA","","15.27","7.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","65219-020-03","NDC","","","","","facility","both","1","EA","UD","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","65219-020-03","NDC","","","","","facility","both","1","EA","","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","65219-086-01","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","65219-086-01","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUC IN NACL, ISO-OSM 2 GRAM/100 ML SOLN","65219-164-01","NDC","","","","","facility","both","1","EA","","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETAMINE 10 MG/ML SOLN","65219-184-01","NDC","","","","","facility","both","1","EA","UD","120.8","60.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 10 MG/ML SOLN","65219-184-01","NDC","","","","","facility","both","1","EA","","120.8","60.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETAMINE 10 MG/ML SOLN","65219-184-20","NDC","","","","","facility","both","1","EA","UD","584","292","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 10 MG/ML SOLN","65219-184-20","NDC","","","","","facility","both","1","EA","","584","292","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","65219-383-04","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IODIXANOL 320 MG IODINE/ML SOLN","65219-383-04","NDC","","","","","facility","both","1","EA","UD","80","40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOMIDATE 2 MG/ML SOLN","65219-447-02","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETOMIDATE 2 MG/ML SOLN","65219-447-02","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FAT EMULSION (INTRALIPID) 20 % EMUL","65219-531-01","NDC","","","","","facility","both","1","EA","UD","2.38","1.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION (INTRALIPID) 20 % EMUL","65219-531-01","NDC","","","","","facility","both","1","EA","","2.67","1.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FAT EMULSION 20 % EMUL 100 ML FLEX CONT","65219-531-10","NDC","","","","","facility","both","1","EA","","27.9","13.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FAT EMULSION 20 % EMUL 100 ML FLEX CONT","65219-531-10","NDC","","","","","facility","both","1","EA","UD","20.5","10.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION (INTRALIPID) 20 % EMUL","65219-533-01","NDC","","","","","facility","both","1","EA","","104","52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FAT EMULSION (INTRALIPID) 20 % EMUL","65219-533-01","NDC","","","","","facility","both","1","EA","UD","104","52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION 20 % EMUL","65219-535-01","NDC","","","","","facility","both","1","EA","UD","132","66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION 20 % EMUL","65219-539-01","NDC","","","","","facility","both","1","EA","UD","2.84","1.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAT EMULSION 20 % EMUL","65219-539-01","NDC","","","","","facility","both","1","EA","","2.89","1.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MITOMYCIN 5 MG SOLR 1 EACH VIAL","65219-564-20","NDC","","","","","facility","both","1","EA","JG","257.6","128.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BUMETANIDE 0.25 MG/ML SOLN","65219-570-01","NDC","","","","","facility","both","1","EA","","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUMETANIDE 0.25 MG/ML SOLN","65219-570-01","NDC","","","","","facility","both","1","EA","UD","13.45","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) SOLN 4 ML VIAL","65219-590-04","NDC","","","","","facility","both","1","EA","","3760.13","1880.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TOCILIZUMAB-AAZG 400 MG/20 ML (20 MG/ML) SOLN 20 ML VIAL","65219-594-20","NDC","","","","","facility","both","1","EA","","9471.56","4735.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROPOFOL 10 MG/ML EMUL","65219-800-01","NDC","","","","","facility","both","1","EA","UD","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPOFOL 10 MG/ML EMUL","65219-800-01","NDC","","","","","facility","both","1","EA","","11.5","5.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","65282-1605-1","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","65282-1605-1","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFAXIMIN 550 MG TABS","65649-303-03","NDC","","","","","facility","both","1","EA","UD","90.66","45.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIFAXIMIN 550 MG TABS","65649-303-03","NDC","","","","","facility","both","1","EA","","90.66","45.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARIPIPRAZOLE LAUROXIL 662 MG/2.4 ML SERS","65757-402-03","NDC","","","","","facility","both","1","EA","UD","10256.74","5128.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE LAUROXIL 882 MG/3.2 ML SERS","65757-403-03","NDC","","","","","facility","both","1","EA","JG,UD","13641.62","6820.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE LAUROXIL 882 MG/3.2 ML SERS","65757-403-03","NDC","","","","","facility","both","1","EA","UD","13641.62","6820.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE LAUROXIL 1,064 MG/3.9 ML SERS","65757-404-03","NDC","","","","","facility","both","1","EA","UD","16441.88","8220.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE LAUROXIL 1,064 MG/3.9 ML SERS","65757-404-03","NDC","","","","","facility","both","1","EA","TB","17959.92","8979.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ARIPIPRAZOLE LAUROXIL INITIO 675 MG/2.4 ML SERS","65757-500-03","NDC","","","","","facility","both","1","EA","UD","11089.26","5544.63","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN 500 MG TABS","65862-008-01","NDC","","","","","facility","both","1","EA","UD","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN 500 MG TABS","65862-008-01","NDC","","","","","facility","both","1","EA","","1.04","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIRTAZAPINE 15 MG ODT.","65862-021-06","NDC","","","","","facility","both","1","EA","UD","2.28","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MIRTAZAPINE 15 MG ODT.","65862-021-06","NDC","","","","","facility","both","1","EA","","2.28","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZIDOVUDINE 10 MG/ML SYRP 240 ML BOTTLE","65862-048-24","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZIDOVUDINE 10 MG/ML SYRP 240 ML BOTTLE","65862-048-24","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEVIRAPINE 50 MG/5 ML SUSPENSION","65862-057-24","NDC","","","","","facility","both","1","EA","UD","3.27","1.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEVIRAPINE 50 MG/5 ML SUSPENSION","65862-057-24","NDC","","","","","facility","both","1","EA","","4.03","2.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TERBINAFINE HCL 250 MG TABS","65862-079-30","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TERBINAFINE HCL 250 MG TABS","65862-079-30","NDC","","","","","facility","both","1","EA","","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROCHLOROTHIAZIDE 25 MG TABS","65862-133-99","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCHLOROTHIAZIDE 25 MG TABS","65862-133-99","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUOXETINE 10 MG CAPS","65862-192-01","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUOXETINE 10 MG CAPS","65862-192-01","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","65862-246-08","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 500 MG TABS","65862-246-08","NDC","","","","","facility","both","1","EA","","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ROSUVASTATIN 5 MG TABS","65862-293-90","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EMTRICITABINE 200 MG CAPS","65862-301-30","NDC","","","","","facility","both","1","EA","","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EMTRICITABINE 200 MG CAPS","65862-301-30","NDC","","","","","facility","both","1","EA","UD","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG ODT.","65862-390-10","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","65862-502-20","NDC","","","","","facility","both","1","EA","","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 500-125 MG TABS","65862-502-20","NDC","","","","","facility","both","1","EA","UD","2.32","1.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 875-125 MG TABS","65862-503-01","NDC","","","","","facility","both","1","EA","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMOXICILLIN-CLAVULANATE 875-125 MG TABS","65862-503-01","NDC","","","","","facility","both","1","EA","UD","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMOXICILLIN-CLAVULANATE 400-57 MG/5 ML SUSR","65862-534-50","NDC","","","","","facility","both","1","EA","UD","31.38","15.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 400 MG TABS","65862-603-30","NDC","","","","","facility","both","1","EA","UD","7.45","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 400 MG TABS","65862-603-30","NDC","","","","","facility","both","1","EA","","7.45","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"REPAGLINIDE 0.5 MG TABS","65862-670-01","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"REPAGLINIDE 2 MG TABS","65862-672-01","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RITONAVIR 100 MG TABS","65862-687-30","NDC","","","","","facility","both","1","EA","","16.34","8.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RITONAVIR 100 MG TABS","65862-687-30","NDC","","","","","facility","both","1","EA","UD","16.34","8.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATAZANAVIR 300 MG CAPS","65862-713-30","NDC","","","","","facility","both","1","EA","","17.5","8.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHENAMINE HIPPURATE 1 GRAM TABS","65862-782-01","NDC","","","","","facility","both","1","EA","","1.84","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARMODAFINIL 50 MG TABS","65862-805-30","NDC","","","","","facility","both","1","EA","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ARMODAFINIL 50 MG TABS","65862-805-30","NDC","","","","","facility","both","1","EA","UD","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRASUGREL 10 MG TABS","65862-830-30","NDC","","","","","facility","both","1","EA","","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRASUGREL 10 MG TABS","65862-830-30","NDC","","","","","facility","both","1","EA","UD","1.77","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENTECAVIR 0.5 MG 0.5 MG TABS","65862-841-30","NDC","","","","","facility","both","1","EA","UD","4.34","2.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SEVELAMER CARBONATE 800 MG TABS","65862-921-27","NDC","","","","","facility","both","1","EA","UD","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SEVELAMER CARBONATE 800 MG TABS","65862-921-27","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SEVELAMER CARBONATE 2400 MG PWPK","65862-931-08","NDC","","","","","facility","both","1","EA","UD","6.67","3.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SEVELAMER CARBONATE 2400 MG PWPK","65862-931-08","NDC","","","","","facility","both","1","EA","","6.67","3.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPOPROSTENOL 1.5 MG SOLR 1 EACH VIAL","66215-402-01","NDC","","","","","facility","both","1","EA","","280.63","140.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"EPOPROSTENOL 1.5 MG SOLR 1 EACH VIAL","66215-402-01","NDC","","","","","facility","both","1","EA","UD","322.74","161.37","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MACITENTAN 10 MG TABS","66215-501-15","NDC","","","","","facility","both","1","EA","","440.66","220.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MACITENTAN 10 MG TABS","66215-501-15","NDC","","","","","facility","both","1","EA","UD","440.66","220.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MACITENTAN 10 MG TABS","66215-501-30","NDC","","","","","facility","both","1","EA","","459.18","229.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SELEXIPAG 200 MCG TABS","66215-602-06","NDC","","","","","facility","both","1","EA","","283.59","141.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SELEXIPAG 200 MCG TABS","66215-602-06","NDC","","","","","facility","both","1","EA","UD","283.59","141.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOCYANINE GREEN 25 MG SOLR","66259-146-01","NDC","","","","","facility","both","1","EA","","618.11","309.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","66302-102-01","NDC","","","","","facility","both","1","EA","JG","1171.39","585.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 2.5 MG/ML SOLN 20 ML VIAL","66302-102-01","NDC","","","","","facility","both","1","EA","","1446.43","723.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","66302-105-01","NDC","","","","","facility","both","1","EA","JG","1446.43","723.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","66302-105-01","NDC","","","","","facility","both","1","EA","JG,UD","4196.8","2098.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL 5 MG/ML SOLN 20 ML VIAL","66302-105-01","NDC","","","","","facility","both","1","EA","","4196.8","2098.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","66302-110-01","NDC","","","","","facility","both","1","EA","JG","6947.17","3473.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TREPROSTINIL 10 MG/ML SOLN 20 ML VIAL","66302-110-01","NDC","","","","","facility","both","1","EA","","8322.35","4161.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) NEBU 2.9 ML AMPUL","66302-206-03","NDC","","","","","facility","both","1","EA","","749.77","374.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) NEBU 2.9 ML AMPUL","66302-206-03","NDC","","","","","facility","both","1","EA","UD","784.65","392.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL DIOLAMINE 0.25 MG TBSR","66302-302-01","NDC","","","","","facility","both","1","EA","UD","141.86","70.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL DIOLAMINE 0.25 MG TBSR","66302-302-02","NDC","","","","","facility","both","1","EA","UD","72.43","36.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL DIOLAMINE 0.25 MG TBSR","66302-302-02","NDC","","","","","facility","both","1","EA","","69.19","34.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TREPROSTINIL DIOLAMINE 1 MG TBSR","66302-310-01","NDC","","","","","facility","both","1","EA","","794.36","397.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TREPROSTINIL DIOLAMINE 1 MG TBSR","66302-310-01","NDC","","","","","facility","both","1","EA","UD","277.76","138.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TREPROSTINIL DIOLAMINE 1 MG TBSR","66302-310-02","NDC","","","","","facility","both","1","EA","UD","277.76","138.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN 325 MG TABS","66553-001-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN 325 MG TABS","66553-001-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASPIRIN 81 MG CHEW","66553-002-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASPIRIN 81 MG CHEW","66553-002-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","66553-004-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","66553-004-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM BICARBONATE 650 MG TABS","66553-008-01","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM BICARBONATE 650 MG TABS","66553-008-01","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ANAKINRA 100 MG/0.67 ML SYRG","66658-234-01","NDC","","","","","facility","both","1","EA","","954.54","477.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ANAKINRA 100 MG/0.67 ML SYRG","66658-234-07","NDC","","","","","facility","both","1","EA","","954.54","477.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 7 ML"
"MEGESTROL 400 MG/10 ML SUSPENSION","66689-020-01","NDC","","","","","facility","both","1","EA","UD","10.66","5.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEGESTROL 400 MG/10 ML SUSPENSION","66689-020-01","NDC","","","","","facility","both","1","EA","","9.27","4.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML SOLN","66689-023-01","NDC","","","","","facility","both","1","EA","UD","13.29","6.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML SOLN","66689-023-01","NDC","","","","","facility","both","1","EA","","13.29","6.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYTOIN 100 MG/4 ML SUSPENSION","66689-036-01","NDC","","","","","facility","both","1","EA","UD","7.67","3.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYTOIN 100 MG/4 ML SUSPENSION","66689-036-01","NDC","","","","","facility","both","1","EA","","7.67","3.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","66689-053-01","NDC","","","","","facility","both","1","EA","","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","66689-053-01","NDC","","","","","facility","both","1","EA","UD","4.51","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","66689-062-01","NDC","","","","","facility","both","1","EA","UD","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","66689-062-01","NDC","","","","","facility","both","1","EA","","52.84","26.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION","66689-203-04","NDC","","","","","facility","both","1","EA","","40.96","20.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MYCOPHENOLATE 200 MG/ML SUSR","66689-307-08","NDC","","","","","facility","both","1","EA","UD","22.21","11.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIROLIMUS 1 MG/ML SOLN","66689-347-02","NDC","","","","","facility","both","1","EA","UD","39.74","19.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCETAXEL 80 MG/8 ML (10 MG/ML) SOLN 8 ML VIAL","66758-050-02","NDC","","","","","facility","both","1","EA","","198.06","99.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BACLOFEN 20 ML VIAL","66794-155-02","NDC","","","","","facility","both","1","EA","JG","994.19","497.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BACLOFEN 20 ML VIAL","66794-155-02","NDC","","","","","facility","both","1","EA","TB","91.14","45.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BACLOFEN 20 ML VIAL","66794-155-02","NDC","","","","","facility","both","1","EA","UD","33.14","16.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","66794-219-63","NDC","","","","","facility","both","1","EA","UD","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID IN DEXTROSE 5% 600 MG/300 ML PGBK","66794-219-63","NDC","","","","","facility","both","1","EA","","50","25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ESTRADIOL 0.01 % (0.1 MG/GRAM) CREA 42.5 G TUBE","66993-002-10","NDC","","","","","facility","both","1","EA","UD","42.5","21.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESTRADIOL 0.01 % (0.1 MG/GRAM) CREA 42.5 G TUBE","66993-002-10","NDC","","","","","facility","both","1","EA","","42.5","21.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ALBUTEROL 90 MCG/ACTUATION HFAA 18 G CANISTER","66993-019-68","NDC","","","","","facility","both","1","EA","UD","126.94","63.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE ER 12 HOUR 300 MG CM12","66993-409-32","NDC","","","","","facility","both","1","EA","","5.87","2.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMAZEPINE ER 12 HOUR 300 MG CM12","66993-409-32","NDC","","","","","facility","both","1","EA","UD","10.73","5.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPAGLIFLOZIN PROPANEDIOL 5 MG TABS","66993-456-30","NDC","","","","","facility","both","1","EA","UD","38.15","19.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPAGLIFLOZIN PROPANEDIOL 5 MG TABS","66993-456-30","NDC","","","","","facility","both","1","EA","","38.15","19.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOBAZAM 10 MG TABS","67386-314-01","NDC","","","","","facility","both","1","EA","UD","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOBAZAM 10 MG TABS","67386-314-01","NDC","","","","","facility","both","1","EA","","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DROXIDOPA 100 MG CAPS","67386-820-19","NDC","","","","","facility","both","1","EA","","4.33","2.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ASCORBIC ACID 500 MG/ML SOLN 50 ML VIAL","67457-118-50","NDC","","","","","facility","both","1","EA","UD","552.5","276.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ASCORBIC ACID 500 MG/ML SOLN 50 ML VIAL","67457-118-50","NDC","","","","","facility","both","1","EA","","552.5","276.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMIODARONE 50 MG/ML SOLN","67457-153-00","NDC","","","","","facility","both","1","EA","UD","13.43","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) SOLN","67457-163-00","NDC","","","","","facility","both","1","EA","UD","483.75","241.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) SOLN","67457-163-00","NDC","","","","","facility","both","1","EA","","483.75","241.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"THIAMINE 100 MG/ML SOLN","67457-196-02","NDC","","","","","facility","both","1","EA","","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"THIAMINE 100 MG/ML SOLN","67457-196-02","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRANEXAMIC ACID 500MG/5ML SOLN","67457-197-10","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"TRANEXAMIC ACID 500MG/5ML SOLN","67457-197-10","NDC","","","","","facility","both","1","EA","UD","26.25","13.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 10 MG/ML SOLN","67457-217-20","NDC","","","","","facility","both","1","EA","","11.13","5.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDRALAZINE 20 MG/ML SOLN","67457-291-00","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDRALAZINE 20 MG/ML SOLN","67457-291-00","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NALOXONE 0.4 MG/ML SOLN","67457-292-00","NDC","","","","","facility","both","1","EA","","29.94","14.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MOXIFLOXACIN 400 MG/250 ML PGBK","67457-323-25","NDC","","","","","facility","both","1","EA","UD","178","89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 400 MG/250 ML PGBK","67457-323-25","NDC","","","","","facility","both","1","EA","","178","89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"FLUPHENAZINE DECANOATE 25 MG/ML SOLN","67457-359-59","NDC","","","","","facility","both","1","EA","UD","51.25","25.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE DECANOATE 25 MG/ML SOLN","67457-359-59","NDC","","","","","facility","both","1","EA","","100","50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PARICALCITOL 5 MCG/ML SOLN","67457-380-12","NDC","","","","","facility","both","1","EA","UD","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLEDRONIC ACID 4 MG/5 ML SOLN 5 ML VIAL","67457-390-54","NDC","","","","","facility","both","1","EA","","140","70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZOLEDRONIC ACID 4 MG/5 ML SOLN 5 ML VIAL","67457-390-54","NDC","","","","","facility","both","1","EA","UD","143.13","71.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 10 MG/ML SOLN 10 ML VIAL","67457-420-00","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE 10 MG/ML SOLN 10 ML VIAL","67457-420-00","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 10 MG/ML SOLN 10 ML VIAL","67457-420-10","NDC","","","","","facility","both","1","EA","","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"DEXAMETHASONE 10 MG/ML SOLN 10 ML VIAL","67457-420-10","NDC","","","","","facility","both","1","EA","UD","27.5","13.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 4 MG/ML SOLN","67457-422-00","NDC","","","","","facility","both","1","EA","","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXAMETHASONE 4 MG/ML SOLN","67457-423-00","NDC","","","","","facility","both","1","EA","UD","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE 4 MG/ML SOLN","67457-423-00","NDC","","","","","facility","both","1","EA","","7.35","3.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HALOPERIDOL 5 MG/ML SOLN","67457-426-00","NDC","","","","","facility","both","1","EA","","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HALOPERIDOL 5 MG/ML SOLN","67457-426-00","NDC","","","","","facility","both","1","EA","UD","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 5 MG/ML SOLN","67457-426-12","NDC","","","","","facility","both","1","EA","UD","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HALOPERIDOL 5 MG/ML SOLN","67457-426-12","NDC","","","","","facility","both","1","EA","","8","4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"TOBRAMYCIN 40 MG/ML SOLN","67457-428-00","NDC","","","","","facility","both","1","EA","UD","13.23","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOBRAMYCIN 40 MG/ML SOLN","67457-428-00","NDC","","","","","facility","both","1","EA","","13.23","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TOBRAMYCIN 40 MG/ML SOLN","67457-428-30","NDC","","","","","facility","both","1","EA","UD","13.23","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAMIDRONATE 30 MG/10 ML (3 MG/ML) SOLN 10 ML VIAL","67457-430-10","NDC","","","","","facility","both","1","EA","UD","177.75","88.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAMIDRONATE 30 MG/10 ML (3 MG/ML) SOLN 10 ML VIAL","67457-430-10","NDC","","","","","facility","both","1","EA","","177.75","88.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FAMOTIDINE (PF) 10 MG/ML SOLN","67457-433-00","NDC","","","","","facility","both","1","EA","UD","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FAMOTIDINE (PF) 10 MG/ML SOLN","67457-433-00","NDC","","","","","facility","both","1","EA","","7.06","3.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DOXORUBICIN 50 MG SOLR 1 EACH VIAL","67457-436-50","NDC","","","","","facility","both","1","EA","","1050.91","525.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIFAMPIN 600 MG SOLR","67457-445-60","NDC","","","","","facility","both","1","EA","","383.24","191.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIFAMPIN 600 MG SOLR","67457-445-60","NDC","","","","","facility","both","1","EA","UD","383.24","191.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAMIDRONATE 90 MG/10 ML (9 MG/ML) SOLN 10 ML VIAL","67457-446-10","NDC","","","","","facility","both","1","EA","","229.94","114.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GEMCITABINE 200 MG SOLR 1 EACH VIAL","67457-464-20","NDC","","","","","facility","both","1","EA","","182.02","91.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOSPHENYTOIN 100 MG PE/2 ML SOLN","67457-516-00","NDC","","","","","facility","both","1","EA","","19.5","9.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IBANDRONATE 3 MG/3 ML SYRG","67457-524-33","NDC","","","","","facility","both","1","EA","JG","1223.24","611.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"IBANDRONATE 3 MG/3 ML SYRG","67457-524-33","NDC","","","","","facility","both","1","EA","","1223.24","611.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LEUCOVORIN CALCIUM 100 MG SOLR 1 EACH VIAL","67457-528-10","NDC","","","","","facility","both","1","EA","","55","27.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 350 MG SOLR 1 EACH VIAL","67457-530-35","NDC","","","","","facility","both","1","EA","","112.5","56.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 350 MG SOLR 1 EACH VIAL","67457-530-35","NDC","","","","","facility","both","1","EA","UD","112.5","56.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOCETAXEL 80 MG/8 ML (10 MG/ML) SOLN 8 ML VIAL","67457-532-08","NDC","","","","","facility","both","1","EA","","198.06","99.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","67457-567-00","NDC","","","","","facility","both","1","EA","","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MAGNESIUM SULFATE 1G/D5W 100ML 1 GRAM/100 ML PGBK","67457-567-00","NDC","","","","","facility","both","1","EA","UD","14","7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","67457-582-00","NDC","","","","","facility","both","1","EA","UD","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","67457-582-00","NDC","","","","","facility","both","1","EA","","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","67457-582-10","NDC","","","","","facility","both","1","EA","","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"FONDAPARINUX 2.5 MG/0.5 ML SYRG","67457-582-10","NDC","","","","","facility","both","1","EA","UD","79.06","39.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 5 MG/0.4 ML SYRG","67457-583-00","NDC","","","","","facility","both","1","EA","","239.72","119.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FONDAPARINUX 5 MG/0.4 ML SYRG","67457-583-00","NDC","","","","","facility","both","1","EA","UD","239.72","119.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FONDAPARINUX 7.5 MG/0.6 ML SYRG","67457-584-00","NDC","","","","","facility","both","1","EA","","185.31","92.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZOLEDRONIC ACID-MANNITOL&WATER 5 MG/100 ML PGBK","67457-619-10","NDC","","","","","facility","both","1","EA","UD","627.5","313.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLEDRONIC ACID-MANNITOL&WATER 5 MG/100 ML PGBK","67457-619-10","NDC","","","","","facility","both","1","EA","","627.5","313.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","67457-640-00","NDC","","","","","facility","both","1","EA","","31.19","15.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) SOLN","67457-640-00","NDC","","","","","facility","both","1","EA","UD","31.25","15.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","67457-657-25","NDC","","","","","facility","both","1","EA","","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ESMOLOL 2,500 MG/250 ML (10 MG/ML) SOLP","67457-657-25","NDC","","","","","facility","both","1","EA","UD","374","187","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCITONIN 200 UNIT/ML SOLN","67457-675-02","NDC","","","","","facility","both","1","EA","JG","11325.5","5662.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CALCITONIN 200 UNIT/ML SOLN","67457-675-02","NDC","","","","","facility","both","1","EA","TB","11325.5","5662.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 30 ML VIAL","67457-779-30","NDC","","","","","facility","both","1","EA","UD","112.7","56.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 30 ML VIAL","67457-779-30","NDC","","","","","facility","both","1","EA","","73.75","36.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL","67457-823-12","NDC","","","","","facility","both","1","EA","UD","128.13","64.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1.25 GRAM SOLR 1 EACH VIAL","67457-823-12","NDC","","","","","facility","both","1","EA","","128.13","64.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 1.5 GRAM SOLR 1 EACH VIAL","67457-824-15","NDC","","","","","facility","both","1","EA","UD","153.25","76.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","67457-852-00","NDC","","","","","facility","both","1","EA","","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","67457-852-00","NDC","","","","","facility","both","1","EA","UD","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","67457-852-04","NDC","","","","","facility","both","1","EA","","8.69","4.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","67457-852-04","NDC","","","","","facility","both","1","EA","UD","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ADENOSINE 3 MG/ML SOLN","67457-855-00","NDC","","","","","facility","both","1","EA","UD","18.13","9.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ADENOSINE 3 MG/ML SOLN","67457-855-00","NDC","","","","","facility","both","1","EA","","18.13","9.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MEDROXYPROGESTERONE 150 MG/ML SUSPENSION","67457-887-00","NDC","","","","","facility","both","1","EA","","217.44","108.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MEDROXYPROGESTERONE 150 MG/ML SUSPENSION","67457-887-00","NDC","","","","","facility","both","1","EA","UD","217.44","108.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"REGADENOSON 0.4 MG/5 ML SYRG","67457-994-05","NDC","","","","","facility","both","1","EA","UD","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"REGADENOSON 0.4 MG/5 ML SYRG","67457-994-05","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POVIDONE-IODINE 10 % SOLN","67618-150-04","NDC","","","","","facility","both","1","EA","","5.54","2.77","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2000-1","NDC","","","","","facility","both","1","EA","","16","8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2000-2","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2000-2","NDC","","","","","facility","both","1","EA","UD","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2001-1","NDC","","","","","facility","both","1","EA","","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2001-1","NDC","","","","","facility","both","1","EA","UD","12","6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2001-2","NDC","","","","","facility","both","1","EA","","12","6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2001-2","NDC","","","","","facility","both","1","EA","UD","18","9","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2001-3","NDC","","","","","facility","both","1","EA","","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) SOLN","67684-2001-3","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM OINT 28.4 G TUBE","67777-005-11","NDC","","","","","facility","both","1","EA","UD","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WHITE PETROLATUM OINT 28.4 G TUBE","67777-005-11","NDC","","","","","facility","both","1","EA","","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"TEMAZEPAM 15 MG CAPS","67877-146-01","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TEMAZEPAM 15 MG CAPS","67877-146-01","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GABAPENTIN 400 MG CAPS","67877-224-05","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIZATRIPTAN 5 MG TABS","67877-261-06","NDC","","","","","facility","both","1","EA","UD","2.72","1.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIZATRIPTAN 5 MG TABS","67877-261-06","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RILUZOLE 50 MG TABS","67877-286-60","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FINASTERIDE 5 MG TABS","67877-288-90","NDC","","","","","facility","both","1","EA","UD","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FINASTERIDE 5 MG TABS","67877-288-90","NDC","","","","","facility","both","1","EA","","1.2","0.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","67877-298-09","NDC","","","","","facility","both","1","EA","","3.9","1.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINEZOLID 600 MG TABS","67877-419-20","NDC","","","","","facility","both","1","EA","UD","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID 600 MG TABS","67877-419-20","NDC","","","","","facility","both","1","EA","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LINEZOLID 600 MG TABS","67877-419-33","NDC","","","","","facility","both","1","EA","UD","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LINEZOLID 600 MG TABS","67877-419-33","NDC","","","","","facility","both","1","EA","","8.28","4.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CINACALCET 30 MG TABS","67877-503-30","NDC","","","","","facility","both","1","EA","","0.75","0.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CINACALCET 30 MG TABS","67877-503-30","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COLESEVELAM 625 MG TABS","67877-506-51","NDC","","","","","facility","both","1","EA","","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFDINIR 300 MG CAPS","67877-543-60","NDC","","","","","facility","both","1","EA","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFDINIR 300 MG CAPS","67877-543-60","NDC","","","","","facility","both","1","EA","UD","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LURASIDONE 20 MG TABS","67877-638-30","NDC","","","","","facility","both","1","EA","UD","2.17","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LURASIDONE 20 MG TABS","67877-638-30","NDC","","","","","facility","both","1","EA","","2.17","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CEFTOLOZANE-TAZOBACTAM 1.5 GRAM SOLR 1 EACH VIAL","67919-030-01","NDC","","","","","facility","both","1","EA","JG,UD","764.17","382.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFTOLOZANE-TAZOBACTAM 1.5 GRAM SOLR 1 EACH VIAL","67919-030-01","NDC","","","","","facility","both","1","EA","UD,TB","832.76","416.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"CEFTOLOZANE-TAZOBACTAM 1.5 GRAM SOLR 1 EACH VIAL","67919-030-01","NDC","","","","","facility","both","1","EA","JG","1457.1","728.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CEFTOLOZANE-TAZOBACTAM 1.5 GRAM SOLR 1 EACH VIAL","67919-030-01","NDC","","","","","facility","both","1","EA","UD","1594.28","797.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYOSCYAMINE 0.125 MG SUBL","68047-253-01","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYOSCYAMINE 0.125 MG SUBL","68047-253-01","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ABACAVIR 300 MG TABS","68084-021-11","NDC","","","","","facility","both","1","EA","","5","2.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ABACAVIR 300 MG TABS","68084-021-11","NDC","","","","","facility","both","1","EA","UD","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 2.5 MG TABS","68084-027-01","NDC","","","","","facility","both","1","EA","UD","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 2.5 MG TABS","68084-027-01","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"WARFARIN 2.5 MG TABS","68084-027-11","NDC","","","","","facility","both","1","EA","UD","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"WARFARIN 2.5 MG TABS","68084-027-11","NDC","","","","","facility","both","1","EA","","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MISOPROSTOL 200 MCG TABS","68084-041-11","NDC","","","","","facility","both","1","EA","","1.92","0.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PAROXETINE 20 MG TABS","68084-045-01","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PAROXETINE 20 MG TABS","68084-045-01","NDC","","","","","facility","both","1","EA","UD","1.35","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 20 MG TABS","68084-045-11","NDC","","","","","facility","both","1","EA","UD","0.17","0.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PAROXETINE 20 MG TABS","68084-045-11","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRETINOIN 10 MG CAPS","68084-075-11","NDC","","","","","facility","both","1","EA","","68.82","34.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA 25-250 MG TABS","68084-094-11","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 10 MG TABS","68084-097-11","NDC","","","","","facility","both","1","EA","","0.03","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 10 MG TABS","68084-097-11","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 20 MG TABS","68084-098-11","NDC","","","","","facility","both","1","EA","UD","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATORVASTATIN 20 MG TABS","68084-098-11","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 40 MG TABS","68084-099-11","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 40 MG TABS","68084-099-11","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIPRASIDONE 20 MG CAPS","68084-103-11","NDC","","","","","facility","both","1","EA","UD","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIPRASIDONE 20 MG CAPS","68084-103-11","NDC","","","","","facility","both","1","EA","","2.25","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZIPRASIDONE 80 MG CAPS","68084-106-11","NDC","","","","","facility","both","1","EA","UD","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIPRASIDONE 80 MG CAPS","68084-106-11","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACYCLOVIR 200 MG CAPS","68084-107-11","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 200 MG CAPS","68084-107-11","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACYCLOVIR 800 MG TABS","68084-109-11","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 800 MG TABS","68084-109-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MIRTAZAPINE 15 MG TABS","68084-119-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEPRAZOLE 20 MG CPDR","68084-128-11","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEPRAZOLE 20 MG CPDR","68084-128-11","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE 4 MG TABS","68084-149-11","NDC","","","","","facility","both","1","EA","","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE 4 MG TABS","68084-149-11","NDC","","","","","facility","both","1","EA","UD","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROMETHAZINE 25 MG TABS","68084-155-11","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZOLPIDEM 5 MG TABS","68084-189-11","NDC","","","","","facility","both","1","EA","","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZOLPIDEM 5 MG TABS","68084-189-11","NDC","","","","","facility","both","1","EA","UD","0.08","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRIMIDONE 250 MG TABS","68084-203-11","NDC","","","","","facility","both","1","EA","","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRIMIDONE 250 MG TABS","68084-203-11","NDC","","","","","facility","both","1","EA","UD","1.52","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINOXIDIL 2.5 MG TABS","68084-204-11","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MINOXIDIL 2.5 MG TABS","68084-204-11","NDC","","","","","facility","both","1","EA","UD","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MINOXIDIL 10 MG TABS","68084-205-11","NDC","","","","","facility","both","1","EA","UD","0.93","0.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZONATATE 100 MG CAPS","68084-214-11","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZONATATE 100 MG CAPS","68084-214-11","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALACYCLOVIR 500 MG TABS","68084-215-11","NDC","","","","","facility","both","1","EA","","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VALACYCLOVIR 500 MG TABS","68084-215-11","NDC","","","","","facility","both","1","EA","UD","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG TABS","68084-220-11","NDC","","","","","facility","both","1","EA","","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZATHIOPRINE 25 MG TABS","68084-229-11","NDC","","","","","facility","both","1","EA","","0.95","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZATHIOPRINE 25 MG TABS","68084-229-11","NDC","","","","","facility","both","1","EA","UD","0.95","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLINDAMYCIN 150 MG CAPS","68084-243-11","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLINDAMYCIN 150 MG CAPS","68084-243-11","NDC","","","","","facility","both","1","EA","UD","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORATADINE 10 MG TABS","68084-248-01","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORATADINE 10 MG TABS","68084-248-01","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LORATADINE 10 MG TABS","68084-248-11","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LORATADINE 10 MG TABS","68084-248-11","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDROXYCHLOROQUINE 200 MG TABS","68084-269-11","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYCHLOROQUINE 200 MG TABS","68084-269-11","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 0.25 MG TABS","68084-270-11","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 0.25 MG TABS","68084-270-11","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 0.5 MG TABS","68084-271-11","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 0.5 MG TABS","68084-271-11","NDC","","","","","facility","both","1","EA","UD","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHAMBUTOL 400 MG TABS","68084-280-11","NDC","","","","","facility","both","1","EA","UD","3.6","1.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHAMBUTOL 400 MG TABS","68084-280-11","NDC","","","","","facility","both","1","EA","","3.6","1.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA CR 25-100 MG TBSR","68084-281-11","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA CR 50-200 MG TBSR","68084-282-11","NDC","","","","","facility","both","1","EA","","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA-LEVODOPA CR 50-200 MG TBSR","68084-282-11","NDC","","","","","facility","both","1","EA","UD","1.57","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYUREA 500 MG CAPS","68084-284-11","NDC","","","","","facility","both","1","EA","UD","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYUREA 500 MG CAPS","68084-284-11","NDC","","","","","facility","both","1","EA","","2.05","1.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUDROCORTISONE 0.1 MG TABS","68084-288-11","NDC","","","","","facility","both","1","EA","UD","2.39","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUDROCORTISONE 0.1 MG TABS","68084-288-11","NDC","","","","","facility","both","1","EA","","2.39","1.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALTREXONE 50 MG TABS","68084-291-11","NDC","","","","","facility","both","1","EA","","3.35","1.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALTREXONE 50 MG TABS","68084-291-11","NDC","","","","","facility","both","1","EA","UD","3.35","1.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TAMSULOSIN 0.4 MG CAPS","68084-299-11","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TAMSULOSIN 0.4 MG CAPS","68084-299-11","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX ER 250 MG TB24","68084-310-11","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX ER 250 MG TB24","68084-310-11","NDC","","","","","facility","both","1","EA","","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 125 MG CDRS","68084-313-11","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX DR 125 MG CDRS","68084-313-11","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE 25 MG TABS","68084-318-11","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LAMOTRIGINE 25 MG TABS","68084-318-11","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE 100 MG TABS","68084-319-11","NDC","","","","","facility","both","1","EA","","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE 100 MG TABS","68084-319-11","NDC","","","","","facility","both","1","EA","UD","0.1","0.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLIMEPIRIDE 4 MG TABS","68084-327-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GLIMEPIRIDE 4 MG TABS","68084-327-11","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOPIRAMATE 25 MG TABS","68084-342-11","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOPIRAMATE 25 MG TABS","68084-342-11","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TOPIRAMATE 100 MG TABS","68084-344-11","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TOPIRAMATE 100 MG TABS","68084-344-11","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOSARTAN 25 MG TABS","68084-346-11","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LOSARTAN 25 MG TABS","68084-346-11","NDC","","","","","facility","both","1","EA","UD","0.23","0.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE 5 MG TABS","68084-354-11","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE 5 MG TABS","68084-354-11","NDC","","","","","facility","both","1","EA","UD","0.12","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYTOIN ER 100 MG CAPS","68084-376-11","NDC","","","","","facility","both","1","EA","UD","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYTOIN ER 100 MG CAPS","68084-376-11","NDC","","","","","facility","both","1","EA","","0.19","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BENZTROPINE 1 MG TABS","68084-388-01","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BENZTROPINE 1 MG TABS","68084-388-01","NDC","","","","","facility","both","1","EA","UD","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZTROPINE 1 MG TABS","68084-388-11","NDC","","","","","facility","both","1","EA","UD","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZTROPINE 1 MG TABS","68084-388-11","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX ER 500 MG TB24","68084-415-11","NDC","","","","","facility","both","1","EA","UD","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX ER 500 MG TB24","68084-415-11","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMAZEPINE 200 MG TABS","68084-444-11","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 10 MG TABS","68084-447-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"HYDRALAZINE 10 MG TABS","68084-447-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 0.5 MG CAPS","68084-449-11","NDC","","","","","facility","both","1","EA","UD","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 0.5 MG CAPS","68084-449-11","NDC","","","","","facility","both","1","EA","","1.5","0.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 10 MG TABS","68084-511-11","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 10 MG TABS","68084-511-11","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 20 MG TABS","68084-512-11","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 20 MG TABS","68084-512-11","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOPIDOGREL 75 MG TABS","68084-536-11","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOPIDOGREL 75 MG TABS","68084-536-11","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TORSEMIDE 20 MG TABS","68084-539-01","NDC","","","","","facility","both","1","EA","","1.64","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TORSEMIDE 20 MG TABS","68084-539-11","NDC","","","","","facility","both","1","EA","UD","0.64","0.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TORSEMIDE 20 MG TABS","68084-539-11","NDC","","","","","facility","both","1","EA","","1.64","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"GUAIFENESIN ER 600 MG TA12","68084-572-11","NDC","","","","","facility","both","1","EA","UD","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUAIFENESIN ER 600 MG TA12","68084-572-11","NDC","","","","","facility","both","1","EA","","1.32","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 80 MG TABS","68084-590-95","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ATORVASTATIN 80 MG TABS","68084-590-95","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 30 MG TR24","68084-597-11","NDC","","","","","facility","both","1","EA","","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIFEDIPINE 24HR 30 MG TR24","68084-597-11","NDC","","","","","facility","both","1","EA","UD","0.26","0.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 60 MG TR24","68084-598-11","NDC","","","","","facility","both","1","EA","","0.39","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIFEDIPINE 24HR 60 MG TR24","68084-598-11","NDC","","","","","facility","both","1","EA","UD","0.39","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PERPHENAZINE 4 MG TABS","68084-602-11","NDC","","","","","facility","both","1","EA","UD","0.41","0.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 90 MG TR24","68084-603-11","NDC","","","","","facility","both","1","EA","UD","0.65","0.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NIFEDIPINE 24HR 90 MG TR24","68084-603-11","NDC","","","","","facility","both","1","EA","","1.65","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ESCITALOPRAM 10 MG TABS","68084-617-01","NDC","","","","","facility","both","1","EA","UD","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ESCITALOPRAM 10 MG TABS","68084-617-01","NDC","","","","","facility","both","1","EA","","1.17","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LITHIUM ER 300 MG TBSR","68084-640-11","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LITHIUM ER 300 MG TBSR","68084-640-11","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SOTALOL 80 MG TABS","68084-654-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION SR 100 MG SR12","68084-697-11","NDC","","","","","facility","both","1","EA","UD","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPROPION SR 100 MG SR12","68084-697-11","NDC","","","","","facility","both","1","EA","","1.12","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE ER 37.5 MG CP24","68084-698-11","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENLAFAXINE ER 37.5 MG CP24","68084-698-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUPROPION SR 150 MG SR12","68084-708-95","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPROPION SR 150 MG SR12","68084-708-95","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","68084-710-11","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","68084-710-11","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE ER 150 MG CP24","68084-713-01","NDC","","","","","facility","both","1","EA","UD","0.34","0.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENLAFAXINE ER 150 MG CP24","68084-713-01","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE ER 150 MG CP24","68084-713-11","NDC","","","","","facility","both","1","EA","UD","0.34","0.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENLAFAXINE ER 150 MG CP24","68084-713-11","NDC","","","","","facility","both","1","EA","","0.34","0.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MOXIFLOXACIN 400 MG TABS","68084-722-65","NDC","","","","","facility","both","1","EA","","7.45","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 100 MG TABS","68084-728-11","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 100 MG TABS","68084-728-11","NDC","","","","","facility","both","1","EA","UD","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GALANTAMINE 4 MG TABS","68084-729-11","NDC","","","","","facility","both","1","EA","","2.96","1.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUCONAZOLE 200 MG TABS","68084-735-11","NDC","","","","","facility","both","1","EA","","1.71","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHADONE 10 MG TABS","68084-738-11","NDC","","","","","facility","both","1","EA","UD","2.06","1.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG TABS","68084-740-11","NDC","","","","","facility","both","1","EA","UD","0.21","0.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLANZAPINE 10 MG TABS","68084-740-11","NDC","","","","","facility","both","1","EA","","0.34","0.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIAMTERENE-HCTZ 37.5-25 MG TABS","68084-750-95","NDC","","","","","facility","both","1","EA","UD","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMTERENE-HCTZ 37.5-25 MG TABS","68084-750-95","NDC","","","","","facility","both","1","EA","","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOPIDOGREL 300 MG TABS","68084-752-95","NDC","","","","","facility","both","1","EA","UD","19.86","9.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOPIDOGREL 300 MG TABS","68084-752-95","NDC","","","","","facility","both","1","EA","","19.86","9.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 5 MG TABS","68084-753-95","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOBENZAPRINE 5 MG TABS","68084-753-95","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIZANIDINE 2 MG TABS","68084-775-95","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIZANIDINE 2 MG TABS","68084-775-95","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIVALPROEX DR 250 MG TBEC","68084-776-11","NDC","","","","","facility","both","1","EA","UD","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIVALPROEX DR 250 MG TBEC","68084-776-11","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPHENIDATE HCL 5 MG TABS","68084-805-11","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPHENIDATE HCL 5 MG TABS","68084-805-11","NDC","","","","","facility","both","1","EA","UD","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAMADOL 50 MG TABS","68084-808-11","NDC","","","","","facility","both","1","EA","","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAMADOL 50 MG TABS","68084-808-11","NDC","","","","","facility","both","1","EA","UD","0.02","0.01","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPHENIDATE HCL 10 MG TABS","68084-823-11","NDC","","","","","facility","both","1","EA","UD","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPHENIDATE HCL 10 MG TABS","68084-823-11","NDC","","","","","facility","both","1","EA","","1.38","0.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXAZOSIN 1 MG TABS","68084-836-95","NDC","","","","","facility","both","1","EA","","1.64","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXAZOSIN 1 MG TABS","68084-836-95","NDC","","","","","facility","both","1","EA","UD","1.64","0.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENLAFAXINE 37.5 MG TABS","68084-844-11","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VENLAFAXINE 37.5 MG TABS","68084-844-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE 75 MG TABS","68084-856-11","NDC","","","","","facility","both","1","EA","","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE 75 MG TABS","68084-856-11","NDC","","","","","facility","both","1","EA","UD","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 250 MG TABS","68084-859-01","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 250 MG TABS","68084-859-01","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEVETIRACETAM 250 MG TABS","68084-859-11","NDC","","","","","facility","both","1","EA","","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEVETIRACETAM 250 MG TABS","68084-859-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MONTELUKAST 10 MG TABS","68084-875-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MONTELUKAST 10 MG TABS","68084-875-11","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCODONE-ACETAMINOPHEN 5-325 MG TABS","68084-895-11","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE 25 MG TABS","68084-896-95","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VENLAFAXINE 25 MG TABS","68084-896-95","NDC","","","","","facility","both","1","EA","UD","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE EC 180 MG TBEC","68084-907-11","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MYCOPHENOLATE EC 180 MG TBEC","68084-907-11","NDC","","","","","facility","both","1","EA","UD","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE EC 180 MG TBEC","68084-907-21","NDC","","","","","facility","both","1","EA","UD","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE EC 180 MG TBEC","68084-907-21","NDC","","","","","facility","both","1","EA","","1.55","0.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PILOCARPINE 5 MG TABS","68084-928-95","NDC","","","","","facility","both","1","EA","","2.16","1.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPYLTHIOURACIL 50 MG TABS","68084-964-95","NDC","","","","","facility","both","1","EA","","2.23","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPYLTHIOURACIL 50 MG TABS","68084-964-95","NDC","","","","","facility","both","1","EA","UD","5.92","2.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALGANCICLOVIR 450 MG TABS","68084-965-95","NDC","","","","","facility","both","1","EA","","12.01","6.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","68084-988-33","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","68084-988-33","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAZOSIN 1 MG CAPS","68084-996-11","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAZOSIN 1 MG CAPS","68084-996-11","NDC","","","","","facility","both","1","EA","","1.25","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE 10 MG/5 ML SOLN","68094-001-59","NDC","","","","","facility","both","1","EA","","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 10 MG/5 ML SOLN","68094-001-59","NDC","","","","","facility","both","1","EA","UD","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE 20 MG/ML SUSPENSION","68094-008-59","NDC","","","","","facility","both","1","EA","","12.37","6.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBAMAZEPINE 20 MG/ML SUSPENSION","68094-008-59","NDC","","","","","facility","both","1","EA","UD","12.37","6.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 5 MG/5 ML SOLN","68094-031-59","NDC","","","","","facility","both","1","EA","UD","0.96","0.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHADONE 5 MG/5 ML SOLN","68094-031-59","NDC","","","","","facility","both","1","EA","","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SEVELAMER CARBONATE 800 MG TABS","68094-034-59","NDC","","","","","facility","both","1","EA","","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SEVELAMER CARBONATE 800 MG TABS","68094-034-59","NDC","","","","","facility","both","1","EA","UD","0.51","0.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","68094-044-59","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM ACETATE(PHOSPHAT BIND) 667 MG CAPS","68094-044-59","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE CONCENTRATE 10 MG/0.5 ML SYRG","68094-045-01","NDC","","","","","facility","both","1","EA","UD","9.88","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE CONCENTRATE 10 MG/0.5 ML SYRG","68094-045-01","NDC","","","","","facility","both","1","EA","","9.88","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEGESTROL 400 MG/10 ML SUSPENSION","68094-063-59","NDC","","","","","facility","both","1","EA","UD","10.27","5.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEGESTROL 400 MG/10 ML SUSPENSION","68094-063-59","NDC","","","","","facility","both","1","EA","","10.27","5.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUANFACINE 1 MG TABS","68094-065-59","NDC","","","","","facility","both","1","EA","UD","1.44","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENTOLAMINE MESYLATE 5 MG SOLR","68094-101-20","NDC","","","","","facility","both","1","EA","TB","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"PHENTOLAMINE MESYLATE 5 MG SOLR","68094-101-20","NDC","","","","","facility","both","1","EA","JG,UD","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENTOLAMINE MESYLATE 5 MG SOLR","68094-101-20","NDC","","","","","facility","both","1","EA","JG","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"PHENTOLAMINE MESYLATE 5 MG SOLR","68094-101-20","NDC","","","","","facility","both","1","EA","","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENTOLAMINE MESYLATE 5 MG SOLR","68094-101-20","NDC","","","","","facility","both","1","EA","UD","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENTOLAMINE MESYLATE 5 MG SOLR","68094-101-20","NDC","","","","","facility","both","1","EA","UD,TB","2077.64","1038.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) LIQD","6809412059","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) LIQD","6809412059","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) SUSPENSION","68094-123-59","NDC","","","","","facility","both","1","EA","","17.74","8.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LOPERAMIDE 1 MG/7.5 ML LIQD","68094-129-59","NDC","","","","","facility","both","1","EA","UD","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LOPERAMIDE 1 MG/7.5 ML LIQD","68094-129-59","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 160 MG/5 ML (5 ML) SUSPENSION","68094-231-59","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 160 MG/5 ML (5 ML) SUSPENSION","68094-231-59","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IBUPROFEN 100 MG/5 ML SUSPENSION","68094-503-59","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IBUPROFEN 100 MG/5 ML SUSPENSION","68094-503-62","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"IBUPROFEN 100 MG/5 ML SUSPENSION","68094-503-62","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 5 MG/5 ML SOLN","68094-750-59","NDC","","","","","facility","both","1","EA","","6.51","3.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIAZEPAM 5 MG/5 ML SOLN","68094-750-59","NDC","","","","","facility","both","1","EA","UD","7.62","3.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 40 MG/4 ML SOLN","68094-756-59","NDC","","","","","facility","both","1","EA","UD","2.34","1.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FUROSEMIDE 40 MG/4 ML SOLN","68094-756-59","NDC","","","","","facility","both","1","EA","","2.34","1.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 40 MG/4 ML SOLN","68094-756-62","NDC","","","","","facility","both","1","EA","UD","2.34","1.17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG/5 ML SOLN","68094-763-59","NDC","","","","","facility","both","1","EA","","9.21","4.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ONDANSETRON 4 MG/5 ML SOLN","68094-763-59","NDC","","","","","facility","both","1","EA","UD","9.21","4.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN ER 500 MG TB24","68094-904-50","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NAPROXEN 125 MG/5 ML SUSPENSION","68134-201-16","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MULTIVIT WITH MIN #53-FA-K-Q10 200 MCG-1,000 MCG-10 MG CAPS","6817600011","NDC","","","","","facility","both","1","EA","","2.48","1.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 125 MG CAPS","68180-166-11","NDC","","","","","facility","both","1","EA","","3.44","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 125 MG CAPS","68180-166-11","NDC","","","","","facility","both","1","EA","UD","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 125 MG CAPS","68180-166-13","NDC","","","","","facility","both","1","EA","","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 125 MG CAPS","68180-166-13","NDC","","","","","facility","both","1","EA","UD","4.44","2.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHAMBUTOL 100 MG TABS","68180-280-01","NDC","","","","","facility","both","1","EA","UD","3.28","1.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHAMBUTOL 100 MG TABS","68180-280-01","NDC","","","","","facility","both","1","EA","","3.28","1.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DARUNAVIR 800 MG TABS","68180-346-06","NDC","","","","","facility","both","1","EA","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DARUNAVIR 800 MG TABS","68180-346-06","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"QUETIAPINE 100 MG TABS","68180-447-01","NDC","","","","","facility","both","1","EA","","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"QUETIAPINE 100 MG TABS","68180-447-01","NDC","","","","","facility","both","1","EA","UD","0.2","0.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMVASTATIN 10 MG TABS","68180-478-02","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMVASTATIN 10 MG TABS","68180-478-02","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESVENLAFAXINE SUCCINATE 25 MG TB24","68180-604-06","NDC","","","","","facility","both","1","EA","","2.19","1.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE MONOHYDRATE 25 MG/5 ML SUSR","68180-657-01","NDC","","","","","facility","both","1","EA","UD","64.84","32.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEFDINIR 300 MG CAPS","68180-711-60","NDC","","","","","facility","both","1","EA","","3","1.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LANTHANUM CARBONATE 500 MG CHEW","68180-819-42","NDC","","","","","facility","both","1","EA","UD","20.82","10.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LANTHANUM CARBONATE 500 MG CHEW","68180-819-42","NDC","","","","","facility","both","1","EA","","20.82","10.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LANTHANUM CARBONATE 500 MG CHEW","68180-819-52","NDC","","","","","facility","both","1","EA","UD","10.91","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LANTHANUM CARBONATE 500 MG CHEW","68180-819-52","NDC","","","","","facility","both","1","EA","","20.82","10.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALBUTEROL 90 MCG/ACTUATION HFAA 8.5 G CANISTER","68180-963-01","NDC","","","","","facility","both","1","EA","UD","126.93","63.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUTEROL 90 MCG/ACTUATION HFAA 8.5 G CANISTER","68180-963-01","NDC","","","","","facility","both","1","EA","","126.93","63.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"LISINOPRIL 10 MG TABS","68180-980-03","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LISINOPRIL 10 MG TABS","68180-980-03","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LISINOPRIL 20 MG TABS","68180-981-01","NDC","","","","","facility","both","1","EA","","0.04","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NYSTATIN 100,000 UNIT/GRAM POWD 15 G SQUEEZ BTL","68308-152-15","NDC","","","","","facility","both","1","EA","UD","25.52","12.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/GRAM POWD 15 G SQUEEZ BTL","68308-152-15","NDC","","","","","facility","both","1","EA","","25.52","12.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","68308-480-47","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYCODONE-ACETAMINOPHEN 10-325 MG TABS","68308-480-47","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 12.5 MG TABS","68382-040-01","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROMETHAZINE 12.5 MG TABS","68382-040-01","NDC","","","","","facility","both","1","EA","UD","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARVEDILOL 3.125 MG TABS","68382-092-05","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 3.125 MG TABS","68382-092-05","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARVEDILOL 12.5 MG TABS","68382-094-05","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","68382-094-05","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 0.25 MG TABS","68382-112-14","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RISPERIDONE 0.25 MG TABS","68382-112-14","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 1 MG TABS","68382-114-14","NDC","","","","","facility","both","1","EA","","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RISPERIDONE 1 MG TABS","68382-114-14","NDC","","","","","facility","both","1","EA","UD","1.4","0.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RAMIPRIL 1.25 MG CAPS","68382-144-06","NDC","","","","","facility","both","1","EA","UD","1.24","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RAMIPRIL 1.25 MG CAPS","68382-144-06","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RAMIPRIL 5 MG CAPS","68382-146-01","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NYSTATIN 100,000 UNIT/GRAM POWD 15 G BOTTLE","68382-370-01","NDC","","","","","facility","both","1","EA","UD","25.52","12.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BOSENTAN 125 MG TABS","68382-447-14","NDC","","","","","facility","both","1","EA","","99.93","49.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIROLIMUS 0.5 MG TABS","68382-520-01","NDC","","","","","facility","both","1","EA","UD","13.07","6.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIROLIMUS 0.5 MG TABS","68382-520-01","NDC","","","","","facility","both","1","EA","","14.07","7.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","68382-529-60","NDC","","","","","facility","both","1","EA","","3.65","1.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHOLESTYRAMINE 4 GRAM PWPK","68382-529-60","NDC","","","","","facility","both","1","EA","UD","3.65","1.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 100 MG TABS","68382-798-01","NDC","","","","","facility","both","1","EA","UD","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 100 MG TABS","68382-798-01","NDC","","","","","facility","both","1","EA","","1.21","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LABETALOL 200 MG TABS","68382-799-01","NDC","","","","","facility","both","1","EA","UD","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 200 MG TABS","68382-799-01","NDC","","","","","facility","both","1","EA","","0.32","0.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAZODONE 50 MG TABS","68382-805-05","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRAZODONE 50 MG TABS","68382-805-10","NDC","","","","","facility","both","1","EA","","0.07","0.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRAZODONE 50 MG TABS","68382-805-10","NDC","","","","","facility","both","1","EA","UD","0.14","0.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMTERENE-HCTZ 75-50 MG TABS","68382-857-01","NDC","","","","","facility","both","1","EA","","1.62","0.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE 100 MG SOLR 1 EACH VIAL","68382-910-01","NDC","","","","","facility","both","1","EA","UD","94.21","47.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE 100 MG SOLR 1 EACH VIAL","68382-910-01","NDC","","","","","facility","both","1","EA","","94.21","47.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 200 MG TR24","68382-982-06","NDC","","","","","facility","both","1","EA","","4.81","2.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LAMOTRIGINE ER 200 MG TR24","68382-982-06","NDC","","","","","facility","both","1","EA","UD","5.81","2.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARSENIC TRIOXIDE 1 MG/ML SOLN 10 ML VIAL","68382-997-01","NDC","","","","","facility","both","1","EA","","732.5","366.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ARSENIC TRIOXIDE 1 MG/ML SOLN 10 ML VIAL","68382-997-10","NDC","","","","","facility","both","1","EA","","732.5","366.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ZONISAMIDE 25 MG CAPS","68462-128-01","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZONISAMIDE 25 MG CAPS","68462-128-01","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ONDANSETRON 4 MG ODT.","68462-157-40","NDC","","","","","facility","both","1","EA","UD","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON 4 MG ODT.","68462-157-40","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MUPIROCIN 2 % OINT 22 G TUBE","68462-180-22","NDC","","","","","facility","both","1","EA","UD","30.72","15.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MUPIROCIN 2 % OINT 22 G TUBE","68462-180-22","NDC","","","","","facility","both","1","EA","","30.72","15.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CLOTRIMAZOLE 1 % CREA 15 G TUBE","68462-181-17","NDC","","","","","facility","both","1","EA","UD","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOTRIMAZOLE 1 % CREA 15 G TUBE","68462-181-17","NDC","","","","","facility","both","1","EA","","15","7.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"LITHIUM 450 MG TBSR","68462-224-01","NDC","","","","","facility","both","1","EA","","1.68","0.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LITHIUM 450 MG TBSR","68462-224-01","NDC","","","","","facility","both","1","EA","UD","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROPINIROLE 5 MG TABS","68462-259-01","NDC","","","","","facility","both","1","EA","","0.28","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 12HR 120 MG TBSR","68462-292-01","NDC","","","","","facility","both","1","EA","UD","2.14","1.07","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 12HR 120 MG TBSR","68462-292-01","NDC","","","","","facility","both","1","EA","","2.81","1.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NORETHINDRONE 5 MG TABS","68462-304-50","NDC","","","","","facility","both","1","EA","","2.8","1.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PRAMIPEXOLE 0.125 MG TABS","68462-330-90","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRAMIPEXOLE 0.125 MG TABS","68462-330-90","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEPRAZOLE 10 MG CPDR","68462-395-30","NDC","","","","","facility","both","1","EA","","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEPRAZOLE 10 MG CPDR","68462-395-30","NDC","","","","","facility","both","1","EA","UD","1.28","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 25 MG CAPS","68462-406-01","NDC","","","","","facility","both","1","EA","UD","1.58","0.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLMESARTAN 5 MG TABS","68462-436-30","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OLMESARTAN 5 MG TABS","68462-436-30","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLMESARTAN 20 MG TABS","68462-437-30","NDC","","","","","facility","both","1","EA","UD","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OLMESARTAN 20 MG TABS","68462-437-30","NDC","","","","","facility","both","1","EA","","1.37","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIZATRIPTAN 5 MG ODT.","68462-467-40","NDC","","","","","facility","both","1","EA","","3.6","1.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUMETANIDE 0.25 MG/ML SOLN","68462-469-40","NDC","","","","","facility","both","1","EA","UD","13.45","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 0.25 MG/ML SOLN","68462-469-40","NDC","","","","","facility","both","1","EA","","13.45","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZOLMITRIPTAN 2.5 MG TABS","68462-497-76","NDC","","","","","facility","both","1","EA","UD","4.95","2.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIPOTRIENE 0.005 % CREA 60 G TUBE","68462-501-65","NDC","","","","","facility","both","1","EA","UD","95.92","47.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENOFIBRATE MICRONIZED 67 MG CAPS","68462-580-01","NDC","","","","","facility","both","1","EA","","0.48","0.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FENOFIBRATE MICRONIZED 67 MG CAPS","68462-580-01","NDC","","","","","facility","both","1","EA","UD","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIMECROLIMUS 1 % CREA 30 G TUBE","68462-609-35","NDC","","","","","facility","both","1","EA","","615.38","307.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NITROGLYCERIN 0.4 MG SUBL","68462-639-25","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.4 MG SUBL","68462-639-25","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BISOPROLOL/HCTZ 2.5-6.25 MG TABS","68462-878-30","NDC","","","","","facility","both","1","EA","","1.61","0.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VARENICLINE 0.5 MG TABS","68462-893-56","NDC","","","","","facility","both","1","EA","","6.89","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FACTOR IX COMPLEX 500 (+/-) UNIT SOLR","68516-3207-1","NDC","","","","","facility","both","1","EA","","13770","6885","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ALBUMIN, HUMAN 5% 5 % SOLP","68516-5214-2","NDC","","","","","facility","both","1","EA","UD","2908.75","1454.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","68516-5216-2","NDC","","","","","facility","both","1","EA","JG,UD","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALBUMIN, HUMAN 25 % SOLP","68516-5216-2","NDC","","","","","facility","both","1","EA","","1166.25","583.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALBUMIN, HUMAN 25 % SOLP","68516-5216-4","NDC","","","","","facility","both","1","EA","JG","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ALBUMIN, HUMAN 25 % SOLP","68516-5216-4","NDC","","","","","facility","both","1","EA","UD","584.38","292.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHACRYNIC ACID 25 MG TABS","68682-011-10","NDC","","","","","facility","both","1","EA","","6.99","3.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBIDOPA 25 MG TABS","68682-200-25","NDC","","","","","facility","both","1","EA","","2.95","1.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PEG 3350-ELECTROLYTES-VIT C 100-7.5-2.691 GRAM PWPK 1 EACH PACKET","68682-201-75","NDC","","","","","facility","both","1","EA","UD","134.8","67.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PEG 3350-ELECTROLYTES-VIT C 100-7.5-2.691 GRAM PWPK 1 EACH PACKET","68682-201-75","NDC","","","","","facility","both","1","EA","","134.8","67.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIMOLOL 0.5 % DROP 5 ML DROP BTL","68682-813-05","NDC","","","","","facility","both","1","EA","","20.15","10.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DILTIAZEM 24HR 240 MG CP24","68682-997-98","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DILTIAZEM 24HR 240 MG CP24","68682-997-98","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRYPAN BLUE 0.06 % SYRG","68803-612-10","NDC","","","","","facility","both","1","EA","","426.92","213.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"TRYPAN BLUE 0.06 % SYRG","68803-612-10","NDC","","","","","facility","both","1","EA","UD","426.92","213.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHAMBUTOL 400 MG TABS","68850-012-02","NDC","","","","","facility","both","1","EA","","4.6","2.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 250 UNIT SOLR","68982-139-01","NDC","","","","","facility","both","1","EA","UD","2214","1107","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 250 UNIT SOLR","68982-139-01","NDC","","","","","facility","both","1","EA","UD,TB","2394","1197","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 250 UNIT SOLR","68982-139-01","NDC","","","","","facility","both","1","EA","JG,UD","2394","1197","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 250 UNIT SOLR","68982-139-01","NDC","","","","","facility","both","1","EA","JG","2448","1224","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 500 UNIT SOLR","68982-141-01","NDC","","","","","facility","both","1","EA","UD","4500","2250","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 500 UNIT SOLR","68982-141-01","NDC","","","","","facility","both","1","EA","JG,UD","4590","2295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 500 UNIT SOLR","68982-141-01","NDC","","","","","facility","both","1","EA","","4590","2295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 500 UNIT SOLR","68982-141-01","NDC","","","","","facility","both","1","EA","UD,TB","4608","2304","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 500 UNIT SOLR","68982-141-01","NDC","","","","","facility","both","1","EA","JG","9180","4590","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 1000 UNIT SOLR","68982-143-01","NDC","","","","","facility","both","1","EA","UD","9000","4500","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 1000 UNIT SOLR","68982-143-01","NDC","","","","","facility","both","1","EA","JG,UD","9306","4653","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 1000 UNIT SOLR","68982-143-01","NDC","","","","","facility","both","1","EA","","9783","4891.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 1000 UNIT SOLR","68982-143-01","NDC","","","","","facility","both","1","EA","UD,TB","10089","5044.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 2,500 UNIT SOLR","68982-147-01","NDC","","","","","facility","both","1","EA","UD,TB","22968","11484","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 2,500 UNIT SOLR","68982-147-01","NDC","","","","","facility","both","1","EA","JG,UD","23724","11862","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 2,500 UNIT SOLR","68982-147-01","NDC","","","","","facility","both","1","EA","JG","23724","11862","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 2,500 UNIT SOLR","68982-147-01","NDC","","","","","facility","both","1","EA","UD","23724","11862","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 2,500 UNIT SOLR","68982-147-01","NDC","","","","","facility","both","1","EA","","25470","12735","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 4,000 UNIT SOLR","68982-151-01","NDC","","","","","facility","both","1","EA","JG","38853","19426.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 4,000 UNIT SOLR","68982-151-01","NDC","","","","","facility","both","1","EA","","36135","18067.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 4,000 UNIT SOLR","68982-151-01","NDC","","","","","facility","both","1","EA","UD,TB","38853","19426.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 4,000 UNIT SOLR","68982-151-01","NDC","","","","","facility","both","1","EA","JG,UD","4590","2295","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPH.FVIII,HEK,B-DELETE 4,000 UNIT SOLR","68982-151-01","NDC","","","","","facility","both","1","EA","UD","36135","18067.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ANTIHEMOPHILIC FACTOR-VWF 500-500 UNIT SOLR","68982-182-01","NDC","","","","","facility","both","1","EA","","4635","2317.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"ANTIHEMOPHILIC FACTOR-VWF 1,000-1,000 UNIT SOLR","68982-182-02","NDC","","","","","facility","both","1","EA","","8370","4185","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 INT'L UNITS"
"TACROLIMUS 1 MG TB24","68992-3010-1","NDC","","","","","facility","both","1","EA","UD","18.51","9.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 1 MG TB24","68992-3010-1","NDC","","","","","facility","both","1","EA","","18.51","9.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 1 MG TB24","68992-3010-3","NDC","","","","","facility","both","1","EA","","10.93","5.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 1 MG TB24","68992-3010-3","NDC","","","","","facility","both","1","EA","UD","18.51","9.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 4 MG TB24","68992-3040-1","NDC","","","","","facility","both","1","EA","","43.73","21.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 4 MG TB24","68992-3040-3","NDC","","","","","facility","both","1","EA","UD","42.03","21.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 4 MG TB24","68992-3040-3","NDC","","","","","facility","both","1","EA","","42.03","21.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TACROLIMUS 0.75 MG TB24","68992-3075-3","NDC","","","","","facility","both","1","EA","UD","14.78","7.39","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TACROLIMUS 0.75 MG TB24","68992-3075-3","NDC","","","","","facility","both","1","EA","","15.78","7.89","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TOPIRAMATE 25 MG TABS","69097-122-03","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TOPIRAMATE 25 MG TABS","69097-122-03","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","69097-524-44","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"DICLOFENAC SODIUM 1 % GEL 100 G TUBE","69097-524-44","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOSFOMYCIN TROMETHAMINE 3 GRAM PACK","69097-579-67","NDC","","","","","facility","both","1","EA","","98","49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FOSFOMYCIN TROMETHAMINE 3 GRAM PACK","69097-579-67","NDC","","","","","facility","both","1","EA","UD","98","49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EMTRICITABINE 200 MG CAPS","69097-642-02","NDC","","","","","facility","both","1","EA","UD","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EMTRICITABINE 200 MG CAPS","69097-642-02","NDC","","","","","facility","both","1","EA","","32.72","16.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SUMATRIPTAN 20 MG/ACTUATION SPRY 6 EACH AER W/ADAP","69097-644-48","NDC","","","","","facility","both","1","EA","UD","443.51","221.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN","69097-708-31","NDC","","","","","facility","both","1","EA","UD","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN","69097-708-31","NDC","","","","","facility","both","1","EA","","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN 1 ML VIAL","69097-708-96","NDC","","","","","facility","both","1","EA","UD","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 10 MG/ML SOLN 1 ML VIAL","69097-708-96","NDC","","","","","facility","both","1","EA","","269.79","134.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML SOLN","69097-709-30","NDC","","","","","facility","both","1","EA","UD","17.33","8.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML SOLN","69097-709-30","NDC","","","","","facility","both","1","EA","","17.33","8.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOBENZAPRINE 10 MG TABS","69097-846-07","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOBENZAPRINE 10 MG TABS","69097-846-07","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYCYCLINE HYCLATE 100 MG CAPS","69238-1100-2","NDC","","","","","facility","both","1","EA","","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYCYCLINE HYCLATE 100 MG CAPS","69238-1100-2","NDC","","","","","facility","both","1","EA","UD","1.34","0.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ETHACRYNIC ACID 25 MG TABS","69238-1126-1","NDC","","","","","facility","both","1","EA","","4","2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOBAZAM 10 MG TABS","69238-1305-1","NDC","","","","","facility","both","1","EA","UD","0.92","0.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CLOBAZAM 10 MG TABS","69238-1305-1","NDC","","","","","facility","both","1","EA","","0.92","0.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALBUTEROL 2 MG TABS","69238-1344-1","NDC","","","","","facility","both","1","EA","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUMETANIDE 0.5 MG TABS","69238-1489-1","NDC","","","","","facility","both","1","EA","UD","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 0.5 MG TABS","69238-1489-1","NDC","","","","","facility","both","1","EA","","1.46","0.73","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLOBETASOL 0.05 % CREA 15 G TUBE","69238-1532-5","NDC","","","","","facility","both","1","EA","","8.51","4.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"SIROLIMUS 1 MG/ML SOLN","69238-1594-6","NDC","","","","","facility","both","1","EA","UD","39.74","19.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLERGONOVINE 0.2 MG TABS","69238-1605-8","NDC","","","","","facility","both","1","EA","","30.44","15.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLERGONOVINE 0.2 MG TABS","69238-1605-8","NDC","","","","","facility","both","1","EA","UD","30.44","15.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 20 MEQ PACK","69238-1617-1","NDC","","","","","facility","both","1","EA","UD","3.88","1.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 20 MEQ PACK","69238-1617-1","NDC","","","","","facility","both","1","EA","","4.88","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 10 MG TABS","69238-2077-1","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROPRANOLOL 10 MG TABS","69238-2077-1","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 20 MG TABS","69238-2078-1","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PROPRANOLOL 20 MG TABS","69238-2078-1","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IMIPRAMINE 10 MG TABS","69315-133-01","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IMIPRAMINE 25 MG TABS","69315-134-01","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IMIPRAMINE 25 MG TABS","69315-134-01","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NYSTATIN 100,000 UNIT/GRAM POWD 15 G SQUEEZ BTL","69315-306-15","NDC","","","","","facility","both","1","EA","","25.52","12.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS","69315-910-01","NDC","","","","","facility","both","1","EA","","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DIPHENOXYLATE-ATROPINE 2.5-0.025 MG TABS","69315-910-01","NDC","","","","","facility","both","1","EA","UD","0.29","0.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 5 MG/ML SYRG","69339-136-03","NDC","","","","","facility","both","1","EA","","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIAZEPAM 5 MG/ML SYRG","69339-136-03","NDC","","","","","facility","both","1","EA","UD","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORHEXIDINE 0.12 % MWSH","69339-138-19","NDC","","","","","facility","both","1","EA","UD","1.58","0.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHLORHEXIDINE 0.12 % MWSH","69339-138-19","NDC","","","","","facility","both","1","EA","","1.39","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 100 ML"
"MAGNESIUM HYDROXIDE 400 MG/5 ML SUSPENSION","69339-153-01","NDC","","","","","facility","both","1","EA","","6.13","3.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LUBIPROSTONE 8 MCG CAPS","69339-162-98","NDC","","","","","facility","both","1","EA","UD","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LUBIPROSTONE 8 MCG CAPS","69339-162-98","NDC","","","","","facility","both","1","EA","","1.98","0.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LUBIPROSTONE 24 MCG CAPS","69339-163-98","NDC","","","","","facility","both","1","EA","UD","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LUBIPROSTONE 24 MCG CAPS","69339-163-98","NDC","","","","","facility","both","1","EA","","2.3","1.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.4 MG SUBL","69339-174-02","NDC","","","","","facility","both","1","EA","","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NITROGLYCERIN 0.4 MG SUBL","69339-174-02","NDC","","","","","facility","both","1","EA","UD","1.22","0.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 50 MG SUPP","69344-102-33","NDC","","","","","facility","both","1","EA","UD","725.62","362.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 50 MG SUPP","69344-102-33","NDC","","","","","facility","both","1","EA","","725.62","362.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENOBARBITAL 32.4 MG TABS","69367-212-01","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENOBARBITAL 32.4 MG TABS","69367-212-01","NDC","","","","","facility","both","1","EA","UD","1.72","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROCORTISONE 25 MG SUPP","69367-243-24","NDC","","","","","facility","both","1","EA","","2.44","1.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) SYRG","69374-919-10","NDC","","","","","facility","both","1","EA","UD","77.5","38.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","69374-924-05","NDC","","","","","facility","both","1","EA","","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","69374-924-05","NDC","","","","","facility","both","1","EA","UD","105.63","52.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN","69374-946-34","NDC","","","","","facility","both","1","EA","UD","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 900 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN","69374-946-34","NDC","","","","","facility","both","1","EA","","28.88","14.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 900 ML"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","69374-957-10","NDC","","","","","facility","both","1","EA","","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"MORPHINE 2 MG/2 ML SYRG","69374-979-02","NDC","","","","","facility","both","1","EA","","18.5","9.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"AMINO ACID 50 GRAM/1000 ML SOLN","69374-988-10","NDC","","","","","facility","both","1","EA","","644.4","322.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 2 ML"
"RIZATRIPTAN 5 MG ODT.","69452-156-74","NDC","","","","","facility","both","1","EA","","3.6","1.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYLAMINE-PYRIDOXINE 10-10 MG TBEC","69452-206-20","NDC","","","","","facility","both","1","EA","","6.89","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOXYLAMINE-PYRIDOXINE 10-10 MG TBEC","69452-206-20","NDC","","","","","facility","both","1","EA","UD","6.89","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX-VITAMIN C-FOLIC ACID 1 MG CAPS","6954326010","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX-VITAMIN C-FOLIC ACID 1 MG CAPS","6954326010","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARISOPRODOL 350 MG TABS","69584-111-10","NDC","","","","","facility","both","1","EA","","1.15","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PERAMPANEL 2 MG TABS","69616-272-30","NDC","","","","","facility","both","1","EA","","41.12","20.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","69618-020-15","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEW","69618-020-15","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL","69784-230-10","NDC","","","","","facility","both","1","EA","UD","6.05","3.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM ACETATE 2 MEQ/ML SOLN 50 ML VIAL","69784-230-10","NDC","","","","","facility","both","1","EA","","6.05","3.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SODIUM ACETATE 2 MEQ/ML SOLN 100 ML VIAL","69784-231-10","NDC","","","","","facility","both","1","EA","","9.88","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SODIUM ACETATE 2 MEQ/ML SOLN 100 ML VIAL","69784-231-10","NDC","","","","","facility","both","1","EA","UD","32","16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","69918-901-10","NDC","","","","","facility","both","1","EA","","377.5","188.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","69918-901-10","NDC","","","","","facility","both","1","EA","JG","468.75","234.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","69918-901-10","NDC","","","","","facility","both","1","EA","TB","565","282.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","69918-901-10","NDC","","","","","facility","both","1","EA","UD","565","282.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 0.8 MG/2 ML (0.4 MG/ML) SYRG","70004-040-06","NDC","","","","","facility","both","1","EA","UD","58.75","29.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 0.8 MG/2 ML (0.4 MG/ML) SYRG","70004-040-06","NDC","","","","","facility","both","1","EA","","58.75","29.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","70004-085-44","NDC","","","","","facility","both","1","EA","UD","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","70004-085-44","NDC","","","","","facility","both","1","EA","","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE IN NACL 0.9 % 30 MG/30 ML (1 MG/ML) SPCA","70004-100-16","NDC","","","","","facility","both","1","EA","UD","57.74","28.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE IN NACL 0.9 % 30 MG/30 ML (1 MG/ML) SPCA","70004-100-16","NDC","","","","","facility","both","1","EA","","57.74","28.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FENTANYL CITRATE 2500MCG IN 50ML 50 MCG/ML SOLN","70004-222-30","NDC","","","","","facility","both","1","EA","UD","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE 2500MCG IN 50ML 50 MCG/ML SOLN","70004-222-30","NDC","","","","","facility","both","1","EA","","131.6","65.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE (PF)-0.9 % NACL 30 MG/30 ML (1 MG/ML) SPCA","70004-303-21","NDC","","","","","facility","both","1","EA","UD","75.74","37.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE (PF)-0.9 % NACL 30 MG/30 ML (1 MG/ML) SPCA","70004-303-21","NDC","","","","","facility","both","1","EA","","75.74","37.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUCONATE","70004-511-30","NDC","","","","","facility","both","1","EA","UD","56.67","28.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE","70004-511-30","NDC","","","","","facility","both","1","EA","","56.67","28.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPHEDRINE 50 MG/10 ML (5 MG/ML) SYRG","70004-600-12","NDC","","","","","facility","both","1","EA","UD","155.63","77.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPHEDRINE 50 MG/10 ML (5 MG/ML) SYRG","70004-600-12","NDC","","","","","facility","both","1","EA","","155.63","77.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","70004-810-12","NDC","","","","","facility","both","1","EA","UD","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","70004-810-12","NDC","","","","","facility","both","1","EA","","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","70004-850-09","NDC","","","","","facility","both","1","EA","UD","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","70004-850-09","NDC","","","","","facility","both","1","EA","","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) SYRG 10 ML SYRINGE","70004-908-12","NDC","","","","","facility","both","1","EA","","112.75","56.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) SYRG 10 ML SYRINGE","70004-908-12","NDC","","","","","facility","both","1","EA","UD","112.75","56.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1500MG/NS 500ML INFUSION","70004-924-44","NDC","","","","","facility","both","1","EA","UD","42","21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1500MG/NS 500ML INFUSION","70004-924-44","NDC","","","","","facility","both","1","EA","","42","21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML SOLN","70004-928-44","NDC","","","","","facility","both","1","EA","UD","66","33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML SOLN","70004-928-44","NDC","","","","","facility","both","1","EA","","66","33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COLCHICINE 0.6 MG TABS","70010-002-01","NDC","","","","","facility","both","1","EA","","1.51","0.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METFORMIN ER 500 MG TB24","70010-491-01","NDC","","","","","facility","both","1","EA","UD","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METFORMIN ER 500 MG TB24","70010-491-01","NDC","","","","","facility","both","1","EA","","1.07","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","70010-770-01","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXAMETHASONE PF 10 MG/ML SOLN","70069-021-01","NDC","","","","","facility","both","1","EA","UD","9.06","4.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXAMETHASONE PF 10 MG/ML SOLN","70069-021-01","NDC","","","","","facility","both","1","EA","","13.44","6.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML DROP 10 ML DROP BTL","70069-051-01","NDC","","","","","facility","both","1","EA","UD","18.5","9.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROPIVACAINE (PF) 0.5% SOLN","70069-064-01","NDC","","","","","facility","both","1","EA","","27.31","13.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ROPIVACAINE (PF) 0.5% SOLN","70069-064-01","NDC","","","","","facility","both","1","EA","UD","16.88","8.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 100 MG/ML SOLN","70069-101-01","NDC","","","","","facility","both","1","EA","UD","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 100 MG/ML SOLN","70069-101-01","NDC","","","","","facility","both","1","EA","","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TROPICAMIDE 1 % DROP","70069-121-01","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TROPICAMIDE 1 % DROP","70069-121-01","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TOBRAMYCIN 0.3 % DROP","70069-131-01","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TOBRAMYCIN 0.3 % DROP","70069-131-01","NDC","","","","","facility","both","1","EA","UD","18.5","9.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PILOCARPINE 1 % DROP","70069-181-01","NDC","","","","","facility","both","1","EA","UD","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PILOCARPINE 1 % DROP","70069-181-01","NDC","","","","","facility","both","1","EA","","221.71","110.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PILOCARPINE 2 % DROP","70069-191-01","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BRIMONIDINE 0.2 % DROP 5 ML DROP BTL","70069-231-01","NDC","","","","","facility","both","1","EA","","22.39","11.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL","70069-261-01","NDC","","","","","facility","both","1","EA","UD","104.06","52.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NITROPRUSSIDE 25 MG/ML SOLN 2 ML VIAL","70069-261-01","NDC","","","","","facility","both","1","EA","","104.06","52.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VERAPAMIL 2.5 MG/ML SOLN","70069-271-01","NDC","","","","","facility","both","1","EA","","11.38","5.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 30 ML VIAL","70069-363-01","NDC","","","","","facility","both","1","EA","UD","40.5","20.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIMETHOPRIM-SULFAMETHOXAZOLE 80-400 MG/5 ML SOLN 30 ML VIAL","70069-363-01","NDC","","","","","facility","both","1","EA","","136.45","68.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LATANOPROST 0.005 % DROP","70069-421-01","NDC","","","","","facility","both","1","EA","UD","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LATANOPROST 0.005 % DROP","70069-421-01","NDC","","","","","facility","both","1","EA","","9.75","4.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML VIAL","70069-728-01","NDC","","","","","facility","both","1","EA","UD","309.38","154.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 100 MG/ML (10%) SOLN 100 ML VIAL","70069-728-01","NDC","","","","","facility","both","1","EA","","309.38","154.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 15 ML VIAL","70069-747-01","NDC","","","","","facility","both","1","EA","UD","14.83","7.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM PHOSPHATES 3 MMOL/ML SOLN 15 ML VIAL","70069-747-01","NDC","","","","","facility","both","1","EA","","14.83","7.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN","70069-803-01","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VALGANCICLOVIR 50 MG/ML SOLR","70069-810-01","NDC","","","","","facility","both","1","EA","UD","10.45","5.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALGANCICLOVIR 50 MG/ML SOLR","70069-810-01","NDC","","","","","facility","both","1","EA","","41.22","20.61","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALIMENTUM 22CAL/OZ 22CAL/OZ LIQD","7007457509","NDC","","","","","facility","both","1","EA","UD","480","240","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALIMENTUM 22CAL/OZ 22CAL/OZ LIQD","7007457509","NDC","","","","","facility","both","1","EA","","480","240","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ALIMENTUM 24CAL/OZ 24CAL/OZ","7007464712","NDC","","","","","facility","both","1","EA","UD","480","240","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ALIMENTUM 24CAL/OZ 24CAL/OZ","7007464712","NDC","","","","","facility","both","1","EA","","480","240","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NOREPINEPHRINE BITARTRATE-D5W 16 MG/250 ML (64 MCG/ML) SOLN","70092-1038-17","NDC","","","","","facility","both","1","EA","UD","198","99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE BITARTRATE-D5W 16 MG/250 ML (64 MCG/ML) SOLN","70092-1038-17","NDC","","","","","facility","both","1","EA","","198","99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","70092-1046-46","NDC","","","","","facility","both","1","EA","","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","70092-1046-46","NDC","","","","","facility","both","1","EA","UD","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYTOCIN 30 UNIT/500 ML SOLN","70092-1068-07","NDC","","","","","facility","both","1","EA","","5.33","2.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"OXYTOCIN 30 UNIT/500 ML SOLN","70092-1068-07","NDC","","","","","facility","both","1","EA","UD","8.4","4.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","70092-1073-44","NDC","","","","","facility","both","1","EA","UD","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","70092-1073-44","NDC","","","","","facility","both","1","EA","","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"HYDROMORPHONE 0.2 MG/ML SOLN","70092-1115-36","NDC","","","","","facility","both","1","EA","","126.2","63.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"HYDROMORPHONE 0.2 MG/ML SOLN","70092-1115-36","NDC","","","","","facility","both","1","EA","UD","131","65.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE IN NORMAL SALINE 50 MG/5 ML (10 MG/ML) SYRG","70092-1119-44","NDC","","","","","facility","both","1","EA","","28.2","14.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"KETAMINE IN NORMAL SALINE 50 MG/5 ML (10 MG/ML) SYRG","70092-1119-44","NDC","","","","","facility","both","1","EA","UD","33.2","16.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CITRATE 4 % (3 ML) SYRG","70092-1148-43","NDC","","","","","facility","both","1","EA","UD","79.94","39.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CITRATE 4 % (3 ML) SYRG","70092-1148-43","NDC","","","","","facility","both","1","EA","","76.24","38.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML SOLN","70092-1177-35","NDC","","","","","facility","both","1","EA","","86","43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"FENTANYL 2MCG/ML-BUPIVACAINE 0.125% IN 100ML NS 2 MCG/ML- 0.125 % RESV","70092-1202-75","NDC","","","","","facility","both","1","EA","","407","203.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"FENTANYL 2MCG/ML-BUPIVACAINE 0.125% IN 100ML NS 2 MCG/ML- 0.125 % RESV","70092-1202-75","NDC","","","","","facility","both","1","EA","UD","407","203.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 2 GRAM/100 ML SOLN","70092-1235-03","NDC","","","","","facility","both","1","EA","UD","100","50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUCONATE 2 GRAM/100 ML SOLN","70092-1235-03","NDC","","","","","facility","both","1","EA","","100","50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE (PF)-0.9 % NACL 30 MG/30 ML (1 MG/ML) SPCA","70092-1293-49","NDC","","","","","facility","both","1","EA","UD","75.74","37.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE (PF)-0.9 % NACL 30 MG/30 ML (1 MG/ML) SPCA","70092-1293-49","NDC","","","","","facility","both","1","EA","","75.74","37.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"MORPHINE (PF) IN 0.9 % SOD CHL 1 MG/ML SOLN","70092-1380-36","NDC","","","","","facility","both","1","EA","UD","94.4","47.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE (PF) IN 0.9 % SOD CHL 1 MG/ML SOLN","70092-1380-36","NDC","","","","","facility","both","1","EA","","94.4","47.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML SYRG","70092-1433-50","NDC","","","","","facility","both","1","EA","","5.56","2.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML SYRG","70092-1433-50","NDC","","","","","facility","both","1","EA","UD","13.89","6.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SYRG","70092-1475-50","NDC","","","","","facility","both","1","EA","UD","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SYRG","70092-1475-50","NDC","","","","","facility","both","1","EA","","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"FENTANYL CITRATE 2500MCG IN 50ML 50 MCG/ML SOLN","70092-1509-35","NDC","","","","","facility","both","1","EA","UD","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE 2500MCG IN 50ML 50 MCG/ML SOLN","70092-1509-35","NDC","","","","","facility","both","1","EA","","7.53","3.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"MORPHINE (PF) IN 0.9 % SOD CHL 30 MG/30 ML (1 MG/ML) SPCA","70092-1519-48","NDC","","","","","facility","both","1","EA","","64.4","32.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"MORPHINE (PF) IN 0.9 % SOD CHL 30 MG/30 ML (1 MG/ML) SPCA","70092-1520-49","NDC","","","","","facility","both","1","EA","UD","57.74","28.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE (PF) IN 0.9 % SOD CHL 30 MG/30 ML (1 MG/ML) SPCA","70092-1520-49","NDC","","","","","facility","both","1","EA","","57.74","28.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","70092-1552-07","NDC","","","","","facility","both","1","EA","UD","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","70092-1552-07","NDC","","","","","facility","both","1","EA","","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"KETAMINE 10 MG/ML SOLN","70092-2119-44","NDC","","","","","facility","both","1","EA","UD","33.2","16.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE 10 MG/ML SOLN","70092-2119-44","NDC","","","","","facility","both","1","EA","","33.2","16.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"PANTOPRAZOLE 40 MG SOLR","70095-024-01","NDC","","","","","facility","both","1","EA","UD","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOPRAZOLE 40 MG SOLR","70095-024-01","NDC","","","","","facility","both","1","EA","","20","10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","70095-025-01","NDC","","","","","facility","both","1","EA","UD","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","70095-025-01","NDC","","","","","facility","both","1","EA","","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","70095-050-01","NDC","","","","","facility","both","1","EA","","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","70095-050-01","NDC","","","","","facility","both","1","EA","UD","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOCYANINE GREEN 25 MG SOLR","70100-424-02","NDC","","","","","facility","both","1","EA","UD","618.11","309.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOCYANINE GREEN 25 MG SOLR","70100-424-02","NDC","","","","","facility","both","1","EA","","618.11","309.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 EACH"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR","70121-1001-1","NDC","","","","","facility","both","1","EA","","42.88","21.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHYLPREDNISOLONE SOD SUCC 125 MG/2 ML SOLR","70121-1001-1","NDC","","","","","facility","both","1","EA","UD","83.25","41.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE (KENALOG) 40 MG/ML SUSPENSION","70121-1049-1","NDC","","","","","facility","both","1","EA","","35.31","17.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRIAMCINOLONE ACETONIDE (KENALOG) 40 MG/ML SUSPENSION","70121-1049-1","NDC","","","","","facility","both","1","EA","UD","35.31","17.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIAMCINOLONE ACETONIDE (KENALOG) 40 MG/ML SUSPENSION","70121-1168-1","NDC","","","","","facility","both","1","EA","","1028.75","514.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","70121-1389-1","NDC","","","","","facility","both","1","EA","UD","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","70121-1389-1","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FILGRASTIM-AYOW 480 MCG/0.8 ML SYRG","70121-1570-1","NDC","","","","","facility","both","1","EA","UD","1139.72","569.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION","70121-1574-1","NDC","","","","","facility","both","1","EA","","3.62","1.81","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION","70121-1574-5","NDC","","","","","facility","both","1","EA","UD","91.88","45.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION","70121-1574-5","NDC","","","","","facility","both","1","EA","","91.88","45.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","70121-1576-1","NDC","","","","","facility","both","1","EA","","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","70121-1576-1","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","70121-1576-7","NDC","","","","","facility","both","1","EA","UD","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","70121-1576-7","NDC","","","","","facility","both","1","EA","","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","70121-1642-1","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","70121-1642-1","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VASOPRESSIN 20 UNIT/ML SOLN","70121-1642-5","NDC","","","","","facility","both","1","EA","","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"VASOPRESSIN 20 UNIT/ML SOLN","70121-1642-5","NDC","","","","","facility","both","1","EA","UD","829.83","414.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE HCL IN 0.9% NACL 50 MG/250 ML (200 MCG/ML) SOLN","70324-901-01","NDC","","","","","facility","both","1","EA","UD","138","69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE HCL IN 0.9% NACL 50 MG/250 ML (200 MCG/ML) SOLN","70324-901-01","NDC","","","","","facility","both","1","EA","","138","69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"PROMETHAZINE 6.25 MG/5 ML SYRP","70408-146-34","NDC","","","","","facility","both","1","EA","UD","1.83","0.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","70436-019-82","NDC","","","","","facility","both","1","EA","UD","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","70436-019-82","NDC","","","","","facility","both","1","EA","","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"VANCOMYCIN 5 GRAM SOLR","70436-022-82","NDC","","","","","facility","both","1","EA","","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 5 GRAM SOLR","70436-022-82","NDC","","","","","facility","both","1","EA","UD","5.07","2.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","70436-203-82","NDC","","","","","facility","both","1","EA","UD","105.68","52.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) SOLN","70436-203-82","NDC","","","","","facility","both","1","EA","","105.68","52.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IIV ADJUVANT VACCINE IM","70461-024-03","NDC","","","","","facility","both","1","EA","PN","62","31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"IIV ADJUVANT VACCINE IM","70461-024-03","NDC","","","","","facility","both","1","EA","","62","31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","70461-024-04","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","70461-024-04","NDC","","","","","facility","both","1","EA","25","62","31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","70461-024-04","NDC","","","","","facility","both","1","EA","PN","62","31","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"DOXYLAMINE-PYRIDOXINE 10-10 MG TBEC","70505-100-10","NDC","","","","","facility","both","1","EA","UD","6.89","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DOXYLAMINE-PYRIDOXINE 10-10 MG TBEC","70505-100-10","NDC","","","","","facility","both","1","EA","","6.89","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE 4 % PTMD","70512-812-01","NDC","","","","","facility","both","1","EA","UD","4.52","2.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 4 % PTMD","70512-812-01","NDC","","","","","facility","both","1","EA","","6.35","3.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIZANIDINE 4 MG TABS","70515-594-15","NDC","","","","","facility","both","1","EA","UD","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIZANIDINE 4 MG TABS","70515-594-15","NDC","","","","","facility","both","1","EA","","1.19","0.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OMEPRAZOLE 2 MG/ML SUSPENSION","70515-625-01","NDC","","","","","facility","both","1","EA","","0.3","0.15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 5 GRAM SOLR","70594-047-01","NDC","","","","","facility","both","1","EA","","20.54","10.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 5 GRAM SOLR","70594-047-01","NDC","","","","","facility","both","1","EA","UD","33.31","16.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","70594-111-01","NDC","","","","","facility","both","1","EA","UD","98.83","49.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","70594-111-01","NDC","","","","","facility","both","1","EA","","107.31","53.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","70594-111-02","NDC","","","","","facility","both","1","EA","","118.87","59.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"ACETYLCYSTEINE 200 MG/ML (20 %) SOLN 30 ML VIAL","70594-111-02","NDC","","","","","facility","both","1","EA","UD","147.38","73.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","70594-114-01","NDC","","","","","facility","both","1","EA","UD","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUPIVACAINE PF (MARCAINE-PF) 0.25% 0.25 % SOLN","70594-114-01","NDC","","","","","facility","both","1","EA","","12.13","6.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CAFFEINE 200 MG TABS","70677-0021-1","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAFFEINE 200 MG TABS","70677-0021-1","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MAGNESIUM CITRATE SOLN","70677-0051-1","NDC","","","","","facility","both","1","EA","","4.55","2.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MAGNESIUM CITRATE SOLN","70677-0051-1","NDC","","","","","facility","both","1","EA","UD","4.55","2.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SENNOSIDES 8.6 MG TABS","70677-0058-1","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SENNOSIDES 8.6 MG TABS","70677-0058-1","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","70677-1037-1","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SPRY 30 ML SQUEEZ BTL","70677-1037-1","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINERAL OIL OIL 473 ML BOTTLE","70677-1110-1","NDC","","","","","facility","both","1","EA","","62.5","31.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINERAL OIL OIL 473 ML BOTTLE","70677-1110-1","NDC","","","","","facility","both","1","EA","UD","62.5","31.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM CITRATE SOLN","70677-1111-1","NDC","","","","","facility","both","1","EA","UD","4.55","2.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MAGNESIUM CITRATE SOLN","70677-1111-1","NDC","","","","","facility","both","1","EA","","4.55","2.28","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CAFFEINE 200 MG TABS","70677-1126-1","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAFFEINE 200 MG TABS","70677-1126-1","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","70677-1154-1","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","70677-1154-1","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACYCLOVIR 5 % OINT 30 G TUBE","70700-107-16","NDC","","","","","facility","both","1","EA","","47.94","23.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PROGESTERONE 100 MG CAPS","70700-162-01","NDC","","","","","facility","both","1","EA","UD","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PROGESTERONE 100 MG CAPS","70700-162-01","NDC","","","","","facility","both","1","EA","","1.6","0.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","70700-169-22","NDC","","","","","facility","both","1","EA","","60.38","30.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"IRINOTECAN 40 MG/2 ML SOLN 2 ML VIAL","70700-169-22","NDC","","","","","facility","both","1","EA","UD","60.38","30.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOSTIGMINE METHYLSULFATE 1 MG/ML SOLN","70700-172-22","NDC","","","","","facility","both","1","EA","UD","16.25","8.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NEOSTIGMINE METHYLSULFATE 1 MG/ML SOLN","70700-172-22","NDC","","","","","facility","both","1","EA","","16.25","8.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FOSFOMYCIN TROMETHAMINE 3 GRAM PACK","70700-268-99","NDC","","","","","facility","both","1","EA","UD","98","49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FOSFOMYCIN TROMETHAMINE 3 GRAM PACK","70700-268-99","NDC","","","","","facility","both","1","EA","","98","49","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEFERASIROX 90 MG TABS","70700-269-30","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEFERASIROX 90 MG TABS","70700-269-30","NDC","","","","","facility","both","1","EA","","5.5","2.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEFERASIROX 360 MG TABS","70700-271-30","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DEFERASIROX 360 MG TABS","70700-271-30","NDC","","","","","facility","both","1","EA","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHYTONADIONE (VITAMIN K1) 5 MG TABS","70710-1014-3","NDC","","","","","facility","both","1","EA","UD","3.09","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 5 MG TABS","70710-1014-3","NDC","","","","","facility","both","1","EA","","3.09","1.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MESALAMINE 1,000 MG SUPP","70710-1302-7","NDC","","","","","facility","both","1","EA","","11","5.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RAMELTEON 8 MG TABS","70710-1344-3","NDC","","","","","facility","both","1","EA","","4.12","2.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 200 MG/20 ML SOLN","70710-1359-1","NDC","","","","","facility","both","1","EA","UD","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACOSAMIDE 200 MG/20 ML SOLN","70710-1359-1","NDC","","","","","facility","both","1","EA","","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FOMEPIZOLE 1 GRAM/ML SOLN 1.5 ML VIAL","70710-1478-1","NDC","","","","","facility","both","1","EA","JG","3605.06","1802.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"FOMEPIZOLE 1 GRAM/ML SOLN 1.5 ML VIAL","70710-1478-1","NDC","","","","","facility","both","1","EA","UD","5529.73","2764.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARMUSTINE 100 MG SOLR 1 EACH VIAL","70710-1525-9","NDC","","","","","facility","both","1","EA","","1955.23","977.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","70710-1724-1","NDC","","","","","facility","both","1","EA","UD","152.5","76.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","70710-1724-1","NDC","","","","","facility","both","1","EA","","165","82.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","70710-1724-6","NDC","","","","","facility","both","1","EA","UD","300","150","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 50 MG SOLR 1 EACH VIAL","70710-1724-6","NDC","","","","","facility","both","1","EA","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","70710-1725-1","NDC","","","","","facility","both","1","EA","UD","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MICAFUNGIN 100 MG SOLR 1 EACH VIAL","70710-1725-1","NDC","","","","","facility","both","1","EA","","302.5","151.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEFLUNOMIDE 10 MG TABS","70748-129-06","NDC","","","","","facility","both","1","EA","","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEFLUNOMIDE 10 MG TABS","70748-129-06","NDC","","","","","facility","both","1","EA","UD","2.5","1.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POSACONAZOLE 100 MG TBEC","70748-258-07","NDC","","","","","facility","both","1","EA","","9.87","4.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POSACONAZOLE 100 MG TBEC","70748-258-07","NDC","","","","","facility","both","1","EA","UD","12","6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMITRIPTYLINE 10 MG TABS","70756-201-11","NDC","","","","","facility","both","1","EA","UD","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMITRIPTYLINE 10 MG TABS","70756-201-11","NDC","","","","","facility","both","1","EA","","1.16","0.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OFLOXACIN 0.3 % DROP 5 ML DROP BTL","70756-609-15","NDC","","","","","facility","both","1","EA","","53.5","26.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10% 10 % DROP","70756-614-30","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10% 10 % DROP","70756-614-30","NDC","","","","","facility","both","1","EA","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","70756-622-10","NDC","","","","","facility","both","1","EA","UD","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","70756-622-10","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PHENYLEPHRINE 2.5 % DROP","70756-629-25","NDC","","","","","facility","both","1","EA","UD","8.03","4.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 2.5 % DROP","70756-629-25","NDC","","","","","facility","both","1","EA","","8.03","4.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"COCAINE 4 % SOLN","70839-362-04","NDC","","","","","facility","both","1","EA","UD","276.5","138.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COCAINE 4 % SOLN","70839-362-04","NDC","","","","","facility","both","1","EA","","276.5","138.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MINOCYCLINE 100 MG SOLR 1 EACH VIAL","70842-160-01","NDC","","","","","facility","both","1","EA","UD,TB","2365.64","1182.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"MINOCYCLINE 100 MG SOLR 1 EACH VIAL","70842-160-01","NDC","","","","","facility","both","1","EA","TB","2365.64","1182.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"MINOCYCLINE 100 MG SOLR 1 EACH VIAL","70842-160-01","NDC","","","","","facility","both","1","EA","JG,UD","2365.64","1182.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","70860-100-41","NDC","","","","","facility","both","1","EA","","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AZITHROMYCIN 500 MG SOLR 1 EACH VIAL","70860-100-41","NDC","","","","","facility","both","1","EA","UD","20.79","10.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","70860-117-41","NDC","","","","","facility","both","1","EA","UD","53.81","26.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","70860-117-41","NDC","","","","","facility","both","1","EA","","105.13","52.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","70860-218-05","NDC","","","","","facility","both","1","EA","","883.61","441.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DILTIAZEM 5 MG/ML SOLN","70860-301-41","NDC","","","","","facility","both","1","EA","","15.81","7.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DILTIAZEM 5 MG/ML SOLN","70860-301-41","NDC","","","","","facility","both","1","EA","UD","15.81","7.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BUMETANIDE 0.25 MG/ML SOLN","70860-405-41","NDC","","","","","facility","both","1","EA","","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUMETANIDE 0.25 MG/ML SOLN","70860-405-41","NDC","","","","","facility","both","1","EA","UD","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ONDANSETRON (PF) 4 MG/2 ML SOLN","70860-776-41","NDC","","","","","facility","both","1","EA","","5.38","2.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","70860-784-05","NDC","","","","","facility","both","1","EA","UD","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","70860-784-05","NDC","","","","","facility","both","1","EA","","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","70860-784-41","NDC","","","","","facility","both","1","EA","UD","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VALPROATE 500 MG/5 ML (100 MG/ML) SOLN 5 ML VIAL","70860-784-41","NDC","","","","","facility","both","1","EA","","15.38","7.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"RIFABUTIN 150 MG CAPS","70954-041-10","NDC","","","","","facility","both","1","EA","UD","13.93","6.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPSONE 25 MG TABS","70954-135-10","NDC","","","","","facility","both","1","EA","UD","6.1","3.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPSONE 25 MG TABS","70954-135-10","NDC","","","","","facility","both","1","EA","","6.1","3.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPSONE 100 MG TABS","70954-136-10","NDC","","","","","facility","both","1","EA","UD","4.24","2.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPSONE 100 MG TABS","70954-136-10","NDC","","","","","facility","both","1","EA","","4.24","2.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPSONE 100 MG TABS","70954-136-20","NDC","","","","","facility","both","1","EA","UD","3.24","1.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPSONE 100 MG TABS","70954-136-20","NDC","","","","","facility","both","1","EA","","4.24","2.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRIHEXYPHENIDYL 2 MG TABS","70954-212-10","NDC","","","","","facility","both","1","EA","UD","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRIHEXYPHENIDYL 2 MG TABS","70954-212-10","NDC","","","","","facility","both","1","EA","","1.23","0.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FLUPHENAZINE 1 MG TABS","70954-273-10","NDC","","","","","facility","both","1","EA","UD","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUPHENAZINE 1 MG TABS","70954-273-10","NDC","","","","","facility","both","1","EA","","2.2","1.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PYRAZINAMIDE 500 MG TABS","70954-484-10","NDC","","","","","facility","both","1","EA","","22.45","11.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PYRAZINAMIDE 500 MG TABS","70954-484-10","NDC","","","","","facility","both","1","EA","UD","22.45","11.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FLUOXETINE 20 MG CAPS","71205-975-00","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) SOLN","71225-133-01","NDC","","","","","facility","both","1","EA","","101.6","50.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) SYRG 10 ML SYRINGE","71266-2001-8","NDC","","","","","facility","both","1","EA","UD","112.75","56.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) SYRG 10 ML SYRINGE","71266-2001-8","NDC","","","","","facility","both","1","EA","","112.75","56.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","71266-2002-9","NDC","","","","","facility","both","1","EA","UD","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROCURONIUM 50 MG/5 ML (10 MG/ML) SYRG 5 ML SYRINGE","71266-2002-9","NDC","","","","","facility","both","1","EA","","54.06","27.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"HYDROMORPHONE 0.2 MG/ML SOLN","71266-5035-1","NDC","","","","","facility","both","1","EA","UD","126.2","63.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 0.2 MG/ML SOLN","71266-5035-1","NDC","","","","","facility","both","1","EA","","126.2","63.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","71266-5100-1","NDC","","","","","facility","both","1","EA","","12.67","6.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","71266-5100-1","NDC","","","","","facility","both","1","EA","UD","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","71266-5103-1","NDC","","","","","facility","both","1","EA","UD","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYTOCIN IN NORMAL SALINE 30 UNIT/500 ML SOLN","71266-5103-1","NDC","","","","","facility","both","1","EA","","34","17","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"BEVACIZUMAB 1.25 MG/0.05 ML SYRG","71266-8006-1","NDC","","","","","facility","both","1","EA","JG,UD","1160.73","580.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"BEVACIZUMAB 1.25 MG/0.05 ML SYRG","71266-8006-1","NDC","","","","","facility","both","1","EA","JG","1160.73","580.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BEVACIZUMAB 1.25 MG/0.05 ML SYRG","71266-8006-1","NDC","","","","","facility","both","1","EA","UD","1160.73","580.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BEVACIZUMAB 1.25 MG/0.05 ML SYRG","71266-8006-1","NDC","","","","","facility","both","1","EA","","1160.73","580.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BEVACIZUMAB 1.25 MG/0.05 ML SYRG","71266-8006-1","NDC","","","","","facility","both","1","EA","TB","1160.73","580.36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"ARGININE-LYSINE-STERILE WATER 25-25 MG/ML SOLN","71266-8020-1","NDC","","","","","facility","both","1","EA","UD","1182","591","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARGININE-LYSINE-STERILE WATER 25-25 MG/ML SOLN","71266-8020-1","NDC","","","","","facility","both","1","EA","","1182","591","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","71266-9011-9","NDC","","","","","facility","both","1","EA","","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) SYRG 10 ML SYRINGE","71266-9011-9","NDC","","","","","facility","both","1","EA","UD","29.88","14.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE IN NACL, ISO-OSMOTIC 50 MG/5 ML (10 MG/ML) SYRG","71266-9080-2","NDC","","","","","facility","both","1","EA","","33.2","16.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"KETAMINE IN NACL, ISO-OSMOTIC 50 MG/5 ML (10 MG/ML) SYRG","71266-9080-2","NDC","","","","","facility","both","1","EA","UD","33.2","16.6","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETAMINE IN NACL, ISO-OSMOTIC 10 MG/ML SOLN","71266-9081-1","NDC","","","","","facility","both","1","EA","","191","95.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"KETAMINE IN NACL, ISO-OSMOTIC 10 MG/ML SOLN","71266-9081-1","NDC","","","","","facility","both","1","EA","UD","191","95.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARDIOPLEGIC DEL NIDO PREMIX 26 MEQ/1,052.8 ML (POTASSIUM) SOLN","71285-0202-1","NDC","","","","","facility","both","1","EA","UD","210","105","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARDIOPLEGIC DEL NIDO PREMIX 26 MEQ/1,052.8 ML (POTASSIUM) SOLN","71285-0202-1","NDC","","","","","facility","both","1","EA","","106","53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 ML"
"OXYTOCIN 30 UNIT/500 ML SOLN","71285-6039-1","NDC","","","","","facility","both","1","EA","","7.08","3.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"OXYTOCIN 30 UNIT/500 ML SOLN","71285-6039-1","NDC","","","","","facility","both","1","EA","UD","2.21","1.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) SOLN","71285-7018-1","NDC","","","","","facility","both","1","EA","UD","68","34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) SOLN","71285-7018-1","NDC","","","","","facility","both","1","EA","","68","34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 20 ML"
"DAPTOMYCIN 500 MG SOLR","71288-016-15","NDC","","","","","facility","both","1","EA","UD","34.86","17.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DAPTOMYCIN 500 MG SOLR","71288-016-15","NDC","","","","","facility","both","1","EA","","46.48","23.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","71288-016-95","NDC","","","","","facility","both","1","EA","","95.45","47.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL","71288-023-20","NDC","","","","","facility","both","1","EA","UD","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 1,000 MG SOLR 1 EACH VIAL","71288-023-20","NDC","","","","","facility","both","1","EA","","21.25","10.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","71288-032-20","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","71288-032-20","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"OXALIPLATIN 50 MG/10 ML (5 MG/ML) SOLN 10 ML VIAL","71288-101-10","NDC","","","","","facility","both","1","EA","","24.51","12.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL","71288-101-20","NDC","","","","","facility","both","1","EA","","43.61","21.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL","71288-101-20","NDC","","","","","facility","both","1","EA","UD","49.91","24.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AZACITIDINE 100 MG SOLR","71288-115-30","NDC","","","","","facility","both","1","EA","","120.61","60.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BORTEZOMIB 3.5 MG SOLR","71288-118-10","NDC","","","","","facility","both","1","EA","JG","91.4","45.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"BORTEZOMIB 3.5 MG SOLR","71288-118-10","NDC","","","","","facility","both","1","EA","TB","91.4","45.7","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BORTEZOMIB 3.5 MG SOLR","71288-118-10","NDC","","","","","facility","both","1","EA","JG,UD","108.88","54.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEUCOVORIN CALCIUM 100 MG SOLR 1 EACH VIAL","71288-161-20","NDC","","","","","facility","both","1","EA","UD","57.5","28.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LEUCOVORIN CALCIUM 100 MG SOLR 1 EACH VIAL","71288-161-20","NDC","","","","","facility","both","1","EA","","57.5","28.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 350 MG SOLR 1 EACH VIAL","71288-163-30","NDC","","","","","facility","both","1","EA","","131.36","65.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LEUCOVORIN CALCIUM 500 MG SOLR 1 EACH VIAL","71288-164-50","NDC","","","","","facility","both","1","EA","","228.45","114.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PEMETREXED DISODIUM 500 MG SOLR 1 EACH VIAL","71288-167-50","NDC","","","","","facility","both","1","EA","","419.24","209.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHG - INJ,REGADENOSON,0.1MG,LEXISCAN","71288-201-85","NDC","","","","","facility","both","1","EA","","2256","1128","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FUROSEMIDE 10 MG/ML SOLN 10 ML VIAL","71288-203-10","NDC","","","","","facility","both","1","EA","UD","12.06","6.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 1,000 MCG/ML SOLN","71288-303-01","NDC","","","","","facility","both","1","EA","","8.81","4.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYANOCOBALAMIN 1,000 MCG/ML SOLN","71288-303-01","NDC","","","","","facility","both","1","EA","UD","8.81","4.40","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","71288-402-10","NDC","","","","","facility","both","1","EA","UD","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN 10 ML VIAL","71288-402-10","NDC","","","","","facility","both","1","EA","","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN","71288-403-01","NDC","","","","","facility","both","1","EA","UD","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 5,000 UNIT/ML SOLN","71288-403-01","NDC","","","","","facility","both","1","EA","","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 40 MG/0.4 ML SYRG","71288-410-82","NDC","","","","","facility","both","1","EA","","20.06","10.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 40 MG/0.4 ML SYRG","71288-410-82","NDC","","","","","facility","both","1","EA","UD","20.06","10.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BIVALIRUDIN 250 MG SOLR","71288-427-10","NDC","","","","","facility","both","1","EA","","68.77","34.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BIVALIRUDIN 250 MG SOLR","71288-427-10","NDC","","","","","facility","both","1","EA","UD","257.19","128.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","71288-427-11","NDC","","","","","facility","both","1","EA","","129.84","64.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"ENOXAPARIN 30 MG/0.3 ML SYRG","71288-432-80","NDC","","","","","facility","both","1","EA","","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 30 MG/0.3 ML SYRG","71288-432-80","NDC","","","","","facility","both","1","EA","UD","16.44","8.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 40 MG/0.4 ML SYRG","71288-433-82","NDC","","","","","facility","both","1","EA","UD","20.06","10.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 40 MG/0.4 ML SYRG","71288-433-82","NDC","","","","","facility","both","1","EA","","20.06","10.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ENOXAPARIN 100 MG/ML SYRG","71288-436-88","NDC","","","","","facility","both","1","EA","UD","46.31","23.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ENOXAPARIN 100 MG/ML SYRG","71288-436-88","NDC","","","","","facility","both","1","EA","","46.31","23.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METHOCARBAMOL 100 MG/ML SOLN","71288-716-10","NDC","","","","","facility","both","1","EA","","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"METHOCARBAMOL 100 MG/ML SOLN","71288-716-10","NDC","","","","","facility","both","1","EA","UD","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 100 MG/ML SOLN","71288-716-11","NDC","","","","","facility","both","1","EA","UD","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 100 MG/ML SOLN","71288-716-11","NDC","","","","","facility","both","1","EA","","39.75","19.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VUTRISIRAN 25 MG/0.5 ML SYRG","71336-1003-1","NDC","","","","","facility","both","1","EA","","466415.13","233207.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHOS-NAK 280-160-250 MG PWPK","7135101099","NDC","","","","","facility","both","1","EA","","1.96","0.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTOBACILLUS ACIDOPH & BULGAR 1 MILLION CELL TABS","7135101250","NDC","","","","","facility","both","1","EA","","1.29","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTOBACILLUS ACIDOPH & BULGAR 1 MILLION CELL TABS","7135101250","NDC","","","","","facility","both","1","EA","UD","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTOBACILLUS ACIDOPH 100 MILLION CELL GRPK","7135101399","NDC","","","","","facility","both","1","EA","UD","3.57","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTOBACILLUS ACIDOPH 100 MILLION CELL GRPK","7135101399","NDC","","","","","facility","both","1","EA","","3.57","1.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FERROUS SULFATE 15 MG ELEMENTAL IRON/ML DROP","7139974805","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"FERROUS SULFATE 15 MG ELEMENTAL IRON/ML DROP","7139974805","NDC","","","","","facility","both","1","EA","UD","2.77","1.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CENOBAMATE 50 MG TABS","71699-050-30","NDC","","","","","facility","both","1","EA","","188.54","94.27","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CENOBAMATE 50 MG TABS","71699-050-30","NDC","","","","","facility","both","1","EA","UD","789.68","394.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NATAMYCIN 5 % DRPS 15 ML DROP BTL","71776-005-15","NDC","","","","","facility","both","1","EA","UD","1190.1","595.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NATAMYCIN 5 % DRPS 15 ML DROP BTL","71776-005-15","NDC","","","","","facility","both","1","EA","","1190.1","595.05","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GLYCOPYRROLATE","71839-124-01","NDC","","","","","facility","both","1","EA","UD","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE","71839-124-01","NDC","","","","","facility","both","1","EA","","4.75","2.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBOPROST 250 MCG/ML SOLN","71839-137-01","NDC","","","","","facility","both","1","EA","UD","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBOPROST 250 MCG/ML SOLN","71839-137-01","NDC","","","","","facility","both","1","EA","","252.5","126.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","71839-143-01","NDC","","","","","facility","both","1","EA","","20.63","10.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","71839-143-01","NDC","","","","","facility","both","1","EA","UD","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","71839-143-25","NDC","","","","","facility","both","1","EA","","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","71839-143-25","NDC","","","","","facility","both","1","EA","UD","61.88","30.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOTHENIC AC-MIN OIL-PET,HYD 41 % OINT 396 G JAR","7214003147","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PANTOTHENIC AC-MIN OIL-PET,HYD 41 % OINT 396 G JAR","7214003147","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"PANTOTHENIC AC-MIN OIL-PET,HYD 41 % OINT 396 G JAR","7214063608","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ROSUVASTATIN 40 MG TABS","72205-005-30","NDC","","","","","facility","both","1","EA","UD","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ROSUVASTATIN 40 MG TABS","72205-005-30","NDC","","","","","facility","both","1","EA","","1.1","0.55","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"FEBUXOSTAT 40 MG TABS","72205-028-30","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DOFETILIDE 125 MCG CAPS","72205-039-60","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ALBENDAZOLE 200 MG TABS","72205-051-08","NDC","","","","","facility","both","1","EA","","103.15","51.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TIAGABINE 4 MG TABS","72205-085-30","NDC","","","","","facility","both","1","EA","UD","5.82","2.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TIAGABINE 4 MG TABS","72205-085-30","NDC","","","","","facility","both","1","EA","","5.82","2.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BUMETANIDE 0.25 MG/ML SOLN","72205-101-01","NDC","","","","","facility","both","1","EA","","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BUMETANIDE 0.25 MG/ML SOLN","72205-101-01","NDC","","","","","facility","both","1","EA","UD","10.95","5.48","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DARUNAVIR 600 MG TABS","72205-184-60","NDC","","","","","facility","both","1","EA","UD","4","2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DARUNAVIR 600 MG TABS","72205-184-60","NDC","","","","","facility","both","1","EA","","4","2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DARUNAVIR 800 MG TABS","72205-185-30","NDC","","","","","facility","both","1","EA","UD","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DARUNAVIR 800 MG TABS","72205-185-30","NDC","","","","","facility","both","1","EA","","7","3.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACOSAMIDE 200 MG/20 ML SOLN","72205-220-01","NDC","","","","","facility","both","1","EA","","208.75","104.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LACOSAMIDE 200 MG/20 ML SOLN","72205-220-01","NDC","","","","","facility","both","1","EA","UD","206.25","103.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN","72266-102-01","NDC","","","","","facility","both","1","EA","UD","15.75","7.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN 40 ML VIAL","72266-103-01","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LABETALOL 5 MG/ML SOLN 40 ML VIAL","72266-103-01","NDC","","","","","facility","both","1","EA","UD","60","30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 30 MG/ML SOLN","72266-118-01","NDC","","","","","facility","both","1","EA","","6.88","3.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 30 MG/ML SOLN","72266-118-01","NDC","","","","","facility","both","1","EA","UD","7.94","3.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 30 MG/ML SOLN","72266-118-01","NDC","","","","","facility","both","1","EA","PN","144","72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"TORADOL PER 15MG","72266-119-01","NDC","","","","","facility","both","1","EA","PN","72","36","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"ONDANSETRON 2 MG/ML SOLN 20 ML VIAL","72266-124-01","NDC","","","","","facility","both","1","EA","","6.25","3.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ONDANSETRON 2 MG/ML SOLN 20 ML VIAL","72266-124-01","NDC","","","","","facility","both","1","EA","UD","10","5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 0.5 % DROP","72266-158-01","NDC","","","","","facility","both","1","EA","UD","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MOXIFLOXACIN 0.5 % DROP","72266-158-01","NDC","","","","","facility","both","1","EA","","1.31","0.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","72266-159-01","NDC","","","","","facility","both","1","EA","UD","96.25","48.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERTAPENEM 1 GRAM SOLR 1 EACH VIAL","72266-159-01","NDC","","","","","facility","both","1","EA","","190","95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZIPRASIDONE 20 MG/ML (FINAL CONC.) SOLR 1 EACH VIAL","72266-160-41","NDC","","","","","facility","both","1","EA","UD","126.94","63.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZIPRASIDONE 20 MG/ML (FINAL CONC.) SOLR 1 EACH VIAL","72266-160-41","NDC","","","","","facility","both","1","EA","","126.94","63.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DORZOLAMIDE 2 % DROP","72266-197-01","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DORZOLAMIDE 2 % DROP","72266-197-01","NDC","","","","","facility","both","1","EA","","18.15","9.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 15 MG/ML SOLN","72266-234-01","NDC","","","","","facility","both","1","EA","UD","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 15 MG/ML SOLN","72266-234-01","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SINCALIDE 5 MCG SOLR 1 EACH VIAL","72266-248-01","NDC","","","","","facility","both","1","EA","","667.06","333.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCITRIOL 1 MCG/ML SOLN","72266-251-01","NDC","","","","","facility","both","1","EA","","39.94","19.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) SOLN","72485-104-01","NDC","","","","","facility","both","1","EA","UD","53.37","26.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) SOLN","72485-104-01","NDC","","","","","facility","both","1","EA","","53.37","26.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VERAPAMIL 2.5 MG/ML SOLN","72485-108-01","NDC","","","","","facility","both","1","EA","UD","11.38","5.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 2.5 MG/ML SOLN","72485-108-01","NDC","","","","","facility","both","1","EA","","11.38","5.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VERAPAMIL 2.5 MG/ML SOLN","72485-108-25","NDC","","","","","facility","both","1","EA","","11.38","5.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"VERAPAMIL 2.5 MG/ML SOLN","72485-108-25","NDC","","","","","facility","both","1","EA","UD","11.38","5.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","72485-404-01","NDC","","","","","facility","both","1","EA","UD","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PIPERACILLIN-TAZOBACTAM 4500 MG SOLR 1 EACH VIAL","72485-404-01","NDC","","","","","facility","both","1","EA","","37.56","18.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","72485-406-01","NDC","","","","","facility","both","1","EA","UD","53.81","26.90","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","72485-406-01","NDC","","","","","facility","both","1","EA","","102.63","51.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","72485-406-10","NDC","","","","","facility","both","1","EA","","207.75","103.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"NAFCILLIN 2 GRAM SOLR 1 EACH VIAL","72485-406-10","NDC","","","","","facility","both","1","EA","UD","310.38","155.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","72485-415-04","NDC","","","","","facility","both","1","EA","","61.38","30.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","72485-415-04","NDC","","","","","facility","both","1","EA","JG,UD","61.38","30.69","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","72485-415-04","NDC","","","","","facility","both","1","EA","TB","179.13","89.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"MYCOPHENOLATE 500 MG SOLR 1 EACH VIAL","72485-415-04","NDC","","","","","facility","both","1","EA","JG","179.13","89.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 4 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","72485-417-01","NDC","","","","","facility","both","1","EA","","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN/SULBACTAM 3 GRAM SOLR 1 EACH VIAL","72485-417-01","NDC","","","","","facility","both","1","EA","UD","22.5","11.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","72485-422-01","NDC","","","","","facility","both","1","EA","","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"AMPICILLIN 2 GRAM SOLR 1 EACH VIAL","72485-422-01","NDC","","","","","facility","both","1","EA","UD","17.06","8.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","72485-505-01","NDC","","","","","facility","both","1","EA","","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENYLEPHRINE 10 MG/ML SOLN 5 ML VIAL","72485-505-01","NDC","","","","","facility","both","1","EA","UD","33.75","16.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOTIFEN 0.025 % (0.035 %) DROP 5 ML DROP BTL","72485-617-10","NDC","","","","","facility","both","1","EA","","11.68","5.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","72485-625-13","NDC","","","","","facility","both","1","EA","UD","294.43","147.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % DRPS 7.5 ML DROP BTL","72485-625-13","NDC","","","","","facility","both","1","EA","","443.49","221.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","72485-670-31","NDC","","","","","facility","both","1","EA","UD","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERYTHROMYCIN 5 MG/GRAM (0.5 %) OINT 1 G TUBE","72485-670-31","NDC","","","","","facility","both","1","EA","","24.12","12.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"METOPROLOL XL 25 MG TB24","72516-030-01","NDC","","","","","facility","both","1","EA","","1.14","0.57","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACYCLOVIR 200 MG CAPS","72578-002-01","NDC","","","","","facility","both","1","EA","","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ACYCLOVIR 200 MG CAPS","72578-002-01","NDC","","","","","facility","both","1","EA","UD","1.27","0.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACYCLOVIR 5 % OINT 30 G TUBE","72578-082-06","NDC","","","","","facility","both","1","EA","","47.94","23.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL","72603-101-01","NDC","","","","","facility","both","1","EA","UD","20.66","10.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXALIPLATIN 100 MG/20 ML SOLN 20 ML VIAL","72603-101-01","NDC","","","","","facility","both","1","EA","","20.66","10.33","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DECITABINE 50 MG SOLR 1 EACH VIAL","72603-107-01","NDC","","","","","facility","both","1","EA","UD","384.8","192.4","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DECITABINE 50 MG SOLR 1 EACH VIAL","72603-107-01","NDC","","","","","facility","both","1","EA","","377.6","188.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","72603-139-01","NDC","","","","","facility","both","1","EA","UD","38.75","19.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","72603-139-01","NDC","","","","","facility","both","1","EA","","38.75","19.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","72603-139-25","NDC","","","","","facility","both","1","EA","UD","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE 100 MG/ML SOLN 2 ML VIAL","72603-139-25","NDC","","","","","facility","both","1","EA","","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LABETALOL 5 MG/ML SOLN 20 ML VIAL","72603-146-01","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LABETALOL 5 MG/ML SOLN 20 ML VIAL","72603-146-01","NDC","","","","","facility","both","1","EA","","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DAPTOMYCIN 500 MG SOLR","72603-152-01","NDC","","","","","facility","both","1","EA","","23.24","11.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","72603-152-01","NDC","","","","","facility","both","1","EA","UD","34.86","17.43","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HEPARIN 1,000 UNIT/ML SOLN","72603-179-01","NDC","","","","","facility","both","1","EA","","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 1,000 UNIT/ML SOLN","72603-179-01","NDC","","","","","facility","both","1","EA","UD","12.44","6.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL","72603-180-01","NDC","","","","","facility","both","1","EA","","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"NOREPINEPHRINE 1 MG/ML SOLN 4 ML VIAL","72603-180-01","NDC","","","","","facility","both","1","EA","UD","23.13","11.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NOREPINEPHRINE 1 MG/ML SOLN","72603-180-10","NDC","","","","","facility","both","1","EA","","41.25","20.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"NOREPINEPHRINE 1 MG/ML SOLN","72603-180-10","NDC","","","","","facility","both","1","EA","UD","85","42.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZOLEDRONIC ACID 4 MG/5 ML SOLN 5 ML VIAL","72603-198-01","NDC","","","","","facility","both","1","EA","","140","70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","72603-209-01","NDC","","","","","facility","both","1","EA","","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","72603-209-01","NDC","","","","","facility","both","1","EA","UD","41.88","20.94","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SOLN 50 ML VIAL","72603-209-25","NDC","","","","","facility","both","1","EA","","120.63","60.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"OXALIPLATIN 50 MG/10 ML (5 MG/ML) SOLN 10 ML VIAL","72603-301-01","NDC","","","","","facility","both","1","EA","UD","13.25","6.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXALIPLATIN 50 MG/10 ML (5 MG/ML) SOLN 10 ML VIAL","72603-301-01","NDC","","","","","facility","both","1","EA","","24.51","12.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN","72603-412-01","NDC","","","","","facility","both","1","EA","","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HEPARIN 5,000 UNIT/ML SOLN","72603-412-01","NDC","","","","","facility","both","1","EA","UD","6.84","3.42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 15 MG/ML SOLN","72611-719-01","NDC","","","","","facility","both","1","EA","","7.44","3.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 30 MG/ML SOLN","72611-722-01","NDC","","","","","facility","both","1","EA","","7.94","3.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"KETOROLAC 30 MG/ML SOLN","72611-722-01","NDC","","","","","facility","both","1","EA","UD","7.94","3.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"KETOROLAC 30 MG/ML SOLN","72611-722-01","NDC","","","","","facility","both","1","EA","PN","144","72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital"
"LABETALOL 5 MG/ML SOLN","72611-734-01","NDC","","","","","facility","both","1","EA","UD","15.75","7.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 500 MG SOLR 1 EACH VIAL","72611-761-01","NDC","","","","","facility","both","1","EA","UD","17.94","8.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VANCOMYCIN 500 MG SOLR 1 EACH VIAL","72611-761-01","NDC","","","","","facility","both","1","EA","","17.94","8.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PEGASPARGASE 750 UNIT/ML SOLN 5 ML VIAL","72694-954-01","NDC","","","","","facility","both","1","EA","TB","68003.42","34001.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"PEGASPARGASE 750 UNIT/ML SOLN 5 ML VIAL","72694-954-01","NDC","","","","","facility","both","1","EA","JG","68003.42","34001.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"PEGASPARGASE 750 UNIT/ML SOLN 5 ML VIAL","72694-954-01","NDC","","","","","facility","both","1","EA","","68003.42","34001.71","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MITOMYCIN 5 MG SOLR 1 EACH VIAL","72819-152-05","NDC","","","","","facility","both","1","EA","","261.6","130.8","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POTASSIUM CHLORIDE 20 MEQ PACK","72888-024-06","NDC","","","","","facility","both","1","EA","UD","4.88","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"POTASSIUM CHLORIDE 20 MEQ PACK","72888-024-06","NDC","","","","","facility","both","1","EA","","4.88","2.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","72888-036-00","NDC","","","","","facility","both","1","EA","","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARVEDILOL 12.5 MG TABS","72888-036-00","NDC","","","","","facility","both","1","EA","UD","0.06","0.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ARIPIPRAZOLE 1 MG/ML SOLN","72888-100-20","NDC","","","","","facility","both","1","EA","UD","8.5","4.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","72888-125-15","NDC","","","","","facility","both","1","EA","UD","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % SOLN","72888-125-15","NDC","","","","","facility","both","1","EA","","4.15","2.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MELPHALAN HCL-BETADEX SBES 50 MG SOLR 1 EACH VIAL","72893-001-01","NDC","","","","","facility","both","1","EA","JG","22391","11195.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"MELPHALAN HCL-BETADEX SBES 50 MG SOLR 1 EACH VIAL","72893-001-01","NDC","","","","","facility","both","1","EA","","22391","11195.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE (PF) IN 0.9 % SOD CHL 30 MG/30 ML (1 MG/ML) SPCA","73013-1020-1","NDC","","","","","facility","both","1","EA","UD","64.4","32.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE (PF) IN 0.9 % SOD CHL 30 MG/30 ML (1 MG/ML) SPCA","73013-1020-1","NDC","","","","","facility","both","1","EA","","64.4","32.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"FENTANYL 2MCG/ML-BUPIVACAINE 0.125% IN 100ML NS 2 MCG/ML- 0.125 % RESV","73013-1028-1","NDC","","","","","facility","both","1","EA","UD","407","203.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL 2MCG/ML-BUPIVACAINE 0.125% IN 100ML NS 2 MCG/ML- 0.125 % RESV","73013-1028-1","NDC","","","","","facility","both","1","EA","","407","203.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 12 ML"
"HYDROMORPHONE 30MG IN 30ML NS 30 MG/30 ML (1 MG/ML) SPCA","73013-1042-1","NDC","","","","","facility","both","1","EA","UD","75.74","37.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 30MG IN 30ML NS 30 MG/30 ML (1 MG/ML) SPCA","73013-1042-1","NDC","","","","","facility","both","1","EA","","75.74","37.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"UBLITUXIMAB-XIIY (BRIUMVI) 25 MG/ML SOLN 6 ML VIAL","73150-150-06","NDC","","","","","facility","both","1","EA","","39296.21","19648.10","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"UBLITUXIMAB-XIIY (BRIUMVI) 25 MG/ML SOLN 6 ML VIAL","73150-150-06","NDC","","","","","facility","both","1","EA","UD","115996.17","57998.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","73293-0001-1","NDC","","","","","facility","both","1","EA","","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LIDOCAINE-PF 10 MG/ML (1%) 10 MG/ML (1 %) SOLN","73293-0001-1","NDC","","","","","facility","both","1","EA","UD","10.25","5.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EFGARTIGIMOD ALFA-FCAB 20 MG/ML SOLN 20 ML VIAL","73475-3041-5","NDC","","","","","facility","both","1","EA","TB","74428.63","37214.32","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"EFGARTIGIMOD ALFA-FCAB 20 MG/ML SOLN 20 ML VIAL","73475-3041-5","NDC","","","","","facility","both","1","EA","UD,TB","56658.6","28329.3","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"EFGARTIGIMOD ALFA-FCAB 20 MG/ML SOLN 20 ML VIAL","73475-3041-5","NDC","","","","","facility","both","1","EA","","44641.98","22320.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"INDOMETHACIN 100 MG SUPP","73702-140-71","NDC","","","","","facility","both","1","EA","UD","338","169","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDOMETHACIN 100 MG SUPP","73702-140-71","NDC","","","","","facility","both","1","EA","","338","169","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZINC OXIDE 13 % CREA 113 G TUBE","7430000301","NDC","","","","","facility","both","1","EA","","11.28","5.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ZINC OXIDE 13 % CREA 113 G TUBE","7430000301","NDC","","","","","facility","both","1","EA","UD","11.28","5.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIBOFLAVIN 100 MG TABS","7431200640","NDC","","","","","facility","both","1","EA","UD","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"RIBOFLAVIN 100 MG TABS","7431200640","NDC","","","","","facility","both","1","EA","","1.08","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERGOCALCIFEROL 200 MCG/ML (8,000 UNIT/ML) DROP","7583401060","NDC","","","","","facility","both","1","EA","","1.74","0.87","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ERGOCALCIFEROL 200 MCG/ML (8,000 UNIT/ML) DROP","7583401060","NDC","","","","","facility","both","1","EA","UD","2.47","1.24","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VERAPAMIL 12HR 180 MG TBSR","75834-158-01","NDC","","","","","facility","both","1","EA","","1.66","0.83","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 12HR 240 MG TBSR","75834-159-01","NDC","","","","","facility","both","1","EA","","1.58","0.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VERAPAMIL 12HR 240 MG TBSR","75834-159-01","NDC","","","","","facility","both","1","EA","UD","1.58","0.79","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC OXIDE 20 % OINT 56.7 G TUBE","75834-170-02","NDC","","","","","facility","both","1","EA","UD","56.7","28.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC OXIDE 20 % OINT 56.7 G TUBE","75834-170-02","NDC","","","","","facility","both","1","EA","","56.7","28.35","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"ERYTHROMYCIN 250 MG TABS","75834-242-30","NDC","","","","","facility","both","1","EA","UD","2.28","1.14","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERYTHROMYCIN 250 MG TABS","75834-242-30","NDC","","","","","facility","both","1","EA","","2.42","1.21","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONIDINE 0.1 MG/24 HR PTWK","75907-023-11","NDC","","","","","facility","both","1","EA","","21.16","10.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CLONIDINE 0.1 MG/24 HR PTWK","75907-023-11","NDC","","","","","facility","both","1","EA","UD","21.16","10.58","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NORTRIPTYLINE 10 MG CAPS","75907-069-01","NDC","","","","","facility","both","1","EA","UD","1.3","0.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL","75907-189-35","NDC","","","","","facility","both","1","EA","","363.82","181.91","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 10 ML VIAL","75907-189-35","NDC","","","","","facility","both","1","EA","UD","809.3","404.65","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","75907-190-07","NDC","","","","","facility","both","1","EA","","92.22","46.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","75907-190-07","NDC","","","","","facility","both","1","EA","UD","344.5","172.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","75907-190-07","NDC","","","","","facility","both","1","EA","JG,UD","465.09","232.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","75907-190-07","NDC","","","","","facility","both","1","EA","TB","465.09","232.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 5 ML VIAL","75907-190-07","NDC","","","","","facility","both","1","EA","JG","720.46","360.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CYCLOPHOSPHAMIDE 200 MG/ML SOLN 2.5 ML VIAL","75907-191-02","NDC","","","","","facility","both","1","EA","","289.57","144.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TEPROTUMUMAB-TRBW 500 MG SOLR 1 EACH VIAL","75987-130-15","NDC","","","","","facility","both","1","EA","JG","97805.34","48902.67","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"TEPROTUMUMAB-TRBW 500 MG SOLR 1 EACH VIAL","75987-130-15","NDC","","","","","facility","both","1","EA","UD","131333.49","65666.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TEPROTUMUMAB-TRBW 500 MG SOLR 1 EACH VIAL","75987-130-15","NDC","","","","","facility","both","1","EA","TB","150939.53","75469.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"TEPROTUMUMAB-TRBW 500 MG SOLR 1 EACH VIAL","75987-130-15","NDC","","","","","facility","both","1","EA","","223945.12","111972.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MORPHINE 2 MG/ML SYRG","76045-004-01","NDC","","","","","facility","both","1","EA","UD","22.22","11.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MORPHINE 2 MG/ML SYRG","76045-004-01","NDC","","","","","facility","both","1","EA","","22.22","11.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 4 MG/ML SYRG","76045-005-01","NDC","","","","","facility","both","1","EA","","22.22","11.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MORPHINE 4 MG/ML SYRG","76045-005-10","NDC","","","","","facility","both","1","EA","","22.22","11.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"MORPHINE 4 MG/ML SYRG","76045-005-10","NDC","","","","","facility","both","1","EA","UD","22.22","11.11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 1 MG/ML SYRG","76045-009-01","NDC","","","","","facility","both","1","EA","UD","15.59","7.80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 1 MG/ML SYRG","76045-009-01","NDC","","","","","facility","both","1","EA","","20.59","10.30","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","76045-009-06","NDC","","","","","facility","both","1","EA","UD","25.9","12.95","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","76045-009-96","NDC","","","","","facility","both","1","EA","UD","13.18","6.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROMORPHONE 0.5 MG/0.5 ML SYRG","76045-009-96","NDC","","","","","facility","both","1","EA","","13.18","6.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METOCLOPRAMIDE 5 MG/ML SYRG","76045-101-20","NDC","","","","","facility","both","1","EA","","19.13","9.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"METOCLOPRAMIDE 5 MG/ML SYRG","76045-101-20","NDC","","","","","facility","both","1","EA","UD","19.13","9.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GLYCOPYRROLATE (PF) IN WATER 0.4 MG/2 ML (0.2 MG/ML) SYRG","76045-203-20","NDC","","","","","facility","both","1","EA","","89.25","44.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 24 ML"
"DIAZEPAM 5 MG/ML SYRG","76045-204-00","NDC","","","","","facility","both","1","EA","UD","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIAZEPAM 5 MG/ML SYRG","76045-204-00","NDC","","","","","facility","both","1","EA","","92.5","46.25","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARFILZOMIB 60 MG SOLR 1 EACH VIAL","76075-101-01","NDC","","","","","facility","both","1","EA","JG","8842.15","4421.08","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CARFILZOMIB 30 MG SOLR 1 EACH VIAL","76075-102-01","NDC","","","","","facility","both","1","EA","JG","11803.45","5901.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"CARFILZOMIB 10 MG SOLR 1 EACH VIAL","76075-103-01","NDC","","","","","facility","both","1","EA","JG","1906.68","953.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"SODIUM CHLORIDE 3 % NEBU","7620402260","NDC","","","","","facility","both","1","EA","UD","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM CHLORIDE 3 % NEBU","7620402260","NDC","","","","","facility","both","1","EA","","2","1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 60 ML"
"IPRATROPIUM 0.02 % SOLN","76204-100-01","NDC","","","","","facility","both","1","EA","UD","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IPRATROPIUM 0.02 % SOLN","76204-100-01","NDC","","","","","facility","both","1","EA","","1.45","0.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"ALBUTEROL 2.5 MG /3 ML (0.083 %) NEBU","76204-200-01","NDC","","","","","facility","both","1","EA","","1.48","0.74","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 30 ML"
"SERTRALINE 100 MG TABS","76282-214-90","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SERTRALINE 100 MG TABS","76282-214-90","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TROSPIUM 20 MG TABS","76282-336-60","NDC","","","","","facility","both","1","EA","","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TROSPIUM 20 MG TABS","76282-336-60","NDC","","","","","facility","both","1","EA","UD","2.24","1.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CITALOPRAM 20 MG TABS","76282-629-90","NDC","","","","","facility","both","1","EA","","0.13","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CITALOPRAM 20 MG TABS","76282-629-90","NDC","","","","","facility","both","1","EA","UD","1.13","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML SYRG","76329-1240-1","NDC","","","","","facility","both","1","EA","","157.06","78.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MORPHINE 30 MG/30 ML (1 MG/ML) PCAS","76329-1912-1","NDC","","","","","facility","both","1","EA","","89.06","44.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"MORPHINE 30 MG/30 ML (1 MG/ML) PCAS","76329-1912-1","NDC","","","","","facility","both","1","EA","UD","89.06","44.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % JELP","76329-3012-5","NDC","","","","","facility","both","1","EA","UD","18.25","9.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % JELP","76329-3012-5","NDC","","","","","facility","both","1","EA","","18.25","9.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"LIDOCAINE 2 % JELP","76329-3013-5","NDC","","","","","facility","both","1","EA","UD","20.23","10.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 2 % JELP","76329-3013-5","NDC","","","","","facility","both","1","EA","","20.23","10.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"D50W SYRG","76329-3302-1","NDC","","","","","facility","both","1","EA","UD","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"D50W SYRG","76329-3302-1","NDC","","","","","facility","both","1","EA","","85.31","42.66","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SYRG","76329-3304-1","NDC","","","","","facility","both","1","EA","","58.75","29.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"CALCIUM CHLORIDE 100 MG/ML (10 %) SYRG","76329-3304-1","NDC","","","","","facility","both","1","EA","UD","58.75","29.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"EPINEPHRINE 0.1 MG/ML SYRG","76329-3318-1","NDC","","","","","facility","both","1","EA","","35.25","17.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"EPINEPHRINE 0.1 MG/ML SYRG","76329-3318-1","NDC","","","","","facility","both","1","EA","UD","35.25","17.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"REGADENOSON 0.4 MG/5 ML SYRG","76329-3321-0","NDC","","","","","facility","both","1","EA","UD","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"REGADENOSON 0.4 MG/5 ML SYRG","76329-3321-0","NDC","","","","","facility","both","1","EA","","82","41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ATROPINE 0.1 MG/ML SYRG","76329-3340-1","NDC","","","","","facility","both","1","EA","UD","55.56","27.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATROPINE 0.1 MG/ML SYRG","76329-3340-1","NDC","","","","","facility","both","1","EA","","55.56","27.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SYRG","76329-3352-1","NDC","","","","","facility","both","1","EA","","70.31","35.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"SODIUM BICARBONATE 8.4 % (1 MEQ/ML) SYRG","76329-3352-1","NDC","","","","","facility","both","1","EA","UD","70.31","35.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXONE 1 MG/ML SYRG","76329-3369-1","NDC","","","","","facility","both","1","EA","UD","100.94","50.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXONE 1 MG/ML SYRG","76329-3369-1","NDC","","","","","facility","both","1","EA","","100.94","50.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIDOCAINE 100 MG/5 ML (2 %) SYRG","76329-3390-1","NDC","","","","","facility","both","1","EA","UD","33.53","16.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE 100 MG/5 ML (2 %) SYRG","76329-3390-1","NDC","","","","","facility","both","1","EA","","33.53","16.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 ML"
"LIDOCAINE HCL 4 % SOLN","76329-6300-5","NDC","","","","","facility","both","1","EA","UD","51.97","25.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LIDOCAINE HCL 4 % SOLN","76329-6300-5","NDC","","","","","facility","both","1","EA","","51.97","25.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 25 ML"
"EPINEPHRINE 1 MG/ML SOLN 30 ML VIAL","76329-9060-0","NDC","","","","","facility","both","1","EA","","75.21","37.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"EPINEPHRINE 1 MG/ML SOLN 30 ML VIAL","76329-9060-0","NDC","","","","","facility","both","1","EA","UD","150.43","75.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PRIMAQUINE 26.3 MG (=15 MG BASE) TABS","76385-102-01","NDC","","","","","facility","both","1","EA","","7.73","3.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 500 MG TABS","76385-123-01","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METHOCARBAMOL 500 MG TABS","76385-123-01","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","76385-124-01","NDC","","","","","facility","both","1","EA","","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"METHOCARBAMOL 750 MG TABS","76385-124-01","NDC","","","","","facility","both","1","EA","UD","1.11","0.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM-VITAMIN D 500 MG-5 MCG (200 UNIT) TABS","7733311025","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM-VITAMIN D 500 MG-5 MCG (200 UNIT) TABS","7733311025","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYCARBOPHIL 625 MG TABS","7733311825","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYCARBOPHIL 625 MG TABS","77333-120-25","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"POLYCARBOPHIL 625 MG TABS","77333-120-25","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTASE 3,000 UNIT TABS","7733343025","NDC","","","","","facility","both","1","EA","","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LACTASE 3,000 UNIT TABS","7733343025","NDC","","","","","facility","both","1","EA","UD","1.18","0.59","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTOBACILLUS ACIDOPH & BULGAR 1 MILLION CELL TABS","7733344125","NDC","","","","","facility","both","1","EA","UD","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTOBACILLUS ACIDOPH & BULGAR 1 MILLION CELL TABS","7733344125","NDC","","","","","facility","both","1","EA","","2.18","1.09","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MELATONIN 3 MG TABS","7733351625","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MELATONIN 3 MG TABS","7733351625","NDC","","","","","facility","both","1","EA","UD","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACCHAROMYCES BOULARDII 250 MG CAPS","7733380025","NDC","","","","","facility","both","1","EA","UD","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACCHAROMYCES BOULARDII 250 MG CAPS","7733380025","NDC","","","","","facility","both","1","EA","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SACCHAROMYCES BOULARDII 250 MG CAPS","7733380050","NDC","","","","","facility","both","1","EA","UD","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SACCHAROMYCES BOULARDII 250 MG CAPS","7733380050","NDC","","","","","facility","both","1","EA","","2.09","1.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SIMETHICONE 80 MG CHEW","77333-812-25","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SIMETHICONE 80 MG CHEW","77333-812-25","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM BICARBONATE 650 MG TABS","7733383125","NDC","","","","","facility","both","1","EA","","1.03","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"THIAMINE MONONITRATE 100 MG TABS","7733393425","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"THIAMINE MONONITRATE 100 MG TABS","7733393425","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 500 MCG TABS","7733393725","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 500 MCG TABS","7733393725","NDC","","","","","facility","both","1","EA","","0.05","0.02","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 1,000 MCG TABS","7733393825","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 1,000 MCG TABS","7733393825","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"PYRIDOXINE (VITAMIN B6) 50 MG TABS","7733394025","NDC","","","","","facility","both","1","EA","","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PYRIDOXINE (VITAMIN B6) 50 MG TABS","7733394025","NDC","","","","","facility","both","1","EA","UD","1.02","0.51","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPS","7733395125","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPS","7733395125","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ZINC SULFATE 50 MG ZINC (220 MG) CAPS","7733398325","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC SULFATE 50 MG ZINC (220 MG) CAPS","7733398325","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"PHENOL AEROSOL SPRAY 1.4 % SPRA","7811201104","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"PHENOL AEROSOL SPRAY 1.4 % SPRA","7811201104","NDC","","","","","facility","both","1","EA","UD","177","88.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BENZOCAINE-MENTHOL 15-10 MG LOZG","7811201746","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CARBAMIDE PEROXIDE 6.5 % DROP 15 ML DROP BTL","7811273623","NDC","","","","","facility","both","1","EA","","3.99","2.00","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BETAMETHASONE ACETATE & SODIUM PHOSPHATE (CELESTONE) 6 MG/ML SUSPENSION","78206-118-01","NDC","","","","","facility","both","1","EA","UD","236.25","118.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BETAMETHASONE ACETATE & SODIUM PHOSPHATE (CELESTONE) 6 MG/ML SUSPENSION","78206-118-01","NDC","","","","","facility","both","1","EA","","236.25","118.12","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ETONOGESTREL 68 MG IMPL","78206-145-01","NDC","","","","","facility","both","1","EA","","1601.96","800.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ETONOGESTREL 68 MG IMPL","78206-145-01","NDC","","","","","facility","both","1","EA","UD","1601.96","800.98","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLIXIMAB-ABDA 100 MG SOLR 1 EACH VIAL","78206-162-01","NDC","","","","","facility","both","1","EA","","10920.06","5460.03","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"INFLIXIMAB-ABDA 100 MG SOLR 1 EACH VIAL","78206-162-01","NDC","","","","","facility","both","1","EA","JG,UD","14536.33","7268.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"INFLIXIMAB-ABDA 100 MG SOLR 1 EACH VIAL","78206-162-01","NDC","","","","","facility","both","1","EA","JG","14536.33","7268.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"INFLIXIMAB-ABDA 100 MG SOLR 1 EACH VIAL","78206-162-01","NDC","","","","","facility","both","1","EA","UD","14536.33","7268.16","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DANTROLENE 20 MG SOLR","78670-003-67","NDC","","","","","facility","both","1","EA","UD","1620.2","810.1","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DANTROLENE 20 MG SOLR","78670-003-67","NDC","","","","","facility","both","1","EA","","1675.64","837.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 6 EACH"
"COENZYME Q10 100 MG CAPS","7985407974","NDC","","","","","facility","both","1","EA","","1.36","0.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"RIBOFLAVIN 100 MG TABS","7985420195","NDC","","","","","facility","both","1","EA","","0.11","0.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"SODIUM HYALURONATE 10 MG/ML SYRG","8065183004","NDC","","","","","facility","both","1","EA","","3276.92","1638.46","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM HYALURONATE 10 MG/ML SYRG","8065183004","NDC","","","","","facility","both","1","EA","UD","750.82","375.41","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYALURONATE 10 MG/ML SYRG","8065183055","NDC","","","","","facility","both","1","EA","UD","1031.24","515.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYALURONATE 10 MG/ML SYRG","8065183055","NDC","","","","","facility","both","1","EA","","551.24","275.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHONDROITIN SULF-SOD HYALURON 3 %-4 %(0.35ML) 1 % (0.4 ML) SYRG","8065183135","NDC","","","","","facility","both","1","EA","","1205.63","602.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHONDROITIN SULF-SOD HYALURON 3 %-4 %(0.35ML) 1 % (0.4 ML) SYRG","8065183135","NDC","","","","","facility","both","1","EA","UD","1205.63","602.82","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHONDROITIN-SODIUM HYALURONATE 3 %-4 %(0.5 ML) 1 % (0.55 ML) SYRG","8065183150","NDC","","","","","facility","both","1","EA","","1271.29","635.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CHONDROITIN-SODIUM HYALURONATE 3 %-4 %(0.5 ML) 1 % (0.55 ML) SYRG","8065183150","NDC","","","","","facility","both","1","EA","UD","1271.29","635.64","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHONDROITIN-SODIUM HYALURONATE 4-3 % (40-30 MG/ML) SYRG","8065183905","NDC","","","","","facility","both","1","EA","UD","934.52","467.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHONDROITIN-SODIUM HYALURONATE 4-3 % (40-30 MG/ML) SYRG","8065183905","NDC","","","","","facility","both","1","EA","","934.52","467.26","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ZINC GLUCONATE 50 MG TABS","8068100200","NDC","","","","","facility","both","1","EA","UD","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ZINC GLUCONATE 50 MG TABS","8068100200","NDC","","","","","facility","both","1","EA","","1.06","0.53","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COENZYME Q10 100 MG CAPS","8068101000","NDC","","","","","facility","both","1","EA","","0.36","0.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NIACIN 100 MG TABS","8068105700","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CYANOCOBALAMIN 100 MCG TABS","8068107100","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CYANOCOBALAMIN 100 MCG TABS","8068107100","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"B COMPLEX WITH C TABS","8068112600","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"B COMPLEX WITH C TABS","8068112600","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VITAMIN E 45 MG (100 UNIT) CAPS","8068113400","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"VITAMIN E 45 MG (100 UNIT) CAPS","8068113400","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM CITRATE 200 MG (950 MG) TABS","8068114000","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CALCIUM CITRATE 200 MG (950 MG) TABS","8068114000","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LANOLIN ALCOH-MIN OIL-W.PETRO-CERESIN CREA 113 G JAR","8068115500","NDC","","","","","facility","both","1","EA","UD","113","56.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LANOLIN ALCOH-MIN OIL-W.PETRO-CERESIN CREA 113 G JAR","8068115500","NDC","","","","","facility","both","1","EA","","113","56.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"CYANOCOBALAMIN 250 MCG TABS","8068116500","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"LIDOCAINE 4 % PTMD","80707-90159","NDC","","","","","facility","both","1","EA","","3.68","1.84","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"TRANEXAMIC ACID 1,000 MG/100 ML (10 MG/ML) PGBK","80830-2329-1","NDC","","","","","facility","both","1","EA","","84","42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRANEXAMIC ACID 1,000 MG/100 ML (10 MG/ML) PGBK","80830-2329-1","NDC","","","","","facility","both","1","EA","UD","84","42","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CALCIUM GLUC IN NACL, ISO-OSM 2 GRAM/100 ML SOLN","80830-2363-1","NDC","","","","","facility","both","1","EA","","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CALCIUM GLUC IN NACL, ISO-OSM 2 GRAM/100 ML SOLN","80830-2363-1","NDC","","","","","facility","both","1","EA","UD","160","80","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METRONIDAZOLE 500 MG/100 ML PGBK","80830-2465-1","NDC","","","","","facility","both","1","EA","","6.4","3.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"ACETAMINOPHEN 160 MG/5 ML (5 ML) SOLN","81033-002-05","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ACETAMINOPHEN 650 MG/20.3 ML SOLN","81033-002-20","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","81033-102-05","NDC","","","","","facility","both","1","EA","UD","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"GUAIFENESIN 100 MG/5 ML LIQD","81033-102-05","NDC","","","","","facility","both","1","EA","","2.35","1.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","81033-102-10","NDC","","","","","facility","both","1","EA","","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"GUAIFENESIN 100 MG/5 ML LIQD","81033-102-10","NDC","","","","","facility","both","1","EA","UD","1.41","0.70","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ATOVAQUONE 750 MG/5 ML SUSPENSION","81033-104-05","NDC","","","","","facility","both","1","EA","","104.67","52.34","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"MULTIVIT-MIN-FERROUS GLUCONATE 12 MG IRON/15 ML LIQD","8103350115","NDC","","","","","facility","both","1","EA","UD","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"OXYMETAZOLINE 0.05 % SOLN 30 ML SQUEEZ BTL","8113170017","NDC","","","","","facility","both","1","EA","","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"OXYMETAZOLINE 0.05 % SOLN 30 ML SQUEEZ BTL","8113170017","NDC","","","","","facility","both","1","EA","UD","30","15","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) SOLN","81284-315-00","NDC","","","","","facility","both","1","EA","UD","1991.24","995.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIHYDROERGOTAMINE 1 MG/ML SOLN","81284-411-00","NDC","","","","","facility","both","1","EA","UD","230.36","115.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DIHYDROERGOTAMINE 1 MG/ML SOLN","81284-411-00","NDC","","","","","facility","both","1","EA","","230.36","115.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DIHYDROERGOTAMINE 1 MG/ML SOLN 1 ML AMPUL","81284-411-05","NDC","","","","","facility","both","1","EA","","230.36","115.18","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 5 ML"
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN","81284-611-00","NDC","","","","","facility","both","1","EA","","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLN","81284-611-00","NDC","","","","","facility","both","1","EA","UD","24.38","12.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXEGOL 12.5 MG TABS","82625-8801-1","NDC","","","","","facility","both","1","EA","UD","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXEGOL 12.5 MG TABS","82625-8801-1","NDC","","","","","facility","both","1","EA","","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALOXEGOL 25 MG TABS","82625-8802-1","NDC","","","","","facility","both","1","EA","UD","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXEGOL 25 MG TABS","82625-8802-1","NDC","","","","","facility","both","1","EA","","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"NALOXEGOL 25 MG TABS","82625-8802-3","NDC","","","","","facility","both","1","EA","UD","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NALOXEGOL 25 MG TABS","82625-8802-3","NDC","","","","","facility","both","1","EA","","29.11","14.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","83090-011-01","NDC","","","","","facility","both","1","EA","","83.83","41.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"DAPTOMYCIN 500 MG SOLR","83090-011-01","NDC","","","","","facility","both","1","EA","UD","141.93","70.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"TRASTUZUMAB-DKST 150 MG SOLR 1 EACH VIAL","83257-001-11","NDC","","","","","facility","both","1","EA","TB","9100.26","4550.13","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","83634-400-10","NDC","","","","","facility","both","1","EA","UD","129.84","64.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","83634-400-10","NDC","","","","","facility","both","1","EA","","129.84","64.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 10 EACH"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","83634-400-41","NDC","","","","","facility","both","1","EA","","53.44","26.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BIVALIRUDIN 250 MG SOLR 1 EACH VIAL","83634-400-41","NDC","","","","","facility","both","1","EA","UD","129.84","64.92","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","83634-451-10","NDC","","","","","facility","both","1","EA","JG","377.5","188.75","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","83634-451-10","NDC","","","","","facility","both","1","EA","","454.38","227.19","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","83634-451-10","NDC","","","","","facility","both","1","EA","JG,UD","471.25","235.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","83634-451-10","NDC","","","","","facility","both","1","EA","UD","471.25","235.62","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"DESMOPRESSIN 4 MCG/ML SOLN 10 ML VIAL","83634-451-10","NDC","","","","","facility","both","1","EA","TB","658.75","329.38","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier TB: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,000 UNIT/GRAM OINT 28.4 G TUBE","84389-111-48","NDC","","","","","facility","both","1","EA","","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G"
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5MG-400 UNIT- 5,000 UNIT/GRAM OINT 28.4 G TUBE","84389-111-48","NDC","","","","","facility","both","1","EA","UD","28.4","14.2","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 G | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYALURONATE 10 MG/ML SYRG","8544636981","NDC","","","","","facility","both","1","EA","","738.44","369.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM HYALURONATE 10 MG/ML SYRG","8544636981","NDC","","","","","facility","both","1","EA","UD","738.44","369.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"SODIUM HYALURONATE 10 MG/ML SYRG","8544-6369-81","NDC","","","","","facility","both","1","EA","","738.44","369.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"SODIUM HYALURONATE 10 MG/ML SYRG","8544-6369-81","NDC","","","","","facility","both","1","EA","UD","738.44","369.22","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CEPHALEXIN 125 MG/5 ML SUSR","9999-0095-01","NDC","","","","","facility","both","1","EA","","3.98","1.99","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LAMIVUDINE 10 MG/ML SOLN","9999-0749-65","NDC","","","","","facility","both","1","EA","","1.75","0.88","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LAMIVUDINE 10 MG/ML SOLN","9999-0749-65","NDC","","","","","facility","both","1","EA","UD","3.7","1.85","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE 300MCG IN 30ML NS 300 MCG/30 ML (10 MCG/ML) SPCA","9999-2389-31","NDC","","","","","facility","both","1","EA","UD","172.94","86.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"FENTANYL CITRATE 300MCG IN 30ML NS 300 MCG/30 ML (10 MCG/ML) SPCA","9999-2389-31","NDC","","","","","facility","both","1","EA","","172.94","86.47","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"BACLOFEN TABS","9999-2650-03","NDC","","","","","facility","both","1","EA","","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"BACLOFEN TABS","9999-2650-03","NDC","","","","","facility","both","1","EA","UD","1.09","0.54","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 12.5 MG TABS","9999-2650-13","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 TAB | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 12.5 MG TABS","9999-2650-13","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 TAB"
"DAPTOMYCIN 50 MG/ML SOLR","9999-2846-57","NDC","","","","","facility","both","1","EA","UD","85.21","42.60","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CHEMOTHERAPY MEDICATION TYPE-IN","9999-2889-58","NDC","","","","","facility","both","1","EA","","3.01","1.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"CHEMOTHERAPY MEDICATION TYPE-IN","9999-2889-58","NDC","","","","","facility","both","1","EA","UD","1.01","0.50","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"LACTULOSE 200GM/NS 1000ML ENEMA","9999-2900-80","NDC","","","","","facility","both","1","EA","","51.53","25.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"LACTULOSE 200GM/NS 1000ML ENEMA","9999-2900-80","NDC","","","","","facility","both","1","EA","UD","51.53","25.76","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYCHLOROQUINE 25 MG/ML SUSPENSION","9999-2921-82","NDC","","","","","facility","both","1","EA","","32.41","16.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROXYCHLOROQUINE 25 MG/ML SUSPENSION","9999-2921-82","NDC","","","","","facility","both","1","EA","UD","32.41","16.20","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"HYDROXYCHLOROQUINE 25 MG/ML SUSPENSION","9999-2921-83","NDC","","","","","facility","both","1","EA","","41.71","20.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN ENEMA 500 MG","9999-2964-43","NDC","","","","","facility","both","1","EA","","45.11","22.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"VANCOMYCIN ENEMA 500 MG","9999-2964-43","NDC","","","","","facility","both","1","EA","UD","45.11","22.56","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BEER","9999-2971-23","NDC","","","","","facility","both","1","EA","UD","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"BEER","9999-2971-23","NDC","","","","","facility","both","1","EA","","5.36","2.68","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML SUSR","9999-9028-97","NDC","","","","","facility","both","1","EA","UD","3.45","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML SUSR","9999-9028-97","NDC","","","","","facility","both","1","EA","","3.45","1.72","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CETACAINE 2 %-2 %-14 % (200 MG/SEC) SPRA","99999-0719-12","NDC","","","","","facility","both","1","EA","","20.88","10.44","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 SPRAY"
"CETACAINE 2 %-2 %-14 % (200 MG/SEC) SPRA","99999-0719-12","NDC","","","","","facility","both","1","EA","UD","26.11","13.06","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 SPRAY | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEDICATION TYPE-IN","99999-1401-13","NDC","","","","","facility","both","1","EA","UD","0.01","0.005","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"MEDICATION TYPE-IN","99999-1401-13","NDC","","","","","facility","both","1","EA","","1","0.5","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"MEDICATION TYPE-IN 1 EACH CHARGE ON DISPENSE","99999-1401-14","NDC","","","","","facility","both","1","EA","","4.46","2.23","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH"
"COCAINE 4% WITH EPINEPHRINE 5ML TOPICAL SOLUTION","99999-2307-54","NDC","","","","","facility","both","1","EA","UD","143.93","71.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"COCAINE 4% WITH EPINEPHRINE 5ML TOPICAL SOLUTION","99999-2307-54","NDC","","","","","facility","both","1","EA","","143.93","71.96","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"HYDROCORTISONE","99999-2312-81","NDC","","","","","facility","both","1","EA","UD","31.56","15.78","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"IIV3 VACC PRESERVATIVE FREE 0.5 ML DOSAGE IM USE","99999233690","NDC","","","","","facility","both","1","EA","","22","11","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"METOPROLOL 12.5 MG TABS","99999-2650-13","NDC","","","","","facility","both","1","EA","UD","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 TAB | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"METOPROLOL 12.5 MG TABS","99999-2650-13","NDC","","","","","facility","both","1","EA","","1.05","0.52","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 TAB"
"TUBE FEED TYPE-IN","99999-2959-92","NDC","","","","","facility","both","1","EA","UD","1.71","0.86","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 EACH | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","99999-5751-05","NDC","","","","","facility","both","1","EA","UD","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"NYSTATIN 100,000 UNIT/ML SUSPENSION","99999-5751-05","NDC","","","","","facility","both","1","EA","","3.94","1.97","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"CARBAMAZEPINE 20 MG/ML SUSPENSION","9999-9913-56","NDC","","","","","facility","both","1","EA","UD","10.08","5.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"
"CARBAMAZEPINE 20 MG/ML SUSPENSION","9999-9913-56","NDC","","","","","facility","both","1","EA","","10.08","5.04","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMANTADINE HCL 50 MG/5 ML SOLN","99999-993-65","NDC","","","","","facility","both","1","EA","","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML"
"AMANTADINE HCL 50 MG/5 ML SOLN","99999-993-65","NDC","","","","","facility","both","1","EA","UD","1.86","0.93","","","","","","","","","","","","","Gross Charge Type: Pharmacy | NDC EA = 1 ML | The modified price is presented in the standard charge value. | Modifier UD: Medicaid level of care 13, as defined by each state"